RNIB – supporting people with sight lossResearch briefing

Expanding community eye care for glaucoma: a pilot Ophthalmic Diagnostic and Treatment CentreAuthor: Helen Lee; Publisher: RNIB; Year of Publication: 2015Revised: February 2016

Key findings from the evaluationWith the successful implementation of an optometry-led Ophthalmic Diagnostic and Treatment Centre (ODTC) for glaucoma: Waiting times between appointments were reduced. The hospital rescheduled fewer appointments in general

ophthalmology outpatient clinics. Although one in four appointments at the ODTC were rescheduled adding, on average, 29 days between appointments.

Patient satisfaction with the ODTC was almost universal.

The lack of readily available routine data with which to identify glaucoma patients and their appointment activity presented challenges to the evaluation of the pilot.

The actual cost of the ODTC pilot was £291.56 per patient seen; this includes significant staff training costs. Without training costs, and assuming the ODTC was to operate at full capacity with no DNAs (did not attend) the cost would be £122.48 per patient.

BackgroundGlaucoma is the second most common cause of certified sight loss in the UK. 3,291 people in England and 192 people in Wales aged over 40 were certified as visually impaired due to glaucoma, between 1st April 2012 and 31st March 2013 (1). With early detection and treatment of ocular hypertension and glaucoma visual field loss can often be prevented or minimized. There is an

RNIB charity numbers 226227, SC039 316 and 1109

association between people experiencing high rates of socioeconomic deprivation and presenting in health care settings with advanced glaucoma (2, 3, 4, 5).

There is increasing demand on ophthalmology departments but without increasing resource this has led to a serious problem of lack of capacity. This has resulted in follow-up appointments being delayed and many incidences of patients not receiving appropriate treatment in a timely fashion (6). Recent research conducted for RNIB Cymru found Consultant Ophthalmologists in six Welsh Health Boards stating that patients are losing their sight due to excessive waiting times (7).

In 2011 RNIB began work with Cwm Taf Health Board in South Wales to explore barriers to accessing eye care services and identify potential interventions to prevent avoidable sight loss. Public Health Wales conducted an eye health equity profile (8) and Shared Intelligence undertook qualitative research with service users and service providers (9). Informed by these pieces of work it was agreed that RNIB and Cwm Taf Health Board would work in partnership to pilot a new service for people with ocular hypertension and ‘stable’ glaucoma. The service is called an Ophthalmic Diagnostic and Treatment Centre (ODTC).

The development and implementation of ODTCs to help manage capacity issues within ophthalmology departments and improve the patient pathway is central to the Welsh Government’s, five year Eye Health Care Delivery Plan (2013). This pilot project was designed to gather learning prior to the roll out of ODTCs; to consider patient flow, assess impact on quality of service, patient satisfaction, waiting times and attendance at both the ODCT and consultant led ophthalmology clinics.

MethodsThe Ophthalmic Diagnostic and Treatment Centre (ODTC) was designed to provide a service for people aged over 40 living in a

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particular area of high socioeconomic deprivation within the Rhondda Valley. The ODTC aimed to: Reduce waiting times for the management of people with stable

glaucoma and ocular hypertension. Improve patient satisfaction offering a more flexible service

closer to home. Improve service uptake and reduce non-attendance at

secondary care glaucoma clinics.

The service was located in a local community hospital and was originally designed to be led by a specialist nurse managing a team of technicians, seeing patients with ‘stable’ glaucoma and ocular hypertension. Patients with ‘stable’ glaucoma refers to those who, for a period of two years have: experienced no new symptoms which could be attributable to progressive visual deterioration (such as a drop in acuity or subjective change of a paracentral visual field defect); intraocular pressure remaining below a level satisfactory for the individual patient; no change in the optic disc appearance; and no significant change in visual field.

Over the period of implementation the service evolved to be optometry-led, seeing patients with suspect, stable and ‘simple’ glaucoma and ocular hypertension. More information about the changes in staffing are provided in the process evaluation section of this briefing. ‘Simple’ glaucoma refers to patients who do not require consultant care (unlike complex cases) but may not have been ‘stable’ for two years.

