SCHEDULE 2 – THE SERVICES

A. Service Specifications Mandatory headings 1 – 4: mandatory but detail for local determination and agreement Optional headings 5-7: optional to use, detail for local determination and agreement. All subheadings for local determination and agreement

Service Specification

No.

1

Service Community Ophthalmology

Commissioner Lead Dr Christine Campling and Dr Raj Thakkar – Aylesbury Vale CCG and Chiltern CCG

Provider Lead Iwona Luczynska-Ngody

Period 1 April 2018 – 31 March 2019

Date of Review March 2019

Vision The vision is for a multi-disciplinary Community Ophthalmology Service (COS) to be consultant led, who would provide the capacity for a wide range of referrals to be dealt with in line with recognised best clinical practice. Strong links will be forged with the secondary care providers. The COS will provide a first class service that is able to offer a world class, consultant-led Ophthalmology management service. It will be held up as a model of best practice across the NHS based on its outcomes, its cooperation and integration with the acute and community services, and the training and education opportunities it offers to all levels of staff.

1. Population Needs

1.1 National/local context and evidence base

This is a well-established community service that has been running for several

years and sees patients with a range of non-urgent ophthalmology problems. Community service provision is in line with the national agenda of ‘care closer to home’ and should meet the following commissioning intentions:

More equitable access and treatment of eye conditions within different levels of deprivation

A reduction in referrals to secondary care services by use of appropriate triage

A reduction in the number of follow ups across all levels of care aligned to CCG policies

Increased patient satisfaction with eye services Services closer to home

Improved communication between specialist clinicians, GP’s and Optometrists

Improved primary care staff knowledge about eye conditions to enable them to manage all appropriate cases

2. Outcomes

2.1 NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurely x

Domain 2 Enhancing quality of life for people with long-term

conditions

Domain 3 Helping people to recover from episodes of ill-health or

following injury

Domain 4 Ensuring people have a positive experience of care

Domain 5 Treating and caring for people in safe environment and

protecting them from avoidable harm

2.2 Local defined outcomes

Increased patient satisfaction

Referral management – patients referred to appropriate service

Cost savings to health economy by reducing referrals to secondary care

Rapid clinical assessment and treatment in the community for a defined set of appropriate clinical conditions

3. Applicable Service Standards

3.1 Aims and objectives of service The aims of this service are as follows:

To provide a consultant led ophthalmology service in the community where patients are seen either by a consultant, ophthalmology registrar, GP with Special interest (GPwSI), optometrist with special interest (OPwSI), Ophthalmic nurse practitioner or Orthoptist – according to NICE, RCOphth, and other relevant clinical guidelines and professional standards

The service will be provided for adults aged 16 years and over, registered with a GP in Buckinghamshire

The Provider will triage all the ophthalmology referrals from Buckinghamshire GPs and direct them to community, secondary care or back to the referrer according to clinical appropriateness

The Provider will give appropriate, timely and clear feedback/advice regarding managing referrals in the patients best interests to the referrers about the triage outcome

Actively managed transfer of clinical management of stable ophthalmic conditions from an acute led secondary care hospital setting to the community setting. The Provider will work closely with secondary care to ensure a smooth transition process without any compromise to patient care. The Provider will manage urgent cases (same day/next day appointment) which will include promoting the service to patients and professionals.

The provider will accept any routine referrals from secondary care which were sent direct to secondary care instead of to the provider.

Improving knowledge of Aylesbury Vale CCG and Chiltern CCG’s health professionals around the management of eye diseases through the development and implementation of education programmes for GPs, optometrists and other practitioners on the agreed clinical pathway.

To actively improve the quality of GP and optometrist referrals such that cases that can be safely managed in primary care are not referred to community or secondary care service

The Provider will update the Ophthalmology referral guidelines regularly to reflect

any change in the national guidelines of good practice, with any amendments approved by Aylesbury Vale CCG and Chiltern CCG.

