Project Name: GHNHSFT One Stop hub and spoke service redesign Joint working

Project Summary:

At present newly diagnosed and existing patients with wAMD have to access ophthalmology imaging services (OCT) at GHNHSFT (Gloucestershire Royal Hospital and Cheltenham General Hospital acute sites).

Due to capacity constraints and the implementation of COVID-19 infection control measures throughput and capacity within for Medical Retina and other sub-specialty clinics has reduced. The increase in aging population has also led to a year-on-year increase in patient referrals.

This has led to significant delays in initial review and follow up appointments, resulting additional anxiety for patients and carers and increased pressure on a service which is already at capacity.

The Trust serves the population across Gloucestershire and has identified a possible opportunity to bring care closer to home by implementation of a hub and spoke model. Stroud has been identified as the Spoke site.

The aims of the project are to therefore:

  • Align ophthalmology services to the strategic priorities set out in the NHS LTP and GIRFT agenda by creating a ‘one stop service’ bringing care closer to home and thus improve patient access to ophthalmology services across Gloucestershire hospitals ensuring patients are seen in the most appropriate care setting.
  • Improve the management of wAMD through enhanced system architecture and purchase of additional equipment, ensuring new patients are seen and medically optimised earlier thus improving outcomes for patients with wAMD and within the other sub-specialties in the short, medium and longer-term.
  • Increase service capacity and efficiency by improved utilisation of space
  • Increase service capacity and efficiency by improved use of resource by empowering the wider workforce to better manage patient flow.
  • Facilitate the use of novel treatments and NICE guideline directed therapy for patients with wAMD.
  • To support the Trust in overcoming the challenges associated with implementing their post Covid-19 recovery plans.

Covid-19 has magnified Trust pressures around ophthalmology services causing further delay to treatment for patients. Therefore, working in partnership with Trust to create a community ‘one stop’ service which improves service delivery for patients leaving within this area and will result in improved quality of care for patients and address the unmet need for this locality.  This project will release space in the acute environments for patients living within their postcodes thus improving general access to care for a wider cohort of patients.

Planned Milestones:

  • Kick-off meeting held with key stakeholders to discuss / agree project plan and collection of baseline patient satisfaction scores.
  • Initiation of building works and pathway readiness including imaging installation.
  • Initiation of clinical activity at spoke sites
  • Collection and analysis of 3-month data
  • Collection and analysis of 6-month data
  • Collection and analysis of 9 month
  • Write up of methodology and case study
  • Submission of business case

Expected Benefits:

Anticipated Benefit to Patients

  • Reduction in waiting times for patients to receive treatment of wAMD therefore accelerating time to treatment and reducing risk of sight loss.
  • Reduction in waiting time for existing patients to access ophthalmology service’s and receive specialist input both within community and acute sites.
  • Reduction in the number of outpatient attendances at the main site and an increase in the number of patients seen closer to home thus reducing the burden on patients and carers.
  • Rapid, efficient access to wAMD services across the clinical pathway.
  • Improvement in patient reported outcomes and satisfaction scores through quality audit from baseline.
  • Improved access to all therapies for the treatment of wAMD.
  • Improved access all patients requiring intravitreal injection treatment
  • Improved access to appointment within virtual environment

Anticipated benefit to the NHS

  • Increase in total capacity to deliver MR service across all indications delivered through a one stop, one site community service.
  • Increase in total capacity to deliver other sub-specialty services within the acute environment.
  • Increase the number of patients able to access ophthalmology service’s and receive specialist input from baseline.
  • Rapid, efficient access to wAMD services across the clinical pathway.
  • Improvement in patient reported outcomes and satisfaction scores through quality audit from baseline.
  • Improved access to all therapies for the treatment of wAMD.

Anticipated benefit to Novartis

  • Improved access to innovative novel therapies for the treatment of wAMD.
  • Improvement in patient reported outcomes and satisfaction scores through quality audit from baseline.
  • Enhanced reputation as partner of choice in working in collaboration with the NHS. 

Start Date & Duration: April 2022 – October 2023 (18 months maximum. As per the Joint Working Agreement, the project will terminate upon its completion or 18 months following its commencement, whichever comes first).

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Project Name: GHNHSFT One Stop hub and spoke service redesign Joint working

Completion Date: April 2023 (As per the Joint Working Agreement, the project terminated upon its completion or 18 months following its commencement. The project was successfully completed in April 2023).

