Table 2. Summary of possible approaches.

	Possible approaches	Key benefits	Specific challenges and considerations
Space	Separation of wet AMD patient treatment from other retinal or non-retinal ophthalmic patients	Wet AMD service no longer competes with other services for space and/or time Separation of patients referred with suspected wet AMD from patients who are undergoing the initiation phase of injections and monthly follow-up allows treatment and assessment clinics to be predictable and efficiently organised	A ‘clean room' is required for intravitreal injections for wet AMD
	Use of other spaces (eg, mobile units or underused existing health-care space such as private hospitals, polyclinics or GP clinics)	Wet AMD service no longer competes with other services for space and/or time Provides additional space for wet AMD service	Ensure continuity of mobile unit availability throughout the year (eg, adverse weather, breakdown) or consider alternative cover Consider convenience for patients Dedicated clean room (for injections) required Assumes staff and equipment are available for the new service
	Decentralisation of services to local district general hospitals, or decentralisation of other services into peripherals (eg, glaucoma)	Relieves pressures on space in the hospital service May be more convenient for patients	Space, appropriate staff and equipment must be available in the peripheral service
	Reorganisation of existing clinic footprint and space	More efficient use of existing space	Most ophthalmic footprints are operational at full capacity in working week-time hours May require funding for equipment and/or clinic renovation
	Virtual clinics (eg, use of community optometrists/other health-care professionals for OCT imaging, or mobile OCT machines)	Reduces capacity issues within the hospital service (see also staff and equipment) Increases access for patients as optometric practices are normally in conveniently accessible locations—particularly relevant in more rural areas where patients may have substantial journey to hospital	Electronic transfer of ophthalmic images from the community for review at the hospital can be problematic, due to IT issues, but is possible. Some optometrists are now getting NHS email accounts, which enable secure electronic transmission of patient information. However, if large file sizes are being transmitted, investment in N3 connections may be required Appropriate viewing stations and clinical governance arrangements may be a challenge Placement of virtual clinics in the right place in the patient pathway is critical for success OCT instruments are expensive and optometrists receive no capital funding for such a purchase A tariff for OCT imaging in optometric care and telemedicine services needs to be developed
Staffing/staff skills	Appropriate utilisation of staff to best suit their skill set (eg, efficient utilisation of consultants' time)	Staff time is utilised more efficiently Higher patient throughput possible (eg, more intravitreal injections per session)	Consider staff morale and personal development (eg, repeated administration of injections may be considered boring) Consider annual leave/staff cover
	Recruitment of middle-grade (non-consultant) medical retinal staff to assist the consultant	Consultant time is freed up and can be used more efficiently	There is a severe UK-wide shortage of middle-grade ophthalmic medical staff Assumes funds available
	Adoption of alternative staff (eg, hospital optometrists, ophthalmic nurses or health-care staff) for a range of tasks from LogMAR VA testing and OCT imaging to retreatment decision-making	The consultant is still involved in the diagnosis and treatment decision-making, but not every patient needs to be seen by the consultant at every visit, thus freeing up consultant time Pressure from large number of follow-up patients is relieved	Depends on individual staff expertise and skills locally Need for consultant to be involved in decision-making process at vital points in the patient pathway remains Requires IT networking for good information flow to speed up consultant decision-making Consider regular designated reporting sessions and triage sessions in medical staff job plans and including telemedicine tariffs
	Stratification of patients by risk of progression, whereby ‘low risk' patients attend virtual clinics in the community or within the hospital eye service	All patients are reviewed monthly and risk of an undetected deterioration is minimised At follow-up visits, specialist staff time is used more effectively to assess only higher risk patients	Availability of LogMAR VA testing and OCT imaging and fundus photography is vital for these patients who are considered at low risk of progression An accurate prediction of the proportion of ‘stable' patients is key
	Employment of a wet AMD clinic coordinator	Clinics are run efficiently and patient appointments and referrals are managed effectively	Assumes funds available Appointee must have good understanding of all issues (patient as well as service) in order to be effective
Equipment	Use of suitably trained community optometrists for OCT imaging in the community	Removes the need for additional OCT machines within the hospital service	Electronic transfer of images for review at the hospital (see ‘space' section above) and Information Governance Purchase of community OCT equipment and networking. OCT instruments are expensive and optometrists receive no grants for their purchase Access to NHSmail, N3 connections, satellite broadband, or PACS by community optometrists
	Mobile OCT machine	Provision of off-site OCT services in community centres or in district hospitals who do not have ophthalmic services	Needs additional staff to undertake OCT Purchase of OCT equipment and remote networking infrastructure Access to NHSmail, N3 connections, satellite broadband, or PACS Remote and off site back up of images
	Electronic Medical Record system	Improves the speed and consistency of decision-making in AMD clinics and delivers detailed audit of clinical outcomes Allows service re-design to improve the efficiency of AMD clinics	Developing a business case to justify the extra investment
Quality assurance	Provide patients with emotional support at clinic or referral to external counselling, peer support or emotional support services as required	Towards best possible standard of care for patients	Patient motivation
	Complete Certificate of Visual Impairment (CVI) registration as appropriate to ensure that patients whose sight has deteriorated to registration level have access to a social care assessment	Patients who require support are assessed by Social Services and have a better chance of being referred to other local support services	Development and roll out of electronic CVI
	Employment of Eye Clinic Liaison Officer (ECLO)	ECLOs can deal with most of the patient requirements outside the treatment itself, including low-level emotional support and signposting to daily living support services, which is crucial for a smooth transition from health to social care	Assumes funds and suitable personnel available NHS Trusts liaison with social services and third sector
	Provide monthly monitoring for all wet AMD patients, but tailored according to patient characteristics and local model adopted	Specialist staff time within the hospital service is used more effectively to see only higher risk patients at follow-up	It is essential that monthly monitoring is provided for all patients—lower risk does not mean no risk
Management planning and business case development	Develop a robust business case that is both realistic and long-term and includes ECLO funding and where necessary a low vision service	Ensures adequate funding for future developments and takes into account any necessary future expansion of the service	Consider likely future indications for intravitreal therapy and any other future developments Accurate costing of the service is important and vital Capacity pressures are generally predictable
	Write a business case that is impactful	Greater chance of business case approval and obtaining funds for expansion of service	Business case must be evidence-based, concise, and realistic Communicate to hospital and Trust management teams the value of appropriate management of wet AMD in terms of income and patient benefit
	Electronic patient medical records	Facilitates auditing, reduction of administrative time and also facilitates evaluation/prioritisation of patients	Requires appropriate IT systems Cost