System & Assurance Framework for Eye-health www.cchec.org.uk Parul Desai Chair, Clinical Council for Eye Health Commissioning Consultant, Moorfields Eye Hospital, London Vision UK: Expert Committee Meeting : ADASS Physical Disabilities, Sensory Impairment and HIV/AIDS Network 18 October 2019

www.ccehc.org.uk An independent advisory body providing evidence-based national clinical leadership, advice and guidance to: policy makers in health, social care and public health those commissioning and providing eye health services Memorandum of Understanding with NHS England Represents the major clinical professions, social care, charity and voluntary organisations within the eye health and care sector Currently chaired by Faculty of Public Health

CCEHC Priorities for eye health services System Development A systems and population-based approach for the planning, commissioning and provision of eye health services CCEHC Priorities for eye health services System Development Service improvement Enabling Infrastructure: health information; digitisation & IT connectivity * Prevention and inequalities Workforce* through the collaborative efforts of commissioners, service providers and clinicians.

at scale – over larger geographies & populations System Development Why: Fragmented commissioning and Fragmented provision Integrated Care Systems (ICSs) are NHS England’s preferred model for healthcare planning, commissioning & provision; to be established by 2021 at scale – over larger geographies & populations The Ask: Eye health should be included in the planning & development of ICSs and their operating infra-structure for networked care, governance, quality assurance and health information How: Implement SAFE : System and Assurance Framework for Eye-health for strategic planning, commissioning & provision of service systems to deliver the system based transformational changes necessary and required by the LTP

System & Assurance Framework for Eye-health © www.ccehc.org.uk

System & Assurance Framework for Eye-health: Attributes SAFE is what good eye health service system looks like and what is expected of it SAFE A framework for strategic planning, commissioning and provision of eye health services, at scale SAFE Service System delivers a whole pathway of care providing a range & continuum of services based on risk stratification of a patient’s condition & the competencies of the professionals providing care; the delivery of which may involve contracting of multiple providers & settings SAFE is Operational at ICS, STP, or equivalent level SAFE Resources (evidence-based) for : “what needs to happen” - NICE or NICE accredited guidelines & NICE TAs “making it happen”- Requirements for service provision, clinical practice, education and training provided by the professional bodies How services are organised and delivered - CCEHC Frameworks for Primary Eye Care, Community Ophthalmology, and Low Vision, Hab/Rehab Services; and standards for Hospital Eye Services from the RCOphth Metrics for review & monitoring of services and the quality of the commissioning process

SAFE Service Systems SAFE is what good eye health service system looks like & what is expected of it SAFE Service Systems for: SAFE Cataract SAFE Glaucoma SAFE Age Related Macular Degeneration SAFE Emergency & Urgent Eye Care SAFE Applicable to - Any condition; Anywhere (UK); Any Level SAFE Implementation guide www.ccehc.org.uk

Service Improvement Why: Silo services .…. confusion, delays, capacity pressures Coordinated, integrated services & support for patients What goes on in the Hospital Eye Service (HES) is understood What could go (in and out of HES)- which is where change is needed - is inconsistently defined and often misunderstood The Ask: Redesign & commissioning of services To allow specialist OP care (Hospital Eye Service) to be prioritised on diagnosis and active management & treatment, and care for high risk and complex conditions How: The CCEHC Frameworks To commission & provide services that are organised and delivered based on - clinical risk of a patient’s condition competencies of the health care professional providing care

CCEHC Frameworks © SAFE Tools for Service Organisation & Delivery Provide the architecture for how services delivering the system pathway are organised, provided and monitored Define the Scope of the types of services required to redesign patient flows in, around and out of, traditional out-patient settings- Primary Eye Care Services Community Eye Services Low Vision Habilitation and Rehabilitation Services Provide clarity on – the relationship between services across the whole system pathway (primary eye, community eye and secondary eye care) the types of services being delivered & their expected benefits governance requirements – within services & at service boundaries Facilitate service coordination and integration to avoid duplication that often currently exists

CCEHC Frameworks SAFE Tools for Service Organisation & Delivery Commissioner Service provided Impact Primary Care Services Local CCG or equivalent First Contact Care Enhanced decision-making services prior to referral for specialist ophthalmic opinion Better Referral Decisions Improve Quality of Referrals Community Eye Services Management & Monitoring of Low risk acute and long term conditions Release Capacity from HES Improve Patient Flows Low Vision, Habilitation, Rehabilitation Services Social Services Patient Support Certification Emotional Functional /Environment Independence Inclusion Mental health

SAFE Service Systems©

Enabling Infrastructure- Health Information Why: reduce unwarranted service variations - availability & outcomes The Ask: Include eye health in the processes for the systematic review and monitoring of health services, being established within ICSs How: Adopt the Portfolio of Indicators for Eye Health and Care Implement SAFE service systems

