COVID-19 Urgent Eyecare Service (CUES) in England

We welcome the clarity that NHS England has now provided on how urgent eye care can safely continue during the pandemic, and the role that primary care optometrists should play in delivering this care. We also support the clear recommendations that primary and secondary eye care health professionals need to work closely together to ensure that patients can access the eye care they need, while minimising the risk of COVID-19 infection.
 
The College has worked collaboratively with the Royal College of Ophthalmologists to develop and endorse the clinical pathways at the heart of the COVID-19 Urgent Eyecare Service.  We recognise that in many parts of England services similar to this are not yet in place and urge all CCGs to commission urgent eye care services as soon as possible.

Service: COVID-19 Urgent Eyecare Service - CUES.  (NHS England Publication approval reference: 001559) 

Commissioner Lead: Regional lead CCG

Period: April 2020 - 

In response to the coronavirus (COVID-19) pandemic, NHS England/Improvement has set out that as routine sight testing has ceased(NHS England Publication approval reference: 001559), COVID-19 urgent and emergency eye care will need to be commissioned and delivered through a contract with local commissioners (ICSs/STPs and CCGs).  

NHSE/I regional teams will work with appropriate commissioners, health systems and optical practices to ensure the availability of appropriate and adequate levels of urgent eye care which will:  

• safely deliver urgent eye care in the community
• deliver remote triage and consultations (by telephone or video) to minimise face-to-face appointments.
• make use of technology to reduce patient – practitioner contact time
• reduce the expected burden on the rest of primary care (GP practices) and reduce  pressures on ophthalmology departments within secondary care
• maintain local access to quality eyecare services for local populations.

All routine sight testing has ceased, and essential General Ophthalmic Services is not an urgent or emergency service.  In response to national COVID-19 guidance hospital ophthalmology departments have reduced all routine out-patient and surgical activity, providing services only for high risk patients and emergency care.  As a consequence, there is a risk that patients with urgent eye health issues will find it difficult to access care, with potential implications for their sight and long term eye health

Primary eye care providers within optical practice teams have a role to play in supporting hospital ophthalmology and primary care teams in the immediate response to the pandemic.
There is evidence at a regional and local level that where  Minor Eye Conditions services are already commissioned by CCGs, services are being changed to support the delivery of urgent eye care from optical practices.  For clarification,Covid-19 Urgent Eye Care Service (CUES) is not a  Minor Eye Conditions Service (MECS).

In order to support CCG areas where no contracts exist with optical practices, and to ensure equitable provision, urgent eye care service should be established where possible across an ICS/STP footprint (rather than at CCG level) in England, to manage presenting patients for which essential GOS is inappropriate (NHS England  Publication approval reference: 001559). 
Through a network of optical practices, and utilisation of technology, patients will be able to gain prompt access to a remote consultation and, in most cases, a care plan for the patient to either self-manage their ocular condition (with access to appropriate topical medications where appropriate), be managed by their optometrist with advice, guidance and remote prescribing as necessary by hospital eye service or be appropriately referred to ophthalmology services.

This will reduce the burden on patients physically visiting GP surgeries, pharmacies and secondary care facilities. The use of technology will allow virtual consultations allowing many people to receive their consultation from their home. 

It will also help to both support the public health agenda (to stay at home), whilst ensuring that patients who are in the high-risk vulnerable category, or patients who are self-isolating can access urgent and emergency eyecare appointments appropriately.

The service specification outlines a COVID-19 urgent eye care service (referred to hereafter as the Service) delivered from optical practices.  It was developed by NHS England, LOCSU and the Clinical Council for Eye Health Commissioning.

