One trust has streamlined its referral system for cataract operations - and reduced waiting times dramatically. Bill Stevenson and Pauline Neal report

A faster, direct-referral scheme for cataract removal, and a reduction in the number of hospital visits, has been the outcome of a project run by Peterborough Hospitals trust in its drive to provide a modern, dependable health service. The NHS Executive published its good-practice guidance in this area under the title Action on Cataracts. The trust has not only implemented all the recommendations but surpassed them with the avoidance of pre-operative outpatient attendance.

This pilot project is a model for any trust considering improving services, even when national support or funding is not forthcoming. Peterborough was short listed for the cataract project, but even though not selected, the trust decided to continue developing ideas for best practice treatment for cataract extraction.

Work on the project began in January 1999, with six weekly evening workshops for GPs, optometrists, surgeons, nursing and managerial staff. The multidisciplinary team was in keeping with the trust's modernisation approach of linking primary and secondary care. The cataract initiative is one example of how this approach has helped the trust review many of its services, both emergency and elective.

The optometrists who took part responded to a general invitation from the trust to meet to develop a better system for patients, making maximum use of their skills. The starting point was to review the process for cataract diagnosis and treatment and develop an alternative pathway.

Training sessions organised by ophthalmic surgeon Anthony Hall provided guidance for suitable cataract referral. Optometrists worked closely with the hospital to agree assessment scoring forms and a new referral mechanism. The idea was that local optometrists would make an informed decision about patients' suitability for routine cataract surgery and contact the hospital for an agreed appointment date - one example of Peterborough's involvement in the national booked admissions programme.

This approach encourages more active participation in the process by the optometrist, who has become involved in not only carrying out eye tests, but also in outlining consent advice, explaining the removal procedure and providing patients with a cataract information leaflet. Patients leave the optometrist with an agreed date for their operation and a health-check questionnaire to complete and return to the hospital.

Nursing staff in the ophthalmology department check the questionnaire when they receive it, and phone the patient to discuss any problems or pre-existing conditions. This is a further opportunity to provide information about the procedure and answer any questions.

Under this system a patient's first hospital visit is on the day of the operation. A further improvement is that take home eye drops are dispensed early to avoid delay to the patient's discharge.

A co-ordinator post created from a medical secretary vacancy enabled the development of fast-track appointment systems and waiting-list management. This provides a single point of contact for optometrists, GPs and patients, who value the personal service and opportunity to discuss their treatment and dates.

Since the pilot project started in September 1999,99 patients have been referred for routine cataract removal.

Of these,81 have undergone surgery, and 14 have had second eye operations.The full clinical audit in March showed that this approach has improved waiting times and increased patient satisfaction levels (see box).When asked if they would recommend this service to others, the overwhelming response from patients was positive.

The consultant's perception is that the patients are better informed and appear to know more about their condition and the operation because of the short time between consultation with the optometrist and the actual procedure. In Peterborough, before the pilot outpatient waits could be up to five months.

Deterioration in eyesight is a major problem for elderly people, whose numbers are increasing.The knock-on effect of shorter waiting times for routine cataract removal is a benefit to all patients requiring ophthalmology services, as the demand on outpatient appointments diminishes.And GPs have more time to deal with other patients.

Several factors have contributed to the pilot's success.

Delivery of a timely and appropriate patient service was an objective shared by the local multidisciplinary team, and the project thrived on the basis of equal partnership and ownership.

The trust was also fortunate in having a well-established change management team, the transformation project, which has experience in bringing together local health and public service organisations to develop services.The project manager, a member of the transformation project team, was able to dedicate 80 per cent of her time and workload to managing the cataract project.

This involved facilitating workshops, visiting GPs, optometrists and meeting patients; gathering data to support the change; producing documentation and forms to support the new process; ensuring ongoing evaluation and review of the pilot progress; and communicating with, and supporting, all the participating disciplines.

The ophthalmology department in Peterborough is well placed to manage a fast-track direct referral system, as it is a stand-alone unit with its own theatre and consulting rooms.Crucially, it was agreed that any budgetary support, such as additional equipment, needed would be forthcoming.

Next steps At its meeting in April the project team discussed expanding the number of trained optometrists referring directly as a second phase of the programme, now that it has been fully audited.

Early evaluation has identified initial variances in the optometrists' scoring of the assessment forms VA and VF14, and these will be redesigned.The scoring threshold will be set at the next meeting.

The project team will publicise the final results of the programme evaluation before the proposed third element, involving all optometrists, which is scheduled for October 2000.

An optometrists' training programme needs to be agreed to ensure a robust assessment and referra l system .

A mechanism is also required to allow continuous evaluation and monitoring of both the fast-track cataract referral process and the impact of this on ophthalmology services as a whole.

Peterborough's vision of streamlining a protracted process that used to involve multiple visits to GPs, opticians and the hospital has been realised.As a result of a partnership approach and a willingness to embrace change, local people can now visit their community optometrist and leave with a time and date for surgery waiting or visiting an outpatient department.We are proud to demonstrate a best-practice example of a 21st century service.

Clinical audit results

57 per cent of patients had their operation within two to four weeks of the date of referral.

36 per cent of patients waited less than two weeks.

Almost three-quarters of patients had their appointment agreed with the hospital while with the optometrist.

One patient who was referred did not meet the criteria due to health problems and the appointment was cancelled, with a date given for reassessment in clinic.

One patient was referred before the cataract was suitable for surgery and the patient was booked on to the waiting list.

Every patient involved in the scheme completed their health-check questionnaire.

Pat ients were comfortable having a telephone conversation with the ophthalmology nurse regarding their health.

Optometrists have played a significant role in providing patient information.

Key points

A fast-track scheme for cataract removal has achieved operations for 56 per cent of patients within four weeks of referral.

More than a third of patients waited less than two weeks.

The scheme is popular with patients whose first hospital appointment is on the day of operation.

Bill Stevenson is director of organisational development and Pauline Neal is transformation project lead, Peterborough Hospitals trust.