UK - find a doctor who will

[littlemermaid]

http://www.drfosterhealth.co.uk/ Find a specialist doctor - UK NHS and private practice. Hot site. You will see your doctor's various clinics at different NHS hospitals and catch him/her in private practice at different venues. You can seach on condition combos eg 'thyroid eye'. Maybe fast-track into private practice for same-week diagnosis while waiting for NHS 'first appointment within 18wk' target, or doctor-shop first to make best use of your GP NHS referral to the right consultant.

NHS is planning 'centres of excellence'. This means we chase the team expertise.
- Your local optometrist or GP (primary care) is unlikely to be this knowledgeable about who's available and may refer locally to general ophthalmology service, or to independent triage business servicing NHS, so check the local hospital website to find the right consultant, eg anterior segment, surface disease, inflammation, so you can ask to be referred to them rather than general.
- Local hospital ophthalmologist (secondary care) will treat as best they can with resources available, and not refer on unless it's uncertain diagnosis, unresponsive. Maybe look for 'second opinion' with specialist, private or NHS, if treatment's not working/don't seem to know what it is/what they're doing? GP is happier referring 'round' local ophth service if you have a diagnosis letter from specialist. May get access this way to NHS tertiary referral teaching hospital, anterior segment team.
- Regional teaching hospitals with eye clinics and research centres also serve their local community with normal access. No restriction on going out of county for treatment. Overloaded, high-volume, but working on efficiency, funded, current on treatment, full-on consultants, 24/7 emergency cover.

We know about NHS Choices http://www.nhs.uk/Pages/HomePage.aspx but what about a second opinion in the NHS?http://www.nhs.uk/chq/pages/910.aspx...categoryid=156
Most GPs are well out of their depth on commissioning in hospital specialisms - but at least they are opening up to the idea, and more creative NHS and private referrals, unless yours is a dinosaur. Chronic red eye is a GP diagnosis nightmare, could be so many scary things: 'Are you sure - this could be so many things, couldn't it?' is the question to get referred on.

Inform your choices even further by searching on your local 'NHS referral pathway eye' for referral criteria, eg here's ours http://www.oxfordradcliffe.nhs.uk/fo...guidelines.pdf (same-day referral for moderate-severe pain). Hmm, that explains a lot. Not always blepharitis though, is it - see further referral critieria including pain, inflammation unresponsive to antibacterials. See how they are being pressed to try to treat chronic eye conditions 'in the community', without expertise. A wise GP does not get the ophthalmoscope out, but refers on to eye doctors. According to clinical guidelines on eye steroids, no one must prescribe eg FML or dexamethosone without being certain it's not viral or fungal, regular monitoring of intraocular pressure. http://www.cks.nhs.uk/clinical_topic...specialty/eyes We had progress asking for monitoring by calling the chronic inflammation 'glaucoma' for which there are targets, protocols and budget. http://guidance.nice.org.uk/CG85 All optometrists are obliged by regulation to refer to hospital or referral service on finding any 'ocular pathology' or raised eye pressure, great shopping tool. http://www.aop.org.uk

Regional hospital eye emergency clinics Check criteria for access, includes pain, inflammation (eyedrop reaction, intraocular pressure out of hours, start records with patient ref number). Try to go in quiet times, only senior staff authorise follow-up. Less likely to get a referral out of local emergency eye clinic, just treatment. Watch out for unsupervised less experienced staff, doing their best, if consultant's not around; ask what they can see, what they're checking for, what they think - they are working on their doctor-patient skills - 'are you sure?...' for referral.

Access to diagnosis/treatment - the power of consultant's secretary, hospital optometrists, Patient Liaison, GP admin, to refer straight to the top, or have a quick word, should not be underestimated for existing patients with a case. Consultant's secretary can ask the consultant what they want to do and book appointments (even required to attempt triage over the 'phone, dear god...). If still getting nowhere, consider an email or letter to a specialist consultant asking for advice, describe case, suggest still undiagnosed/untreated. If obstructive/ignorant non-clinical staff, say 'shouldn't we ask someone medical?...' If obstructive clinical staff, say 'shouldn't we ask an ophthalmologist/the consultant to have a quick look?...' A diplomatic suggestion that the system has failed and you should be seeing Dr X sometimes meets with sympathy and may obtain a consultation, especially if in clinic that day.

Clinical need priority problems start with general ophthalmologist clinics when there is nothing to see in the slit-lamp but surface pain is chronically bad. Keep going until you find a dry eye ophthalmologist who's current. Trust your gut feelings on their available services/expertise. This is when you may need to pay a specialist from the regional hospital in private practice for diagnosis if you can't get NHS referral, due to priorities and targets. Keep a diary of impact on life to make the case for referral to regional anterior segment team in the NHS. Also ask for NHS pain management service. The goal is a regular ophthalmologist team who work with you to adjust treatment towards a 'spiral of improvement', available when needed.

Opticians - many faking knowledge on dry eye now to flog drops, especially unqualifed staff. But there's a lot of qualified optometrists better informed on dry eye than some hospital ophthalmologists.