The service was nurse-led from July 2012 to June 2013; in July 2013 it became optometrist led. Evaluation data was collected until mid November 2014. Cwm Taf Health Board has continued to fund the ODTC beyond the lifetime of the pilot project.

London School of Hygiene and Tropical Medicine (LSHTM) conducted independent process, outcome and economic

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evaluation of the pilot. There were five components of the evaluation: 1. Analysis of routine hospital data2. Patient satisfaction surveys conducted before and after the

introduction of the new services 3. Follow-up interviews with patients attending the ODTC 4. Process interviews with key people involved in the

development, implementation and delivery of the ODTC5. A cost consequence analysis.

The evaluation included a comparison group of patients with ‘stable’ or ‘simple’ glaucoma living in the Cynon Valley and using ophthalmology services in various local hospitals.

The evaluation was granted NHS ethical approval from Bromley Research Ethics Committee (11/LO/1264) and local Research & Development (R&D) office approval from Cwm Taf Health Board (CT/214/80513/11/12).

Findings from analysis of routine dataFor baseline data appointment activity of 1,429 patients was analysed for a minimum of one year prior to the opening of the ODTC. One third of patients (435/1,429) were from the intervention area.

For the follow up period, once the ODTC was operating as an optometry-led, appointment data for 1,412 patients was analysed. As at baseline nearly a third of patients were from the intervention site (421/1,421).

At baseline: The mean interval between appointments (excluding new

referrals) was 160 days. The average waiting time between appointments was

significantly longer for people from the intervention area. People in the intervention area waited on average 208 days compared

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to those from the comparison site who waited on average 137 days.

Over one in five follow-up appointments were rescheduled by the hospital (23%) adding on average 48 days to the interval between appointments.

Newly referred patients did not experience rescheduling of appointments to the same extent as continuing patients, which may be related to performance targets.

Only 5% of patients did not attend (DNA) their ophthalmology outpatient appointment.

At follow up: The mean number of days between appointments for patients

from the intervention area reduced 208 days to 126 days for those seen at the non-ODTC clinics and 111 days for those seen at the ODTC.

There was no longer a significant difference in waiting times between appointments for patients from the intervention and comparison areas.

Rescheduling of appointments at non-ODTC clinics was reduced to 10% (compared to 23% at baseline) adding an average of 53 days to the interval between appointments.

However, 25% of appointments were rescheduled for patients attending the ODTC. On average extending the interval between appointments by 29 days.

Only 4.6% of patients did not attend (DNA) at the ODTC clinic and 3.6% of non-ODTC clinics.

At the same time as the ODTC was established the general ophthalmology outpatient clinics were reorganised.

The table below summarises this information. Measure At baseline At follow up

Non-ODTC clinics

ODTC

The mean interval between

160 days 126 days 111 days

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appointmentsAppointments cancelled by the hospital

23% 10% 25%

Extra days added due to hospital rescheduling

48 days 53 days 29 days

Patient did not attend (DNA)

5% 4% 5%

The lack of readily available routine data with which to identify glaucoma patients and their appointment activity presented challenges to the evaluation of the pilot. It is also likely to inhibit effective service planning. At the outset of the project it was assumed non attendance by patients (DNAs) was a significant problem that the ODTC would help to address. Once the independent evaluators LSHTM had analysed hospital data it became apparent that DNAs were at such a low level there was little room for improvement; however hospital initiated cancellation were a significant problem.

Findings from the patient satisfaction surveyAt baseline: 86 usable questionnaires were completed by glaucoma patients

attending general ophthalmology clinics; 24 were from the intervention area and 59 from the comparison site.

66% of patients thought it important to see a doctor. 48% of patients were shown how to administer their eye drops.

At follow up: 112 useable questionnaires were completed, 53 from ODTC

and 59 from the general ophthalmology clinic. Patients at the ODTC travelled less distance, were less likely to

use a car and incurred less travel costs.