SAFE Metrics for service monitoring Portfolio of Indicators for Eye Health & Care populations at risk of poor eye health ……….. needs assessment access, availability and outcomes of key eye health & care services Portfolio Safety Indicator 11 - adopted by NICE Quality Standards & ECTP “% Hospital appointments that occur within 25% of their intended follow up period Quality Standards for Commissioning series of statements focusing on the quality of the commissioning process ensuring that structures and process are in place for safe & effective service provision

Portfolio of Indicators for Eye Health and Care Pathway : Patient Support REGION Portfolio - Broad Indicator PHOF : 4.12iv [2016-17] Portfolio Indicator - 18 Source: NHS Digital [2016-17] CERTIFICATION of Vision Impairment (CVI) NEW All-Cause (All Ages) REGISTERED Blind & Partially Sighted Persons ( All Ages) Count (N) Crude Rate per 100,000 NEW (N) ALL on Register (N) North West 3370 46.7 2485 44,115 North East 1443 54.7 1200 14,620 York & Humber 45.8 3100 31030 West Midlands 2083 35.9 2115 29725 East Midlands 1821 38.5 1445 24075 East England 2390 39 2010 29585 South West 2789 50.6 2405 34195 South East 3560 39.4 3690 43900 London 2639 30 2155 39230 ENGLAND 23453 42.4 20605 290,475

Example Portfolio Output - ICS PATHWAY INDICATOR Need Broad Population Indicators - selected from PHOF Screening 2i % Uptake of DESP Screening of ALL eligible >=12yr   2ii % uptake of DESP Screening in CYP aged 12-24 yr Presentation / Referral 4i Number (and %) of CCGs procuring a Glaucoma Referral Filtering Pathway 5 Cataract Referral Pathway commissioned Diagnosis & Treatment 7 and 8 Visual Acuity Outcomes of High Volume Activity: Anti-VEGF treatment and Cataract Surgery 9 % of Urgent DESP Referrals seen within recommended interval Review & Monitoring 11 % Hospital appointments booked within 25% of their intended follow up period Patient Support 16 ECLO) Service commissioned & provided. 17 LVHR Services commissioned & provided PHOF 4.12 iv New Certification of Vision Impairment (All Ages) - N and Crude Rate per 100,000 18 Registered Bind & Partially Sighted persons: ALL registered & New at time of reporting

Patient Support Services : What’s in the Grey Box? Availability & Core Service Offer for - Low Vision Habilitation Rehabilitation Pathways for access to services Workforce competency standards Governance – service service boundaries Outcomes – availability, timeliness, effectiveness Variations Gaps

The Ask Consistency What else could the CCEHC do to support you? for the “core” service offer workforce competencies service governance service outcomes What else could the CCEHC do to support you?

Key messages for Transformational Change Systems delivering the whole pathway across health & care – at Scale redistribution of how services are organised and delivered within the area redistribution of patient flows between service providers within the area Organisation & Delivery of Services for the Service System Pathway Risk stratification of a patient’s condition & competencies of the health professional providing care Consistent service terminology, scope & standards, Collective governance and understanding of service inter-relationships Designed to improve patient flows along the system pathway Systematic monitoring of service quality & safety to make sense of variations & inform appropriate action

Alignment to current health policy NHS Long Term Plan – January 2019 https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ Sets out the priorities for healthcare over the next ten years and how the NHS funding settlement will be used LTP Chapter 1: Integrated Care Systems (ICSs) by 2021 SAFE LTP Chapter 1 and 3: Redesign Out-Patient (OP) services Provide pro-active, coordinated, integrated services and support to patients CCEHC Frameworks LTP Chapters 3 and 6: The NHS will reduce unjustified variation in performance Portfolio of Indicators for Eye Health and Care SAFE Metrics

CCEHC Sources www.ccehc.org.uk SAFE – Systems and Assurance Framework for Eye-health SAFE Service Systems : Cataract Glaucoma Age Related Macular Degeneration Emergency & Urgent Eye Care SAFE Metrics: Portfolio of Indicators for Eye Health & Care Quality Standards for Commissioning SAFE Implementation https://www.college-optometrists.org/the-college/ccehc/safe-systems-assurance-framework-for-eye-health.html CCEHC Frameworks: Primary Eye Care Services https://www.college-optometrists.org/uploads/assets/uploaded/48bcf894-303a-4118-b8b82179f4773826.pdf Community Ophthalmology Services https://www.college-optometrists.org/uploads/assets/uploaded/24a46a81-41d9-4485-a0f1b26b514e08e9.pdf Low Vision Habilitation & Rehabilitation Services https://www.college-optometrists.org/uploads/assets/uploaded/74261e4b-b5ca-427a-b24cc3f7690929db.pdf NHS LTP: Priorities for delivering the NHS LTP for Eye Health https://www.college-optometrists.org/the-college/ccehc/planning-commissioning.html