Care pathways for glaucoma detection and monitoring in the UK

Abstract

Glaucoma presents considerable challenges in providing clinically and cost-effective care pathways. While UK population screening is not seen as justifiable, arrangements for case finding have historically been considered relatively ineffective. Detection challenges include an undetected disease burden, whether from populations failing to access services or difficulties in delivering effective case-finding strategies, and a high false positive rate from referrals via traditional case finding pathways. The enhanced General Ophthalmic Service (GOS) in Scotland and locally commissioned glaucoma referral filtering services (GRFS) elsewhere have undoubtedly reduced false positive referrals, and there is emerging evidence of effectiveness of these pathways. At the same time, it is recognised that implementing GRFS does not intrinsically reduce the burden of undetected glaucoma and late presentation, and obvious challenges remain. In terms of diagnosis and monitoring, considerable growth in capacity remains essential, and non-medical health care professional (HCP) co-management and virtual clinics continue to be important solutions in offering requisite capacity. National guidelines, commissioning recommendations, and the Common Clinical Competency Framework have clarified requirements for such services, including recommendations on training and accreditation of HCPs. At the same time, the nature of consultant-delivered care and expectations on the glaucoma specialist's role has evolved alongside these developments. Despite progress in recent decades, given projected capacity requirements, further care pathways innovations appear mandated. While the timeline for implementing potential artificial intelligence innovations in streamlining care pathways is far from established, the glaucoma burden presents an expectation that such developments will need to be at the vanguard of future developments.

Fig. 1

GERS care pathway example from the Manchester scheme (after Gunn et al. 2018). In the traditional model referral for suspect glaucoma is via the GP. In the GERS pathway, the accredited optometrist, post examination, either makes a direct referral to Manchester Royal Eye Hospital (MREH) for specialist assessment or discharges the patient from the scheme

Fig. 2

Timeline chart incorporating key legislation, guidelines, safety alerts and key professional developments in the three decades between 1989 and 2019. The figure shows the wider context and enablers for progression of non-medical HCP’s engagement in glaucoma care pathways beyond those traditionally encountered in previous decades. Key to acronyms: IP (independent prescribing); CoO (College of Optometrists); GRRS (Glaucoma Referral Refinement Scheme); GOC (General Optical Council); DoH (Department of Health); NICE (National Institute for Health Care and Excellence); NPSA (National Patient Safety Agency); GOS (General Ophthalmic Service); HQ (Higher Qualification); SIGN (Scottish Intercollegiate Guidelines Network); and CCC (Common Clinical Competency)

Fig. 3

Clinical Council for Eye Health Commissioning (CCEHC) System and Assurance Framework for Eye-health (SAFE) Glaucoma Service System

Fig. 4

The Local Optical Support Unit (LOCSU) has developed an integrated service pathway made available to local optical committees and commissioners to consider as a tool for developing glaucoma care pathways for monitoring patients with glaucoma and related conditions in the community