Ophthalmology triage service reduces inappropriate referrals

Dr John Bibby describes how his PCT has helped to reduce long waiting times for the local hospital°s ophthalmology outpatient clinic

An important aim of the NHS Plan is to reduce waiting list times.¹ While systematic reviews of interventions to build capacity have found little robust evidence,² there are many interventions at different points in the patient journey that are being employed by PCTs to try to improve the balance between capacity and demand.³

These interventions can occur at any point in the patient journey (see Figure 1, below).

Figure 1: Improving access to secondary care: the patient journey and opportunities for intervention

Shipley Ophthalmic Assessment Project

The Shipley Ophthalmic Assessment Project (SOAP) triage service was developed in 1994 as one solution to the problem of a long waiting list for ophthalmology outpatient appointments at the local Bradford Hospitals Trust.⁴ These long waiting times resulted from:

Increasing numbers of GP referrals
Uncertainty of referral urgency
Poor quality GP referral letters

A core skill required of GPs is to be able to diagnose normality and to know when it is necessary to refer a patient for a specialist opinion.⁵ However, many GPs feel unsure about ophthalmology problems and as a result many referrals are considered inappropriate by consultants.

Tackling the problem

The senior ophthalmology consultant and I decided to look at novel ways of addressing the problem. We decided to develop a locality based triage system, run by a highly trained optometrist.

In Bradford we are fortunate in having a University Department of Optometry and an optometry PhD who worked part time in the University and part time in the hospital and who had time available to carry out a weekly triage clinic in the community.

The senior consultant, the optometrist and I developed protocols for the following common eye conditions:

Cataracts
Raised intraocular pressure
Floaters and flashers
Age-related macular degeneration.

Each of these conditions was subdivided into three groups according to severity of symptoms:

No referral necessary
Routine referral
Immediate referral.

Using these protocols and the equipment listed below, a service was set up for the locality in an extension block of the Windhill Green Medical Centre, where several outreach services were already located. The extension block staff provided the administrative support.

Instead of GPs referring directly to the hospital outpatient clinic, where the wait to be seen was more than 6 months, patients were referred to the SOAP triage service where the waiting time has remained less than 2 weeks.

Before the SOAP project was developed, the patient pathway was usually optician - GP - hospital consultant. Now it is optician - GP - SOAP triage - hospital consultant. This may seem a retrograde move because an extra step is involved. However, only 36% of the patients seen by the triage service have needed to be referred to the consultant. The remaining 64% have either not needed referral or have been managed by optician review.

How cost effective is the service?

The initial outlay for equipment in 1994 was £15000, which came from fund-holding savings. The equipment consisted of:

Refractive equipment (Trial case, Trial frame, Snellen chart)
Pelli-Robson contrast sensitivity chart
Slit lamp
Applanation tonometer
Indirect ophthalmoscope
Visual field analyser
Amsler chart
Gonioscope.

The optometrist is paid a sessional rate, and there are overheads for the rooms used and depreciation on the equipment. The resultant cost for a triage appointment is 50% of a hospital outpatient appointment. Some 64% of patients need the triage appointment alone, but the remaining 36% need both a triage appointment and a hospital appointment. The overall saving is therefore 30%.

Triage services have a break-even point, which depends on the number of patients who need both triage and hospital appointments and the cost of depreciation of the equipment. The more patients there are who need both appointments and the greater the capital outlay, the less cost effective a triage system will be.

For the SOAP service the break-even point is reached if more than 50% of patients are filtered out. Our filter-out rate has remained at around 60-64% and so the service has remained cost effective for the past 8 years.

Initially the service was available only to a few local practices and just 934 patients were seen in the first 5 years. However, the service is now available to all 13 practices in the North Bradford PCT - a total of 92,000 patients. The number of sessions has increased from one to two per week and the service currently provides 700 appointments per year.

The types of visual problems seen in the triage service are shown in Box (1below).

