Cohort profile: Design and methods for Project HERCULES (Healthcare Exemplar for Recovery from COVID 19 Using Linear Examination Systems): Multi-disciplinary implementation and evaluation of an asynchronous review clinic in NHS eye-care services.

Objectives: To describe the research principles and cohort characteristics of the multi-disciplinary Project HERCULES, an innovative model of safe high-volume outpatient eye-care service for patients with stable chronic eye diseases. Results and analyses of the workstreams within Project HERCULES will be reported elsewhere. The rationale was to improve eye-care capacity in the National Health Service (NHS) in England through the creation of technician-delivered monitoring in a large retail-unit in a London shopping-centre, with remote asynchronous review of results by clinicians (named Eye-Testing and Review through Asynchronous Clinic (Eye-TRAC)). UCL's Bartlett School of Sustainable Construction developed the RIBA (Royal Institute of British Architects) Stage 1 briefing requirements for optimal design specifications for this model of care from first principles research, by analysing ergonomic data from multiple iterations.

Methods: Patients aged 18 years or above being monitored in secondary care in Moorfields Eye Hospital NHS Trust for stable glaucoma or retinal conditions were given appointments at Eye-TRAC at Brent Cross, London. Patients were also recruited at City Road and Hoxton Eye-TRACs, as comparators for the motion tracking study. Willing participants were recruited when attending Eye-TRAC from 11th October 2021-1st December 2023, during this time four spatial "iterations," with different configurations of equipment were investigated in succession. Recruited participants provided information on their eye health and quality of life via a questionnaire, as well as agreeing to wear a tracking device. The tracking device was worn for the duration of their clinic visit and along with directly observed timings built a picture of patient and staff flow through the clinic. Rapid qualitative and ethnographic analyses were conducted, drawing on staff, manager and patient interviews and observation of service delivery and challenges. Separately, anonymised data from across the Trust informed an analysis of the impact of opening the Eye-TRACs on Trust-wide waiting times. A nationwide discrete choice experiment was also conducted to assess patients', healthcare providers', and the public's preferences for key service features..

Findings To Date And Conclusion: 41,567 patients attended the Brent Cross Eye-TRAC between 11th October 2021 and 1st December 2023. 5,539 patients were recruited to Project HERCULES. Spatial configurations promoting independently parallel patient journeys with limited queuing, and direct line of sight between diagnostic stations, supported efficient patient flow. The latter iteration incorporated cataract clinics. Although it added more system complexity, it enabled the evaluation of a further indication for use of Eye-TRAC.

Future Plans: The analysis of trust-wide data on the impact of the Eye-TRACs on waiting times and a nationwide evaluation of stakeholders' preferences regarding diagnostic and monitoring services for stable disease are underway. We will also identify and enumerate limitations in information technology that create bottlenecks in the review process. Qualitative analysis of patient and staff feedback alongside rapid ethnographic work to streamline services is also under way. We seek to develop a framework to help inform NHS guidance and future service planning for ophthalmology and other outpatient diagnostic services. Our data will be analysed to identify enhancements to further streamline operational efficiency.