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Only 26% felt it important to see a doctor compared to 66% at baseline.

In response to an open question, patients most commonly reported that they didn’t mind who they saw as long as

“they know what they are doing”; “are qualified”; “properly trained”; and “know their job”.

ODTC patients were younger than those seen elsewhere and a lower proportion reported co-morbidities.

Fewer ODTC patients reported being ‘bothered’ by their treatment.

50% of ODTC patients reported being shown how to use their drops and 71% of patients in general ophthalmology clinics compared to 48% of patients at baseline.

The table below summarises this information. Measure At baseline At follow up

Non-ODTC clinics

ODTC

Usable questionnaires 86 59 53Felt it important to see a doctor

66% 43% 26%

Shown how to administer eye drops

48% 71% 50%

Process evaluationStaffing and testsTelephone interviews were conducted with six staff members involved in developing and implementing the ODTC.

It was originally intended that that ODTC in the Rhondda Valley would be led by a specialist nurse, supported by two Band 3 ophthalmic technicians. The nurse would provide: Patients with advice about treatment adherence. Visual fields interpretation.

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Optic disc assessment. Stereo-disc photography.The ophthalmic technicians would conduct: Visual acuity (Snellen). Visual fields (field of vision). Pachymetry (thickness of the cornea). Goldmann Applanation tonometry (inner eye pressure). Pharmacological dilatation of the pupils (shape and appearance

of the optic nerve).

However, a number of challenges emerged with this arrangement. Most importantly perhaps it was realised that the lead person needed more diagnostic expertise if the ODTC was to save time and provide efficiencies.

The rural location of the Rhondda Valley ODTC was found to be one of the major reasons why a nurse-led model did not prove suitable. The ODTC was not located close to a specialist ophthalmology- led clinic, so if any concerns emerged, it was not possible for staff to easily ask the consultant to assess and advise, or simply redirect the patient from the ODTC back into the general clinic, without additional appointments. During the pilot phase the ODTC was not linked to ophthalmology practitioners electronically. In the absence of specialist training pathways for nurses in this field, the development of the necessary expertise relied on learning through experience ‘on the job’. The lack of sufficiently specialist skills, combined with the lack of electronic/digital facilities to share data, necessitated referring patients from the ODTC back into the hospital system for a second opinion. While this was essential for the safety and well-being of patients, it undermined one of the original aims: namely to reduce the necessity for patients to attend the hospital out-patient clinics.

Therefore a decision was made to appoint two part-time optometrists in place of the specialist nurse to lead a team of ophthalmic technicians. In preparation for leading the ODTC the

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optometrists worked alongside the consultant ophthalmologist for several months. The optometrists competency for seeing patients within the ODTC was established by competency based supervised practice, working alongside the consultant ophthalmologist in his general clinic prior to starting in ODTC.

In line with NICE guidance (10) the optometrists leading the ODTC had specialist qualifications in glaucoma management. One had a post graduate certificate in ‘Optometric Management of Glaucoma’ from City University London, and the other had a diploma in glaucoma from WOPEC (Wales Optometry Postgraduate Education Centre) as well as the College of Optometrist’s professional certificate in glaucoma. In addition the optometrists had considerable experience working alongside the Consultant Ophthalmologist managing the treatment of patients with OHT and glaucoma. The Consultant Ophthalmologist gave consent for the optometrists to lead the ODTC once they had completed specific training with him and he was confident of their competency to diagnose, monitor, treat and detect change in clinical status of patients with OHT, simple and stable glaucoma.

Once deemed competent, the consultant would review the notes of the patients seen on a weekly basis. There is no national electronic patient record (EPR) available; therefore the consultant would review the notes, visual fields and 3D images the following day prior to starting his own clinic. Any discrepancies between findings and decision making were highlighted to the optometrist. In addition to this, patients who showed deterioration of their visual field, disc appearance or control of inter-ocular pressure at the ODTC were booked back into the consultant led clinic. Therefore review of ODTC findings also happened as part of the process of clinicians reviewing patient’s notes prior to seeing a patient. Consultant support was available for the ODTC provided by non glaucoma consultant led clinics running alongside the ODTC and specialist Glaucoma advice was available by telephone from the District General Hospital. With two optometrists working in the

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clinic, inter-optometry peer support and review was available between staff.

