The big gap in information about why clinical care pathways are what they are locally and what might be achievable locally, is meant to be filled by this document. The Guide we have produced is only a starter, and the next step has to be development of effective clinical governance, which is really not well developed in primary care yet. A good clinical governance framework is necessary to design new ways of working, put in place systems that allow monitoring of care, highlight poor performance, and provide feedback on how to improve clinical quality. Of course, Chief Executives in primary care organisations are just as accountable and responsible for what goes on in their organisations in terms of clinical safety, as their secondary care trusts counterparts. Yet an effective clinical governance structure seems to be not in place.
The other aspect is affordability. There are currently proposals for shared care in ophthalmology that are, if costed up properly, simply not affordable in the current financial envelope. Budgets for an increase in medical indemnity are also nonexistent, and where delivery of care pathways is to be changed, this will naturally introduce new risk, that has to be covered from a financial point of view insurance. It is worthwile remembering that currently indemnity insurance amongst secondary care clinicians in ophthalmology can go up to £20,000 per annum.
There is, still, uncertainty about what commissioning, and effective commissioning is about. The fact that the Intelligent Commissioning Board gave a definition, makes clear that in their mind the concept had not quite crystallised yet.
We are aware that the guide will be aimed at Primary Care commissioners, but will be read also by our colleagues in secondary care, and so some information may be superfluous for primary care organisations, but not for secondary care workers, and vice versa. However, we hope that in the end it will be a good basis on which commissioning ophthalmic care can be based, and that it will provide a basis also for fruitful discussions between commissioners and providers, and create an atmosphere of understanding.
We would like to thank all our contributors to this guide, and their help in making this possible, and the support of the Ophthalmic Group Committee of the British Medical Association for in supporting the publication of this guide.


The Guide has been produced in printed form, but can be sent to you in electronic format. If you would like a copy, please leave your request at the following email address: commissioning@aoo.org.uk