Reducing the postcode lottery by standardising pathways – A system approach to integrated care in Lancashire and South Cumbria

  • 28 Mar 2022
  • Shveta Bansal and Hayley Michell

Ahead of Integrated Care Systems (ICS) becoming mandatory bodies in England in July 2022, Shveta Bansal, Clinical Director of Ophthalmology at Lancashire Teaching Hospitals NHS Trust and Clinical Lead for the Ophthalmology Collaborative in Lancashire and South Cumbria ICS, and Hayley Michell, Managing Consultant (NHS Transformation Unit) and Ophthalmology Programme Lead, share their experience of shifting towards integrating care.

What was the driver towards a more integrated approach to eye care?

Our work in Lancashire and South Cumbria began in October 2020 when ophthalmology was chosen by the Lancashire and South Cumbria Provider Collaboration Board as a priority area to inspire joined up working across the region. This led to the creation of the ophthalmology Design Oversight Forum in January 2021 – where a shared vision of standardising ophthalmic services across the region was created.  The collaboration currently involves four NHS Trusts – Lancashire Teaching Hospitals, Blackpool Teaching Hospitals, University Hospitals of Morecambe Bay and East Lancashire Hospitals.

The process began by agreeing on the case for change and this involved a range of stakeholders from across the system. There was a clear consensus that there were four key drivers– rising demand, lack of capacity, workforce shortages and financial constraints. It was clear that if we did nothing to improve our services more and more people would lose vision.

Discussion then turned to considering how we could improve patient care, a direct response to the case for change. This  led to the development of our vision for Lancashire and South Cumbria – crucial to which is collaborating at scale to develop a fully integrated eye care service.

How did you decide what practical improvements were needed?

It was really important to get the right people in the room including a mixture of clinical and operational representation from each of the trusts. Commissioners were also invited to attend, along with primary care,  members of the Getting It Right First Time and National Eye Care Recovery and Transformation Programmes and Local Optical Committee Support Unit (LOCSU) leads. Eventually, key representatives from all these groups have become regular members of the group.

As a group, we have the mutual aim of supporting system-wide implementation of the Community Urgent Eye Care Service (CUES) for outpatient cataract patients. This can act as a real catalyst for developing integrated pathways. CUES was originally developed in response to COVID-19 and the suspension of many eye care services, and it can reduce the need for patients to attend GP, A&E and hospital eye departments. Whilst this had been implemented across two trusts within our ICS, with significant benefit, two trusts are working towards this. This disparity in provision had led to inequality in care provision and is a potential roadblock to developing other integrated care pathways, including care in a community setting. We felt that once CUES was implemented, it would also open the door to the expansion of other shared services.

A key part of our vision is standardising pathways and access to care across the ICS – reducing the “postcode lottery”. This will need to be underpinned by robust data collection. An example is the cataract pathway, where we were working to implement a standardised risk stratification form for all units and collect the risk stratification score in each unit so that the data is comparable. Currently, the only risk stratification score for cataracts is based on medical comorbidities (HRG codes) which are often irrelevant to the high volume-low complexity pathway. Whilst units were collecting information on risk stratification, this was often inconsistent and the information difficult/impossible to retrieve. In order to deliver High Volume Low Complexity lists, this information is vital and has been one of our main priorities as a group.

What is in the pipeline over the next year?

There are lots more planned for 2022. A new commissioning service specification describing a whole integrated eyecare service, designed and drafted by the Design Oversight Forum, is soon to be finalised. This is very exciting as, in our experience, very rarely are such decisions made jointly in this way. The specification will articulate agreed ways for us to collaborate and standardise care provision and will include CUES, cataract and glaucoma provision and shared pathways with the community.

We will also be looking closely at Electronic Eyecare Referral Systems (EERS), working with NHS Digital to ensure the rollout is standardised across the ICS. This is a key enabler for integration and will enable primary care clinicians to send electronic referrals and support hospital eye care departments to manage referrals and patient care more efficiently.

Excitingly, a business case for an Electronic Patient Record (EPR) system has been approved and will be rolled out in 2022. This will also make the pathway much smoother across the whole system, meaning an improved experience for patients where they do not find themselves repeating the same information multiple times to different parts of the system.  It was essential that all four units across the ICS agreed on the same EPR and again clinician engagement has been a key enabler to this.

Having started with the focus on cataract pathways, we will also turn our attention to improving glaucoma and AMD outpatient pathways. This will use the same clinical redesign approach and learn the lessons from how we’ve integrated the cataract pathway.

Are there any lessons you’d like to share?

A very clear governance process was helpful, so we could make decisions in an efficient logical way with the right input. This includes a tripartite leadership structure of Trust Chief Executive, Trust Chair and a workstream Clinical Lead.  The Design Oversight Forum provides a platform to engage relevant stakeholders from across the region and meets monthly to assure key deliverables, celebrate successes and lessons learned and to hear about national initiatives. These are complemented by Trust specific conversations to progress actions in-between.

Making sure meetings are action-focused has also been important in getting buy-in from senior representatives from trusts, as they can see the benefit of being involved.

Involving commissioners at an early stage is crucial too – it would be difficult to make any progress without their engagement in this.

Is there any other advice you would give to ophthalmologists looking to shape eye care services in their area?

There really is a good opportunity for acute providers, primary care optometrists and commissioners to work together and decide what good service should look like across a large geography before pathways are implemented. While this has always been ideal, it has rarely been so in practice. Clinical leads can speak to their ICS board team or trusts, setting out that they would like to create a regional eye care network with admin support, and what they want to achieve.

For other ophthalmologists, finding like-minded clinicians in your own and neighbouring trusts is a good first step. Then there is nothing to stop you then writing to the Chief Executive of your ICS board setting out your objectives for integrating eye services and the resources you think you’ll need.


Further information

If you would like more information on the experience of Lancashire and South Cumbria, please contact [email protected].

The way that eye care services are designed and commissioned is changing in England. From July 2022, clinical commissioning groups will be abolished and their powers will be transferred to integrated care systems (ICSs).

RCOphth will share further information and advice to help ophthalmologists become involved in integrated care in their region. If you have any comments or questions, please contact [email protected]