Visionary Briefing (May 2020)
The four aims of this briefing are:
- To provide some key messages for Visionary members supporting people using eye care services during and beyond the pandemic.
- To bring together information on the impact of the pandemic on eye care services and how they are currently being delivered (as of mid-May 2020).
- To explore how services are being adapted for a future where – for a least 12-18 months – COVID-19 and the various mitigation and distancing measures will continue to have a significant impact.
- To provide perspective through the inclusion of 2 case studies, one from a patient and one from a hospital optometrist.
Treatment pathways and patient outcomes for all health conditions have been significantly impacted by the COVID-19 pandemic. Nearly 10% of all outpatient appointments (9 million annually) are for eye clinics. Ophthalmologists perform 6% of all surgery in the UK. The need to protect patients by reducing trips to hospital, combined with a redeployment of most hospital staff to COVID-19 wards and critical care, has led to an overnight re-design of hospital eye services, working with patients, community providers and technology partners.
In relation to hospital eye services, the Royal College of Ophthalmologists issued a statement on the 9th April to confirm that:
- All routine ophthalmic surgery should be postponed in NHS ophthalmology departments, private hospitals and independent treatments centres.
- All face-to-face outpatient activity should be postponed unless patients are at high risk of rapid, significant harm if their appointment is delayed.
- Ophthalmology Accident and Emergency Departments should stay open with consultant level support for both triage decisions and seeing patients.
- Routine diabetic retinopathy screening should be postponed.
At the time of writing (21 May 2020) the situation described above has not changed. However, eye-health professionals from across the pathway are having discussions about re-starting routine treatments such as cataract surgery.
The message is clear from NHS and all professional bodies that despite the suspension of routine services, urgent and emergency care continues to be offered as well as support with conditions such as wet AMD, retinal detachments and uncontrolled glaucoma as described in this podcast from Mike Burdon, president of the Royal College of Ophthalmologists.
For services in Wales and thoughts on what might happen post-COVID-19 listen to this RNIB Connect interview with Wynn Williams (ophthalmologist).
In terms of Community Optometry, many practices have been delivering essential services to patients in very challenging circumstances whilst also delivering emergency and urgent services with no commissioned framework for service delivery.
To address this patient need, in England a Covid-19 Urgent Eyecare Service (CUES) has been developed by the Local Optical Support Unit (LOCSU), NHS England and the Clinical Council for Eye Health Commissioning (CCEHC), endorsed by the College of Optometrists and Royal College of Ophthalmologists.
This single specification service is to be delivered via primary care optical practice, supported by hospital ophthalmology services, commissioned locally by CCGs.
In summary, the service will allow patients to gain prompt access to a remote consultation leading to a care plan for the patient to:
- self-manage their ocular condition (with access to appropriate topical medications where appropriate); or
- be managed by an optical professional with advice, guidance and remote prescribing as necessary; or
- be appropriately referred to hospital ophthalmology services
Scotland’s emergency eye care provision sees new centres established to reduce the need to attend hospital. Read more here.
In Wales a list of optometry practices remaining open and a brief guidance on services during COVID-19 can be found here.
ECLO (Eye Clinic Liaison Officer services):
The majority of ECLO Services are provided by RNIB. Here is a statement from David Clarke, Director of Services at RNIB (14th April 2020.)
‘These are difficult times and a real challenge for services such as ECLO that are typically delivered face to face in eye departments. However, at RNIB we have made the decision, as far as is possible, to not furlough front line staff who are providing blind and partially sighted people with advice, information and support. This has been the case with all our ECLOs across the UK who have been redeployed as home workers using laptops with secure communications. With some eye clinics partially closed the difficulty is sustaining a constant referral route into support. However, we have developed a few initiatives to try to overcome this:
- Ongoing referrals from medical staff – Referrals made directly from eye departments that are still operating into ECLOs working from home. In some cases, the numbers have risen or remained constant. However, as more clinics close these numbers may fall.
- Staying in Touch calls (SIT) – Referrals from enquiries made to our advice centre and directed to ECLOs. We have developed a route from advice line into ECLO that should see a steady flow of ‘ECLO’ type referrals against a triaged ‘most in need’ criteria. This is a service open to anyone contacting our advice line on 0303-123-9999 and hence open to all of your members and their members/beneficiaries.
- Revisiting existing patients who recently had contact – Contacting recent patients (over the last 12 months) whom we know would have been due further treatment or had appointments planned.
- Enhancing self-referral routes 1 – Adding ECLO contact details to social media and websites of CCGs/Ophthalmic units/social care providers
- Enhancing self-referral routes 2 – Adding RNIB Helpline/ECLO contact details to appointment cancellation letters to provide a self-referral route into our services.
Further to this, in the next few weeks RNIB will be contacting stakeholders in the NHS to offer a follow up service to contact patients (from particular risk groups) that have had appointments cancelled. We are not doing this right away because we know how hard the NHS staff are working on the real problems in front of them. However, this initiative will be a move towards supporting recovery.’
We are aware that some Visionary members providing ECLO services are operating in a similar way to those employed by RNIB.
We do not have definitive data on changes to the rates of certification, however several professionals have reported that rates have declined over the last 2 months.
All face to face Low Vision assessments have been cancelled across the UK. Typically, patients are being advised and supported by telephone where they have already had a referral. Equipment already ordered prior to lockdown should still be being delivered, and any training is having to be done by a combination of phone and in some cases by video link. The impact on patients who have need of low Vision services is increased risk of trips and falls, medication errors and being unable to read and use technology. The reduction in the general quality of life at a time when a patient may be living alone will inevitably also lead to a significant increase in emotional distress.
One sight-loss charity, iSight Cornwall have adapted their low vision service in response to COVID-19 to deliver it remotely so that people can still get the information, aids and equipment they need.
