The Royal College of Ophthalmologists last week hosted a webinar with King’s Mill Hospital Ophthalmology Department and NHS England’s Outpatient Recovery and Transformation team to explore how patient-initiated follow-up (PIFU) can be successfully implemented in ophthalmology. The session, held following the publication of the King’s Mill PIFU case study and attended by almost 100 people from a range of professions, saw an expert panel deliver presentations on the role PIFU can play in increasing capacity as part of a wider set of actions, followed by an audience Q&A.
The challenges facing outpatient services
RCOphth’s Honorary Secretary Mel Hingorani opened the webinar by outlining the strain ophthalmology services are under across England. She highlighted statistics from the RCOphth workforce census 2022 showing less than a quarter of ophthalmology units have enough consultants and specialty and associate specialist (SAS) doctors to meet patient demand and the majority of units finding it harder to recruit and retain staff compared to a year ago.
These capacity challenges compound ophthalmology outpatient pressures, with the vast majority of eye units (81%) becoming more concerned about the impact outpatient backlogs are having on their ability to deliver care, 63% anticipating it will take at least a year to clear their outpatient backlogs and 26% expecting it to take over three years to clear.
Alongside the capacity pressures exerted by workforce shortages, current models of outpatient delivery across the NHS, including ophthalmology, can be improved. Sarah Kemp, Senior Project Manager for Outpatient Recovery and Transformation at NHS England highlighted that 20% of outpatient appointments are cancelled or classified as ‘did not attends’ and 57% of outpatient clinics finish late every week. NHSE also highlight that patients themselves are ready for change, with 68% indicating their comfort with remote consultations, avoiding the average 48-minute travel time between a patient’s home and hospital.
What solutions are there to increase capacity?
A range of solutions are needed to increase capacity to meet current demand, tackle backlogs and meet future patient need.
Hingorani highlighting that an expansion of the workforce is the most important long-term solution to meeting patient need.
She also emphasised the need for better integration between primary care optometry and secondary eye care services. While the College continues to campaign for and develop these longer-term solutions, Hingorani also pointed to shorter term solutions that could be implemented quickly. These include greater use of risk stratification of outpatient appointments, investments in outpatient space in eye units by NHS organisations, and of course patient-initiated follow-up.
Kemp pointed to the significant potential PIFU has in ophthalmology, highlighting that NHS England is seeing increasing uptake of formalised PIFU in a range of services, from a 1.29% PIFU utilisation rate in April 2022 to 2.31% in March 2023. She explained that while PIFU utilisation is also increasing in ophthalmology – from 0.27% in April 2022 to 0.67% in March 2023 – there was still significant room for growth in its use across the specialty.
How can PIFU deliver increased capacity as part of a wider set of reforms?
Vineeta Munshi, Consultant Ophthalmic Surgeon, Delicia Jayakumar, Specialty Doctor in Ophthalmology, and Sharon Bentley, Operations Manager for Ophthalmology at King’s Mill Hospital – part of the Sherwood Forest NHS Trust – delivered a presentation on their work to expand PIFU in general ophthalmology.
The ophthalmology service at Sherwood Forest is split between two sites at Kings Mill Hospital and Newark Hospital, and during the development of PIFU consisted of:
- 5 full-time consultants
- 1 part time consultant
- 4 locums
- 5 SAS doctors
- 2 trainees.
Jayakumar explained how delivering PIFU – as part of a wider 5-strand Outpatient Innovation Programme – allowed the department to overcome a range of challenges including workforce constraints, a lack of clinic space and COVID-related infection control measures to save appointments and reduce backlogs.
The King’s Mill expanded PIFU model is underpinned by a set of conditions that clinicians decided were clinically appropriate to place on PIFU pathways. A shared decision-making conversation is held between the patient and clinician about their suitability for PIFU and, if agreed, the patient is informed about next steps by the clinician using a ‘Patient Communication Script’. The patient is placed onto PIFU in a purpose-built Patient Administration System, where the administrative staff can collate a PIFU-specific dashboard to monitor the date patients were put onto their pathway, the date they request an appointment (the ‘activation date’), and the time between activating and follow-up appointment.
Jayakumar explained that her department was able to reduce overdue referrals by 80% compared to 2020 levels, with the elimination of referrals more overdue than 13 weeks. The unit also saved 1,957 outpatient appointments in total through PIFU alone, averaging around 104 appointments each month, allowing these appointments to be repurposed for more complex cases while also saving patient time and helping to meet NHS England’s Priorities and Operational Planning Guidance 2022/23 aim to move or discharge 5% of outpatient attendances to PIFU pathways.
Following the presentation from King’s Mill there were a range of questions and topics explored in the audience Q&A:
Does PIFU impact discharge rates and could patients be ‘missed’ if not activating a follow-up when they need it?
Responding, Vineeta Munshi stated that because clinicians had agreed a set of PIFU inclusion and exclusion criteria, naming conditions and symptoms that are appropriate for PIFU pathways, patients with urgent or particularly challenging diseases such as wet age-related macular degeneration (AMD) were not placed on these pathways. Only when the clinician is certain that the patient is safe to be placed on a PIFU pathway will they be placed on one, and thus far this had not been an issue, she added.
Sharon Bentley highlighted that discharge rates at King’s Mill had not dropped since the expansion of PIFU.
What kind of discharges are sent to King’s Mill by their local diagnostic hub?
Munshi explained that the diagnostic hub was typically for glaucoma and medical retina patients, and most of those patients are seen in associated clinics so PIFU is not used for those patients. She added that only stable dry AMD patients were added on to PIFU pathways, while patients with glaucoma or wet AMD were not.
Which condition saw the greatest number of patients placed on PIFU pathways?
Blepharitis was common, Jayakumar stated, as were a range of other general ophthalmology conditions including dry eye and iritis. However, some medical retina patients were on PIFU as well.
Would PIFU work well for paediatric ophthalmology?
Mel Hingorani outlined that paediatric ophthalmology was perfectly suited to expanded PIFU offerings given the type of conditions – particularly those with unpredictable flare-ups – frequently seen within the sub-specialty.
Sarah Kemp stated that PIFU can be suitable in multiple settings, including in paediatrics. There was a myth that PIFU is not suitable for paediatrics, but Kemp highlighting that NHS England have many examples of providers delivering PIFU in paediatric services well and they were concentrating on busting this myth.
Was PIFU a way of helping clinicians discharge because they had a safety net?
PIFU pathways were not a substitute for discharge, Munshi explained, but because King’s Mill was a district hospital with many locums and junior staff at the time of development who may not have the confidence to discharge, PIFU provided them with confidence to discharge where appropriate.
Could PIFU be used for patients that will definitely need to be seen again but not for a long time, providing them with an option to arrange an appointment sooner than planned if needed?
King’s Mill had not thought about doing that, according to Munshi, but they were discussing whether to increase the length of time for some conditions such as stable dry AMD.
The ocular plastics service was using PIFU quite frequently, she added, with the relevant clinician describing it as a useful tool.
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