1 Commissioning services for people at risk of developing glaucoma

1 Commissioning services for people at risk of developing glaucoma

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This guide for commissioners looks at commissioning services for the referral, diagnosis and monitoring of people at risk of developing glaucoma, defined as people with ocular hypertension (OHT) and people with suspected chronic open angle glaucoma (COAG). It does not look at commissioning services for people with diagnosed COAG.

COAG, suspected COAG and OHT are common conditions which, if not diagnosed and managed correctly, can lead to partial sightedness (sight impairment) and blindness (severe sight impairment). The conditions are usually asymptomatic until they are advanced, and many people will be unaware there is a problem with their eyes until severe visual damage has occurred.

People with an increased risk of developing COAG include:

  • people aged over 40 years

  • women (around 80% of people with COAG are women)

  • people with OHT

  • people with a family history of glaucoma

  • people of African or African-Caribbean family origin

  • people with diabetes

  • people with moderate and high myopia (short sightedness).

OHT is a major risk factor for developing COAG, although COAG can occur with or without raised eye pressure. OHT is defined as consistently or recurrently elevated intraocular pressure (IOP) greater than 21 mmHg. It is estimated that 3–5% of people over 40 have OHT: around 1 million people in England.

Approximately 10% of UK blindness registrations are attributed to glaucoma. Around half a million people are currently affected by COAG in England and there are around 300,000 first outpatient attendances for glaucoma in the Hospital Eye Service every year. The prevalence of OHT, suspected COAG and COAG, and demand for eye services is expected to increase because of an ageing population and public health issues such as the rising prevalence of obesity and diabetes.

People with OHT or suspected COAG, as well as people with normal IOP but a suspicious optic nerve head appearance and/or suspicious or equivocal visual field changes, should be routinely monitored. Early identification of OHT, suspected COAG and COAG, followed by monitoring and controlling the condition to prevent or minimise further damage, is crucial to maintaining sight.

Implementation of the NICE guidance to meet the quality standard for glaucoma, together with Department of Health proposals to address demand pressures on the Hospital Eye Service by commissioning community-based eye care services, may lead to improvements in the way services are configured[1]. In many areas this may require increased capacity for assessment and monitoring in the community.

1.1 Commissioning for outcomes

It is expected that achieving the high-quality care set out in the quality standard for glaucoma could contribute to a reduction in Certificate of Visual Impairment registration rates for glaucoma (CVI: sight impaired and severely sight impaired).

Commissioners should refer to NHS outcomes framework when commissioning services for people at risk of developing glaucoma. Commissioning services underpinned by the best available evidence and NICE quality standards may help commissioners and providers achieve the following outcomes:

  • enhancing quality of life for people with long-term conditions

  • ensuring that people have a positive experience of care

  • treating and caring for people in a safe environment and protecting them from avoidable harm.

Commissioning well-integrated whole pathway services for people with glaucoma may also contribute to:

  • reducing unnecessary referrals to the Hospital Eye Service

  • increasing capacity within Hospital Eye Service glaucoma clinics

  • reducing patient anxiety.

1.2 Key clinical and quality issues

Key clinical issues in providing an effective service for people at risk of developing glaucoma are:

  • managing demand pressure on the Hospital Eye Service for people with OHT and suspected glaucoma

  • ensuring that people receive all relevant diagnostic tests in accordance with NICE guidance, if COAG is suspected

  • ensuring people are referred to a suitably trained healthcare professional in a timely manner for a definite diagnosis if COAG is suspected

  • ensuring people with OHT or suspected COAG have a management plan formulated by a suitably trained healthcare professional

  • ensuring people diagnosed with suspected COAG or with OHT are monitored at intervals according to their risk of progressive loss of vision, in accordance with NICE guidance.

  • NICE has accredited the process used by NICE to produce guides for commissioners. Accreditation is valid for 5 years from November 2011 and applies to guides produced since November 2008 using the processes described in 'Process manual for developing guides from NICE for commissioners: Information for internal NICE teams' (2011). More information on accreditation can be viewed at www.nice.org.uk/accreditation