The service will be delivered in compliance with CCG policies and procedures including low priority/complex cases

To improve the education of patients around self-management of their conditions.

Reduction in waiting times for assessment in line with the 18 week referral to treatment targets.

To improve communication and smooth the patient journey between specialist and primary care

To provide better value for money due to a more cost effective use of resources

To improve patient satisfaction through delivering a quick, accessible and quality service

Improving the management of eye disease through implementation of national and best practice guidelines, e.g. NICE, Care closer to home etc.

To implement the pathway for suspected glaucoma patients. The current pathway will direct all new glaucoma and suspected glaucoma patients to BHT, where they will be assessed. Those patients identified as ‘Stable’ will be transferred to the Community Provider (subject to patient choice). The new pathway is attached at Appendix 1. Additional pathways directing patients to other providers of glaucoma services may be introduced during the contract.

3.2 Service description/care pathway The key elements of the Community Ophthalmology Service will be as follows:

A multidisciplinary community service, led by a Consultant.

The service will only manage adults age16 years and over

The booking into community clinics should be either via electronic referral (NHS e-Referral system) or NHS email. Faxes will still be accepted in the short term but will be phased out.

The referrals will be managed by the Provider’s Referral Management Centre [RMC].

Clinical triage of all the referrals received will be undertaken by an ophthalmology doctor within 2 working days.

The Provider will adhere to the 18-week Referral to Treatment target.

Assessment, investigation and treatment of all patients with eye conditions referenced in section 3.4 below

All onward referrals to secondary care will be sent via the Provider’s RMC, and will be monitored as part of the monthly monitoring regime to be forwarded to the Commissioner Primary care education and pathway management.

The Provider will provide feedback to the referrers following triage of the referrals.

The Provider will provide education to patients and carers to enable self-care and prevention.

The service will undertake appropriate procedures including minor surgery (which can be safely done in the community) to manage the above list of conditions. This service does not replace routine eye examinations, eye tests or prescriptions for spectacles and a sight test will not be performed as part of the assessment or treatment. Where a sight test/routine eye examination is required, the ophthalmic professional will redirect the patient to their usual community optometrist. Redirection for an eye test will usually happen at triage before the patient is offered an assessment appointment. The service will not include tests, examinations or any prescription covered under General Ophthalmic Service (GOS) The Provider confirms that it will provide the following elements:

Full diagnostic service and reporting of results

Patient advice and education in a format that the patient easily understands

Initial treatment, if required, the service will only prescribe items on the Bucks

formulary and against local clinical guidelines including primary care Antibiotic guidelines.

Patients will be given prescriptions for treatment when required. If further treatment will be required within 2 weeks, the provider must provide a prescription for a full course or one month’s supply.

The medication supplied and/or prescribed should be in line with the agreed formulary and the cost is included in the tariff

Follow up management

Consultation report after each appointment containing treatment plan/discharge summary to be sent to the patient’s GP within 4 working days, with a copy to the patient.

The consultation report will be printed; all medication will be prescribed generically unless agreed with the CCG. Clear dosage instructions and duration of treatment or review date must be included together with any actions for the GP clearly documented.

An education programme for primary care clinicians and optometrists

Maintain a full clinical register and record of all patients treated

Collect data for network wide audit and conduct local audits Regular clinical audit will be undertaken by the Provider to ensure all referrals are triaged appropriately and directed to appropriate care as agreed as part of the specification. The period and time of the audit will be mutually agreed by the Commissioner and the Provider and outcomes of audit provided to the Commissioner on request.

