ABSTRACT: Purpose: To describe the research principles and cohort characteristics of the multi-disciplinary Project HERCULES, which evaluated implementation of an innovative model of high-volume outpatient eyecare service to monitor patients with stable chronic eye diseases. The rationale was to improve capacity and efficiency of eyecare 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 Clinics (Eye-TRACs)). UCLs Bartlett School of Sustainable Construction produced the RIBA (Royal Institute of British Architects) Stage 1 briefing requirements for optimal design specifications and operational parameters for this new model of care from first principles research, by analysing and developing ergonomic data from multiple iterations. Participants: 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. Willing participants were recruited when attending Eye-TRAC from September 2021- November 2023 and formed the intervention cohort. The comparator cohort consisted of patients that continued to be monitored in secondary care during the same period. Other than residence of the participants, there were no other demographic or disease severity differences in this cohort. Additionally, anonymised data from across the Trust informed an analysis of the impact of opening the Eye-TRACs on Trust-wide waiting times. A nationwide stakeholder preference survey of health-care professionals, members of the public and ophthalmology patients was carried out. Findings to date and conclusion: 41,567 patients attended the Brent Cross Eye-TRAC between September 2021 and November 2023. 5,539 patients were recruited to Project HERCULES. Four spatial iterations, with different configurations of equipment were investigated in succession. 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: Qualitative analysis of patient and staff feedback alongside rapid ethnographic work to streamline services is under way. We seek to develop a framework to help inform NHS guidance for ophthalmology and other outpatient diagnostic services. Our data will be analysed to identify enhancements to further streamline operational efficiency. We will identify and enumerate limitations in information technology that create bottle-necks in the review process.

PJF reports personal fees from Abbvie, Allergan, Carl Zeiss, Google/ DeepMind and Santen, a grant from Alcon, outside the submitted work. HJ is a consultant to Alcon, Scope Ophthalmics, Rebio Technologies, Nanomerics and Laboratoires Thea and has received speaking fees from Santen, Laboratoires Thea, Visufarma and Scope Ophthalmics. CSC and SNd have honorary research contracts with MEH for the purposes of receiving data for this work.

This study was funded by Moorfields Eye Hospital NHS Foundation Trust via The NIHR Moorfields Biomedical Research Centre at Moorfields Eye hospital and UCL Institute of Ophthalmology, with additional support from Moorfields Eye Charity, Ubisense, Zeiss UK and Optos. Insurance for non-negligent and negligent harm was covered by the sponsor through the NHS indemnity scheme.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Project HERCULES was approved by North East - York NHS Research Ethics Committee (IRAS 303760) IRAS - Intergrated Research Application System

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

Professor Duncan Wilsons team have provided motion tracking data on this public URL: https://github.com/djdunc/hercules/tree/main/data/live All reasonable further data collaboration requests will be considered.

https://github.com/djdunc/hercules/tree/main/data/live