1. Minor Eye Conditions Service (MECS) Matthew Jinkinson, Optometrist, Chair Stockport LOC Clinical Lead for Minor Eye Conditions Service

2. Outline: Background and pathway Audit of the service Signs and symptoms for MECS signposting Any questions and discussion

3. Background 2014-5 Stockport spend on ophthalmology was around £11.7m with activity of over 56,000 episodes of care. Clinical outcomes excellent and patient experience very positive but access challenging Increasing demand for secondary care eye casualty appointments with some long waits and impact on capacity for other ophthalmology Internal audits by Stockport secondary care found that a proportion of presenting conditions could be safely assessed and treated by primary care optometrists History of primary and secondary care innovation and joint pathway development in Stockport

4. NHS Stockport CCGs commissioned the MECS service from April 2013 with aims: Safe, effective management of suitable eye conditions in the community with faster access than routine referral to hospital Differential diagnosis and appropriate referral when needed for patients with potentially urgent symptoms Release capacity in secondary care Reduce use of GP appointments for minor eye conditions Reduce antibiotic prescribing

5. The service went out as an Any Qualified Provider tender and the contract was awarded to GM Primary Eyecare Ltd. GM Primary Eyecare Ltd is the single optometry federation representing all optical practices within Greater Manchester and is overseen by the 7 Local Optical Committees in Greater Manchester.

6. Stockport MECS Service Providers 23 optometry practices across the Borough of Stockport, all have satisfied the governance requirements as set out in the NHS Standard Contract and all practitioners providing the service have completed appropriate skills validation within the elements required for MECS. The contract and key performance indicators are monitored quarterly by the CCG

7. Inclusion Criteria Loss of vision including transient loss Flashes and floaters Ocular pain Differential diagnosis of red eye Foreign body and emergency contact lens removal (not by the fitting practitioner) Dry eye Blepharitis Epiphora Trichiasis Differential diagnosis of lumps and bumps in the vicinity of the eye Patient reported field defects

8. Exclusion Criteria Patients identified to have severe eye conditions which need hospital attention eg. orbital cellulitis, temporal arteritis Eye problems related to herpes zoster Adult squints, long standing diplopia Removal of suture Patient’s reported symptoms indicate that a sight test is more appropriate than this service Repeat field tests to aid diagnosis following an eye examination Suspected cancers of the eye Dry age related macular degeneration

9. Patient Access into MECS Signposting from GP or GP staff, Pharmacy, out of hours provider, A&E, Eye Department or other Optometrists The Service is on local NHS111 directory of services Self Referral There is a leaflet to give to patients at the point of signposting (an copy has been provided) and it is downloadable from www.stockportmecs.co.uk, this includes all the practice locations and phone numbers for patient to arrange an appointment.www.stockportmecs.co.uk Alternatively you are more than welcome to call one of the practices yourself to ensure patient is seen within the service.

10. Similarly to Eye Casualty, MECS is not a walk in service, triage and appointments are required There is no single point of access for the service, however the first practice contacted should act like a single point of access service to triage and arrange an appointment at one of the providers or signpost elsewhere if more appropriate.

11. Triage process When the patient first contacts the service they will be asked a series of triaging questions including eligibility by ensuring they are registered with a Stockport GP. The triaging questions lead to one of the following results: 1.Urgent (24 hour) appointment required 2.Routine (5 day) appointment required 3.Signpost to self-care / Pharmacy Minor Ailment Service 4.Advised sight test (either NHS or Private dependent of GOS eligibility criteria) 5.Patient unwell requires medical attention (e.g TIA/stroke pathway)

13. Signpost to self-care / Minor Ailments Service (MAS) To expand a little further on this point as this part of the pathway was implemented in December 2015, you should all have received, or will do shortly, a letter from GM Primary Eyecare explaining this. A patient who self-refers to MECS with a mildly red, mildly sticky or itchy eye will be signposted to MAS for treatment and advised to return to MECS if treatment under MAS does not clear symptoms.

14. DNAs As a failsafe for patients who do not attend for their appointment the practice must call the patient to arrange another appointment or discover the reason why the patient DNA and take any appropriate action.