3.3 Population covered Geographic coverage/boundaries Aylesbury Vale CCG is group of 19 GP practices covering north and central Buckinghamshire, including Aylesbury, and serves a population of over 200,000. Chiltern CCG is a group of 34 GP practices in Amersham, Wycombe and across South Buckinghamshire, serving a population of over 320,000. Patients must be registered with a GP within either Aylesbury Vale or Chiltern CCG to be seen within the Community Ophthalmology Service. 3.4 Any acceptance and exclusion criteria and thresholds Conditions Included

Follow up of stable primary open angle Glaucoma

Flashers and floaters with more than one week history

Decreased visual acuity

Retinal lesion

Red/Dry eye

Lid lesion

Watery eye

Blurred Vision

Dry AMD

Blepharitis

Eyelash problem

Field Defects

‘New’ suspected glaucoma cases and complex on-going glaucoma patients -these patients will be treated at BHT but should still be referred to the Provider for triage

NHS South, Central and West Commissioning Support Unit’s policy for Restricted Procedures, Treatments and Interventions 2016/17 for NHS Aylesbury Vale CCG and NHS Chiltern CCG must be followed for any referrals for any conditions listed as ‘Procedure that requires prior approval’.

Exclusions

Patients requiring emergency or acute hospital care

Patients where cancer is thought to be the most likely diagnosis – patients with suspected cancer must follow the 2 week wait pathway

Patients under 16

Patients who are not registered with a GP within Buckinghamshire

Diabetic Retinopathy

Flashers and floaters – with less than one week history or continuous flashers.

Cataract surgery

In patient surgery including corneal, intra-ocular and major lid procedures

Wet AMD

Low priority cosmetic procedures

Referrals for any conditions listed as ‘Procedure not routinely funded’ in NHS South, Central and West Commissioning Support Unit’s policy for Restricted Procedures, Treatments and Interventions 2016/17 for NHS Aylesbury Vale CCG and NHS Chiltern CCG

3.5 Interdependence with other services/providers Whole System Relationships Aylesbury Vale and Chiltern CCGs Primary care for referrals into the service Optometrists Local acute trust to provide support for onward referrals to secondary care Relevant Clinical Networks and Screening Programmes Diabetic retinopathy screening service

3.6 Continual service improvement plan The providers will demonstrate ongoing improvements and innovations to service delivery by participating in quality improvement programmes, service redesign, benchmarking and other initiatives with Aylesbury Vale CCG and Chiltern CCG and service users.

The provider will work with patients to foster partnerships and facilitate opportunities for patient involvement and feedback on the service. This will be done in the following ways, where appropriate:

• Patient Survey, questionnaires, focus groups, comment and suggestion Schemes • Work with the PALs service • Complaints • Staff feedback on patients’ experience • Bi-annual action plan addressing issues raised through above activity

4. Service Standards 4.1 Service Model Triage Service All the referrals will be received via the Provider’s RMC

All routine referrals should be reviewed and accepted or rejected within 2 working days of receipt of referral by a specialist

The Provider will use the electronic triage system hosted by SystmOne for clinical triage. Patients can be referred from the community service into a hospital service as per agreed clinical guidelines attached at Appendix 1. All the onward referrals will be sent via the

Provider’s RMC and GPs will be kept informed of their progress and final outcome.

A report of all these referrals will be provided to the CCG’s and/or their Commissioning

Support Service every month.

The Providers will be required to have processes in place to evidence that valid consent, including from those who have communication or language support needs, is obtained by suitably qualified staff for all treatments/procedures. This will also include evidencing that where a patient lacks the mental capacity to give consent, the principles of the Mental Capacity Act 2005 Code of Practice has been adhered to.

Under the new pathway for Glaucoma, (Stable) Glaucoma patients will be referred from BHT following initial consultant review. Assessment/Treatment Service:

The Provider confirms that it will provide the following elements:

Full diagnostic service and reporting of results

Patient advice and education.

Initial treatment, if required, the service will only prescribe items on the Bucks formulary and against local clinical guidelines including primary care Antibiotic guidelines.

Patients will be given prescriptions for treatment when required. If further treatment will be required within 2 weeks, the provider must provide a prescription for a full course or one month’s supply.