Within the ODTC the optometrists provided advice to patients about treatment adherence, examined patients, reviewed their conditions, analysed the results of the tests conducted by technicians and prescribed, advised, or referred accordingly. If optometrists noted some concerns, such as the deterioration of a patient’s condition, but felt these were not major enough to warrant a referral to the hospital, they could make another appointment sooner than they would routinely and so keep the patient under closer review. If, for example, a cataract was detected, the optometrists could refer the patient directly for an operation without the patient having to be seen in the ophthalmologist’s clinic first for a referral to surgery. They also undertook gonioscopy tests (to assess the angle in the eye where the iris meets the cornea).

There was not consensus about whether a remotely based ODTC needs to be led by an optometrist or a specialist nurse but rather a strong feeling the lead health professional requires specialist training to ensure they have the necessary insight, experience and diagnostic skills.

The ODTC enabled patients to have additional tests during a single visit. Previously patients would have attended a separate clinic for a visual field test.

Criteria for seeing patients: stable or simple glaucomaThe original intention was that the ODTC would see patients with stable glaucoma. However it became apparent that in practice this was not a reliable basis for selection, as any such diagnosis or conclusion can quickly become out of date. So when the service became optometry-led the criteria for selecting patients was revised, from ‘stable’ to ’simple’, meaning that most patients with glaucoma and OHT in the geographical catchment area aged who were aged over 40 effectively became eligible.

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Patient perspectiveIn-depth interviews were conducted with twelve patients attending the ODTC.

Most were unaware of the type of professional they saw, for example, ‘Mr A’s deputy’, ‘specialist nurse’, ‘a nice young man’.Patients’ main concern was that the health professional was someone who ‘knows what they’re doing’.

Patients who had previously attended the Royal Glamorgan Hospital were asked if they had experienced hospital initiated cancellation of appointments. Several had, and they described it as happening frequently and often the rescheduled appointment was also cancelled. Feelings about this were mixed. Some people did not see it as a problem if the appointment is quickly rescheduled. However one patient described being concerned about the high pressure in her eyes as she was due to be seen in six months but ended up waiting twelve months before being seen.

Patients were asked about their experience of time spent with staff and information provided at the ODTC as compared to the general ophthalmology clinic. However they were not able to comment on any differences. It is probable that patients will have to attend fewer appointments at the ODTC compared to attending ophthalmology outpatient clinics because visual field tests are conducted during the one appointment alongside other tests and examinations.

Economic evaluation

A cost consequence analysis (CCA) was conducted. CCA is similar to a cost-effectiveness analysis in terms of the questions addressed, but is applied to evaluate interventions with more than one outcome. Health and non-health outcomes are identified and quantified, but not valued or combined into a comparable single

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measure. Costs were ascertained for expenditure on staff (including training), equipment and consumables. Actual expenditure on clinical and support (secretarial, medical records and reception) staff was included. The actual costs of the resources used were used even when these differed from what was planned.

The staff included one optometrist (Band 7), one half time receptionist (Band 2) and another half time receptionist (Band 3), two technicians (Band 3) and a service manager (Band 8) for the last six weeks of the pilot. During the project, a clinic manager (Band 8) replaced a technician (Band 3) who left in order to allow the pilot to continue, but for only one of the two weekly clinics.

Training the optometrists was an important aspect of the pilot. Using the hourly cost of the consultant and the optometrists, we multiplied this by the number of training sessions undertaken over the course of the pilot.

