Local Tariff Variation and Ophthalmology Commissioning
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Ophthalmology, as a specialty, recognises the need to change and modernise the delivery of care as demand has increased incrementally year on year. It is a high-volume specialty (over 8% of all outpatients seen and 7% of all surgical activity) and relates to a variety of very different disease management requirements – from conditions that will not need any follow up, eg high volume cataract surgical pathways to those that require regular assessment and treatment appointments for several years, or even for life eg glaucoma and medical retinal conditions.
Local tariff variation is a tool that potentially can be used to encourage the development of innovative patient services. The local variation rules (Section 6.2 of the 2016/17 National Tariff Payment System) are intended to give commissioners and providers an opportunity to innovate the design and provision of services for patients. Given the clinical diversity of ophthalmology and the extensive commissioning evidence and advice available, the use of local variation should be considered to facilitate the adoption of nationally mandated patient pathways as well as those that are recognised or recommended as best practice.
The The National Institute for Health and Care Excellence (NICE) approved interventions for the management of age related macular degeneration, diabetic macular oedema (DMO), retinal vein occlusion (RVO), and the NICE guidance for the management glaucoma and NICE quality standards for glaucoma contain both recommendations for specific treatments and extensive advice on treatment pathways. Commissioners and providers can use NICE quality standards to self-assess the quality and appropriateness of their services hence informing commissioning decisions and agreements.
In addition, The Royal College of Ophthalmologists has produced Commissioning Guidelines for Cataract and Glaucoma using NICE accredited methodology. The commissioning guidance documents aim to improve the health and wellbeing of people and communities, and support local service redesign to ensure the provision of high quality, cost effective services that meet the needs of the local population and take into account patient experience. They contain detailed evidence and recommendations to aid commissioning conversations and contract agreements.
The RCOphth has also published The Way Forward which summarises a range of possible delivery solutions across a broader range of ophthalmic subspecialties. These can be adopted and adapted to produce services responsive to local need and capacity. Further examples will emerge from the ongoing ophthalmic Getting It Right First Time (GIRFT) project which has the dual aim of sharing best practice and reducing unwarranted variation in England.
The RCOphth recognises that innovation requires a highly skilled multidisciplinary work force. It has therefore published advice on developing skills and manpower to support new pathways. This can be found in the Common Clinical Competency Framework for eye care professionals.
The relationship between primary and secondary care is different in the eye care sector compared to other sectors of the healthcare economy. This is due to the presence of optometrists and their role in case finding and referral rights to secondary care. Commissioning Frameworks produced by the Clinical Council for Eye Health Commissioning (CCEHC) dealing with Community and Primary Care ophthalmology offer a basis for understanding and commissioning across the optometric and ophthalmic sectors.
There are multiple other sources and examples of innovation. These include documents produced by the Local Optical Committee Support Unit (LOCSU) and within appendix 1 of the RCOphth’s outpatient commissioning document.
In summary, there is a wide variety of possible new pathways, as well as the flexibility offered to commissioners and providers to work outside the national tariff, to improve patient care and outcomes. However, close working between commissioners and providers from all disciplines in the ophthalmic sector (ophthalmology, optometry, nursing, orthoptic, ophthalmic technicians) together with the NHS England Local Eye Health Networks and patient engagement groups, is essential to ensure good clinical governance, and appropriate contracting and pricing, of such innovative pathways.
Commissioners and providers must also work together to ensure that ophthalmic data are available and risks are managed, not only for the whole ophthalmic service but also for key areas of care such as cataract, medical retina and glaucoma.
The RCOphth is keen to support members in developing and commissioning new pathways. To enable the sharing of good practice we would encourage members to contact the College, email@example.com with contracting and commissioning details of any projects they wish to share or any questions they have on these issues.