The medication supplied and/or prescribed should be in line with the agreed formulary and the cost is included in the tariff.

Follow up management

The consultation report will be printed; all medication will be prescribed generically unless agreed with the CCG. Clear dosage instructions and duration of treatment or review date must be included together with any actions for the GP clearly documented.

An education programme for primary care clinicians and optometrists

Maintain a full clinical register and record of all patients treated

Collect data for network wide audit and conduct local audits Regular clinical audit will be undertaken by the Provider to ensure all referrals are triaged appropriately and directed to appropriate care as agreed as part of the specification. The period and time of the audit will be mutually agreed by the Commissioner and the Provider and outcomes of audit provided to the Commissioner on request. Equipment: The Provider confirms that it will purchase, maintain and replace as necessary all relevant equipment required to provide the service. As a minimum, this is expected to include:

Humphrey visual field machine (or equivalent threshold visual field screener) and printer

Slit lamp

Goldmann Applanation tonometer

Ophthalmoscope

Amsler charts

Epilation equipment

Diagnostic drugs (mydriatics, stains, local anaesthetics, etc.)

Volk lens

Triple mirror

Indirect Ophthalmoscope

Retinoscope Medicines Management

The Provider will ensure that it has the required clinical expertise to procure and stock medication from a formulary agreed with the Commissioner in its clinics.

The Provider will ensure that it has a clinical governance lead who will ensure that all prescribing is within national and locally agreed guidelines and treatment pathways.

Patients will be given routine and urgent prescriptions for treatment when required. Patients requiring a repeat prescription will be able to obtain it from their GPs.

Prescribing decisions and recommendations will only be made by independent prescribers.

The Provider will provide to the Commissioner on request evidence of its ability to ensure compliance with Care Quality Commission (CQC) standards for Management of Medicines on request.

The Provider will provide to the Commissioner on request evidence of compliance with any relevant Safety Alert Broadcast systems, NPSA and MHRA safety alerts and notices.

Prescribers will follow local policies and procedures on the introduction of new, specialist therapies, high cost drugs and transfers of prescribing responsibilities.

Prescribers will follow local policies and procedures on the prescribing of unlicensed specially formulated medication (specials).

The Provider will monitor its prescribing as good practice and provide a report to Aylesbury Vale CCG and Chiltern CCG on request.

The Provider will have in place a formal process for sharing incidents with Aylesbury Vale CCG and Chiltern CCG including documentation with planned action.

The Provider will have a process in place to report Adverse Drug Reactions via Yellow card reporting system in line with local procedures and policies.

The patient pathway should include community pharmacies to address medication adherence, information on prescriptions, counselling on first supply, any other queries.

The Provider will ensure compliance with the legal frameworks governing medicines usage, including: Safe storage and secure handling of medicines Procurement of medicines Prescribing supply and administration Waste Management Legislation Medicines used as any part of the following will be included in the contract tariff in line with PbR guidance: As part of minor surgery As part of diagnostic procedures As part of clinical assessment

4.2 Location of Service Delivery The service will offer flexible access for patients in community locations with the following remit:

The service will be delivered in the community locations from the following sites: Prospect House Surgery, Great Missenden Cressex Medical Centre, High Wycombe Chalfonts and Gerrards Cross Hospital Verney Close Surgery, Buckingham Poplar Grove Surgery, Aylesbury Lincoln House, Princes Risborough

Patients to be able to choose their preferred location of services within the scope of this contract

Any changes to the Location of Service Delivery shall be agreed between the Provider and Commissioner and shall be included within the contract by a formal Contract Variation.

4.3 Days/Hours of Operation The Provider will ensure that the service is open for patient consultations 50 weeks per year between Monday-Friday as a minimum.