Outcome Summary:

  • Increase in total capacity for treatment of patients with wAMD in Stroud
  • Increase in the number of urgent retinal and rapid access slots released to routine retinal care patients
  • Increase in the proportion of patients receiving review and treatment in one visit to a site vs baseline
  • Increase in capacity for patients access to Optical Coherence Tomography (OCT) and colour photography services
  • Decrease in time AMD injection patient spends in the department on a treatment pathway
  • Increase in patient satisfaction measured from baseline

Key Project Outcomes Data:

  • Increase in proportion of patients receiving review and treatment in one visit to a site resulting in an additional 80-130 slots for wAMD patients each month
  • Increase in proportion of patients receiving review in one visit to a site meaning an extra 72-80 slots in virtual clinics each month
  • Creation of additional capacity for patients to access OCT services creating an additional 72-80 slots per month
  • Decrease in wait time in AMD injection pathway – Reduction of time in clinic from > 90 minutes to between 49 to 86 min with an average of 76 min.
  • Increase in patient satisfaction scores – increase in Excellent response from 82% to 88% to date. All other responses have been “very good” with no responses less than “very good.”
  • Number of urgent retinal and rapid access slots released in acute site, approximately 50 per month
  • 100% of patients polled 6 months post project start up felt they were treated with dignity and respect, were seen on time of their appointment and had full confidence in the staff treating them.

Outcomes:

The project began in 2020 to set up the first hub and spoke site in Gloucestershire for Ophthalmology virtual clinics and wAMD clinics allowing patients to be seen nearer to home and thus releasing capacity in the acute sites for other activity. 

Data was analysed to identify how many patients with wAMD resided within a 10-mile radius of Stroud General Hospital (SGH) and who upon clinical review would also be suitable for treatment at a hub and spoke site in either our virtual eye clinic or wAMD clinic. Patients were contacted to discuss their preference of treatment site; patients overwhelmingly chose SGH being to their homes.

The service started by running virtual eye clinics from June 2022 with wAMD clinics starting in August 2022, initially on reduced templates to ensure the smooth running of clinics for both staff and patients.  Both clinics are now running one day a week, every week of the month.  Month on month the efficiency of the clinics in relation to patient numbers has improved.

Outcomes:

Clinical:

  • The 2-week rapid access wait times are now being achieved
  • Increased wAMD capacity for follow up, helping with timely follow up for patients
  • Patients attending virtual clinics have the benefit of a doctor being on site in the wAMD clinic at the same time to assist with review for any urgent issues identified whereas they would otherwise have to come back for another appointment to see a doctor at a later date

Patient:

  • Patients feel like they are having a more personalised treatment pathway.
  • 100% of patients are being seen on time at SGH.
  • 100% of patients feel they are treated with dignity and respect and have confidence in the staff treating them.
  • Clinics are more orderly as less patients in waiting areas and not as many clinics running at the same time.
  • Patients feel staff have more time.
  • Patients benefit from free parking.
  • Regular patient satisfaction questionnaires show the satisfaction levels have increased.  Since starting patient feedback, the results have been excellent (currently 88% excellent and 12% very good) with patients commenting;

“Very pleased there is a new clinic in Stroud, much closer to home.  It was quiet in waiting room. The nurse explained everything.”

Nursing/OPD:

  • Closer working relationships built up between outpatient staff at SGH and the acute sites.
  • Training has taken place at the acute site for the SGH nurses, but the contact has continued post training with regular communication.
  • Nurses at SGH have developed extra clinical skills which should help with increase in job satisfaction.
  • IT links have been improved between the SGH and acute sites due to funds being spent to upgrade connections as part of this project.  This has impacted on other general and retinal clinics running on other days.
  • Equipment available for Ophthalmology clinics on site has improved due to kit bought as part of this project.

Doctors:

  • Community hospitals are a calmer environment for doctors to work within as they have less clinics running than the acute sites.
  • Ample opportunity to provide further teaching of injector skills to develop the staffing further.

It is hoped that the success of the wAMD and virtual eye clinics in Stroud General Hospital (SGH)can be replicated in other community hospitals.

Conclusion:

This project initiated the identification of the most vulnerable patients living within the Stroud vicinity and who, if suitable for treatment at a hub and spoke site, would feel the most impact on their patient experience and welfare by being treated closer to home. The improvements seen within the project will be continued and built up in respect of number of clinics running, patients seen and increased improvement in patient experience.

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