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Primary care inquiry - Eye health – General Optical Council response About us: 1. The GOC is the regulator for the optical professions in the UK. Our purpose is to protect the public by promoting high standards of education, performance and conduct amongst opticians. We currently register around 28,000 optometrists, dispensing opticians, student opticians and optical businesses. 2. An optometrist tests sight and can diagnose eye conditions. They can also fit and supply glasses, low vision aids or contact lenses. An independent prescribing optometrist is qualified to treat eye disease, although they may not undertake surgical procedures. A dispensing optician is the person who fits and supplies your glasses or low vision aids. A contact lens optician is a dispensing optician qualified to fit and supply contact lenses. 3. Ophthalmologists, including ophthalmic medical practitioners, (doctors specialising in the eye) are registered with the General Medical Council. Orthoptists, who deal with problems relating to the movement of the eye and work in hospitals, are registered with the Health and Care Professions Council. How appropriately trained and qualified opticians can play a greater role in providing NHS primary care services 4. The ageing population will have many health needs, including eye health needs. One in five over-75s and half of over-90s are currently living with sight loss, with high rates especially prevalent among women, BME groups and adults with learning disabilities. RNIB predicts that by 2050 nearly four million people in the UK will be suffering with sight loss.1 5. The ageing population suffering from increased sight loss will place a strain on Hospital Eye Services (HES), with ophthalmologists facing the challenges of managing increased number of patients with glaucoma whilst dealing with the rising demand for operations such as cataracts. According to the latest Hospital Episode Statistics for England 8.3% of all outpatient attendances at NHS hospitals were in clinics run by Ophthalmologists – the third highest of all outpatient specialties and an 11% increase since 2011.2 1 2 http://www.rnib.org.uk/knowledge-and-research-hub/key-information-and-statistics Health and Social Care Information Centre Hospital Outpatient Activity 2010-11 and 2013-14 6. Community optometry can help to ease the burden on ophthalmologists and secondary care, and is already starting to do so in Scotland, Wales, Northern Ireland and some parts of England where CCGs have commissioned enhanced services. This means that optometrists with the right level of education and training can carry out work over and above the traditional role of carrying out sight tests. This work includes acute eyecare services, glaucoma repeat measures, and pre and post cataract assessment.3 7. Dispensing opticians can also carry out enhanced services. With their advanced competencies in the dispensing of complex low vision appliances to people with partial sight loss, they could be actively contributing to a real and vital improvement in the standard and availability of low vision care. 8. In England, opticians can play a large role in the New Care Models set out in the NHS Five Year Forward View (5YFV). Optical practices might therefore have a role in the Multispecialty Community Providers model, carrying out work such as management of minor eye conditions and post-operative cataract assessments. 9. With extra training to register with the GOC as an independent prescriber, optometrists could provide services using more than just their core skills – for example the management of glaucoma patients. 10. Under the Primary and Acute Care Systems model, optical practices also do more, working to provide more services that are provided by Hospital Eye Services at the moment. For example this is currently happening in Bedford, where the Moorfields Eye Centre at Bedford Hospital contracts local optical practices to carry out pre-and-post cataract optical assessments. 11. In Scotland, optometrists carrying out enhanced services are more common. There is funding for the optician to be the first port of call for patients with acute eye problems – a ‘GP for the eyes’. Funding is also available for NHS primary care optometrists to perform supplementary eye exam allowing optometrists to review results of eye exams and manage a greater range of eye conditions. This is helping to free up both GP appointments and HES appointments, to the benefit of patients and the NHS alike. Similarly in Wales, Eye Health Examination Wales (EHEW) is allowing optometrists to do far more examination in the community, working with Hospital Eye Services. 12. The Scottish Intercollegiate Guidance Network (SIGN - the Scottish equivalent of NICE) have recently produced guidance for optometrists. This best-practice 3 The developing role of optometrists as part of the NHS primary care team, Parkins et al Optometry in Practice 2014 Vol 15 Issue 4 p177 guidance provides advice on which patients should be referred into secondary eye-care services. This guideline also provides guidance on which patients may be discharged from secondary care and safely followed up in the community.4 This helps to free up resources in HES. 13. In England, whilst NHS England has responsibility for the General Optical Services contract – which covers the basic NHS sight test - any enhanced services have to be individually commissioned by CCGs. This is taking place successfully in some areas, but not on a national scale. CCGs are successfully collaborating in some areas on a regional level though, such as the London Eye Health Network. Education and standards: 14. Optometrists with an independent prescribing (IP) qualification are particularly able to undertake enhanced service work. The qualification, which enables practitioners to enter onto one of the GOC’s specialist registers, allows them to prescribe drugs for ocular conditions within their scope of practice. Qualified independent prescribers will take responsibility for the clinical assessment of a patient, establish a diagnosis and determine the clinical management required, including prescribing where necessary. 15. Currently, a far higher proportion of optometrists in Scotland are IP-qualified than in England. In England just 1.5 per cent of optometrists are registered as independent prescribers, compared with over 8 per cent in Scotland5. Ensuring that practitioners have access and the incentive to train is crucial to the success of this work. 16. As the regulator, we are considering how models of education can best equip practitioners with the necessary skills for them to fulfil their potential – both in considering the training they undertake at undergraduate level, and their career-long learning as part of our Continuing Education and Training (CET) scheme. 