Domain 1    Preventing people from dying prematurely    X
Domain 2    Enhancing quality of life for people with long-term conditions    
Domain 3    Helping people to recover from episodes of ill-health or following injury    X
Domain 4    Ensuring people have a positive experience of care    X
Domain 5    Treating and caring for people in safe environment and protecting them from avoidable harm    X

The expected benefits of the Service include:   

• Reduction in the number of ophthalmology attendances (an essential outcome in response to the COVID-19 due to limited staff and numbers of clinicians redeployed to assist patients requiring critical care.
• Reduction in the number of eye-related GP appointments
• Release hospital workforce for more complex ophthalmic care and potential for front-line COVID-19 response
• Reduce coronavirus infection risk by minimising patient travel and patient – practitioner contact time
• Provide a rapid, safe access, high quality service for patients
• Reduce the total number of patient face to face appointments
• Improve the quality of referrals and referral pathway
• Care closer to home and in a lower risk setting
• Direction to self-care; e.g. patient leaflets, websites, online symptom checker
• Improve quality of life
• Provide accurate data about outcomes and patient satisfaction across multiple providers
• Provide outcome data to providers to enable quality improvement

The primary aim of the Service is to ensure people can access urgent eyecare within primary care, utilising the established trained workforce in optical practices.
 
This is essential to reduce demand on primary care including general practice and pharmacy, and the pressures on the hospital eye services during the coronavirus (Covid-19) pandemic, and inform the requirements for service development for the recovery phase that will follow 

The service objectives are to: 

• Deliver a COVID-19 urgent eye care service to people, from optical practices, acting as urgent eye care hubs, in the community as set out in NHS England Publication approval reference: 001559. 
• Improve access to local timely care for patients with urgent ocular presentations, reducing the need to travel to the hospital 
• Identify at risk and confirmed people with COVID-19 and, where patient needs aren’t met by remote consultation within the service, refer to appropriate services with advice on restrictions to access.
• Deliver clinical triage, assessment, treatment and advice by telephone or video to reduce the need for face-to-face contact, where appropriate, avoiding the need for many patients to leave their home. 
• Provide face to face consultations where required in some optical practices,
• Apply appropriate social distancing and infection control measures where a face-to-face consultation is required.  
• Facilitate urgent and emergency eye referrals, where necessary, following local referral protocols (Alerting where the patient reports symptoms of Covid-19, or is in an at-risk group)
• Ensure the knowledge and skills of the optical practice workforce (Optometrists, Dispensing Opticians and Contact lens Opticians) are utilised as primary health care providers. 
• Provide an equivalent remote service to people who are house-bound or shielding during the period of COVID-19.
• Provide access to specialist ophthalmic advice and guidance and remote prescribing when required to support practitioner clinical decision making and treatment. 
• Support compliance with COVID-19 control measures and follow best practice PPE guidance relating to infection control (Service policies and protocols will be regularly updated in line with national Public Health England (PHE) guidance ) 
• Consider a single point of access (SPoA) when required to ensure patients are directed to the most suitable care setting/service with the appropriate level of urgency.

The Service will provide initial contact, telephone triage, remote consultations and where necessary face to face assessments and management of recent onset symptomatic or urgent ocular presentations.

The Service will maintain a minimum number of face to face patient interactions by:

• adopting remote consultation by the most appropriate clinician
• triage to the most appropriate clinician if a face to face appointment is necessary
• optimising each consultation with ophthalmologist, or optometrist with independent prescribing advice & guidance, where appropriate.

Initial telephone contact and access to clinical triage – access to the Service is restricted to telephone booking only, to:

• identify people with Covid-19 symptoms, at risk /self-isolating people to signpost to appropriate services. 
• offer telephone/ video consultation and selfcare advice or provide signed orders remotely, where appropriate
• offer face to face appointments with optometrist following telephone/video consultations for those who are presenting with urgent and higher risk symptoms (observing PPE guidance and social distancing advice)
• Signpost to emergency services, as appropriate.

Urgent Eye Care – see Patient Pathway and Service Risk Stratification, Conditions and Pathway documents. The Service might typically include people presenting with a red or painful eye, foreign body, sudden change in vision, or flashes and floaters which might suggest retinal detachment, who would otherwise present to general practice, hospital services and A&E.

Patients can self-present (by telephone) or be referred / redirected from other services for clinical assessment and management.

• The Service will utilise current clinical capability within optical practice 
• Should a local optical practice be closed, a recorded telephone message will redirect the caller to the nearest optical practice, acting as an urgent eyecare hub. 
• By accepting redirected referrals from the Hospital Eye Service for assessment / continued care
• The Service will recognise that where available, optometrists with higher qualifications (independent prescribing and higher qualifications from the College of Optometrists e.g. glaucoma qualifications) will be able to manage a broader scope of eye conditions, initiate treatment and deliver care as necessary, as well as supporting other practitioners with advice and guidance as required. 
• Optometrists without  higher qualifications can be supported in decision making and providing treatment through advice, guidance and remote prescribing from the hospital eye service
• It is accepted that in many areas, referrals to ophthalmology may require clinical discussion first (or by email if not urgent) with an ophthalmologist to explore alternative management options thereby reducing the need to attend hospital, provide additional advice and guidance, determine the appropriate timing for attendance or agree a collaborative approach for patient management.

