Cohort profile: design and methods for Project HERCULES (Healthcare Exemplar for Recovery from COVID 19 by Use of Linear Examination Systems). Multi-disciplinary implementation and evaluation of an asynchronous review clinic for monitoring chronic eye disease in English NHS services
Authors: Muhundhakumar Dhakshi , Clarke Caroline S , Mills Grant , Ramsay Angus I G , Sailer Kerstin , Scully Peter , Wilson Duncan , Fu Dun Jack , Ndwandwe Siyabonga , Pachilova Rosica , Symons Anne , Napier Steve , Adesanya Joy , Gazzard Gus , Hamilton Robin , Wilson Jonathan , Webster Paul , Khaw Peng T. , Sivaprasad Sobha , Jayaram Hari , Foster Paul J. ,   HERCULES Consortium
Published: November 2024

Purpose

To describe the research principles and cohort characteristics of the multidisciplinary Project HERCULES, which evaluated implementation of an innovative model of high-volume outpatient eyecare service to monitor patients with stable chronic eye diseases. The rationale was to improve capacity and efficiency of eyecare in the National Health Service (NHS) in England through the creation of technician-delivered monitoring in a large retail-unit in a London shopping-centre, with remote asynchronous review of results by clinicians (named Eye-Testing and Review through Asynchronous Clinics (Eye-TRACs)). UCL’s Bartlett School of Sustainable Construction produced the RIBA (Royal Institute of British Architects) Stage 1 briefing requirements for optimal design specifications and operational parameters for this new model of care from first principles research, by analysing and developing ergonomic data from multiple iterations.

Participants

Patients aged 18 years or above being monitored in secondary care in Moorfields Eye Hospital NHS Trust for stable glaucoma or retinal conditions were given appointments at Eye-TRAC at Brent Cross, London. Willing participants were recruited when attending Eye-TRAC from September 2021-November 2023 and formed the ‘intervention cohort’. The ‘comparator cohort’ consisted of patients that continued to be monitored in secondary care during the same period. Other than residence of the participants, there were no other demographic or disease severity differences in this cohort. Additionally, anonymised data from across the Trust informed an analysis of the impact of opening the Eye-TRACs on Trust-wide waiting times. A nationwide stakeholder preference survey of health-care professionals, members of the public and ophthalmology patients was carried out.

Findings to date and conclusion

41,567 patients attended the Brent Cross Eye-TRAC between September 2021 and November 2023. 5,539 patients were recruited to Project HERCULES. Four spatial “iterations,” with different configurations of equipment were investigated in succession. Spatial configurations promoting independently parallel patient journeys with limited queuing, and direct line of sight between diagnostic stations, supported efficient patient flow. The latter iteration incorporated cataract clinics. Although it added more system complexity, it enabled the evaluation of a further indication for use of Eye-TRAC.

Future plans

Qualitative analysis of patient and staff feedback alongside rapid ethnographic work to streamline services is under way. We seek to develop a framework to help inform NHS guidance for ophthalmology and other outpatient diagnostic services. Our data will be analysed to identify enhancements to further streamline operational efficiency. We will identify and enumerate limitations in information technology that create bottle-necks in the review process.

Sponsor

Moorfields Eye Hospital NHS Foundation Trust

Sponsor protocol reference

JAYH1011

Integrated Research Application System (IRAS) ID

303760

Funders

NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust & UCL Institute of Ophthalmology, London, UK

Moorfields Eye Hospital NHS Foundation Trust Moorfields Eye Charity

Ubisense Ltd, Zeiss, Optos

STRENGTHS AND LIMITATIONS of this study

Our multi-disciplinary research team is a major strength of the work; new collaborations and understandings have arisen that cut across academic disciplines and we hope this will provide meaningful lessons for health services now and in future.

Design development that used rapid experimentation to test new ideas (before spending significant resources on them) was employed; we collected data to build an evidence base, dynamically test new environments, build protypes and execute analysis iteratively.

Continuous input from technicians, administrative and managerial staff led to improvements in later iterations and greater buy-in from staff and ultimately the success of the project.

Patient and public involvement was integral to the design and development of the quantitative and qualitative work.

Due to the need for rapid service capacity expansion and high-volume throughput (as a result of the pandemic) the conditions and comparisons within the study could not be tightly controlled.