Equipment used at the ODTC had a longer life span than the duration of the pilot so the costs were calculated on a pro-rata monthly basis. The Pachymeter and 3D Kowa camera were estimated to have a five year lifespan, the 3D Kowa camera, the Humphrey Field Analyser and Slit Lamp had a ten year lifespan, and the visual chart had a 15 year. Maintenance costs were not included, due to lack of data, which should be noted as a limitation, and may result in the equipment costs being under-estimated.

Total project costs and cost per patient identifiedThe total cost of the ODTC for the six month period (1/07/13-31/12/13) was estimated to be £67,350 and the cost per patient seen £291.56. This includes the resources actually used, and takes account of DNAs. If there were no DNAs, the cost per person seen would be £229.08. If the ODTC had run at full capacity (with every available slot filled and without any DNAs) we estimated the cost per patient seen would have been £191.06.

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Summary of costs and outcomes over six month period for ODTC (July-Dec 2013).Programme Costs Programme Outcomes

TOTAL STAFF COSTS  

CLINICS & APPOINTMENTS  

Clinical £42,428.87Total no. of clinics scheduled 48

Non-clinical £12,955.58Total no. of clinics cancelled 1

   Total no. of appointments available 353

TOTAL £55,384.45

APPOINTMENTS & PATIENTS  

TOTAL EQUIPMENT HIRE & Consumables No. of booked appts 294

Equipment hire £11,602.24 No. of attended appts 231

Consumables £363.58 Appointments attended78.6%

TOTAL £11,965.82 D.N.A rate 5.4%

C.N.A rate15.3%

Cost per patient seen (with DNAs) £291.56Cost per person if no DNAs £229.08Cost per person if at full capacity & no DNAs £191.06

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TOTAL £67,350.27

Clinic capacityThe total number of clinics over the six month period was 47 (with an additional one clinic cancelled). There were two weekly clinic sessions, one on Mondays lasting 3.5 hours and the other on Wednesdays lasting 4 hours. Each appointment slot was 30 minutes, so this translates to seven slots available at the Monday clinic and eight slots at the Wednesday clinic. The potential capacity during the six months was 352 patients, although this might not allow for time within the session to do admin or non-patient facing clinical work, therefore this may not be feasible. 294 appointments were booked over the six months, and 231 patients were seen (the DNA rate was 5.4%).

CostsStaff costs accounted for 82.23% of the total costs (clinical staff costs were 76.61% of all staffing costs). Equipment and consumables accounted for 17.8% and consumables less than 1% of the total cost.

Training of the optometrists by the consultant took up 36% of the total costs or 44% of the staff costs. It is estimated that it cost £12,141 to train each optometrist. The consultant trained each optometrist over the duration of the six month period for a total of 42 sessions. Each optometrist was trained on alternative weeks, so each one received 21 training sessions. Any roll out, or up scaling of the ODTC model would need to include training costs if additional optometrists were required. However, once trained, and if employing the same optometrist, more clinic sessions could be added which would bring down the cost per patient seen over a longer time period.

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It is estimated that the total equipment cost over the six month period was £11,602, or £1,934 per month, not including maintenance costs.

Sensitivity analysisThe evaluators tested the model using alternative assumptions, to estimate how the cost per patient differed if, for example, capacity was increased and DNAs were decreased. It would be unfeasible to expect no DNAs, but possibly the number of empty slots could be minimised if there was a system of overbooking, or additional/alternative appointment reminders were in place.

The clinic ran at 83% capacity if the number of appointment slots available were compared to the number of appointments booked. However, when we compared the number of appointments attended to the number of slots available, then it could be interpreted that the clinic ran at approximately 65% capacity. But, as this was a pilot intervention, we had to consider the set up costs (including training) and lead-in time, so a full capacity of 353 patients was probably not feasible or realistic, at least in the short-term. Nevertheless, when we calculated 85% capacity, 300 patients could be seen (or 60 patients more than were actually seen in the pilot). This figure is very close the actual number of appointments booked (n=294) indicating that it would be worth considering an over-booking process to allow for DNAs and to better fill the capacity available.

