Sharma, A; (2018) Glaucoma Care. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

What is the problem? The number of people coming to the hospital eye departments is likely to increase in the future, as a result of an ageing population, increased optometric case finding and raised public awareness. This fact coupled with the increased economic pressures in health-care financing, and the relative shortage of ophthalmologists in the United Kingdom is going to put significant strain on ophthalmology provision. As a result of these issues, there has been a drive by the government to move eye care into the community and to have more primary care involvement. A variety of alternative models have been proposed for patient care in the community. An important part of assessing these models is to investigate their relative cost effectiveness as well as safety, capacity and patient acceptance. What are the current models? There have been many shared care models that have been proposed. These have included the Community and Hospital Allied Network Glaucoma Evaluation Scheme (CHANGES), the Peterborough Scheme, East Devon Scheme, Waltham Forest Scheme and the Nottingham Scheme. One of the main schemes was the Bristol Shared Care Scheme. This scheme was shown not to be cost effective. It did show that community optometrist’s measurements were of comparable accuracy to those made in the hospital. The annual cost per patient follow-up by a community optometrist was £68.98-£108.98 compared to £14.50-£59.95 in the hospital. The main reason for the cost difference was due to a variation in the patient recall interval between the community and hospital. The second reason was due to the re-referral of patients back from the community clinics to the hospital clinics. What was our contribution? We developed an Integrated Glaucoma Care Model. This involved training and accrediting community optometrists to run Moorfields glaucoma clinics in their Optometric practices whilst alternating attending glaucoma clinics in the hospital. Our results showed that it was more costly to run the community based glaucoma clinics compared to hospital based clinics. These were the same findings as in the Bristol shared care model. The main reasons for the higher costs in the community were due to the large overhead costs of running the glaucoma scheme in the community optometric practices as well as fewer patients being seen in the community compared to the hospital. The community optometrists involved in our scheme were in general found to be competent, efficient and safe. The patient perspectives of our model were overall positive with a large majority of patients happy to be seen in the community again. What were our recommendations? Our main recommendation was to evolve our model to run the shared care scheme within the hospital setting to avoid the high rental costs of the optometric practices. This model is being successfully run at Bristol Eye Hospital where there is a complete shared care department involving optometrists. This type of model could utilise hospital optometrists but could also have accredited community optometrists attending the hospital and participating in such schemes. A second possibility could be to run these shared care schemes in hospital satellite settings or mobile units. An example of this is the Newmedica model. There is a clear requirement for cost effectiveness evaluation of such schemes along with an assessment of safety, capacity and patient acceptance before any conclusions can be reached.

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