Eye care has had a long history in Ireland with the Mason family of Aran Quay in Dublin being referred to in the 1767 Dublin Chronicles as an ‘occulist’. In 1905 the Irish Optical Association was formed, which became the Association of Opticians of Ireland in 1945, and finally the Association of Optometrists Ireland in 1986. However, it was not until the 1956 Opticians Act was enacted that the profession became formally recognised as a registered profession. In 1959, the first full-time optometry course opened its doors in Dublin Institute of Technology (DIT) Kevin Street.
While the formal recognition of the profession, by means of the 1956 Opticians Act was an important milestone for the profession; it was a piece of legislation of its time and not without significant flaws.
Firstly, the positives – the act created the Opticians Board to make and keep a register of those entitled to practise as an ophthalmic optician and dispensing optician. It formalised entry criteria to the register and gave the Opticians Board powers to make rules governing the practice of registrants. The legislation restricted the prescribing of spectacles to registered ophthalmic opticians (optometrists) or medical practitioners; it restricted the dispensing and/or sale of spectacles (which the act defined as including contact lenses) to registered ophthalmic opticians, dispensing opticians or medical practitioners. The use of all titles or variations thereof were restricted to registrants. Furthermore, it gave the Opticians Board powers to prosecute both registrants and non-registrants who breach the legislation.
The major problem from the point of view of optometry in Ireland was section 48 of the act which in its original form restricted an optometrist from doing anything other than prescribing or dispensing spectacles, with a firm prohibition on any form of diagnosis. In addition, it took the ludicrous position of permitting optometrists to use diagnostic drugs for the purpose of dilation but not for ‘paralysing the accommodation system’.
This provision was included to prevent optometrists from carrying out cycloplegic examination of children and was driven by elements of the ophthalmology community. This created great confusion for many years as many optometrists were under the mistaken impression that as the effective mydriatic in use ie tropicamide also had an, albeit weak, cycloplegic action, dilation was also outlawed.
Certain elements of the medical community have in the past made a big deal about opticians (sic) not being able to examine children properly or to diagnose eye conditions. Representatives of the profession have always countered this falsehood with the argument that there is a world of difference between not being permitted to do something and not being able to do something.
Originally only ophthalmologists were permitted to provide eye examination services and receive remuneration from government schemes. A huge amount of work behind the scenes saw optometry and dispensing added to the Treatment Benefit Panel in the 1970s. Under this scheme the government paid optometrists directly to provide eye examinations to members of the public eligible from their pay related social insurance (PRSI); optometrists and dispensing opticians were also eligible to join the panel to get direct remuneration from the government to provide spectacles to eligible persons. Further work in the 1990s saw the same right to service extended to medical card holders.
In terms of legislation the only amendment to the Opticians Act came in 2003; which changed some small things in the act but principally amended section 48 and created an even bigger mess (see Table 1 for the wording of the 2003 amendment).
Table 1
Section 48 (As amended 2003).
1 A registered optician who is not a registered medical practitioner shall not, on or after the appointed day —
(a) treat any disease of the eye or prescribe or administer any drug or other medical preparation for that purpose,
(b) suggest by any written or oral statement or by any action that he has made or is capable of making a medical diagnosis of a disease of the eye or that, in relation to the treatment of the eyes, he has done or is capable of doing anything which is other than —
(i) in the case of a registered ophthalmic optician, the prescribing or provision of spectacles, or
(ii) in the case of a registered dispensing optician, the provision of spectacles.
2 A person who contravenes subsection (1) of this section shall be guilty of an offence under this section and shall be liable on summary conviction thereof to a fine not exceeding, in the case of a first offence, twenty pounds and, in the case of a second or any subsequent offence, one hundred pounds.
3 Nothing in this section shall be construed as preventing a registered ophthalmic optician from providing, in accordance with rules, orthoptic treatment for any person on the written direction of a registered medical practitioner who has examined that person, or from suggesting that he has provided or is capable of providing as aforesaid.
4 Where in the course of an eye examination, a registered optician referred to in subsection (1) suspects the presence of a disease or condition of the eye, the registered optician shall inform the patient of this and recommend that the patient consult with a registered medical practitioner
The amendment removed all mention of drugs from the Opticians Act. It also amended the section to include a requirement ‘where a registered optometrist suspects a condition or disease of the eye’ that the patient should be advised to seek medical attention. However, by definition informing a patient to seek medical advice is definitively doing other than prescribing or dispensing spectacles. In effect to comply with section 48(1) you must breach section 48(4) and vice versa.
In addition, the amended act does not feature comprehensive fitness to practise provisions, making it not fit for purpose in a modern regulatory environment. As a result of the shortcomings of the act, the Association of Optometrists, Ireland (AOI) has long been engaged in efforts to have the legislation modernised.
Out of the blue, in the 2008 budget speech; in the midst of the financial meltdown; the minister for finance announced that as part of a clampdown on government quangos, the Opticians Act would be repealed and the professions of optometry regulated under a piece of legislation called the Health & Social Care Professionals Act 2005 (HSCP Act). This unilateral announcement was made with no prior consultation with either the profession or the regulator.
This prompted a lengthy negotiation process, which proved difficult in part due to the Department of Health & Children’s original position that they would prefer to deal with the regulator, ie the Opticians Board. The other professions originally designated to be regulated by CORU had not previously had any formal regulation (Table 2 shows the list of professions). However, the HSCP Act specifically calls for engagement with the professions involved in any transfer. Following strong representations from the AOI, the Department of Health & Children then included the AOI in the negotiation process before a subsequent call for public consultation.