The main priority is to address the need for the rapid commissioning, and implementation of, an accessible urgent eye care service in areas without an existing CCG commissioned primary eye care pathway for the duration of the coronavirus (COVID-19) pandemic as outlined in NHS England Publication approval reference: 001559. 

The Service should be commissioned as a minimum on an ICS/STP footprint using existing commissioning relationships and mechanisms. Where appropriate, larger regional groupings may wish to commission at a larger scale.  In health communities where a prime provider is already involved in the delivery of locally commissioned optometric services, commissioners should expect to continue using this mechanism to deliver and manage the CUES service. Commissioners without such relationships should consider their use to deliver the CUES service.

Across England, many CCGs hold primary eye care service contracts for the delivery of Minor Eye Conditions (MECS). Some CCGs and primary eye care services have already agreed amended service delivery specifications to use the skills of primary eye care practitioners to triage, manage and prioritise patients presenting with an urgent eye condition. This Service specification is not intended to interfere with locally agreed arrangements to manage the COVID-19 pandemic, where they are working well. However, the patient pathway, and the risk stratification / service pathway may serve as a guide to optimise existing services to the standards laid out in the service specification.

Any service requires clinical leadership in enabling and assuring the delivery of high-quality care. The Service will therefore provide effective clinical leadership using the principles of multidisciplinary and organisational collaboration, training, clinical governance and clinical audit.  

A locally based clinical lead optometrist will oversee the implementation and performance management of the Service, and will work in partnership with the Trust clinical lead ophthalmologist to agree local pathways; revisions to local ophthalmology triage guidelines, joint care protocols and support responsive service co-developments, as required. 

Emergent pandemics are times of high uncertainty, the commissioners and service provider and local ophthalmology department will need to work collaboratively to adapt and develop the service to best meet the immediate and intermediate needs of the local health care system, for the duration of the pandemic. 

Working in an integrated way with local ophthalmology teams the Service has the potential to provide a basis for offering further support during the recovery of routine hospital eye services:

For discussion, the following could include (but should not be limited to):

• Ophthalmology (or single point of) advice and guidance (may not be available from service implementation).  A dedicated advice & guidance phone line with rapid access to senior clinician/decision maker and prescriber would support collaborative management.
• Single Point of Access – to support signposting / transfer of patients between secondary and primary care - this could include redirected referrals following triage by HES urgent care / A&E.  
• Post-operative care – delivered from optical practice following a hospital-initiated management plan 
• Support for ongoing HES follow up care - data gathering to support HES virtual assessments (visual acuity / IOP / wound healing / imaging / OCT) 
• Telemedicine could be explored to further develop the offer in optical practice.  

The detailed Service delivery model and supporting documents are provided below:

The Service  will be accessible to all adult and child patients presenting with an urgent eye condition, although it is envisaged that the majority of users will be registered with a GP within the relevant ICS/STP boundary. 

The Service will accommodate those who are not registered with any GP but are resident and eligible for NHS care e.g. members of travelling communities, homeless people.

Acceptance:

People self-presenting with an urgent eye condition requiring consultation (Closed door policies apply with telephone booking only)

Patients referred to the Service by another health care provider (e.g. GP or following hospital triage).

Exclusion:

People with a minor eye condition or long-term condition who already have an appropriate management plan.

People with an eyecare need that is best met within essential GOS services

Note - People identified with Covid-19 symptoms, confirmed Covid-19 infection or in one of the at-risk groups must be managed by remote consultation or referral, as they will not be offered a face-to-face consultation within the service. 

• Ophthalmology providers  
• Local Optical Committees  
• GPs and their practice staff 
• Pharmacy practice staff 
• Primary optical practice staff 

All Providers are expected to maintain secure patient records, and when required, cooperate and securely share (e.g. NHS mail) information with others involved in a patients’ clinical care, treatment and support while having regard to the patients’ right to confidentiality.

