These were the key projects for the Retinal Outreach, Integration and Research Health Integration Team (RENOIR HIT).
Developing outreach clinics
RENOIR HIT’s biggest project was developing a modernised system of outreach clinics using new imaging technologies to monitor and treat patients with age-related macular degeneration and retinal problems, such as those due to diabetes. The team implemented a hub and spoke system, whereby training, leadership and initial assessments take place at Bristol Eye Hospital, and when patients have been moved into a care pathway, further monitoring and some treatment takes place at an outreach clinic.
Sited at convenient locations for patients in Bristol, North Somerset and South Gloucestershire, the clinics use a virtual retinal photography system manned by technicians to produce high-definition scans of each patient’s retina. Consultants and medical staff at a central location can then study the computer images to decide on the best treatment options. Treatment clinics are also held at the outreach locations for particular groups of patients.
The team opened a new site at South Bristol Community Hospital in July 2013, followed by a site at a GP practice in Worle, close to Weston-Super-Mare, in October 2014, and a mobile retinal treatment unit for patients in north Bristol followed in May 2016. All these services have received excellent feedback from the patients using them. Ninety-eight per cent of patients rate the new service as very good or excellent, with the remaining 2 per cent rating them as good.
Using staff more cost-effectively
The team extended the role of optometrists in the delivery of care for both retinal disorders as well as glaucoma. Optometrists now undertake much of the routine follow-up management for patients with glaucoma and macular degeneration.
They have also increased the role of technical staff in the management of patients with retinal disorders, so that they can take on tasks that were previously undertaken by nurses, but in a more cost-effective way. The role nurses has been extended to include the delivery of intravitreal therapies, previously only undertaken by doctors and therefore significantly increasing cost-efficient service delivery.
Using new information technologies in service delivery
Bristol Eye Hospital (BEH) has kept full electronic patient records (EPR) for patients with retinal disorders since 2007, and runs ‘paperless’ clinics for certain retinal conditions. This has led to a rich clinical database, ensuring good outcomes and governance whilst facilitating further research, and non-commissioned income generation.
The retinal team at BEH has been at the forefront nationally for the increased use of optical coherence tomography (OCT) and photographic assessments for patients with retinal disorders. More than 40 per cent of all diabetic retinopathy follow-ups are seen in this more cost-effective way.
The use of electronic patient records and networked imaging has enabled the development of outreach clinics, where patients attend for imaging assessments. The images are examined back in the ‘hub’ at Bristol Eye Hospital by trained staff. Further wide-field imaging developments have allowed greater numbers of patients to be followed up in imaging clinics, further increasing capacity and efficiency.
Developing care pathways for patients with retinal disorders
Categorising patients into the relevant care pathways hugely improves the efficiency of a service. For example some patients can be followed up with imaging alone, others need intravitreal treatment, while others will need laser treatment. The electronic patient record dataset has enabled the team to identify the patients suitable for each pathway.
The training of non-medical staff to assess certain patients appropriately facilitates decisions on patient treatment with minimal involvement from doctors. Consultant time is then reserved for more complex cases and treatments, supervision and training.