Cost per patient seenActual pilot costs (including training)

‘Scenario B’ Optometrist led (recurrent costs with no training)

With 5.4% DNAs £291.56 £186.91With no DNAs (clinic offering slots at 85%

£229.08 £146.85

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capacity)If at full capacity and no DNAs

£191.06 £122.48

Error: Reference source not foundsummarises the various modelled costs per patient seen. The middle line would be the most realistic, as these calculations were based on the number of appointments booked and correspond to the more ‘realistic’ 85% capacity described above.

Scenario B – Ongoing Optometrist Service, without training/set up costs

Summary of ‘Scenario B’ - Optometrist Led Clinic as a recurrent 6 month cost (no training included)Programme Costs

TOTAL STAFF COSTS  

Clinical £19,489.73Non-clinical £11,719.80   TOTAL £31,209.53

TOTAL EQUIPMENT HIRE & Consumables

Equipment hire £11,602.24Consumables £363.58TOTAL £11,965.82

Cost per patient £186.91

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seen (with DNAs)Cost per person if no DNAs £146.85Cost per person if at full capacity & no DNAs £122.48

TOTAL £43,175.35

In scenario B the training costs were removed to estimate the recurrent costs of an established optometrist led service, and these estimates could be used to calculate the expected ongoing costs.

Removing the training element, the total programme costs over the six month period fell to £43,175. If calculated over a longer time period (past the initial set up period) the costs would decrease by almost 36%, as training would not be required. The cost per patient seen was £186.91 assuming DNAs were still 5.4%. If there were no DNAs, then the costs per person seen in Scenario B was £148.85 and running at full clinic capacity with no DNAs, the cost reduced to £122.48 per patient.

Comparison of ODTC with usual careAlthough a cost consequence analysis does not set out to calculate the incremental cost of one service compared to another, it is possible to make some assumptions based on published figures. The ODTC was designed to provide a one-stop shop, whereby all necessary appointments were provided in the same visit. In ‘usual care’ patients attend three separate outpatient appointments’; a visual field test, then on another day a photograph, and on a third occasion an appointment with a doctor. The published cost of an ophthalmology outpatient appointment is £106 for first appointments and £60 for follow ups (11), so the

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estimated cost of usual care is £226 assuming one first appointment and two follow ups. We estimated that the cost of a person seen in an ODTC setting ranged between £122.48 and £291.56. The range is wide because we have calculated a range of scenarios, some less feasible than others (i.e. assuming full capacity and no DNAs which is highly unlikely).

The highest end of the range, is for a new and developing service such as the one presented in this report (where training accounted for 36% and attendance was 65% of full capacity). A realistic comparator, in a fully established service would be £146.85 assuming the clinic were running at 85% capacity, or £187.79 if training of one optometrist were included (data not shown).

In summary The actual cost of the ODTC pilot was £291.56 per patient; this

includes significant staff training costs. The cost of running an ongoing ODTC service without including

initial staff training costs, assuming 85% capacity and 5% DNAs would be £186.91.

If the ODTC was operating at full capacity without training costs and assuming no DNAs the cost would be £122.48 per patient.

ConclusionThe pilot ODTC in the Rhondda Valley has resulted in reduced waiting times between appointments for patients. Patient satisfaction was near universal, and patients from the Rhondda seen at the ODTC travelled less distance, were less likely to travel by car and incurred less cost than patients from the intervention area seen at other clinics. Patients attending the ODTC generally had to attend fewer appointments compared to those attending consultant led ophthalmology outpatient clinics. This is because at the ODTC visual field tests were conducted during the one appointment alongside other tests and examinations.

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The increased capacity that the ODTC provides appears to have had a positive effect on general ophthalmology clinics in that a lower proportion of patients experience hospital initiated rescheduling of appointments. However rescheduling of appointments at the ODTC was significant.

Recommendations1. Disseminate learning from this pilot project across Wales and

the rest of the UK to inform the development of eye care service delivery, to help increase capacity within glaucoma clinics and therefore ensure patients’ receive timely treatment.

