1. 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

2.
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

3. 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.

4. 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

5. System & Assurance Framework for Eye-health ©

6. 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

7. 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

8. 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

9. 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

10. 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

11. SAFE Service Systems©

12. 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

13. 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 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

14. Portfolio of Indicators for Eye Health and Care Pathway : Patient Support
REGION
Portfolio - Broad Indicator PHOF : 4.12iv [ ]
Portfolio Indicator Source: NHS Digital [ ]
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

15. 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 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

16. 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

17. 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?

18. 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

19. Alignment to current health policy
NHS Long Term Plan – January
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

20. 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
CCEHC Frameworks:
Primary Eye Care Services
Community Ophthalmology Services
Low Vision Habilitation & Rehabilitation Services
NHS LTP: Priorities for delivering the NHS LTP for Eye Health