HERCULES

Background – pressure on NHS ophthalmology services

People fear blindness more than severe angina or kidney dialysis. Patients suffering chronic eye disease comprise a high-risk demographic for COVID-19 morbidity and mortality, most being elderly, many with multiple systemic comorbidities and disproportionately of Black, Asian & minority ethnic (BAME) heritage. The 2013 direct cost of NHS eye care was £3 billion, with a further £6 billion/year of indirect costs of sight loss.

The suspension of non-urgent NHS work during the COVID-19 pandemic led to millions of delayed healthcare appointments across the United Kingdom. Prior to the pandemic, 3,384 ophthalmology patients suffered follow-up delays of over 1 year, with 1% of these people suffering severe loss of vision. Across the pandemic, over one million NHS ophthalmology appointments were delayed, creating a huge backlog and the potential for thousands of cases of avoidable blindness, leading to a need to redesign how care is delivered.

A new way to deliver timely eye appointments

To help address these backlogs, a new pop-up diagnostic hub was opened in 2021 at a London shopping centre in a collaboration between UCL and Moorfields Eye Hospital. The new clinic, based in a retail unit at Brent Cross shopping centre, has been designed by a team of UCL architects and scientists led by Professor Paul J Foster (UCL Institute of Ophthalmology), and is part of a NIHR-supported research project. The clinic’s location enables some people to be seen closer to their homes, providing a convenient way for them to access diagnostic eye care.

Focusing on this new service, a team led by the UCL Department of Behavioural Science and Health is evaluating the implementation, efficiency, performance, and experiences of diagnostic hubs.

Our questions:

1.    What is the existing evidence about implementation, outcomes, and value of rapid diagnostic hubs?
2.    What are patients’ preferences for rapid diagnostic hubs for people with stable chronic eye conditions?
3.    Which factors influence implementation and delivery of care in these rapid diagnostic hubs?
4.    How do staff and patients experience these rapid diagnostic hubs?
5.    What are the effects of different models/forms of rapid diagnosis hubs on delivery of care and patient outcomes?
6.    Do rapid diagnostic hubs deliver cost effective and value-based health care?

What we will do:

•    Reviewing the evidence: 
1) We will identify the evidence base for diagnostic hubs, including stakeholder views, the nature of evaluation, cost effectiveness, impact on quality of care and outcomes, impact on patient experience, and lessons for implementation.
2) We will conduct a rapid realist review of the evidence for high volume, low complexity cataract surgery services, focusing on how these services are organised and implemented, their impact on service delivery and healthcare outcomes, and which factors influence this.
•    Understanding stakeholder priorities: we will conduct a Discrete Choice Experiment – a survey that asks patients, staff, and other stakeholders about which features of diagnostic services they think are most important.
•    Understanding how services are delivered: we will interview patients and staff about their experiences of diagnostic hubs – how they work and how they are put into action, including how the services are led, how people are involved in planning, and how staff are trained. We will also observe how the services work in practice, including patient assessments, team meetings, and staff training sessions.
•    Analysing care delivery, outcomes, and value for money: we will analyse the diagnostic hubs in terms of service delivery (e.g. number of assessments carried out, number of patients who did not attend appointments), patient outcomes (e.g. patients’ self-reported outcomes and experience data), and costs (e.g. equipment, staffing, and training).
•    Bringing together lessons for the NHS: We will combine these approaches to provide lessons that may support development of community diagnostic clinics in other parts of the NHS.

News story: UCL News, Dec 2021 

Project duration:

October 2021 - June 2024

Project Lead: 

Dr Angus Ramsay (BSH, UCL)

Evaluation team:

Dr Caroline Clarke (Primary Care and Population Health, UCL)
Dr Josefine Magnusson (King’s College London)
Mr Siyabonga Ndwandwe (Primary Care and Population Health)
Stephanie Kumpunen (BSH, UCL)
Germán A. Alarcón Garavito (BSH, UCL)
Professor Naomi Fulop (BSH, UCL)
Ms Saheli Gandhi (BSH, UCL) 
Ms Holly Elphinstone (BSH, UCL)
Mr Steve Napier (Patient Representative)
 

Wider HERCULES team

NIHR Biomedical Research Centre, Moorfields Eye Hospital & University College, London
Professor Paul J Foster (Co-Principal Investigator)
Professor Sobha Sivaprasad (Co-Principal Investigator )
Dr Hari Jayaram (Co-Principal Investigator)

Bartlett School of Architecture, University College, London
Professor  Grant Mills
Professor Kerstin Sailer
Professor  Peter Scully
Dr Anne Symons

Clinical Operational Research Unit, University College, London
Professor Martin Utley

School of Management, University College, London
Professor Rouba Ibrahim

UCL Interaction Centre, University College, London
Professor Enrico Costanza
Dr Georgia Panagiotidou

HERCULES collaborators

Prof Gus Gazzard, Glaucoma Service Moorfields Eye Hospital
Mr Christopher Leak, Cataract Service, Moorfields Eye Hospital
Mr Robin Hamilton, Medical Retina Service, Moorfields Eye Hospital
Mr Luke Nicholson, Medical Retina Service, Moorfields Eye Hospital
Dr Dolores Conroy, Institute of Ophthalmology, University College London
Ms Joy Adesanya, Research & Development, Moorfields Eye Hospital
Commercial Partners: Zeiss, Optos, Ubisense

Funder: 

National Institute for Health and Care Research Moorfields Biomedical Research Centre 

Contact email address:

Dr Angus Ramsay (Evaluation Lead): angus.ramsay@ucl.ac.uk
Holly Elphinstone (Research Project Manager) h.elphinstone@ucl.ac.uk
Saheli Gandhi (Research Project Manager): saheli.gandhi@ucl.ac.uk