17. We have also recently reviewed our Standards of Practice for optometrists and dispensing opticians. One of the reasons was to ensure our standards reflect the way the professions are developing in the UK, and will continue to develop in the future. 4 5 ( include the full title of the document in the footnote) http://sign.ac.uk/guidelines/fulltext/144/index.html Source: GOC registers 18. The standards are flexible enough to deal with future developments in practice across the four nations of the UK. They are also flexible enough for registrants to apply regardless of whether they are employees, locums or business owners and whether they work on the high street, in hospital or in domiciliary settings. 19. The standards are consistent with the standards of other healthcare professionals and so will help registrants who wish to provide enhanced community services as part of teams spanning primary and secondary care. 20. The standards will also help us to ensure that we are meeting the recommendations of the Francis Inquiry – for example in ensuring registrants comply with the duty of candour, demonstrate care and compassion in their work and report concerns that may place patient safety at risk. To help embed the new standards, all opticians will have to complete CET on them in the next cycle. 21. More information is available at https://www.optical.org/en/Standards/index.cfm 22. We are also currently consulting on a voluntary code of practice for online contact lens sellers, aimed at ensuring they require patients to have regular checks and aftercare. This approach is designed to improve public awareness about how to buy and use contact lenses safely, therefore reducing the need for them to need primary care. Public perceptions: 23. One barrier to optometrists undertaking more of this work is the public perception of optometrists. Because most work in a commercialised high street setting, many patients and members of the public do not necessarily associate opticians with the healthcare side of their work. 24. For example, recent GOC research6 showed that 68 per cent of people’s main association with opticians (optometrists and dispensing opticians) is testing sight for the purpose of prescribing glasses or contact lenses compared with just 16 per cent whose main association with them is detecting eye health problems. Only a third associated opticians with detecting eye health problems at all. Meanwhile 54 per cent of people would go to their GP if they had an eye health problem, compared with just 19 per cent who would go 6 https://www.optical.org/en/news_publications/news_item.cfm/goc-research-shows-high-level-ofconfidence-in-opticians their optician. GPs, however, will rarely have the full range of equipment that optometrists do to thoroughly examine eyes. 25. Overcoming this gap between the public perception of what opticians can do and what they are trained and qualified to do is crucial in ensuring that the public feel confident in receiving enhanced services in the community Regulation as an enabler of new models of care 26. Regulation must ensure patient safety while enabling optometrists and dispensing opticians to develop their scope of practice and maximising their role in delivering healthcare. As noted above, one of the major drivers behind the recent revision of our standards was to ensure that they are suitable to allow for the way the professions are developing in all four countries of the UK. 27. However to fully maximise the potential of opticians, legislative changes may be necessary. The Opticians Act has not had any major revisions since 1989, and many of those changes were aimed at deregulating the optical market and increasing consumer choice. As a consequence, in terms of the new models of care the legislation is fairly rigid – for example, it is highly specific in terms of which healthcare professionals can carry out which restricted functions. This outdated and restrictive legislation may not be ideal as care services move to a more multidisciplinary environment with the expectation that healthcare professionals will work together more closely and with some clinical tasks being delegated to a wider range of practitioners than before. 28. We are also keen to see deregulation in other areas of our work. We are the only healthcare professional regulator that regulates students, a position we do not see as necessary or proportionate. However, we remain under a statutory obligation to do so. 29. We are also keen to reform our system of business regulation. Our preferred method being to extend registration to all businesses providing restricted functions and to revise our code of conduct for businesses to make it more aligned with the risks associated with business practices. There would also be scope to simplify regulation by, for example, removing the requirement for a majority of directors to be registered optometrists or dispensing opticians. 30. We had hoped to achieve these changes through the Professional Accountability Bill – this was drafted by the UK Law Commissions, with the aim of modernising and bringing more consistency to the legislation underpinning ourselves and the other eight UK professional regulators. The Bill would also bring other benefits such as improving the efficiency of our fitness to practise process. We note that the Government still wishes to legislate when Parliamentary time allows, and would urge that this happens at the earliest opportunity. Conclusion: 31. Optometrists and dispensing opticians have significant potential to undertake more work in a primary care setting – both acute work and in the management of long-term conditions. The optical professions are rapidly changing, and practice is increasingly diverging in the four nations of the UK. With the right training and the right regulatory framework in place optical professionals operating in primary care settings can make an important contribution to lifting some of the burden on the NHS acute sector, while ensuring patients get treatment in a community setting which is appropriate to their needs. We would be interested in discussing these issues further with members of the committee, and how regulation can enable new models of care to develop.