Private specialist appointment costs are aligned to private health insurance standard rates, eg £120-180, unless it's inflated for Harley Street. Docs grouping in dedicated clinics is a sign of peer-group respect. Private practice is not just about freedom (professional indemnity premiums for ophth are huge) and cars, it's about access. The NHS practice is overloaded and restricted by 'clinical need' and hospital policy (consultants v hospital managers, ongoing) - they are giving us this opportunity, even if it's a one-off diagnosis or reassurance, if we need them. Money wasted if they're not current on what you've got. If anyone has managed to get eg BUPA to cover for chronic disease monitoring, please let me know...

Paediatric eye inflammation management for under-16s is excluded/overlooked in all of the above NHS local provision, triage guidelines, budget. Best treated by paediatric ophthalmologists in children's eye clinic in specialist tertiary referral hospital. We were refused NHS tertiary referral from primary and secondary sectors, misdiagnosed, no advice, serial discharge/re-presenting. Private paediatric surface disease ophthalmologist - cornea vascularising, punctate keratopathy - gave us access. Untreated child blepharokeratoconjunctivitis http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1772603/ If anyone wants to talk about this, paediatric, welcome to PM me.

Be nice to them in the NHS, though, make the best of the opportunities, and show a bit of support. BMA opposes NHS Reform Bill until amendment: '4.Will continue to oppose any Bill which seeks to break down the NHS family and treat healthcare as a commodity to be bought and sold in a commercial market'. Respect, guys. http://www.bma.org.uk/healthcare_pol...mstatement.jsp

[EllMitcho]

very useful thread thank you - I will refer to this in the future when I go round the NHS merry go round once more - cheers!

[littlemermaid]

EllMitcho, v welcome. If anyone loves NHS inside gossip as much as I do HospitalDr: For a second opinion and BMA blogs.

[littlemermaid]

Caveat emptor (buyer beware) in the private provider eye clinics. Care Quality Commission investigates Clinicenta (Carillion) at NHS Lister Hospital, Herts, Aug 2012 'failure to provide proper follow-up care' http://www.guardian.co.uk/society/20...nta?CMP=twt_gu

[littlemermaid]

'Guidance on NHS Patients who wish to pay for Additional Private Care, Dept of Health 2009' http://webarchive.nationalarchives.g.../dh_096576.pdf This would include paying for eg non-funded eyedrops and treatments. NB the patient has to ask the NHS Consultant before they can offer any other options or advice (search 'code of conduct for private practice'.)

Attempts to physically separate NHS/paying/partly-insured patients using the same clinics and equipment are pretty funny so far, eg dividing the same waiting room with a curtain. Conflicting, the way they lump NHS staff in with 'private clinical services'.

'The private provider should normally deal with non-emergency complications resulting from the private element of care.' para 8.2, p14. Read the small print when you sign the paperwork if you are attending a private hospital chain as an Outpatient, rather than Inpatient for a procedure. In terms of liability, the Consultant may be hiring a room (provided free even sometimes) to treat Outpatients as an individual, whereas Inpatients are in contract with the hospital company for services. Amazingly, NHS work by a private provider is not yet always covered by NHS indemnity http://bma.org.uk/practical-support-...pendent-sector Outside the Consultant clinic hours there is normally no qualified cover. The clinic may imply the doctor is available 24/7 and this means by phone through a secretarial service. Any further interventions arising from treatment problems are billed for, or patients are referred to NHS GP, NHS GP Out of Hours, or NHS A&E. Medical Records kept by the private provider are not available to the NHS unless for NHS contracted work and may not be secure.

Where paid/private insured services are offered in or by an NHS hospital, NHS cover is available with the same team and shared Medical Records - see NHS hospital websites. Private work is covered by NHS indemnity for NHS hospital employees (check for other non-NHS eg consultant).

'Where the same diagnostic, monitoring or other procedure is needed for both the NHS element of care and the private element, the NHS should provide this free of charge as part of the patient’s NHS entitlement and share the results with the private provider if necessary. Patients should not be unnecessarily subjected to two sets of tests or interventions.' para 8.2, p14. Presumably that includes vision screening.

Patient Advice & Liaison Service (PALS) has expanded in the NHS Trusts to include patient experience tracking and wider advice on negotiating the 'system'. They will help not just with advice and information, but will phone eg GP Practice Manager or Consultant appointments secretaries to sort problems out. They report direct to the NHS Trust Boards with stats.

The NHS website is being frequently updated http://www.nhs.uk/Pages/HomePage.aspx as the Clinical Commissioning Groups (CCGs) replace PCTs. My friend at the BMA says we are legally entitled to Choose & Book anywhere in the country for specialist services but there may be some confusion among GPs so be persistent, partly because there is no Register of Specialists yet. http://www.chooseandbook.nhs.uk/patients

The CCGs commission NHS primary care services including optometry and specify NHS 'care pathways' eg eye checks for glaucoma risk, and that includes people prescribed eye steroids at risk of raised eye pressure. It is up to the individual optician whether they want to provide NHS co-care services but a list should be available from the CCG or local ophthalmic care committee. Optometrists working part-time in hospital/high street can be very helpful, with better training and experience. ('Working models of enhanced eyecare' in Bristol, Grampian, Wales, Somerset, Manchester, Stockport, p 46, Annex 4 Bosanquet report 2010, otherwise standards are not ensured.)