For general information on the work of Low Vision services, please click Here.
An up to date position on Rehabilitation services, provided by the Rehabilitation Workers Professional Network (RWPN) can be found here: RWPN update 7th May 2020.
In terms of Habilitation support for children and young people, the situation is similar in that all face to face support has been suspended. Guidedogs have produced some helpful guides such as this one on Helping your visually impaired child learn at home
What’s likely to happen to eye health and sight-loss services in future?
It is now widely accepted that we are likely to be living with COVID-19 for some time to come. Until a viable vaccine is discovered and distributed, many people who have underlying conditions or are in other higher risk categories will continue to need to isolate or at least distance from others. Additionally, health and care staff will need to be protected from anyone who may be carrying the virus.
Those involved in planning, commissioning and delivering eye care services have been discussing what this means for how their services will be delivered and routine services and procedures will gradually be reintroduced where feasible. The approach being taking is that of ‘positive risk’ which considers the relative impact of not treating a patient (avoidable sight-loss, reduction in quality of life for example) against the risk of contracting the virus.
Hospitals, clinics and treatment centres have now had 2 months to adapt to social distancing and risk management and treatments such as cataracts will start to become available again in the coming months in some areas of the UK as soon a guidelines have been drawn-up and approved by The Royal College of Ophthalmologists.
The NHS Open for Business campaign aims to increase the number of people accessing NHS services for non-coronavirus medical issues when they have a medical need or have been instructed to. In England this campaign is being led by Public Health England.
RNIB have responded to the campaign as follows:
‘We feel it is vital that the campaign includes messaging about eye health. Ophthalmology is the largest outpatient speciality and there is evidence that people are not attending for emergency eye care probably because of confusion about where to go, concern about contracting Covid-19 and over burdening NHS staff.
Sight loss charities and the Royal College of Optometrists are sharing information with the public and eye care patients about the importance of seeking helping if people are experiencing rapid changes in their vision, but our reach cannot compare to the NHS Open for Business campaign. Incorporating specific messages about seeking help for urgent and emergency eye care into the NHS Open for Business campaign would be tremendously helpful and help to prevent hundreds of people unnecessarily losing vision.’
Even before COVID-19, many eye health services were struggling to bridge the gap between capacity and demand in the face of the increasing prevalence of sight-threatening diseases such as macular degeneration, glaucoma and diabetic retinopathy. Innovation through patient-partnership, service redesign, and digital health solutions has been accelerated by the disruption of Covid-19.
(We recognise that you may already have done/be doing some or all the below)
- Get the message out to your existing service users and the wider public to contact their GP, any opticians or call NHS111 without delay if they feel they might need urgent eye care.
- Contact your local Optical Committee to find out what arrangements are in place locally for community optometry services in England, visit the Local Optical Support Unit. Further details here.
You can let them know what services your organisation is currently delivering so they can refer people.
- Call your local eye hospital/unit regularly to find out what arrangements they have in place for patients when attending and what services are currently being provided. Things will change from week to week so make sure you have an up to date picture. Some of you have already been approached to support patients in accessing video consultations using the NHS ‘Attend Anywhere’ platform. This could be the starting point for a longer-term relationship that may present commissioning opportunities for sight-loss charities. You can also inform them about the services your organisation is offering to so they can refer patients. This is especially important in units where the has been no ECLO service in place.
- Record the lived-experiences of people who use services during this period and especially those attending community or hospital- based clinics. These can be useful when evaluating, challenging or even praising service providers. It will also serve as an archive of experiences to refer to in future should we face similar pandemics.
Appendix: Case Studies
Case Study 1: The patient perspective
Life in the eye clinic: triage, telemedicine and digital as the new normal
(Elaine Manna, Patient)
I have age-related macular degeneration (AMD). In 2000 I completely lost the sight in my left eye. In 2012, I realised that the same process was starting in my right eye. This time there were new treatments available and my sight was saved. But I—like many others—need ongoing access to monitoring and treatment. When COVID-19 hit I was worried that the hospitals would be completely closed and we would not get the treatment we need. But in fact this crisis has led to patients and professionals working together in new ways.
My hospital—Moorfields Eye Hospital—has put telephone consultations and video calls in place for most patients. For those of us who need to come to the hospital for treatment, we find that it is much quieter than usual. It is a bit surreal to see so few other patients! We were provided with masks and gloves at the entrance of the building and our temperatures were taken. Social distancing was in place with many seats covered in tape to keep everyone safe.
When I saw my consultant, Pearse, our usual smiles were hidden by the face masks. Covid-19 was at the forefront of all our minds. I realised I hadn’t been in a room with anyone for six weeks. To reduce contact time, the whole process was stripped back and faster than usual—short discussion, no retinal scans, straight to my (anti-VEGF) injection treatment as we already knew that my wet AMD was currently active. I was deeply grateful to everyone continuing to provide world-class care in such anxious and demanding times.
When this crisis is over I want there to be “no going back” to the way we did things before. I feel the virus has shown us more clearly what is really important, and what isn’t. We have been forced to innovate together and discover new ways of doing things that can help reduce the number of times patients like me need to come to clinic, and also how to make those clinic visits more efficient and faster.
(Courtesy of the BMJ Opinion 5th May 2020)
Case Study 2: Community Optometrist (David Barker)
As an optometrist working in the community these have been challenging times, with many practices closed completely or at least working under very different conditions. We have also been doing many telephone and video consultations and have been surprised at how many minor eye conditions we can deal with like this. Patients who have been anxious about going to hospital find it reassuring to speak to us as someone they know, and who can provide a link to the hospital eye services. We are all re-thinking our models of care, planning how their practices will look like when we emerge from the crisis.
(Courtesy of ‘The BMJ Opinion’ 5th May 2020)