GMCSU on Behalf of NHS Stockport CCG - Wet Age Related Macular Degeneration (AMD) Service.

Descriptions

NHS STOCKPORT CCG is seeking to commission a treatment and management service for patients with wet age related macular degeneration (AMD). The aim is to provide services which are closer to home and are rapidly accessible. Assessment of the condition should be rapid and within two week of referral by GP/Optometrist and treatment (where clinically appropriate) should commence within one week of diagnosis of treatable wet AMD.Local Context.Stockport has a population of 285,000 people (English Public Health Observatories, 2012) with comparatively mixed health to the England average.Priorities in Stockport include reducing consumption of, and harm related to, alcohol, improving and promoting mental wellbeing and resilience at all ages and reducing health inequalities by giving children a healthy start.Whilst it is essential Stockport CCG reduces inappropriate admissions and referrals in order that NHS resources are used cost effectively, the CCG is committed to high quality clinical care; “the right treatment, at the right time, in the right place and at the right price”.The estimated level of obesity in adults (22%) is better than the England average (24%). However, 21.5% of adults are smokers, which is higher than the average for England and research shows that smoking increases the risk of AMD two-fold (English Public Health Observatories, 2012)The current AMD service pathway for Stockport patients has been in place for a number of years and the CCG are introducing a new service specification to ensure that the service is fit for purpose under the new NHS landscape. This service has been developed in line with service user feedback, the wider Ophthalmology strategy nationally and for the CCG and Stockport CCG's healthcare strategy including the 3 domains;— Patient Safety;— Effectiveness;— Patient Experience.Currently NICE have approved three treatments for wet AMD, which are listed below:— the anti-VEGF drug Ranibizumab (Lucentis) injected directly into the eye;— Aflibercept (National Institute for Care and Excellence, 2013) (Eylea®, solution for injectionphotodynamic therapy.Evidence BasedThere are on average about 26,000 new cases of wet AMD in the UK each year, with the condition affecting more women than men. By definition the condition usually affects people who are aged over 55+ years of age but incidence increases markedly with increasing age to peak in the 80-85 year age groups. The most commonly cited risk factor for AMD is cigarette smoking; the risk of developing AMD is 3.6 times greater for current and former smokers than people who have never smoke. The aetiology of wet AMD is outlined below:There are two main types of AMD – ‘wet' (exudative) and 'dry' (atrophic).Wet AMD (neovascular), the most severe but more treatable, has an incidence of 1 in 10 cases. However, it accounts for 90% of all AMD blindness (Varmus, 1997). It is characterised by the development of immature blood vessels (angiogenesis) - a process known as choroidal neovascularisation (CNV). CNV can be subdivided into classic and occult forms. Through investigation by fluorescein angiography the location of these vessels on the retina is determined. Location of the blood vessels is important in terms of its effect on vision and effectiveness of treatment as these vessels haemorrhage easily and cause lesions on the macular leading to rapid visual impairment. A protein known as vascular endothelial growth factor (VEGF) has been implicated in the development and progression of CNV. Drugs that inhibit the action of VEGF have been developed for the treatment of wet AMD.Dry AMD (non-neovascular) is the most common form of AMD, occurring in 9 out of 10 cases. It is an extensive atrophy (wasting) of cells that progresses slowly therefore, it usually takes several years for vision to become seriously affected. Approximately 10-20% of people with dry AMD progress to the wet, exudative form of AMD. There is currently no treatment for dry AMD but it is usually less severe and more slowly progressive than the wet form.This service will ensure that patients are seen and treated in an environment most appropriate to their clinical needs. This service will ensure that patients have access to translation services where required, low vision services and that links are forged with the NHS STOCKPORT Eye Clinic Liaison Officer (ECLO) for emotional and practical advice.Location(s) of service delivery.The service will be a local Stockport service, with possible multiple delivery points bringing the service closer to home for patients. Service locations should be accessible by car and within reasonable access of public transport routes. Appointments should be available on several days of the working week, in the evenings and at weekends. , The option for earlier or later appointments in line with seasonal changes (dark nights) would be advantageous for the patient demographic and transport options. AMD clinics will be led by a Medical Retinal Specialist Consultant ophthalmologist. The provider should consider future demand for the wet AMD service and have the flexibility to provide additional sites to meet demand as required.