Health professionals delivering services must be registered with the regulatory body (General Optical Council) as appropriate to their profession and must adhere to the professional standards and codes of practice set out by that body. 

• NICE Guidelines
• The College of Optometrists Guidance for Professional Practice
• The College of Optometrists Clinical Management Guidelines.
• Local guidelines between optometrists and ophthalmology with a reasonably comprehensive list of conditions /urgency/setting for care (NB guidelines will need to be agreed for the service and not for each and every local Trust).

The provider will demonstrate that there are clear organisation governance systems and structures, with clear lines of accountability and responsibility. The provider will ensure clinical and corporate governance processes are in place to include:

• Full recording of clinical notes       
• Incident reporting (jointly, where appropriate)
• Infection control
• Serious Incidents (SIs) reporting & investigation 
• Quality assurance
• Patient confidentiality 
• Clear policies to manage risk and procedures to identify and remedy poor professional performance
• Clear mechanisms for where joint reporting/management of incidents/complaints/SIs, clinical audit and learning shared across whole pathway including optometrists and HES (as rapid reporting and learning will be required for such a new and rapidly implemented service).
• Escalation routes are set out clearly with problems being solved as early as possible 
• Communication and sharing information take place with all partners at the appropriate level 

There will be a locally based clinical lead optometrist for the Service who will support local implementation of the service pathway working closely with the Trust clinical lead ophthalmologist, as necessary. The clinical lead optometrist and the clinical lead ophthalmologist will also act as their respective service clinical governance leads. Working collaboratively across the system, as governance leads, they should review and recommend updates to the service specification, subject to CCG approval, in light of performance and clinical governance data and to manage safety issues detected after initial implementation. If there are multiple Trust clinical leads for ophthalmology, wherever practicable, one will act as the single lead ophthalmologist to liaise with the service clinical lead optometrist and facilitate interactions with, and support from, other Trust ophthalmology leads to any clinical details and clinical governance for the service.

Once the service is in place, there should be remote updates to provide a learning forum for all practitioners delivering urgent care. This could be organised by the clinical leads and delivered by senior /HQ/IP optometrists, local ophthalmologists via webinar. Provider to consider email groups or regular telecalls to support learning and anonymised case discussions, feedback learning on good practice, incidents etc. 

Audit and performance measures to be agreed between optometric and ophthalmic leads and any other regional leads. 

Essential data collection 

• Numbers of patients seen, and in which type of care delivery
• Every clinical interaction and outcome must be recorded by optical practices
• Adherence to local clinical protocols
• Serious Incidents and incidents of inappropriate care
• Other audits as requested by the commissioner

Retrospective audit

• Number of patients diverted from HES because of alternative provision
• Total number of appointments by type (remote & face to face)
• Number of follow up appointments by type (remote & face to face) 
• Number ofF2F in optical practice 
• Audit of HES referrals received 
• HES delays in treatment and impact on patient outcomes
• Overall patient experience/satisfaction

Clinical Council for Eye Health Commissioning (CCEHC) System and Assurance Framework for Eye-health (SAFE) – Emergency and Urgent Care [ADD LINK HERE]. Published November 2018. 

NICE Guideline Age-related macular degeneration [NG82] published January 2018.

Royal College of Ophthalmologists, The Way Forward - Emergency Eye Care 2017.  

Clinical Council for Eye Health Commissioning (CCEHC) SAFE: Quality Indicators for Commissioning. Published March 2018.  

Clinical Council for Eye Health Commissioning - Primary Eye Care Framework (2018).

Guidance is subject to regular update, the following websites are regularly updated 

•    NHS England: A new guidance webpage for primary care - contains all COVID-19 resources for primary care, including the optical SOP. 

•    UK Government.

•    The College of Optometrists - COVID guidance and updates for practice.

•    ABDO advice to members.

•    RCOphth guidance  - COVID guidance COVID-19 clinical guidance for ophthalmologists (from a HES perspective)

•    Protecting Patients, Protecting Staff.

•    Association of Optometrist guidance relating to COVID -19

Consider inclusion in the development of local referral protocols

None

None

Primary optical practices holding a General Ophthalmic Services contract