NHS eye screening is available in registered optometrists in Wales through the Primary Eyecare Acute Referral Scheme (PEARS), same day walk-in and ongoing monitoring http://www.wales.nhs.uk/sites3/page....3555&orgid=562.

Request copies and carry your own Medical Records, eg test results and clinic letters, if seeing different providers. The NHS Trust Medical Records department will also copy them http://www.nhs.uk/chq/pages/1309.aspx?categoryid=68. Copies of Consultant clinical letters are sent to GPs and can also be requested there. It will be years before compatible Electronic Medical Records are implemented across the NHS and communication between providers is difficult.
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If it's not working out, it's a fair assumption that the left hand doesn't know what the right hand is doing, so keep asking the questions. Please post up to share your experience and with corrections to help everyone with this

[littlemermaid]

http://www.bmj.com/content/347/bmj.f4524 Self-pay NHS Ophthalmology services with full NHS Consultant, consultant network, and clinical support team, covered by NHS liability insurance, 24/7 qualified cover, A&E, shared and accessible Medical Records and imaging, at cheaper rates than Private Hospital providers (more parity with actual NHS cost). For when access to NHS Ophthalmology services or second opinion has not been easily available, perhaps due to postcode lottery, clinic priorities, misdiagnosis, or underqualified GP referral decision-makers.

If you have private medical insurance, consider using it in NHS Hospitals to access expertise, clinical services, consultant and research networks, and support NHS hospital income. Insurer lists of approved doctors favour and specify named senior NHS consultants and surgeons, preferring lead clinicians - the NHS 'guarantee'.

Check private hospital, independent clinic, or independent consultant for training, regulation, 24/7 qualified weekend and emergency cover, insurance, access to medical records, follow-up monitoring, failed procedure and complications arrangements and costs, before committing. If the answer is 'see your GP' or 'attend A&E' or 'go to NHS Moorfields or NHS regional tertiary hospital', think what you are paying for and committing to. Look out for co-pay on uninsured costs. Check whether the anaesthetist is a regular known and trusted by the surgeon. Expect to be referred into the NHS hospital specialist teams if they find anything difficult.

Any GP or high street Optometrist can refer anywhere in the NHS Ophthalmology service http://www.chooseandbook.nhs.uk/ or private sector. We have a legal right in the NHS to access to the right specialists for the condition (NHS Constitution, 2009) http://www.chooseandbook.nhs.uk/staf...patient-choice. If a Clinical Commissioning Group has failed to provide this, referral can be made to hospital Ophthalmology consultants by other hospital consultants, out of hours GP services, A&E, and high street Optometrists.

Check and know your individual region's provision for hospital Eye Clinic emergency access and hours in various outreach clinics. Unless we are with a trusted consultant, sometimes it's best to travel to the regional centre hospital for expertise, diagnosis, equipment and access to follow-up. Then access local services ongoing. Best out-of-hours cover is in a tertiary hospital with an Ophthalmologist in A&E. Some fast-access eye clinics prefer a phone or fax referral from a doc or optometrist, but look at emergency eye clinic criteria for self-referral ie just turning up especially for sudden onset problems.

High street Optometrists have good equipment for examining the eyes and are obliged by their Regulations to refer to Ophthalmologists if they detect conditions. Eye exams are free for NHS patients with eye conditions normally treated in hospital as Optometrists become more integrated with NHS services for eyes and hearing http://www.nhs.uk/NHSEngland/AboutNH...opticians.aspx. The individual Optometrist claims NHS costs for eye checks, negotiated with the CCG (Clinical Commissioning Group) for eye services.

An NHS Consultant in private practice can, of course, refer any patient to their own NHS clinic. Interestingly, any doctor in private practice can refer to any NHS clinic (BMA guidelines).

http://www.drfosterhealth.co.uk/consultant-guide/ Here's the current Dr Foster Consultant Guide.
And the Private Hospital Guide http://www.drfosterhealth.co.uk/cons...nsultant-list/
Docs don't seem to advertise all their private practice the way they used to, particularly when retained by independent clinics, but Google does.
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Just a reminder how fabulous the NHS is though, when we find our way around http://www.nhs.uk/Pages/HomePage.aspx

'In severe cases of untreated dry eye syndrome or cases that do not respond well to treatment, the associated inflammation (redness and swelling) can damage the surface of the cornea (the transparent layer at the front of the eye). This is called keratitis. Sometimes the cornea can become vulnerable to ulceration and infection, which is a sight-threatening condition. This is frequently associated with pain. It is essential you go to an accident and emergency department if you notice reduction in your vision.' http://www.nhs.uk/Conditions/Dry-eye...lications.aspx