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Today the Healthcare Safety Investigation Branch (HSIB) has released a new report investigating the lack of timely monitoring of patients with glaucoma.
It focuses on the case of a 34-year old woman who lost her sight as a result of delayed follow-up appointments, over a period of 13 months, due to a lack of capacity within her local hospital eye service. The report highlights the wider national context, citing research by the British Ophthalmology Surveillance Unit which found around 22 patients a month suffer severe or permanent sight loss as a result of these delays.
The HSIB report makes seven recommendations to the Royal College of Ophthalmologists, NHS England/Improvement, NHS Digital and the International Glaucoma Association. These are aimed at addressing the capacity issues facing hospital eye services and looking to strengthen reporting arrangements and compliance against performance standards for the follow-up appointments.
Sadly, this issue is not a new one. In a report to the Public Administration Select Committee in 2003, Dr Richard Harrad (Clinical Director of the Bristol Eye Hospital) highlighted concerns about the cancellation and delay of follow-up appointments resulting in a loss of vision for patients.  At the time he drew the connection with seeking to achieve waiting times targets for new outpatient appointments at the expense of follow-up appointments. This is also an issue that the HSIB report highlights, noting that ‘(t)he national 18-week referral to treatment target prioritises newly referred patients over those requiring follow-up’.
Building on National Institute for Health and Care Excellence (NICE) guidance for best practice in diagnosis and follow-up standards in glaucoma diagnosis and management, the National Patient Safety Agency (NPSA) published a report on this in 2009. It drew on 135 cases from the National Reporting and Learning System where patients had ‘lost their sight or suffered deterioration in their vision because appointments are postponed, cancelled or patients are not put into the follow up system at all’.
This NPSA report highlighted the scale of the problem and provided a rationale and compliance checklist so that commissioners could 'use evidence on delayed or cancelled follow-up appointments for patients with glaucoma as part of a needs assessment plan’.
Patient Safety Learning welcomes the HSIB report. Given the history of failing to address this important patient safety issue in the last two decades, can patients feel confident that change will now happen? The urgency of implementation is heightened in the context of future demographic changes, as it is predicted by the year 2035 that there will be a 44% increase in the number of people living with glaucoma.
There are three areas which we believe are of particular importance if these recommendations are to be implemented effectively:
HSIB make recommendations to several different organisations. This will require coordination and leadership to ensure that this report leads to change and safer care. Who is responsible and accountable for leading and delivering the changes required? Some of the most substantive recommendations around ensuring compliance and monitoring performance around follow-up appointments sit with NHS England/Improvement. Are they best placed to lead on this overall? Or is this an issue for the Department of Health and Social Care? And if not either of them, then who?
2) Targets that don’t deliver safer care
The HSIB report highlights the challenge of adequately prioritising follow-up appointments for patients who are at the greatest risk of avoidable sight loss when NHS targets prioritise initial appointments. When setting performance targets we believe that there should be a patient safety impact assessment undertaken as an integral part of the process in both their formation and implementation. Without this, there is a risk that decision makers will not be aware of any unintended consequences and patient safety could be compromised.
We consider that part of the problem is that patient safety is typically treated as one of several strategic priorities and in practice this means that it can inevitably be traded off against other priorities. We believe that patient safety is part of the purpose of health care and should not be negotiable.
3) Shared Learning
The HSIB report references good practice and learning that can help to tackle problems around delays in glaucoma follow-up appointments.
One example is the use of High Impact Interventions issued by NHS England which detail the risk controls needed to reduce the risk of harm to patients when faced by capacity issues. The report states that NHS England has been sharing these resources but notes that while ‘national leadership has driven forward change, these risk controls are not fully in place in many trusts.’
There are no recommendations in the report that relate to shared learning, so we believe that there is a real danger that these techniques remain limited to pockets of good practice. We consider that NHS England/Improvement and others should to enable information to be shared in a more systematic way and that organisations should be required (not just advised) to implement good practice. We think that organisations should be held to account if they do not do so. At Patient Safety Learning we look to share information on the risk of unsafe care and good practice to improve patient safety on the hub, our online platform for patient safety.
Healthcare Safety Investigation Branch, Lack of timely monitoring of patients with glaucoma, January 2020. https://www.hsib.org.uk/investigations-cases/lack-timely-monitoring-patients-glaucoma/final-report/
Foot, B and MacEwen, C.J, Surveillance of Sight Loss due to delay in ophthalmic treatment or review: frequency, cause and outcome, Eye 2017. https://www.nature.com/articles/eye20171
Public Administration Select Committee, On Target? Government By Measurement: Fifth Report of Session 2002-03 – Volume 1, July 2003. https://publications.parliament.uk/pa/cm200203/cmselect/cmpubadm/62/62.pdf
National Patient Safety Agency, Rapid Response Report NPSA/2009/RRR004: Preventing delay to follow up for patients with glaucoma, 2009. https://www.rcophth.ac.uk/wp-content/uploads/2015/01/NPSA_RRR_on_glaucoma_2009_supporting_info.pdf
Healthcare Safety Investigation Branch, Latest HSIB report highlights ‘devastating’ impact of delays and pressure on national glaucoma services, 9 January 2020. https://www.hsib.org.uk/news/latest-hsib-report-highlights-devastating-impact-of-delays-and-pressure-on-national-glaucoma-services/