Manchester CUES demonstrates primary and secondary care partnership opportunity

22 June 2020

With early Covid-19 Urgent Eyecare Services now in operation, LOCSU is investigating its impact on patient outcomes and primary and secondary care practitioners.

In our latest podcast LOCSU CEO Richard Whittington and Interim Clinical Director Zoe Richmond talked to Robert Harper, Optometrist Consultant and Helen Wilson, Principal Optometrist Acute Eyecare at the Royal Manchester Eye Hospital to discuss CUES from a secondary care perspective, including the critical factors underpinning its success and what it has revealed about the potential for innovative, patient-centred, connected eyecare.

Links to the podcast appear at the end of this article.

CUES in Manchester – the right direction of travel

Reflecting on the perception of CUES from the perspective of secondary care, Robert Harper notes that at the Royal Manchester Eye Hospital the service has been received very positively. He attributes this to the existing strong engagement between hospital optometry and primary care optometry. Prior to the Covid-19 pandemic, discussions were already ongoing about how community-based services led by primary care could help alleviate some of the capacity challenges faced by the hospital, and CUES accelerated this initiative.

Robert also highlights two significant factors that underpin CUES’ feasibility:

the growing number of optometrists with OCT imaging facilities and expertise
the critical mass of optometrists with an independent prescribing qualification.

These open the doors to far broader provision in primary eyecare, as he explains: “This is an important factor to support having a broader case mix within the CUES service, allowing additional complexity to be managed in the community, taking it above and beyond what might have been achievable with the MECS.”

Helen agrees that engagement has underpinned the implementation of CUES. She leads the optometry input into emergency services at Manchester Eye Hospital and she and her colleagues have been integral to training primary care optometrists in independent prescribing, developing models and guidance to allow them to manage a greater range of conditions with confidence.

Zoe emphasises that this is exactly what CUES was designed to achieve: “The core principle of CUES is the focus on building long term relationships between primary and secondary care for the development of the primary care workforce and better use of the equipment and estate in primary care.” She continues: “We wanted to recognise the whole workforce and we were acutely aware that we have optometrists in primary care who have their hands tied behind their backs. They can use their skills in some roles in hospital eye services, but in their own practices they can’t. CUES delivers all this. That’s why CUES is fit for the future and is the foundation on which we need to build.”

The patient benefits are tangible too, as Helen explains: “Prior to the pandemic we were seeing in excess of 100 patients attending our walk-in service every day and it was getting unmanageable. Patients with recurring conditions would far rather get their prescriptions from their local optometrist than wait four hours in the eye department of the hospital.” She also emphasises that secondary care staff are very supportive of CUES. “From the emergency eye department perspective and that of our nurse practitioners, we all want this to work. When patients attend the department either as a walk-in or by phone, we can now advise them that there are alternatives that we didn’t have before.”

Connectivity is critical

Connectivity is a critical component. CUES has been commissioned in Manchester in combination with the OPERA platform (Optometric Electronic Referral and Assessment). This brings NHS IT-approved infrastructure into primary care allowing direct referral through the NHS e-Referral Service (e-RS) to the hospital, allowing images to be transferred and enabling two-way communication between primary and secondary care.

This opens huge doors, as Zoe explains: “Until recently advice and guidance from secondary to primary care wasn’t a reality. There wasn’t a direct relationship between primary care optometry and the hospital team. With CUES and the IT platform around it we’ve got the connectivity to allow ophthalmology advice and guidance to optometrists in primary care. Consultations can happen in primary care, directly supported by the hospital team, meaning that patient doesn’t have to go to hospital at all; they can be fully managed in primary care.”

Clever Commissioning: getting the right patient seen by the right person in the right setting

How can the benefits CUES is delivering be sustained into the post-COVID environment? Ultimately, says Robert, we need to eliminate tensions between primary and secondary care and work on the basis that it is about ensuring that “the right patient is seen by the right person in the right setting.” This, agreed all, relies on clever commissioning.

Unpicking that idea, Zoe explained: “We need to be delivering as much as we can to each patient before we make a referral, but we also need to be able to pull in advice and guidance from hospital colleagues at the right time. We need to make every patient contact count – this is what we should keep at the core of a new model of care.”

Doing this requires the right ethos when approaching commissioning, Robert says: “I believe we’re all interested in the fundamental aim of improving patient care and public eye health. It shouldn’t be a case of people wanting to hang on to work that could more appropriately be done by others. But equally, if that work is being delivered elsewhere in the sector and continues to involve input from secondary care, clever commissioning would ensure there is motivation from both primary care and secondary care to contribute to that improved pathway and the roles and responsibilities of all parties concerned in those care episodes are reflected in the funding that is allocated to that care activity. We need that ethos at the heart of commissioning to make it work.”

Driving innovation in patient-centred care

The innovation prompted by COVID-19 needs to continue and, believes Zoe, clever commissioning should be about allowing innovation. “Clinicians should be able to come together and develop new models of ideas and shared outcomes… and, because commissioning is done locally, we need a mechanism for sharing those models, learning and improvements – that’s a key part of LOCSU’s role.”

As the discussion continued, it became clear that there is a once-in-a-generation opportunity to evolve from previously ingrained practices and to look at how what might have been seen initially as workarounds – such as virtual consultations – are proving safe, convenient, just as effective as previous methods and often preferred by patients. It was also noted that, rather than talking about condition-specific treatment pathways, discussion in the sector is now tending to be more centred around the patient and mechanisms for delivering care in the best way possible.

As Richard summed up: “Out of adversity often comes opportunity and there seems to be a strong appetite for making that a reality in the optical sector to develop a new, integrated way of working delivering extended services at scale for the benefit of patients.”