Commissioning and Value for Money in Ophthalmology

Joint Clinical Commissioning Guidance for Glaucoma Services

Published by The Royal College of Ophthalmologists and The College of Optometrists (14 February 2013). Dr Charles Alessi, senior adviser to Public Health England and Chairman of the National Association of Primary Care and NHS Clinical Commissioners has welcomed new guidance for commissioners of eye care from the College of Optometrists and the Royal College of Ophthalmologists.

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Times of economic stringency place a particular responsibility on those who commission and provide health care to work together to ensure that the money entrusted by Parliament to the National Health Service is spent as wisely as possible. The value of a service or an intervention is a complex concept which embraces cost, gains in health and well-being, quality and safety of care, prevention of ill-health and maintenance of independence.

Where difficult economic circumstances create an imperative to obtain more value for the same cost or to maintain value while reducing costs, it is necessary to ask fundamental questions about the way in which care is provided. Responsibility for this task should be shared between those who commission health care, those who deliver health care and service users. Unfortunately, such discussions can be fraught because of anxiety about service cuts, rationing of care, hospital closures or job losses, but this is not an adequate reason to duck the responsibility to ask, and answer searching questions.

The task of evaluating and redesigning clinical services may be complex and time-consuming even where there is universal support and good evidence for change. It can sometimes also be difficult to be sure that a specific change will deliver projected benefits without unexpected side-effects.   However, a detailed understanding of the condition(s) being treated and the population to which care is being provided are essential pre-requisites for the successful redesign of clinical services.    

When a quest for value for money is the main stimulus for service redesign, it is a common temptation to treat the task as a damage-limitation exercise by asking questions such as: “Can we reduce the frequency of visits or length of stay without compromising outcomes?”, “Can the same tasks be undertaken by less skilled staff?”, “How many steps can we take out of the pathway without it becoming unsafe?”, “Can we raise the threshold for this intervention without significant loss of well-being?”

A better way to redesign for value is a “bottom up” approach which asks questions such as “If we were providing this service for the first time for this population, what facilities and skills would we need for it to deliver what its users value as simply and safely as possible?” and “How do we ensure that the service reaches those who will clearly benefit?”

It is possible that the two approaches may end up with similar models of service, but the second approach is much more likely to secure the willing engagement of stakeholders and reach conclusions that are supported by good evidence.

Through its Royal Charter, The Royal College of Ophthalmologists is committed to “[the maintenance of] proper standards in the practice of ophthalmology for the benefit of the public” and to “[the promotion of] study and research in ophthalmology and related subjects”. It is working with the Department of Health and with other organisations concerned with eye health to ensure that the quest for value for money in eye care services in difficult economic times is informed by the best available evidence to support high quality care for patients. 

During 2011, the College, as a signatory to the UK Vision Strategy contributed to the development of an electronic resource to provide information for commissioners on ocular health and disease (www.commissioningforeyecare.org.uk). Since July 2011, the College has been working with the College of Optometrists and the NHS RightCare team (led by Sir Muir Gray) to bring together the best available evidence on value and quality of care in a number of specific eye care pathways. Joint Clinical Commissioning Guidance from The College of Optometrists and The Royal College of Ophthalmologists has now been published Glaucoma services.

The following 'commissioning' web pages aim to illustrate how it is possible to be “cost-conscious”, without sacrificing quality of care in ophthalmology using a number of common areas of clinical care as examples. It also brings together a number of College projects, guidance documents and other relevant resources to provide an overview of the evidence on which College opinion and policy on the commissioning of ophthalmology services is based. These pages will undergo regular review and update.

• Cataract
  
• Glaucoma and OHT
  
• Age-Related Macular Degeneration
  
• Diabetic Retinopathy
  
• Oculoplastic surgery
  
• Vision Screening for Children
  
• IT and value for money
  
• Resources