Title: Hospital to Community: identifying the value of optometrists monitoring & managing chronic sight threatening eye disease in primary care.
Funder: Health and Care Research Wales (Welsh Government)

Abstract: BACKGRAOUND: Neovascular age-related macular degeneration (nAMD) and glaucoma are chronic sight threatening eye diseases that need life-long monitoring & treatment. Statistics show that only 2/3 of patients at risk of irreversible sight loss are seen within target date, because of pressures on hospital eye services (HES). Alternative evidenced based ways of delivering care are possible using trained primary care based optometrists delivering enhanced optometric services (EOS). Welsh Government’s vision for the future describes care delivered as close to home as possible with people able to access hospitals when they need it. Providing safe & effective EOS in primary care might relieve pressure on HES, but must not be at the expense of patient experience. It must also represent good value. The carbon footprint of using primary care rather than hospital service might also be reduced. This is why this research is necessary. AIM: To evaluate the patient benefits & value of effective models of EOS that could be implemented in Wales by primary care-based optometrists for people with nAMD & glaucoma. The perspective of the research is that of both patient & NHS Wales. METHODS: Literature reviews will be undertaken at the initiation of the project to ensure all the research builds on existing knowledge. A Concurrent Nested Design (mixed model) with a predominant health economics strand will be used. The nested qualitative approach includes a sequential Realistic Review & Evaluation & three cycles of realist enquiry. In addition, surveys of stakeholder groups will be undertaken to further inform the research. The economic impact of changing services will be investigated by using economic modelling techniques for synthesises of clinical, epidemiological & economical evidence into an evaluation framework. Explanatory programme theories will consider how, why, for whom & to what extent services are valued so that learning can be translated across Wales. Surveys will collect feedback from people who have experienced services & will establish whether optometrists have capacity or are willing to take on the work. The quantitative research investigates the carbon footprint, economic impact, potential resource release & opportunity costs of provision of EOS in this context. A Stakeholder panel that includes patients & public will guide & inform the research. Study outputs: At the conclusion of this research we will understand the context, mechanisms & outcomes for HES & EOS, what matters to patients & other stakeholders, how an optimised service could be configured & what the impact on carbon footprint might be. We also aim to estimate & describe the opportunity costs of extending ophthalmic care for people with nAMD & glaucoma into primary care. We intend to estimate the level at which the primary care based optometrists can deliver care the costs of providing that care. The outputs of the research should enable NHS Wales & stakeholders to characterise patient centred sustainable & cost-effective primary eye care for people with glaucoma & nAMD. The research will also create learning that can be applied to pathways for other eye conditions. Our findings will be developed in partnership with our stakeholder panel & disseminated to study informants, patients & public, health boards & professional groups through face to face engagement as well as the more usual publication & dissemination channels.

Lay abstract: Neovascular age related macular degeneration (nAMD) and glaucoma are eye diseases that cause sight loss or even blindness if not treated early and regularly by healthcare professionals. As health services in hospitals that provide care to people with these eye diseases are under so much pressure in Wales, only 2/3 of people with these diseases, are seen at the hospital when they should be. This means that they may lose some or all of their sight. The hospital services that provide care for people with nAMD and glaucoma have problems coping with increasing patient numbers and this is made worse by a shortage of doctors trained to manage these eye conditions. It is possible to provide care for some people with these eye conditions in other ways outside of the hospital. These ways have been shown to work and can be provided using optometrists (healthcare professionals who examine the eyes to detect weaknesses in vision, signs of injury, eye diseases, usually in a practice in a town centre) who have extra training. These enhanced optometric services (EOS) can be provided in practices more local to a person’s home. Providing EOS should relieve pressure on the hospital and allow the people working in those services to give other people care and reduce the time waiting to be seen. Changing to EOS must also have patient benefits and, because the money spent on health care is not unlimited, must be good value for money. This research is needed to be sure that making this change meets these standards. The research will weigh up the benefits of providing different types of EOS that could be provided or are already in place in Wales against care received only in hospital. We will also find out if this change reduces the carbon footprint.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.2 HEALTH AND WELFARE ECONOMICS
Health categories: EYE