Statement on proposed new 2017/18 and 2018/19 National Tariff Payment System
The Royal College of Ophthalmologists (RCOphth) notes that this consultation was primarily for commissioners and providers under Section 118 of the Health & Social Care Act.
However, we have responded to the consultation as we feel strongly that the 2017/18 and 2018/19 National Tariff Payment System1 disadvantages some of the more vulnerable groups of eye care patients, specifically those that require follow-up appointments. The new tariff payment scheme will increase payment for new patients but reduce the tariff paid for review patients by 30%. The consultation closed 7 December.
The RCOphth had asked their clinical leads to discuss the new tariff payment system with their hospital/Trust finance directors to encourage them to respond to the consultation, which is now closed.
The government’s underlying aims to discourage unnecessary follow-ups, to see patients in the community, to increase numbers of new patients seen and stimulate new ways of working are recognised as important and are fully supported in the light of the demands placed on our specialty and which have been recognised as having detrimental effects on patient care.
Patient safety must be paramount. This proposal to alter the tariff system will place unnecessary pressure on departments to discharge patients at a time when there is no suitable community care option available. This suggests that it has been developed without considering the needs of patients with different conditions, especially those with chronic diseases.
It is widely recognised that patients with long-term eye conditions account for an increasing proportion of the activity in the healthcare system.
It is therefore vital that the needs and safety of this patient group are central to any consideration about the future of the healthcare system. Face to face follow up with a consultant is often the most appropriate form of care for these patients and clinicians should not be financially disincentivised from taking this course of action. This is even more important in cases where there is no safe and viable alternative in primary or community care.
Review patients are significantly more likely to have sight threatening pathology than new patients. The average new follow up appointment ratio for patients with glaucoma is 1:16, age related macular degeneration is 1:12 and diabetic eye disease is 1:12. This reflects the needs of the patients and the lack of service in the community to examine and treat these patients; in short, it is not possible to discharge them safely.
The RCOphth has already gathered evidence that the lack of capacity for follow up patients in the Hospital Eye Service has led to irreversible loss of vision in patients due to delay in clinical review. The ‘Surveillance of Sight Loss due to delay in ophthalmic review in the UK: Frequency, cause and outcome’2 study is building on evidence from the NSPA and NRLS over a 15-year period that demonstrates delayed management of follow up patients due to a lack of capacity in the system which is exacerbated by the 18 week RTT, as this acts as a perverse incentive to see review patients.
The unintended consequences of this change in the tariff system will be similar and will act as a further lever for patient harm, unless time is given to train and develop an adequate primary care workforce that can deal with the needs of these patient groups and data are gathered so that managers and clinicians can actively construct new care models and safe discharge policies.
Effects on primary care
The natural response to this change will be for clinicians to be instructed to discharge all patients after the first appointment, asking them to attend their GP for a new referral at the clinically indicated time for review. This will have a devastating effect on an already overburdened and under resourced primary care system. Appropriate training and capacity needs must be developed within the community (GPs and optometrists) to undertake this additional work. There is the additional consequence that these high risk patients will be lost to follow up under such a system.
Stop-gap measures such as the proposed changes to the tariff system for outpatient consultations will not tackle pressures on outpatient services in a safe and effective way. Investment in general practice and primary care, particularly in training for healthcare professionals in the wider general practice team to provide a greater range of services, is needed in order to achieve alternatives for these patients.
Energy should be focused on taking a more strategic review of the patient referral system and professional relationships across the primary and secondary care interface in order to ensure that GPs, optometrists and hospital doctors are aware of other available services and are therefore able to refer new patients or discharge outpatients to the appropriate care setting.
The RCOphth is working on feasibility projects of decreasing the number of new referrals into hospital eye services, such as the use of community optometry Minor Eye Conditions Schemes, glaucoma referral refinement and the use of technology (OCT) to reduce diabetic retinopathy referrals. Such schemes require recruitment, training and retention of healthcare professionals and agreed roles. Competencies for these roles are being developed.
Additional measures which allow for follow-up of suitable patients out of the hospital setting into more appropriate care settings3 are fully supported as is the development of other healthcare professionals to undertake some of this care. The Common Clinical Competency Framework4 sets out guidance for standardising competencies required by non-medical healthcare professionals.
The current situation is that there is neither the workforce, nor the capacity or systems outside hospitals that is able to deliver these services. It is estimated that the additional training required for HCPs will take up to two years to come into effect. Initial new funding will be required but this will lead to long-term savings.
The Royal College of Ophthalmologists is committed to ensuring that patients are treated in environments that are most convenient and most suited to their clinical needs and by the right professional with the appropriate skills in the right location. We would welcome discussions with NHS England about our concerns and the potential consequences brought about by the new tariff payment system. We are asking that the system remains unchanged for new and follow-up appointments until we can identify mechanisms within a realistic timeframe to do this safely and not compromise patient care.