There is a lot of rhetoric about moving care closer to home but how easy is it and can quality be maintained?

There is a lot of rhetoric about moving care closer to home but how easy is it and can quality be maintained?

Buckinghamshire PCT thinks so, and has accredited Practice Networks to offer primary care ophthalmology on its patch. The company is paid on a cost per case basis, rather than a block contract, so it is down to Practice Networks to drum up the work.

'We need to encourage GPs and optometrists to refer to us,' says Debbie Raven, chief operations officer for practice network services, a division of Practice Networks.

The service had already been running for six years for the former Chiltern and South Buckinghamshire PCT, headed up by Dr Lyn Jenkins, a GP and opthalmologist. Dr Jenkins had worked in hospital, and started the service when he returned to general practice. He received 30 referrals each month.

Dr Jenkins went into partnership with Practice Networks and is now the company's clinical lead for primary care ophthalmology. The service currently receives 60 referrals each month, after just one month in its new form.

Ms Raven says: 'The [PCT] merger gave us the opportunity to look at what was a fantastic service, but on a small scale.'

What about quality? This has been validated through an audit by an independent consultant. She judged that the primary care ophthalmology service has equivalent standards of care to a hospital-based service.

Clinical governance requirements are met through regular audit and appraisal by an independent consultant in ophthalmology. But as Ms Raven points out, access is better.

The service operates as a hub and spoke model. All referrals are faxed into the same administrative team. They are classified as 'routine', for patients who need to be seen within a month, or 'as soon', which means within two weeks.

But at the moment, all patients are being seen within two weeks, compared to the hospital target of 18 weeks. For urgent cases, the referrer phones in, then faxes the referral and patients are seen the same day.

Depending on the urgency of the case, when the administrative team phones the patient to offer them an appointment, they are given a choice of location and time. At the moment, there is a choice of six clinics across Buckinghamshire, based in GP surgeries and community hospitals, but this is set to rise to seven or eight.

The company has a couple of teams who offer clinics in various locations daily throughout the patch.They use equipment from GP surgeries, along with their own mobile equipment. Each team has a specialist nurse, ophthalmologist, ophthalmology assistant, and a primary care ophthalmic practitioner - an optometrist with a diploma in ophthalmology. Appointments are organised so the most appropriate professional sees the patient.

So, access is better, but what about cost? A first appointment costs£65 in primary care, compared to more than£100 under the tariff. Follow-up appointments are between£35 and£50. Minor operations, laser treatments and plugs each cost£80, which is substantially lower than the tariff price.

The service provides value for money, and Dr Jenkins estimates it can treat around 60 per cent of patients who are currently seen in secondary care. The target is to to refer less than ten per cent of patients on to the hospital eye service, and this is being hit.

The PCT is getting value for money, but what do patients think? A patient satisfaction questionnaire is sent to every tenth patient, and people say they like the access and quickness of the service. Patients also like the fact that the service is closer to their homes. They find it less intimidating and more relaxed because it is not in a hospital.Results are with their GP or optometrist within a week, and if a follow-up appointment is needed, it is made while the patient is there. Ms Raven says: 'Patients like the fact that the circle is being completed while they're with us.'

GPs have given a mixed response. 'We would like to see more referrals from GPs,' says Ms Raven. 'This is a new service and everybody feels threatened by change, but generally they are coming on board and referring to us.'

Around 40 per cent of referrals come from GPs, and the remainder from optometrists, who Ms Raven says 'love the easy access'.

Practice Networks is keen to not only accept referrals from GPs and optometrists, but to subcontract them for work. GPs and optometrists who want to take a diploma in ophthalmology can attend the primary care ophthalmology clinics for mentoring.' We're very keen to work in partnership with local communities,' Ms Raven adds.

Practice Networks is also keen to expand the service, and is currently in talks with two other PCTs, who can decide on a block contract, or can follow Buckinghamshire and opt for a cost per case deal.

Jennifer Taylor