Clinics will be provided Monday to Friday and there will be appointments available each of these days. Referral opening times are:

08:30 – 18:00 Monday to Friday although patients are not called before 09:00 as this has

proved to be unpopular

09:00 – 13:00 Saturdays

Clinics are held between office opening hours Monday to Friday 9:00-17:00. Saturday morning clinics are held at Prospect House Surgery 9.00 to 13.00 at least once a month. Clinics may be expanded according to demand and service developments. The Provider will ensure the commissioner is kept informed of developments within the service. The service provider will provide relevant information to patients as to what services to access should a treatment complication arise outside these normal hours. 4.4 Response time and prioritisation Although the service does not treat emergency patients, provision should be made to triage urgent patients each day. The following triage categories are used for booking appointments:

Urgent – Up to 2 working days from triage

Soon - 2 weeks from triage (likely to be flash and floaters)

Routine – 4 weeks from triage

Once the routine referral has been received by RMC, the Provider will contact patients within 2 working days from the date of triage and offer them an appointment within 4 weeks of the referral being received. A choice of appointment days and times will be offered and patients will have the option of booking appointments outside the 4 weeks period for eventualities such as holidays.

Urgent referrals will be triaged within 8 hours of receipt of the referral and an appointment will be offered within 2 working days from triage.

For any onward referral to secondary care, a full statement (the equivalent of a discharge letter to the GP) should be provided and made available to the receiving hospital/service within 4 working days.

The Provider will need to ensure that the achievement of the 18 week referral to treatment target is not compromised.

The Provider will offer a comprehensive range of patient information and will direct patients to other resources such as support groups in order to educate support and empower them to

live with their eye problems. Information will be formatted according to Bucks CCGs’

guidelines, and agreed by Bucks CCGs’ Communications Department and should be made

available in different languages as required (to be identified by the Equality Impact Assessment).

Following the patient’s appointment a report will be sent to the patient and their GP,

including a diagnosis and management plan. This will be sent within 4 working days of the appointment.

All letters to patients and GPs must be typed and will be posted within 4 working days of the appointment and will contain as a minimum:

• Patient’s name, date of birth and NHS number

• Named clinician in charge. • Primary and where appropriate, secondary diagnosis and/ or procedure. • Referral to other service • Diagnostic tests • Full management plan and follow up arrangements and suggestions for further

treatments, which could if necessary be added by the GP should the patient fail to respond to initial therapy.

• A medication update for the patient stating dose, frequency and duration of course of newly prescribed drugs and notification if any medications are stopped.

• Ophthalmology specialist contact number for ease of communication and query. • Where possible copies of clinical protocols/guidelines. • Education • Clearly stated management for GP section

Cancellation

If a patient cancels their appointment with more than 24 hours’ notice they will be offered

another appointment.

If a patient cancels twice on consecutive appointments they are liable to be discharged except in exceptional circumstances. A warning will be given after the first cancellation.

If a patient cannot book a further appointment for valid reasons, the appointment may be left open for a maximum of one month

DNA The service will have a patient appointment reminder system in order to minimise DNA If a patient did not attend their appointment (either new or follow up) they will be contacted to book a new appointment within 2 weeks. If a new appointment is not booked and no contact is made, they will be discharged except in exceptional circumstances.

Once discharged if a patient telephones the department they will be advised to go back to their primary care clinician for another referral if they still require treatment. In exceptional circumstances a patient may be offered another appointment once discharged. 4.5 Referral to other appropriate Services The Provider will refer on to the following services in line with the onward referral protocol

attached as Appendix 2 and via the Provider’s RMC, if appropriate:

• Diagnostics (MRI, CT etc.) • Secondary care clinicians (in line with CCG policies including consultant to

consultant referrals (C2C) and Procedures of Limited Clinical Value) • Back to the patients registered GP

• Any community services relevant to the patients’ needs

Patients referred onwards from this service to secondary care or primary care service should have a full treatment plan that has also been shared with the referring clinician, and includes:

• The results of all tests and preoperative health assessment including scans films and reports

• Reason for referral • Recommended procedure(s) • Full information about appropriate secondary care providers in line with NHS e-

Referral guidance 4.6 Discharge Criteria and Planning Patients will only be discharged from the service when it is clinically appropriate to do so. They will either be discharged back to the care of their own GP, or to secondary care ophthalmology consultant services. In either case, a full report will be prepared and sent to the relevant clinician.