Box 1: Visual problems seen by the SOAP triage service
Blurred/reduced vision/visual disturbance	24%
Raised intraocular pressure	23%
Cataract	19%
Visual defect	10%
Flashers/floaters	12%
Ocular irritation	5%
Miscellaneous	7%

Box 2: Findings of the patient questionnaire (average scores)
Getting to the clinic	3.2
The waiting area	3.5
The waiting time	3.6
The explanation given	3.7
The overall experience	3.8
Scores: 1 = bad, 2 = poor, 3 = good, 4 = excellent

Box 3: Findings of the GP questionnaire
	Yes	No
Was SOAP helpful?	97%	3%
Did it alter your management?	75%	25%
Overall the service was:
Good	75%
Excellent	5%

Measuring the success of the service

One possible criticism of the service is that patients with ophthalmology problems are not being referred to hospital when they should have been. We addressed this issue by reviewing the GP records of the first 100 patients who were seen by the service and deemed not to need hospital referral.

These showed that in the 5 years since the start of the service only two of the first 100 patients not thought to need hospital referral had eventually been seen in hospital. Both were cases of cataracts that had deteriorated in the intervening years. These findings supported the high level of reliability of the triage service.

The first 100 patients to be seen were also asked to fill in a questionnaire that asked them to rate various aspects of the service on a scale of 1 to 4. Eighty-two responded and the results are shown in Box 2 (above). The 23 referring GPs were also asked for their opinions of the service (Box 3 above).

The SOAP service has proved beneficial to patients, reduced waiting times and proved cost effective. The break-even point means that the service must be monitored to ensure that the percentage of unnecessary referrals filtered out stays at more than 50%.

If all referrals were appropriate the triage service would not be needed, and this gives rise to the question of whether or not it would be better to educate local opticians and GPs in the ´correct° referral practice. While this could have been attempted, it was considered more effective to train a single optometrist in triage skills than to reeducate 70 GPs and 20 optometrists.

A round table discussion involving local GPs and optometrists considered why 64% of referrals were unnecessary. The contributing factors were felt to be:

GPs felt unsure about making an ophthalmology diagnosis. Even when they felt a referral was not required, if the local optician had told the patient to visit the GP to arrange a referral, GPs found it hard to convince the patient that referral was unnecessary.
Opticians have a legal obligation to inform GPs of abnormalities but not to diagnose. To protect themselves, they were over-cautious in recommending referral to hospital.
Failure of opticians to measure visual field defects and/or intraocular pressure.
Poor interpretation of results.
Opticians° inexperience.
Use of optometry clinical assistants, who may be less experienced or committed.

Perceived pressure on opticians not to perform full examinations.

The future for ophthalmology triage

Our triage service was awarded Beacon status in the first wave in 1999, and after 8 years it continues to develop. There are now two trained optometrists each providing one session per week.

The waiting list has remained at less than 2 weeks; however, those patients (36%) who are referred to the hospital are still not seen as quickly as we had expected. This is because the other three PCTs in Bradford have not yet developed a comparable triage service, so the benefit of 64% fewer referrals is not seen in a shorter waiting time for North Bradford PCT°s patients because the hospital appointments released are filled by patients from the other PCTs.

The benefit will only be felt by our PCT when all the local PCTs use a similar system, or when we are able to move to an outpatient system with appointments allocated per PCT.

The locality triage system could be applied to many other specialties particularly those that do not have high capital equipment costs and those where there is a great variation in GP referral rate. In North Bradford we have already extended this system to dermatology and orthopaedic clinics with considerable success.

References

Department of Health. The NHS Plan. London: DoH, 2000.
Grimshaw J et al. Systematic review of interventions to improve outpatient referrals from primary to secondary care. London: Department of Health, 2000.
Eve R, Gerrish K, Mares et al. More than one way to skin a cat. Building capacity in primary care to reduce pressure on hospitals. Sheffield: The Centre for Innovation in Primary Care, 2001.
Hill L. North Bradford PCG waiting list and activity management strategy. North Bradford PCG, 2000.

Mathers N, Hodgkin P. The gatekeeper and the wizard: a fairy tale. Br Med J 1989; 298: 172-4.