Ophthalmology summit: 23 November 2022

Following a period of declining ophthalmology performance and an increasing number of patients waiting longer than their clinical review date for their appointments, a ministerial summit was held to discuss what the system needs to do collectively and individually in response to this.

Health boards were asked to present their plans to improve performance and recover their ophthalmology services against a number of key themes including their actions to address the backlog, meet the R1 target whilst transforming their services to become sustainable. This includes regional plans. The three themes for discussion were:

• cataracts
• glaucoma
• medical retina

Andrew Sallows, Director for Planned Care Improvement and Recovery opened the summit and clearly set out the rational for the summit including the desired outcomes.

He described a service that is struggling to recover from the pandemic with waiting lists that are growing and increasing risk of patients suffering sight loss or irreversible harm.

The service cannot continue doing more of the same, there has to be change in order to bring the system into balance again. Health boards have been tasked to identify and implement new ways of working. This needs to include working smarter to clear the backlog of patients through increasing virtual activity, utilising staff to work at the top of their licence and an increased use of community services. Where possible, all health boards should be looking to regionalise services and pool specialised staff and equipment.

The national plan for Transforming Planned Care and Recovering Waiting Times 2022 to 2025 published last April sets out a very clear aspiration for recovery. It is very clear about the actions needed to be taken now to increase activity. Our approach for recovery focuses on removing the backlog of those who are waiting too long for their first outpatient appointment, follow up appointment and treatment, as well as working towards a more sustainable approach utilising transformed models of care, further engagement utilising the community sector and clinically led, best practice ways of working which will deliver more robust, efficient, safe and timely pathways and services.

In September 2022, the Minister agreed in principle the terms of service of a new optometry contract and its associated financial costs which will enable real improvements for patients. With this and the investment in ophthalmology already made there is an expectation to increase capacity and reduce waiting times.

The delivery unit presented a detailed analysis of the current waiting lists. In September 2022, 47.5% of patients classed as R1 were waiting within their target review date against a target of 95%. 113,049 patients are waiting longer than their clinically agreed review date. Of these, 79,070 (69.9%) are classed as Health Risk Factor (HRF) R1. A total of 134,025 open patient pathways, where the patient was assessed as Health Risk Factor R1, were waiting for an outpatient appointment.

At an all-Wales level the volume of patients being referred has returned to pre-pandemic levels however this is not consistent across all health boards with some significantly above pre-pandemic levels (Aneurin Bevan, Cwm Taf Morgannwg and Powys) while others remain below (Hywel Dda, Betsi Cadwaladr, and Cardiff and Vale). However, overall outpatient activity levels remain below pre-pandemic levels.

Again there is variation across health boards with Hywel Dda, Cwm Taf Morgannwg and Cardiff and Vale struggling to get back to core levels. While this scenario remains, the waiting list will continue to grow. There is a necessity to understand what is driving this variation and learn from those health boards that have increased their activity levels.

Even when taking clinical prioritisation into consideration there is also a significant variation in the numbers being treated in turn across health boards with Aneurin Bevan, Betsi Cadwaladr and Cardiff and Vale treating around 30% from their over 52 week waiting cohort. None of the health boards will achieve the Ministerial ambition of no patients waiting more than 52 weeks for an outpatient appointment by end of March 2023.

The Minister for Health and Social Services in her address was clear about her expectations. She noted that  the challenges faced by ophthalmic services are significant and concerning and reflected that health boards are struggling to see and treat patients in a timely manner and asked what more can be done to increase the number of patients being seen. She was concerned about the increases in harm being noted due to these long waits and also highlighted that ophthalmology is likely to be the worst performing specialty against the  over 52 week new outpatient ambition in December. The numbers on the total ophthalmology waiting list are now in excess of 90,000 and have grown by over 12,000 since the Pyott review was concluded in November 2021. It is estimated that by the end of December there will be over 4,800 patients waiting over 104 weeks for their first outpatient appointment and more than 19,500 waiting over 52 weeks. The minister highlighted that considerable improvements were being noted at Aneurin Bevan, Hywel Dda and Cardiff and Vale University Health Boards and asked if health boards could work collectively to learn from others.

The Minister concluded by asking health boards to consider:

• How can the number of cataract patients per list be increased?
• What can be done to regionalise services? 
• What services could be supported by community optometry and how can nurses, optometrists and other essential health care professionals be utilised more effectively?
• What does a sustainable eye-care service look like and what needs to happen at a national, regional, community and local level to deliver this?