The Provider will inform the patient’s GP by letter every time a patient is seen and if the

patient is discharged from the service or is referred on to another service, within 4 days of consultation.

The discharge letter should contain:

• Patient’s name, date of birth and NHS number

• Named clinician in charge • Primary and where appropriate, secondary diagnosis and/ or procedure • Reason for discharge • Clearly documented action for the GP if required • Referral to other service if required • Diagnostic tests • Full management plan and follow up arrangements and suggestions for further

treatments, which could if necessary be added by the GP should the patient fail to respond to initial therapy.

• A medication update for the patient stating dose, frequency and duration of course of newly prescribed drugs and notification if any medications are stopped

• Ophthalmology specialist contact number for ease of communication and query • Where possible copies of clinical protocols/guidelines

4.6 Training and Support to Referrers The Provider will provide ongoing support and education for referring GPs and optometrists in order to ensure that best management practice is shared. The Provider will develop and regularly update the referral guidelines to ensure the best clinical practice.

The Provider will give appropriate feedback to the referrers about the triage outcome. This will also inform the education and training programme to the referrers.

The Provider and Commissioner will review and update the referral guidelines as and when appropriate.

An email advice service will be provided to support the referrers.

Open educational meetings for all GPs, optometrist, nurses and other community staff to attend will be organised including seminars, lectures and case studies. The required number of these events is developed in conjunction with the Commissioners and is set out and agreed in the Provider education plan. Education will also be provided in the form of newsletters, webinars, YouTube films and an annual report on referrals.

The Provider will offer in-clinic training for GPs, optometrists, including aspects of diagnosis and treatment to improve skills. The number of sessions offered would depend on how many clinics are run by the provider 4.7 Subcontractors Providers may sub-contract parts of the service, but must notify the Commissioners. However, the provider will remain the accountable body with the commissioning body for all monitoring against the service specification.

5. Applicable Service Standards

5.1 Applicable national standards (e.g. NICE) The providers will carry out the service in accordance with best practice in health care and shall comply with the standards and recommendations contained in, issued or referenced as follows:

• Issued by the Health Care including Standards for Better Health • Commissioning toolkit for eye care services, DH publication, 2007 • The Healthcare Act (2006) Part 2 (Prevention and Control of Healthcare Associated

Infections) • The National Institute for Health and Clinical Excellence

• Audit Commission “Quicker Treatment Closer to Home” (2004)

• Any relevant National Service Frameworks • Issued by any relevant professional body • Data Protection Act 1998

5.2 Applicable standards set out in Guidance and/or issued by a competent body

(e.g. Royal Colleges) 5.3 Applicable local standards

5. Applicable quality requirements and CQUIN goals

5.1 Applicable Quality/ Activity Requirements (See Schedule 4 Parts [A-D]) The expected outcomes of the outpatient appointment are:

Undertake diagnostic tests

Discharge the patient back to the GP with advice to the GP on a management plan that can be instituted by primary care

Discharge the patient after assessment, diagnosis and treatment

Collect outcome data regarding patient perception of improvement of their condition

5.2 Applicable CQUIN goals (See Schedule 4 Part [E])

6. Location of Provider Offices

The Provider’s offices are located at: The Practice Group, Rose House, Bell Lane Office Village, Bell Lane, Little Chalfont. Amersham

Buckinghamshire HP6 6FA

Appendix 1

Appendix 2

Community Ophthalmology Service Pathway - Triage

Community Ophthalmology Service Pathway - Appointment

Community Ophthalmology Service Pathway – Post Appointment