Services for people at risk of developing glaucoma

This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg44

5 Service specification for services for people at risk of developing glaucoma

Commissioners should collaborate with clinicians, local stakeholders and service users when determining what is needed from services for people with ocular hypertension (OHT), suspected chronic open angle glaucoma (COAG) or COAG in order to meet local needs. The care pathway should be person-centred and integrated with other elements of care for people with glaucoma and other eye conditions.

Commissioners may wish to consider commissioning services for people at risk of developing glaucoma in several different ways, and mixed models of provision are likely to be appropriate within a local area. Commissioners may wish to take action to stimulate the local market if there are identified shortages of providers at any point in the pathway and should note that any qualified providers may include private or third sector providers.

Commissioners should ensure that the services they commission represent value for money and offer the best possible outcomes for their service users. Commissioners should refer to the NICE quality standard on glaucoma when commissioning services and should include quality statements and measures within the service specification element of the standard contract where appropriate. If poor performance is identified, commissioners can discuss the level of performance with their providers and address any issues and concerns before introducing more formal contractual remedies.

Commissioners may choose to use NICE quality standards to ensure that high-quality care is being commissioned through the contracting process, to establish key performance indicators as part of a tendering process and/or to incentivise provider performance by using the indicators in association with incentive payments such as Commissioning for Quality and Innovation (CQUIN).

Commissioners should ensure that they consider both the clinical and cost effectiveness of the service, and any related services, and take into account clinicians' and patient's and carers' views and those of other stakeholders when making commissioning decisions.

Table 3 includes considerations for commissioners when developing a contract specification for services for people at risk of developing glaucoma.

Table 3 Considerations for contract specification

Heading	Section	To be described in service specification
Purpose	Policy context	National policy drivers (see section 7). Evidence base (for example, NICE guidance and quality standards, NHS evidence).
	Local strategic context	Local commissioning drivers (for example, managing demand in the Hospital Eye Service, QIPP, CQUIN). Invest to save. Results of joint strategic needs assessment (JSNA).
	Aims and objectives of service	The expected outcomes of the service(s) (see section 1.1).
Service scope	Define service user groups	Demographic profile of the local population (age, gender, ethnicity, socio-economic status). Local recorded and expected prevalence of glaucoma, suspected COAG, OHT, diabetes, and moderate and high myopia. Evidence of inequalities in outcomes between specific groups. Number of Hospital Eye Service referrals and appointments relating to COAG, suspected COAG and OHT, including number of inappropriate referrals and false positives. Number of people currently being monitored and treated in the Hospital Eye Service, community-based ophthalmology services, community-based optometry services, and other relevant services including general practice. Number of people who see their GP and have a recorded incidence of glaucoma or OHT. Population groups that will be targeted.
	Inclusion and exclusion criteria	Define criteria for different elements of pathway, in accordance with NICE guidance and locally determined criteria. May include: IOP measure age diagnosis clinical status treatment indicated.
	Geographical population	Proportion of people living in urban and/or rural areas. Areas of higher-than-average need (for example, areas with a high population of older people or African and African-Caribbean groups). Population coverage required or geographical boundaries.
	Service description / care package	Mapping existing services for people with OHT, suspected COAG and COAG. Commissioning of core service components. Interface with other local services including social care, primary care, Hospital Eye Service, community optometry services, community ophthalmology.
Service delivery	Location	Service location(s), defining accessibility requirements. Integration with other services for people with glaucoma, other eye conditions, and for people with diabetes.
	Days/hours	Expected hours of operation, including days, evenings and weekends. Expected number of patients for assessment, diagnosis, monitoring and treatment, taking into account potential increased or decreased flow through the system
	Referral processes	Referral criteria and processes for people with raised intraocular pressure (IOP) alone, OHT, suspected COAG and COAG. Management of 'unable to attends' (UTAs) and 'did not attends' (DNAs). System for indicating urgency of referral.
	Response times	Needs-based and outcomes-based. Define monitoring times according to NICE guidance.
	Care pathways	Agreed clinical protocols or guidelines to support decision-making in the patient pathway. Pathways for people with complex needs and comorbidities.
	Discharge Processes	Process for discharge from services for people with a low risk of ever developing COAG and acceptable IOP, specifying patient-held management plan.
	Staffing	Profile of existing community- and hospital-based optometry and ophthalmology workforce, nurse specialists, orthoptists, GPs with special interest. Staffing levels to be funded: minimum band or levels of experience and competency and expected skill mix. Skill mix and competencies of staff for specific areas of care (for example, monitoring people with OHT or suspected COAG, referral refinement, management).
	Information sharing	Define information sharing, confidentiality and audit requirements, including IT support and infrastructure. Raising awareness of services for people at risk of developing glaucoma (do patients and health and social care professionals know how to access services?).
Quality assurance and clinical governance	Patient and public involvement	Processes to understand patient experience of glaucoma services in order to develop and monitor services. See also Patient experience online network. Expectations of how patient opinion, preference and experience will be used to inform service delivery (for example, focus groups, representation on working groups, and surveys). Monitoring of complaints and compliments and how they are used to inform service.
	Quality indicators	NICE quality standards define high-quality care. Patient satisfaction surveys and access to treatment. Define outcomes and (proxy) measures including outcomes provided within the NICE quality standard on glaucoma.
	Performance monitoring	Local need and demand for assessment, diagnosis, monitoring and treatment of people with OHT, suspected COAG and COAG. Impact of service(s) on referrals to Hospital Eye Service. Measurement of referrals, numbers of people receiving monitoring and treatment, number of discharges with patient-held management plan (to be determined locally using best evidence if national guidance not available).
	Equality	Measures to ensure equality of access to services, taking into account the risks of unintentional discrimination against groups who are often under-represented, such as people who do not speak English as a first language. Consider equity of access for people living within residential and nursing homes and those who are housebound; or people within prisons.
	Staff training and competency	Processes for monitoring clinical practice and competency, including professional registration, qualifications and clinical supervision arrangements. Skill mix and competencies required across the care pathway, including competencies required for assessing IOP, monitoring OHT and suspected COAG, prescribing and referral refinement. See Skills for Health for examples. Staff development – appraisal and personal development plans, and mandatory training.
	Audit	Specify expectations for audit, which may include change in patterns of referrals to the Hospital Eye Service.
	Staff and patient safety	Procedures for risk assessment. Formal procedures for incident reporting and monitoring. Address any safeguarding concerns and promote the welfare of vulnerable adults.
Activity Plan		Long-term impact of increased access to community-based or hospital-based services on referrals to other services. Long-term impact of improved diagnosis of OHT or suspected COAG on referrals to other services.
Cost	Value for money	Likely cost of new or additional services Anticipated set-up costs. How will pricing be set? Potential for better value for money. Are people at risk of developing glaucoma receiving the most appropriate services? Cost of facilities (for example, venue hire). QIPP. See the commissioning and benchmarking tool for further information.