Discussion

Healthcare spending in the UK will fall in real terms over the next several years and glaucoma specialists will need to provide more care with less money. To achieve this and continue to deliver high quality care to glaucoma patients, new models of care will be required. One such model is described herein and uses an internet-based virtual clinic to enable a glaucoma specialist to review all the clinical information and confirm or alter the interim clinical decision made by the assessing optometrist. We analysed the inter-observer agreement between optometrists and glaucoma specialist to determine if this specialist supervision provided an additional benefit to community-based optometrist assessment alone. There was substantial agreement between each group as represented by a Kappa statistic of 0.69.

Ensuring patient safety is a critical consideration in the development of any new model of care. We assessed patient safety by determining if any high-risk patients were identified by the glaucoma specialist who had not been identified as high risk by the assessing optometrist. While there were only a small number of high-risk patients missed by the optometrist (13), each of these clinical situations can potentially result in a missed opportunity to prevent blindness and this is a benefit that must not be underestimated, particularly if public confidence in the system is to be maintained. With any novel health intervention, patient safety is paramount; these data demonstrate that consultant supervision catches a relatively large number of patients who were underdiagnosed by the optometrist. In all, 15% of patients diagnosed as normal by an optometrist were actually found to have glaucoma (94 of 625) and a similar number (13.5% 691 of 5120) of patients who were said to be stable by the optometrist were actually considered to be at higher risk after ophthalmic review. However, potentially the greatest risk to patient safety was the 6.5% (838 of 12 892) of patients thought to be low risk by the optometrist who were actually found to be unstable and thus requiring a clinical review within 6 weeks. Delay in these patients seeking a prompt face-to-face consultation with a glaucoma specialist could result in delayed treatment and unnecessary loss of vision.

The purpose of outsourcing is to streamline clinics and maximise the quality of care that can be delivered within an inelastic budget. An important part of this involves reviewing patients at intervals appropriate to their risk of blindness. There was an understandable tendency among optometrists to be ‘risk-averse’ and to review patients more frequently than was thought necessary by glaucoma specialists.

Table 2 shows data pertaining to the total number of annual review appointments required based upon the assumption that ‘normal’ patients are discharged, that ‘stable’ patients are seen once per annum, ‘low-risk’ patients are seen twice per annum and ‘unstable’ patients seen four times per annum. It can be seen that the virtual review process reduces the overall number of patient review appointments per annum.

By identifying this overservicing and reducing the overall number of reviews by 2.4%, glaucoma specialists created an additional cost saving into the programme. A reduction of 2.4% in reviews extrapolated to 2.4 million glaucoma attendances throughout England equates to 57 600 fewer glaucoma review appointments per year and a saving to the National Health Service (NHS) of nearly £3 million (assuming a net additional cost of about £50 per appointment and including cost of the virtual review). However, it must be noted that this study does not include a cost–benefit analysis and no comment can be made about the cost–benefit of a virtual glaucoma clinic compared with traditional inhospital care.

This study has several limitations. It was a retrospective analysis of an operational programme that has been running in the Bristol region and elsewhere for 6 years and therefore selection of patients was not controlled. Data therefore may not be applicable to other populations. However, it does suggest that virtual clinics conducted over the internet by glaucoma specialists are an important safety oversight where community optometrists may otherwise be managing glaucoma patients in isolation. Furthermore, such virtual clinics potentially cut the cost of delivering glaucoma care in the community by reducing the number of unnecessary review visits. The model described optimises use of resources by using technicians to collect data and optometrists to triage patients before directing only those patients deemed at-risk of visual loss to be seen by specialist medical staff within the hospital. We see this model as an important tool in the delivery of glaucoma care in much the same way that diabetic screening services have evolved to screen for diabetic retinopathy, allowing only those at high risk to be referred for specialist consultation within the HES.

This is the first publication on a novel approach to dealing with the very large number of glaucoma patients that threaten to swamp the NHS. We have suggested that virtual supervision is an appropriate and cost effective part of such a service innovation. Ophthalmic supervision of optometrists provides a useful feedback loop that can assist the optometrist to develop their clinical skills. We have preliminary data that suggest an increase in the kappa score over time as optometrists improve their skills. Further questions need to be addressed in order to maximise cost and resource efficiency. Is the ophthalmic supervision required once optometrists reach a certain level? Are optometrists required or can technicians upload the data for ophthalmic review? Can we use more modern progression analysis software to improve detection of patients who are deteriorating? Can this system be transferred to developing regions where there is a shortage of eye care professionals?