A tarnished reputation

[Andrew MacLean]

For all its shortcomings, I still maintain that I get a first rate service from the same clinic that dealt my son such a crushing disappointment. I do know of practitioners in Glasgow who operate on the basis of a lot of experience of KC, and we have the benefit of the glasgow Caledonian University where they teach optometrists and operate a contact lens service.

That said, I have come to know and trust the optometry team at the hospital clinic and I know the clinic administrator. What I do not know is who needs to tie up the information that lurks somewhere in their system so that people are not discharged for no reason.

Andrew

[Lynn White]

Ali

I agree with much of what you say. However, it is precisely because CL fitting was centralised 15 or so years ago that we now have the situation that "normal" optometrists have little experience of the various irregular cornea conditions. And obviously, I do not advocate simply setting people adrift to go to "any" optometrist. As with any other condition, if there was a shared care scheme, it would involve accreditation which in itself requires training and a necessity to demonstrate skills in this area.

What I have been trying to say is that continued care of keratoconus in the hospital system is reliant on funding and this is beginning to be a real issue across the board in the NHS due to the general financial crisis. Not every area in the UK even has access to a hospital clinic and not all clinics have access to the wide range of lenses you list, often down to funding and/or expertise. I know this because I teach workshops to practitioners all over the country and the one factor that comes up time after time is the fact that provision for keratoconus is extremely patchy countrywide and there are areas where you cannot get NHS supply through hospitals OR contractors. I also know of contact lens clinics in hospitals where there are no corneal specialists and many other hospitals where you cannot get to see an ophthalmologist on the same day if there is a problem detected.

I also know that some hospitals themselves are looking for ways to get community optometrists involved to reduce clinic numbers, as they are finding it harder to cope within funding constrictions. For many mild, non progressing cases, there is no need for the expertise of a dedicated CL clinic. They could be dealt within the community with the hospital clinic acting as a safety net. There is also no need, technically speaking, for the hospital to be directly involved in supplying replacement lenses. This in itself is often a major problem to someone reliant on CLs for work etc.

I am not advocating "getting rid of clinics altogether", I am advocating shared care and giving patients choice to go to the High Street if it is appropriate. Being without lenses is not simply an inconvenience, it can cause people to lose jobs.

The current NHS system has been built up on the premise that there is no other course of management possible for keratoconics other than contact lens management until or if the person requires a corneal graft. In the last few years, we have seen a massive change in KC management. Corneal collagen cross linking (CXL) has revolutionised the way we think about KC. Together with INTACs, phakic implant and other techniques, there are many, mainly private, surgical options available to patients and it is now possible to think the previously unthinkable: that with early diagnosis, KC progression could be halted and treated successfully. This is indeed why many refractive surgery clinics are now treating KC.

This means that increasing numbers of KC patients can be fitted with less specialised contact lenses,or even standard commercial soft lenses and can be managed in the High Street. Yes, this means more education for optometrists and yes, this means more co-operation between community optometrists and hospitals. This is not an impossible task though!

All I am saying is: just because a system has been working well for a number of years does not mean there should never be change. The world moves on. When I first came into practice, a good part of my work was supplying extended wear contact lenses to patients who had had cataracts removed and much of this work was in hospital CL clinics. Now, patients have intra ocular implants and are managed with shared care schemes between community optoms and hospitals. I am sure no-one wants to go back to the way it was!

And to all who have excellent care through your own hospital: what I am trying to say is that this is not the case countrywide, it is not the fault of those that work within the system and it is equally not the fault of those who cannot get equitable care. Someone has to speak up for them and try and initiate improvements. And that is all I am doing!

Lynn

[Ali Akay]

Lynn

I am not sure how it would be cheaper for NHS for KC patients to be managed in the community. With a shared care scheme optoms would obviously need to be paid for the appointments, and the lenses (less patient's statutory charges where applicable). Its not good from patients' point of view, but having long waiting lists does keep the cost down as it limits the number of fittings! I am not advocating this as a good thing but it is a reality. When I have tried to get one hospital to increase the number of sessions I do to reduce the waiting list, I was told it couldnt be done as it would cost too much! I agree that a good shared care scheme might benefit the patients but I really cant see how it would reduce the cost, I think cost would actually escalate. As you know modern KC lenses arent exactly cheap, and its not uncommon to need several lenses to reach the optimum fit. Unfortunately, with the way things are at present, we are seeing a constant pressure to cut costs despite the governments's pledges that NHS is ringfenced from the cuts. I dont think its realistic when budgets of other departments are being cut so much, they're just being more underhand with NHS for political reasons.