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Winifred Simpson is smiling. After a thorough eye examination in her living room, the housebound 86-year-old has just been told that with a new spectacle prescription and a special reading lamp, she will once again be able to enjoy her books and newspapers. After months of blurred vision, this is welcome news.

Simpson is a typical patient of The Outside Clinic domiciliary service. With arthritis in her knees and breathing difficulties, she is incapable of getting to a high street optician for an eye test, but her age and limited mobility means that she qualifies for a free eye test in her own home - along with thousands of others across the UK.

The Outside Clinic, says managing director Damien Kenning, is working hard to reach as many of them as possible.

unseen but not forgotten

The domiciliary service has been running for 20 years, but it previously focused on group visits at, for example, nursing homes, prisons and schools.

However, the 2000 report Unseen and Forgotten by the Royal National Institute of the Blind prompted the service to rethink its activities.

'The RNIB identified a chronic under provision of optometrists for people who are housebound, such as the elderly,' explains Kenning. 'With this need identified, we followed up on it. Previously, between 70 and 80 per cent of our work was with groups, but that has changed, and now between 75 and 85 per cent of our work is with individuals. That is a huge shift for us.'

Kenning states that the clinic currently sees several hundred patients a day across the UK. A new television advertising campaign is likely to boost these numbers even further.

'We are trying to bring the home service to the attention of individuals, so we are placing advertisements on television - on Sky, ITV 1 and on channels 4 and 5. We want to get our message out there,' says Kenning.

The Outside Clinic currently employs 50 full-time optometrists who work within different areas of the UK. They see, on average, between seven and eight patients a day. While the economies of scale are not as great as conducting group visits, strategic planning makes the individual home visits more than feasible.

'One of the reasons practitioners provide group-based domiciliary services is because of economies of scale. If you sent a practitioner to one location, it is very economical. Sending an optometrist to an individual's home for one eye test is not as economical. But what we are finding is that with the greater awareness of the service, more people are requesting it, and the more people in one area that do so, the more economical it becomes for us to provide it,' Kenning says.

The Outside Clinic has invested heavily in an IT system which plans out each optometrist's working day, maximising time with patients and minimising travel.

'Our system plans out a travel route, and sets the patient appointments accordingly. It works out travel time and allows for set-up and pack-up time. Also, if there is a cancellation, the system has a log of all requests, so it can slot in other appointments if a vacancy arises,' Kenning explains. 'This allows us to build a sensible working day for each of our optometrists. There would be nothing more frustrating for professionals than spending their time driving, and not testing.'

Ensuring practitioners have all the support they need is crucial to the success of the clinic. But so too is ensuring high standards of professionalism are maintained. Kenning notes that several systems are in place to monitor standards of service.

'We are very strict on patient records - these are closely monitored. All good organisations have clinical governance in place, and we are no exception,' Kenning said. 'Our practitioners are regularly assessed, or observed, in their work.

The company conducts regular spot checks to ensure the highest clinical standards are maintained.

'We also write to every patient we see. Every patient gets a letter, we want to make sure we get it right every time. Patients will tell us if we are getting it wrong, but I have to say the replies we get are usually positive and often very heartfelt. Patients are often very appreciative that a professional has come to see them at home.

'If home eye tests are arranged efficiently, they can be economical and it means patients receive the best possible test, while practitioners receive the best possible support.'

working conditions

Nick Wingate, domiciliary optometrist and Outside Clinic professional services manager, says the role is very different to that of a high street optometrist. He likens it to a cross between a hospital optometrist and a high street optometrist, and notes it has its own unique set of challenges.

'Quite often it is the environment that you have to deal with which can be the most difficult part of the job,' Wingate says. 'Behind the front door, everyone's house is different. You are not always able to achieve practice-like conditions. But you learn how to compensate, and still provide a quality eye examination.'

There are other aspects that domiciliary optometrists need to consider during their work, Wingate says. Most importantly, the capabilities of a person to attend a high street optician. Only people who cannot get to an optician unaccompanied qualify for the eye tests.

'We do have to be careful in ensuring that those we see are in fact disabled and cannot get to an opticians. In some cases it is just obvious that there is no way they could get there. In other cases we have to have a discussion with them. If it becomes apparent that they can get to an optician, then we have to decline to see them,' Wingate says.

What he does enjoy though is patient interaction, and domiciliary work provides plenty of opportunities for this. Good patient interaction, he notes, is especially important for the group of people he visits.

'You need to talk to them and put them at ease,' he says. 'We always call ahead to let people know that we are coming, as it makes them more comfortable. Letting somebody into their home can make a patient feel vulnerable, especially some of the older patients. It is important to avoid that.

'We are here to solve problems, and to do that we need to spend time talking to our patients. We need to find out what they know about their eye condition, which will be important in helping us decide what we will do.

I enjoy talking to people, and you end up finding out quite a lot about the patients and their lives. After working in the same area for some time you end up finding out quite a lot about the people there and sometimes you'll realise you know the same people.

'You don't see as many patients as you might in a high street practice, but you end up doing more for each patient. I have helped people with a number of disabilities, such as arthritis, osteoporosis and Parkinson's disease. With someone like Winifred Simpson we made a big difference to her life. It was only a small change - new spectacles and a reading lamp - but it will mean she is able to read her books and newspapers again, and stay in touch with the world. That is a big thing for her.'

Simpson herself is already convinced of the value of the domiciliary service. '[The eye test] was incredibly thorough, and I felt relaxed throughout. I was grateful for the time that the optometrist spent with me, and it was certainly more comfortable and relaxing for me, being able to stay in my own home. It really was the best eye test I've ever had.'

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