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Could we do better? In the second in OTS new series on clinical audit, optometrist Susan Parker reports on the Stockport ophthalmology referrals audit.

FOR THE 2011-12 Quality and Outcomes Framework, eight Stockport GP practices chose ophthalmology as an area for quality improvement and decided to audit all practice referrals to ophthalmology.

Questions for the audit were:

* What was the reason for referral and was it necessary?

* Was the referral route correct?

* Were any risks to patient safety identified?

* Was there any potential to reduce referrals?

* Was the quality of optometrist referral letters good?



* An optometrist referral was considered necessary if there was no primary care alternative and College Guidance would have suggested referral, or if diagnosis, treatment or further investigations were reported by secondary care

* A GP referral was considered necessary if there was no primary care provision for the investigation or treatment required

* Cataract referrals on the wrong route were counted as necessary if listed for surgery

* A referral was considered to be on the correct route if the referral pathway and stated urgency followed College Guidance and local referral protocols, making use of primary care enhanced services when indicated (for urgent referrals in Stockport this is by fax or telephone directly from the optometrist or GP to the eye casualty or by fax to the wet AMD rapid access service).

Data collection

The audit was conducted over a four-week period, after which GPs, submitted copies of all routine and acute referrals to secondary care ophthalmology for anonymised analysis. Data were collected on reason for referral and outcome where available. Two experienced optometrists agreed the criteria on which judgments would be made, taking into account previous audit of optometrist referrals and College Guidance and Professional Standards.


Of the 224 referrals, 56% were originally from an optometrist, with 44% from a GP.

Reason for referral to secondary care

Overall, 90% of the referrals were judged to be necessary (Figure 1).

Referral route

There were two referrals from optometrists for possible wet AMD, which should have been directly referred to the rapid access wet AMD service. In both cases, the GP referred routinely to the wrong provider.

There were 10 referrals from optometrists by letter via the GP for new flashes, floaters and/or PVD. College Guidance suggests the optometrist should fully investigate these patients, and where nothing abnormal is found, review them at an appropriate interval.

If the optometrist finds signs of retinal break, or is unable to fully investigate, they should direct the patient for investigation with an appropriate degree of urgency. In most cases, even when the optometrist asked for soon or urgent referral, the GP failed to refer these patients urgently to secondary care.

There were 19 referrals to secondary care for cataract. NHS Stockport commissions a direct cataract referral enhanced service to which GPs should direct all cataract referrals. Previous audit demonstrated that 38% of GP referrals for cataract were not listed for surgery.

There were four patients referred to hospital by GPs who should have been sent for a sight test; one, for example, having eye ache after driving long distances.

Referral letter quality

A referral was considered complete if the patient, practice and optometrist were identifiable and refraction, visual acuities, CD ratios, intraocular pressure if over 40 and (when mentioned) visual field results were present. There were 86 copies of optometrist referrals in the data, of which 58% were complete. A large proportion, (72%) of the optometrist letters were handwritten and a number of these were partly illegible (Figure 2).

Of the optometrist referrals, 17% were completely or partially illegible after being scanned for electronic referral. This loss of information may prevent the patient from being seen in an appropriate timescale.

Most incomplete referrals missed one or two items, but a couple had no sight test data entered at all. The most commonly missed was CD ratio, with visual acuity close behind (Figure 3).

Potential to reduce referrals

Judged against the above standards, 10% of the referrals were unnecessary and could have been avoided. Reasons for referral were also reviewed against inclusion criteria for a primary eyecare assessment and referral service and 46 patients (20%) could have been seen in such a service. GPs referred 76% of these, two thirds of which were for red eye and corneal abrasion/foreign body.

Outcomes and learning

Individual reports were distributed to the participating GP practices. Learning points, including avoiding unnecessary referrals, making safe referrals and a flowchart of local referral routes was cascaded to all GPs in Stockport. The LOC website now has a page specifically for GPs.

All GPs and optometrists have been reminded of the correct protocols for urgent referrals and cataract referrals. Stockport LOC website, in common with many LOC websites, has referral protocols with links to adjacent LOCs for cross-border referrals.

There were a number of referrals for new flashes and floaters following a sight test, which did not follow College Guidance. These patients should be examined in line with College Guidance or referred more urgently than via the GP, which typically takes 12 weeks.

If patients have signs of wet AMD they should be referred according to urgent referral routes, as this can be a rapidly progressing condition with delay putting patients at risk. Inappropriate referral of wet AMD is a now major reason for clinical negligence claims. All Stockport contractors have been reminded of their contractual requirements to make performers, including locums and administrative staff, aware of the correct local referral protocols.

Optometrist referrals were usually appropriate and some were excellent. However, more than a few did not give a good impression to the reader. All GP and hospital letters in the audit were typed, and yet the majority of optometrist letters were handwritten. A referral which is difficult to read also makes it hard for the receiving ophthalmologist to triage the patient with the appropriate degree of urgency and to feed back to the referring clinician.

It is important that all referrals are legible. Optometrists should ensure that their referrals to GPs can be read. Optometry practice owners and managers should consider the impression a hasty, handwritten referral gives to GPs as the new commissioners in primary care. Also to be considered is the difficulty of producing readable copies for patients and practice records, or replacements if referrals are lost in the post. Time should be made available during the optometrist's working day to write referrals. Electronic GOSl8s are available, and practice software usually has the facility to produce referral letters. If optometrists must hand write referrals, they are urged to use a pen which remains clear when scanned.

A tentative diagnosis should be included, and an indication of urgency. If referring to the GP only, for example for a blood pressure check, it is advisable to state that no onward referral is needed. A local education event for optometrists on making effective referrals is planned for later this year.

Most of the referrals for red eye were from GPs who do not generally have the equipment and expertise for differential diagnosis of red eye. There was also a number of patients with new flashes and floaters. The referrals were judged against inclusion criteria for the LOSCU PEARS pathway and 20% would have been suitable for this service if available. Stockport Clinical Commissioning Group used this information and a separate audit of the eye casualty service to inform the development of a primary care minor eye conditions service specification, which is currently under any qualified provider procurement.

The next audit in the series looks at the prevalence of Charles Bonnet syndrome in a low vision clinic. Please send OT your audits for publication. Optometrists Trevor Warburton and Barbara Ryan will assist with advice on the layout, headings and length. Send them to emilymccormick@

Susan Parker is a primary care optometrist and optometric adviser to NHS Stockport.
Figure 2 Quality of referral letters from optometrists

Handwritten 72
Legible when scanned 83
Tentative diagnosis 67
Referral complete 62
Optometrist name 72
Practice name 82

Note: Table made from bar graph.

Figure 3 Proportion of missed data out of 36
referrals deemed as not being complete

DOB 9%
S/T Date 2%
CD 29%
VA 27%
Refraction 7%
IOP 11%
Fields 15%

Note: Table made from pie chart.
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Article Details
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Author:Parker, Susan
Publication:Optometry Today
Geographic Code:4EUUK
Date:Aug 17, 2012
Previous Article:CET update at the NOC.
Next Article:CL practitioner of the year.

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