Gwyn Williams, the National Clinical Lead for ophthalmology and the Llywdd of the Royal College of Ophthalmology set out the vision for eye care in Wales. Reflecting the recommendations as set out by the Pyott report which had been commissioned by the planned care programme. The Pyott report highlights how our services need to develop to provide the best possible results for patients as well as enabling us to redefine eye care in Wales. Gwyn pointed to the excellent examples of good practice in Wales as well as ten key recommendations to provide a sustainable and future proof ophthalmic service. Gwyn’s message was clear – we need to act now.

Health boards have been asked for plans incorporating the recommendations of the Pyott report however, these have been slow in being implemented and as yet have not matured enough to release tangible benefits to the service and patients. As a result, performance continues to remain unsatisfactory.

Declan Flanagan, Consultant Ophthalmologists set out some actions that all health boards could do immediately to improve productivity and efficiency. He highlighted the guidance issued by the Royal College of Ophthalmology and GIRFT on how to deliver high volume routine cataract surgery. The guidance is clear in that standard lists should deliver at least eight procedures a list. At present health board are delivering between 3-6. It was felt that this variation in the number of cataract procedures per list across health boards is unacceptable. Clearly there are efficiencies within the service to bring activity to comparable levels with the rest of the UK.

There was a clinician led debate about how best the service could be supported to recover. The discussion included the following:

• Wales has the least number of ophthalmologists per capita compared with the rest of the UK with serious issues of recruitment and retention.
• Large portions of the estate are unfit for purpose and are therefore limiting activity.
• Changes that can be made without waiting for capital investment in new centres.
• Relocating services within existing estates, pooling resources on a regional basis can and should be done now.
• Partnership working with optometric services in the community and the training and upskilling opportunities would aid in recruitment and retention are all things we are able to act upon now.
• Health boards should consider the GIRFT principles.
• Improve referral and discharge processes, use of mutual aid and regional working.
• Ensure that patients are seen efficiently at the appropriate time and by the most appropriate professional – use of high street optometrists.
• Deliver routine cataract surgery in a maximum of 30 minutes of theatre time, through streamlining turnaround processes. This often requires staff to facilitate faster turnaround and does not apply to more complex cases.
• Use primary care optometry services to review patients who have had uncomplicated /routine cataract surgery. 
• Implement the recommendations from the Pyott review that can be delivered now with pace.
• Access to accurate and real time informatics should be at the forefront of managing ophthalmic services.
• Consideration should be given to the expansion of specialist corneal services.
• Consideration should be given to how and when a service for cross-linking should be developed to include appropriate education of community optometrists.
• Anaesthetic cover in theatre – a streamlined cataract pathway with agreed anaesthesiology cover should be recommended for a sustainable cataract service.
• Increase the number of independent prescribing and Ophthalmic Diagnostic Treatment Centres (ODTCs).

The discussion concluded that given the difficult financial climate we are currently in we cannot rely on more funding to deliver the solutions. The service needs to change and that change needs to happen now. The Pyott recommendations have given us a blueprint of what needs to change, and it is our duty to do this as quickly as possible.

The Minister for Health and Social Services was clear about her expectations on the service:

We cannot do more of the same and expect different results. We must look to work differently, making use of the technology available to us and working together across health board boundaries and regions. Working differently includes looking at ways to maximise the resources we already have and where possible. We need to make better use of sharing our successes and learning from each other.

The following expectations and actions were set:

• Performance against the R1 measure to be at 60% by the end of this financial year.
• No patients waiting over 52 weeks for their first outpatient appointment by the end of December.
• No patient waiting over 104 weeks for treatment by the end of March.
• Where possible health boards will look to increase their cataract productivity and efficiency.
• Ophthalmology teams across Wales agreed to develop a present a proposal that would accelerate regional delivery.
• Implement the GiRFT and RCOphth national guidelines.
• Health boards to plan and determine the ophthalmology workforce they will need to meet forecast demand.
• Health boards to continue to develop their business intelligence to improve their grip and control over services.
• Health boards and DHCW to develop a credible implementation plan and timeline for Open Eyes which will be agreed and overseen by the planned care improvement and recovery team.
• Health boards to maintain good communication and support services for all patients.
• The planned care improvement and recovery team to share good practice examples across all health boards and facilitate national learning and implementation.
• Health boards to work together on a regional and national basis to support the workforce shortages and capacity gaps at a local level.
• Health Boards to determine deliverable regional solutions as a matter of urgency, progress will be overseen by the planned care improvement and recovery team who will co-ordinate any necessary national initiatives.
• Commission an imperative clinically led plan for ophthalmic services across NHS Wales that builds on the Pyott report which will determine, detail and describe how the current system should transition and transform locally, regionally and nationally in a phased manner to bring about short, medium and long-term improvements and ensure a sustainable future model.