Improving Ophthalmology Access

Problem Statement

• An ageing population and the prevalence of poorly managed diabetes within our community means that more people are developing chronic eye conditions. These conditions frequently require lifelong monitoring, and often treatment, to prevent irreversible visual loss.
• This has resulted in rapidly accumulating demand for specialist management of chronic eye conditions. CM Health has struggled to keep up with this demand.
• On 1 July 2017, the total number of overdue follow-up ophthalmology clinic patients was 6095, with 3631 of those patients waiting longer than 50% of intended wait time.

What are we trying to achieve?

Our goal is to ensure that no more than 5% of follow up patients wait for longer or equal to 50% of the intended time by 30 June 2019.

What have we done?

• In the first half of 2018 (following collaboration with the Royal Australian and New Zealand College of Ophthalmologists) and again in the first half of 2019 we ran weekend and after-hours clinics (Mega Clinics) to try to resolve our overdue follow up volumes. These clinics are still ongoing. They rely on CM Health staff doing significant overtime and external locums provided through an agency. Rewardingly, many senior medical officer and trainee volunteers from around New Zealand have also contributed.
• We implemented an Acuity Index Tool enabling us to have excellent visibility of those patients most at risk of vision loss, so we can prioritise them for appointments.
• We challenged models of care, for example by introducing one-stop bilateral intravitreal injections, and implementing standardised national guidelines for the treatment of glaucoma and virtual reviews of post-intravitreal patient images.
• We created capacity, for example by combining some First Specialist Appointment (FSA) and preadmission processes for cataract surgery.
• We stopped accepting referrals for some conditions (that were not sight threatening).
• We made changes in the workforce. We trained advanced practitioner optometrists to treat stable glaucoma under the supervision of a senior medical officer, before moving the treatment into their own private practices.
• We revised our did-not-attend processes to reduce the number of unused appointments.
• We collaborated with Auckland DHB, in line with the Regional Ophthalmology Strategy, with gains through joint recruitment of clinicians and technicians, data alignment, and shared equipment.

We attempted to increase capacity by opening three additional clinic rooms on the Middlemore Hospital site.

What did we find?

The Mega Clinics were the most effective and dramatic intervention for reducing the number of overdue follow ups, and managing the risk associated with this. However, the more successful we are in seeing patients in a clinically appropriate timeframe, the more capacity we need. This was expected, but is difficult to quantify. As we have refined our planning, we have adjusted (upward) our expectations about ongoing demand, improving our understanding of what is required for sustainable solutions. It is important to note that the Mega Clinics are designed for short-term ‘blitzes’ and are not a sustainable strategy for managing waiting lists.

The chart below captures our successes from our interventions. Since December 2018, we have lost ground. This reflects a seasonal variation, experienced in other years, due to staff and patient holidays over the Christmas period and the flow on effects of that.

The most successful intervention for identifying patients who are most at risk was the introduction of the Acuity Index Tool.

We have identified a small number of patients who have potentially been harmed as a result of delayed follow up. Each patient has had a case review and we continue to provide appropriate support to them, including referral to ACC. The Health Quality and Safety Commission has been advised of three cases of adverse outcomes in this group.

Some conditions that we are no longer able to see and treat contributed to inequity within the Counties Manukau region, as Auckland DHB domiciled patients are treated for these conditions.

Improved production planning is required, with investment in growth, if we are to provide a sustainable ophthalmology service to our population. Working regionally with Auckland DHB is an excellent strategy to achieve this.

How did we make a difference?

As of the end May 2019, our overdue follow up numbers have decreased to 3924 (compared to 6245 in May 2017). There are currently 1252 overdue patients who have waited longer than 50% of the intended time, a reduction from 3716 in May 2017. We have not yet achieved the target – but we have made a big impact.

Where to from here?

• Building expansion and associated recruitment.
• Increasing collaboration with Auckland DHB (under the Regional Ophthalmology Strategy).
• Mega Clinics to continue in the 2019/2020 year.
• Continue reassessing models of care. This includes a pilot of technology-led post-avastin clinics, with virtual senior medical officer review.