The traditional patient referral pathway for low vision is obsolete, is now the time to try something new?

If you talk with eyecare professionals up and down the country, it seems what is commonly known as the patient referral pathway leaves a lot to be desired. Simply put, the patient referral pathway is the systems in place to allow people who have been diagnosed with some form of visual impairment or blindness, to access assistive technology.

We can see the benefit of explaining the steps on the current patient referral pathway, however, to do so would be very difficult as it entirely depends on where one is located within the UK – and this is a big part of the problem.

With the arrival of the COVID-19 pandemic leading to changes in systems and procedure across the nation, is now the time to radically redesign the patient referral pathway with the aim of benefitting both patients and eye care professionals?

We spoke with long-practising Optometrist, Simon Berry, and a leading dispensing optician in the Basingstoke area, to discover what the perception is of the current system and, perhaps, what could be done to fix it:

 

Can you tell us a little about the issues with the current way the referral pathway works?

 

SB: “The current referral pathways are confused, limited and variable. In many places, the first time that patients will discover, or be told, they would benefit from a low vision aid is from their local optometrist. However, currently, the infrastructure and politics around funding make it generally impossible for Optometrists to offer any low vision aids to their patients.

In most areas, there is no community funding to supply an NHS LVA to the patient. As a result, the optometrist will refer the patient on to their local NHS eye clinic to receive an LVA.

In my opinion, this lack of NHS funded low vision aids in primary care is one of the issues. Local Optometrists already have a professional relationship with their patients and it makes sense for them to be involved. However, without access to LVAs, opticians have no incentive to learn or understand about the various technological aids that are available, the path of least resistance is to direct the patient back into the system in the shape of an NHS eye clinic referral.

Once the referral has been placed, everything gets delayed because of the waiting times. And there is a duplication of care as the patient is then re-assessed by another Optometrist or Ophthalmologist before receiving any LVA. This duplication of care is not only costly and inefficient for the health service but also the patient.

Follow-up LVA appointments are also an issue because many hospital eye departments are stretched for resources. There is a lack of continuity of care meaning that there are numerous examples of patients that end up with lots of magnifiers that they just don’t use. This is a waste of a limited resource.

At the heart of this issue is a lack of communication between all the different professionals that see the patient on the referral pathway and the lack of a single point of contact for the patient to follow up with. Every professional is good at their job, but with LVA pathways there are a lot of professionals involved – Optometrists, Ophthalmologists, ECLOs, rehabilitation officers. The system would work much more smoothly if we all communicated effectively.

When it comes to NHS care, it is a complete postcode lottery. Each trust, sometimes each hospital, will have different rules. Most provide NHS funded LVA, but others will only offer NHS LVAs for people over 60; some use a range of providers whilst some choose to order from only one provider. Some balance the quality of the LVA over cost whilst some aim for the cheapest possible. There is no standardisation of this care across the UK.

Furthermore, the NHS Optometrists aren’t often in control of their budget, and there is no facility to apply for more funding for more complex aids.  This means that sometimes the ‘NHS’ LVA service can be quite basic. When it comes to the more advanced assistive technologies, then there is no referral pathway available, and patients are often left to research and buy the product themselves. There is very little independent advice available to the patient.”.

 

AN: “Low vision care via the NHS in the UK is too varied and inconsistent. Access to eye clinics is sometimes impossible. Often, the range of devices is small, and they are basic and low quality. Referral pathways are confused and difficult to navigate and rarely are patients signposted directly to distributors.

Staff are too often poorly trained and not motivated or incentivised to create real choices for users. They rely too heavily on the voluntary sector, where the problem of poor knowledge and training on assistive technology and inconsistent information also exists.

I am passionate about providing the very best eye care to my patients, and I need focused and sustainable support from a distributor I can trust. I do not have the time to explore all the options for my patients – I just need to narrow down the choices during my consultations and then hand my patients over for an efficient further assessment that will deliver the appropriate assistive technology to them. It sounds simple, but unfortunately, this is not what is happening in the majority of cases”.

 

What could be the solution? Is there a need for a radical redesign of the steps on the patient referral pathway or with some subtle alterations could it become better?

 

AN: “I think there is scope for assistive technology suppliers to work more closely with the primary care sector, high street opticians and the like.

I feel that there is still a general confusion amongst eye health professionals about the multiple approaches from distributors and dislike of sales pitches. There is also an awareness of their widening gaps in their knowledge about assistive technologies in terms of new devices and evolution of existing tech, stratification of devices, matching of devices to conditions/diseases and how devices perform in the “real world”. There is frustration with the inconsistent and incomplete sources of information and expert advice to which their patients could be ideally referred.

There is a growing desire for sustainable and financially rewarding relationships with trusted providers who can offer us a commercial model and focused guidance around particularly new technologies and devices, including the compatibility of such technology for those patients with dementia, learning difficulties or other conditions”.

 

SB: “Perhaps a radical approach could be an answer, and could now be the time to do it with everything that is going on with COVID?

Give the patient the power to decide.

What if we were to take the onus away from Optometrists and Hospital Trusts entirely, once a patient is identified as needing an LVA they are given a voucher. The value of the voucher would change depending on the need and the severity of the sight loss. Vouchers are supplied by the CCG. Patients can choose where they spend their voucher and what they spend it on (similar to a GOS 3.) They can choose to spend it in primary care or secondary care, and once it is spent then a second one cannot be issued without reassessment.

This means that LVAs become available in primary care to those Optometrists who wish to be involved, pathways will evolve to be more efficient and there is less waste in the system because patients would not use more magnifiers than they require. It also means that if a more complex LVA is needed, patients can use their voucher to part-fund their device.

This would put the quality of care in the hands of the individual patient.”

 

`