2. Our pilot indicated that Ophthalmic Diagnostic and Treatment Centres (ODTC) can be led by a range of eye health professionals including ophthalmic nurses or optometrists. It is however essential these professionals receive specialist training to ensure they have appropriate expertise and diagnostic skills.

3. Hospital data about attendance at glaucoma ophthalmology outpatient clinics improved over the lifetime of the project. It is essential that detailed, accurate and update information is available on attendance and outcomes from outpatient ophthalmology clinics to monitor and evaluate the impact of services and enable effective service planning.

4. Adherence to treatment for glaucoma and ocular hypertension can be problematic for patients, changes in lifestyle, co-morbidities etc effect people’s ability to comply with treatment regimes. It is therefore recommended that treatment adherence is routinely discussed with patients in all glaucoma clinics.

5. It became apparent through this pilot study that hospital initiated rescheduling of appointments was a significant issue in both consultant led ophthalmology clinics and the ODTC. This is problematic for patient care and increases the risk of patients being ‘lost’ in the system. It is recommended that examples of good practice are identified where

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ophthalmology services have reduced rescheduling of appointments and these are shared throughout the UK to improve patient care.

Acknowledgments RNIB is grateful for the support of staff within the Cwm Taf Health Board for the development and implementation of the ODTC particularly Craige Wilson, Assistant Director of Operations; Mark Deacon, Head of Orthoptics and Manager of ODTC; Jay Menon Consultant Ophthalmologist with specialist interest in Glaucoma; Lynne Neale Eye Clinic Nurse Manager; Sue Brooks the Eye Clinic Liaison Officer.

This pilot project could not have been undertaken without the support and guidance of members of the Advisory Group: Michael Austin, Consultant Ophthalmologist, Abertawe Bro Morgannwg University Health Board; Sian Biddyr, Eye Health Promotion Manager, RNIB Cymru; Shaun Leamon, RNIB; Selwyn Jones, Optometrist.

The independent evaluation reported here was undertaken by a team at London School of Hygiene and Tropical Medicine led by Wendy Macdowall, including Dalya Marks, Jessica Datta and Elizabeth Holdsworth.

References(1)Leamon, S., Davies, M., (2014) Number of adults and

children certified with sight impairment and severe sight impairment in England and Wales: April 2012 to March 2013. RNIB

(2)R., Wood, F., (2010) A glaucoma equity profile: correlating disease distribution with service provision and uptake in a population in Northern England, UK. Eye 24:1478-85

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(3)Fraser, S., Bunce, C., Wormald, R., Brunner, E. (2001) Deprivation and late presentation of glaucoma: case-control study. Br Med J 322:639-43

(4)Ng, W.S., Agarwal, P.K., Sidiki, S., McKay, L., Townend, J., Azuara-Blanco, A., (2010) The effect of socio-economic deprivation on severity of glaucoma at presentation. Br J Ophthalmol 94:85-7

(5)Sukumar, S., Spencer, F., Fenerty, C., Harper, R., Henson, D., (2009) The influence of socioeconomic and clinical factors upon the presenting visual field status of patients with glaucoma. Eye 23:1038-44

(6)National Patient Safety Agency (2009) Rapid Response Report. Preventing delay to follow up for patients with glaucoma. NHS National Patient Safety Agency.

(7)Boyce, T., (2014) Real patients coming to real harm. Ophthalmology services in Wales. RNIB Cymru

(8)Reilly, R., Humphreys, C., (2011) Cwm Taf Eye Health Equity Profile. Public Health Wales NHS Trust http://www.wales.nhs.uk/sitesplus/922/page/49905 (accessed 15/7/15)

(9)Richardson, I., (2012) The barriers and enablers that affect access to primary and secondary eye care services – Cwm Taf site report. RNIB

(10) NICE Glaucoma: diagnosis and management CG85, April 2009

(11) NHS Payment By Results Tariff 2013-14. https://www.gov.uk/government/publications/payment-by-results-pbr-operational-guidance-and-tariffs (accessed 15/7/15)

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