Task and finish groups conclude work to explore cataract provision and growing role played by independent sector providers
Following joint task and finish groups convened by The Royal College of Ophthalmologists and NHS England, guidance has been published on cataract commissioning, the referral and post-operative pathways, and training in independent sector providers.
We updated you in May 2022 that RCOphth would be holding cross-sector groups to address some of the challenges to long term sustainable patient care created by the growing role played by independent sector providers (ISPs) delivering NHS cataract surgery in England.
This work has now concluded with two key outputs:
- Supplementary Cataract Contracting Guidance (available via the Eye Care Hub)
- Blueprint for cataract training in the independent sector.
Cataract contracting guidance
Following publication of its cataract service specification in March 2022, which RCOphth was closely involved in and welcomed, NHS England has published further cataract contracting guidance. This is aimed at clarifying issues such as non-contracted activity, conflicts of interest, how to enable patient choice and requirements for post-operative care.
Aimed at commissioners and providers of NHS-funded cataract surgery in England, key points from the guidance include:
1. The need to move away from non-contracted arrangements.
‘Where there is a material volume of activity, commissioners and providers should agree a contract rather than operate under non-contract activity arrangements. Where a provider wishes to offer a service…the commissioner should be prepared to offer a contract where that provider meets their local commissioning criteria for that service. The provider should demonstrate that they meet the standard as set in the national specification in all areas they provide the service.’
2. Commissioners should consider joint contracting arrangements where ISPs operate across a number of regions.
‘Where the same provider location is operating across a number of ICBs, commissioners should consider joint contracting arrangements under a host commissioner. This may require some standardisation of the service models, prior approval schemes and expectations across ICBs but will simplify contract management and ensure coverage’.
‘Where a material volume of cataract activity is being, or is likely to be, provided under non-contract activity, commissioners should not assume the existence of a host contract. This must be requested as it forms the basis of the implied contract’.
3. The importance of patients receiving accurate information, and how single point of access (SPOA) schemes can enable that.
‘Providers must make information about the services and waiting times available in a timely fashion, and commissioners must make sure that the main referrers, optometrists and GPs, have access to this information. Each provider should use the same metric for wait times.
‘A single point of access (SPOA) could be commissioned to facilitate patient choice. This may provide better information upon which patients can make informed decisions if the referrer does not have timely and complete information about available services…Commissioners and providers should have confidence that the process is fair and transparent’.
4. Commissioners should mitigate the risk of conflicts of interest.
‘Commissioners should also be aware of real and perceived conflicts of interest and other contractual complexity when agreeing and managing contracts for cataract services. For the assurance of commissioners and other providers there should be transparency and mechanisms to address conflicts of interest, to ensure that the operation of patient choice is not adversely affected or distorted. Examples of concerns that have been raised include:
- Where an optometric provider or triage provider offers, or has a financial interest in, cataract services
- There may be perceptions that some providers of cataract services are incentivising optometrists to refer patients to them by offering linked payments for post-operative care, to be carried out by the optometrist
- If a cataract provider has a structure in which the commissioned provider and operator are separate legal entities’.
5. Providers must manage post-operative complications, and review their processes with the commissioner if ‘unplanned’ transfers occur.
‘The provider performing surgery must manage the post operative complications including arranging any agreed transfer to a more appropriate provider. Receiving clinicians need the right information to make an informed decision about that patient’s care’.
‘After any unplanned post-operative transfer incident, the originating provider must review their processes with the commissioner to understand why the transfer was not managed by the surgical provider in order to stop it from happening again’.
6. Commissioners should ‘standardise the pathway and payments for any post-operative care across providers. Complete NOD data should be collected and submitted as part of any post operative pathway’.
7. A standardised discharge template has been developed, which should be consulted when developing discharge summaries.
This short template includes:
- The principles of best practice – patient choice, non-digital summary, rapid return in case of issues and clarity of communication
- A minimum dataset – patient, operation, post-op medication and follow-up plan
- Further information for patients – clarity of plan for other eye, lay instructions for patient/carer.
Blueprint for cataract training in the independent sector
Working with training programme directors, NHS England, ophthalmologists in training and independent sector providers, in October we published a blueprint to help providers and trainers enable appropriate and safe cataract training within the independent sector (IS), where these training opportunities are needed.
Key points from the blueprint include:
- Within every NHS setting that delivers a cataract service, training opportunities must be maximised.
- Every independent sector provider (ISP) delivering NHS-funded cataract surgery must be able to train NHS ophthalmic trainees on at least 11% of whole cases within two years – in line with NHS England’s March 2022 cataract service specification and supporting guidance (both accessible via the Eye Care Hub).
- Commissioners, including through the Integrated Care Body (ICB) structure, must ensure that within contractual arrangements all ISPs delivering NHS-funded cataract surgery demonstrate they are able to train NHS ophthalmology trainees on 11% of all NHS cataracts within two years.
- All pre-placement and intra-placement documentation must be available to both NHS and ISP training partners during all placements.
- To enable training to take place successfully in ISPs where it is needed and appropriate, it is essential that ISPs and NHS trusts work together to proactively plan how the placement will be delivered. These discussions should begin at least one month prior to the training beginning within the ISP.
The blueprint covers practical information on how to determine whether trainees need training opportunities in ISPs, which areas trusts and ISPs should plan collaboratively one month prior to placements (including a timetabled list, trainer accreditation and indemnity cover), and what information ISPs, training programme directors and trainees should provide prior to placement. The blueprint also outlines a template timeline for the different milestones and steps that should be taken during a placement in an ISP.
What will we do now?
We believe that the two outputs summarised above should help ensure that the delivery of NHS cataract services in England operates more effectively. It is particularly important that NHS England has stressed the need to move away from non-contracted activity. Having contracts in place in all instances between the provider and commissioning body/bodies would lead to more stability for the whole service.
RCOphth will continue to work with all stakeholders to ensure that that the role played by independent sector providers in delivering cataract surgery contributes to the delivery of sustainable patient care, including by enabling access to surgical training.
We will continue to liaise closely with policymakers at NHS England to highlight where there are issues that need to be addressed, including around the implementation of the cataract service specification and supplementary guidance, and work collaboratively to develop practical solutions.
RCOphth will support efforts to ensure that key guidance on cataract commissioning is effectively communicated to commissioners in integrated care systems.
We will also monitor trends in the delivery of cataract surgery – as we did with our analysis published in August 2022 – providing clear information that will help inform those making decisions relating to the commissioning and delivery of cataract services.