15. Clinical Assessment Patient is assessed by accredited practitioner, advice and treatment given or referral elsewhere if required Along with verbal advice the patient is given written information to ensure nothing is forgotten and treatment plan understood. Patient is issued written order should medications be required. If the practitioner feels the condition need to be followed up then this is arranged. Follow ups for 3 months are included in the tariff for the first appointment.

16. Prescribing Solution Thanks to support from NHS England and Community Pharmacy Greater Manchester we now have a pathway for eligible patients to be dispensed their required medication via the NHS directly from the Pharmacy without the need for a GP to issue an FP10. MedicationFormStrengthQuantity ChloramphenicolEye drops*0.5%10ml ChloramphenicolEye ointment*1%4g Fusidic AcidEye drops1%5g HypromelloseEye drops0.5%10ml Carbomer 980Eye gel0.2%10g Liquid ParaffinEye ointment 3.5 or 5g Antazoline and Xylometazoline (Otrivine-antistin) Eye drops0.5%/0.05 % 10ml Sodium Cromoglycate Eye drops2%10ml/13.5ml Sodium Hyaluronate Preservative Free 0.15%10ml

17. Prescribing If there are medications not on the previous list then the optometrist may then request this from the GP. If the patient will require these medications on a repeat prescription (e.g. following diagnosis of dry eye) then the request for repeat prescription etc will be in the comments box of the MECS report received by the GP practice.

18. Patient experience In year 14-15 - 99.29% of patient were Extremely Likely or Likely to recommend the service to friends or family (response rate 91.78% of patients)

19. Outcomes and Audit In Q1 & Q2 2015 82.94% of patients were treated / managed by the service (including patients that had follow up within the service) Only 12.81% of patients were referred to secondary care. Outcome Total Episodes Q1 and Q2 Total Percentage Treated/Managed by service 157772.14% Follow Up 23610.80% Routine referral to GP (not for onward referral) 934.25% Urgent referral direct to HES 1999.10% Routine referral to ophthalmology via GP 813.71% Grand Total 2186100.00%

20. Outcomes and Audit Attendance at Eye Casualty clinic for Stockport patients has almost flat-lined (increase of 0.4%) with little year on year increase since the service began, compared with other CCG areas where there is an increase in attendance of 26% over 2 years. However there is more that can be done, an audit of eye casualty attendance during April 2015 117 additional patients could have been managed within MECS. The majority of those patients that could have been managed within MECS originated in referrals from GP and A&E.

21. Audit Conclusion from the audit by NHSSFT ophthalmology recommends that all patients meeting inclusion criteria are initially referred to MECS for assessment rather than being referred to eye casualty. Training has taken place with A&E staff to increase awareness of MECS and ensure that signposting to MECS is an outcome from initial nurse triage in A &E. Collaborative working between optometry and pharmacy is increasing awareness amongst Pharmacists to signpost to MECS rather than GP for eye related conditions and for optometry to signpost to MAS.

22. What signs and symptom groups would you look out for to refer to MECS? Red Eye, with or without pain Sticky discharge, with or without pain.

23. Itch, red, inflamed eye. Other words patient may use that could be referred to MECS: watery, gritty, dry, lump on lid, irritation, sensitive to bright light, weepy, smarting, tacky, etc

24. History of Foreign Body in eye (except chemical injury which is best directed straight to A&E along with eye wash out)

25. Patient reporting new floaters in vision: ‘black spot’‘hair in front of eye’ ‘seeing fly in front of vision’ ‘Curtain/ veil across vision’ Patient may also report flashing lights in vision: ‘Lightening strike’‘Spark of light seen at edge of vision’ becareful that they are short lasting and not migraine aura which typically last for a period of time (~20mins)

26. Loss of vision: Patients reporting recent onset loss of vision, whether that be distortion, loss of peripheral vision (but still feeling well – suspect stroke assessment with GP if generally unwell), central or peripheral haze. Patients who have noted a gradual change – longer than 3 months should be recommended to book a sight test. Double vision – ‘I am getting double of images on TV’, ‘I am seeing two when I know there is only one’ Refer to MECS if GH doesn’t suggest possible stroke.

27. Could anything improve the service?

28. Thanks for listening. Any questions? Matthew Jinkinson, matthew.jinkinson@nhs.net