Table 2
Original professions included under Health & Social Care Professionals Council
- Clinical biochemist
- Dietitian
- Medical scientist
- Occupational therapist
- Orthoptist
- Physiotherapist
- Podiatrist
- Psychologist
- Radiographer
- Social care worker
- Social worker
- Speech and language therapist
As part of the public consultation a variety of interested parties made representations, which included a very inflammatory document produced by the Irish College of Ophthalmologists. As a result the Department of Health & Children called for a series of meetings and submissions in relation to patient safety and any changes in the proposed new legislation.
In a rebranding exercise, the body administering the HSCP Act has been renamed as CORU; a variation of the Irish language word for ‘care’. In order for the professions to be regulated by CORU, legislation is required to facilitate this. As a result of the intensive negotiations that took place, the minister for health, following advice from the chief medical officer, decided that section 48 should not be carried forward in any form.
The AOI also strongly argued that it was vital to ensure that the right to prescribe spectacles and to dispense spectacles continued to be a function restricted to registrants. As the act defines spectacles to include contact lenses, there was considerable debate on how to define contact lenses and the result is a very comprehensive definition included in the legislation (Table 3).
Table 3
Definition of contact lenses
‘Contact lenses’ includes any device, designed to be worn in contact with the ocular surface, for the correction of vision, for the provision of a decorative or cosmetic effect, for a therapeutic purpose, or for any other reason, and regardless of the optical properties or the absence of optical properties of the device’
The AOI made strong representations that the process should not inadvertently lead to deregulation of dispensing either by accident or design. As such the language used in the draft format of the bill; Health (Miscellaneous Provisions) Amendment Act mirrors the 1956 act in this respect. It is disappointing in the extreme to see FODO lobbying now at this late stage for an amendment that would water down the role of registered persons and open the door to partial deregulation.
The Minister for Health appointed an Interim Optical Registration Board over the summer to begin the process of producing by-laws and procedures in order to have a smooth transition to the current Opticians Board. The current Opticians Board is due to finish its elected terms in December 2014.
Highlights of new legislation
- Removes ban on treatment/management by optometrists
- Introduces mandatory CPD as a condition of registration
- Required compliance with a Code of Conduct & Ethics
- Introduces comprehensive fitness to practise provisions
- Comprehensive definition of contact lenses in legislation
- Dispensing to remain a function of registrants only.
What does the being registered under CORU mean to the optometrist in practice? Firstly registration and retention fees will be paid to CORU not to the Opticians Board. As a result of an agreement with public sector unions as part of cost-saving measures in response to the Trioka and austerity measures, fees are likely to be capped during the initial phase.
All registrants of CORU are required to comply with a Code of Conduct & Ethics, breach of which will result in a fitness to practise investigation. CORU has produced a framework code, which has been adapted and submitted to the Interim Board. This draft code will be published for public consultation in the near future. The draft code outlines a number of areas with which registrants will have to comply (Table 4).
Table 4
Headings of Code of Conduct & Ethics
Conduct
- Act in the best interests of service users
- Respect the confidentiality and privacy of service users and their families
- Maintain high standards of personal conduct and behaviour
- Provide information about conduct and competence
Performance
- Address health issues related to your fitness to practise
- Obey laws and regulations
- Act within the limits of your knowledge, skills, competence and experience
- Keep your professional knowledge and skills up to date
- Get informed consent from service users
- Communicate with service users, carers and other professionals
- Assist and advise colleagues, recently qualified registrants and students
- Teach, supervise and assess students and other professionals
- Supervise tasks that you give to others
- Keep accurate records
- Address health and safety risks
- Address risks to service users
- Dispensing
Ethics
- Demonstrate ethical awareness
- Respect the rights and dignity of service users
- Carry out your duties in a professional and ethical way
- Undertake research in an ethical manner
- Make sure that advertising is truthful, accurate and lawful
One of the areas that has led to considerable confusion with practitioners has been the issue of CPD. The Code of Conduct & Ethics requires all registrants to participate in CPD; it also states that registrants must keep a record of their CPD and make it available on request from CORU. Participation in CPD activities will also dictate the scope of practice available to registrants.
CORU has produced a Framework document on CPD which sets a basic target of approximately 60 hours of CPD over a two-year period. However, it is not specified from when the CPD framework document will apply. Therefore, from the first date of registration, optometrists and dispensing opticians will be required by CORU to participate in CPD, but that the nature and extent (ie number of hours) will not be defined until the new Optical Registration Board amends the CPD framework document and enacts a relevant set of by-laws. The AOI has been running a series of roadshows for members to explain this in more detail.
The single biggest change is the removal of the prohibition on treatment/management of eye conditions by optometrists. Scope of practice will no longer be limited by statute, rather by the education, training (CPD) and experience of the practitioner as an individual. This does not mean a free-for-all with optometrists automatically gaining the right to provide ocular theraputics; it is not expressly forbidden anymore. But, if an optometrist wants to provide such a service, they would have to be able to demonstrate to a fitness to practise committee that they were compliant with section 7 of the Code of Conduct & Ethics.
The original Opticians Act was in some ways a security blanket for practitioners; what was permitted was very limited, but clearly delineated. Under CORU, registrants will now have to make a conscious decision about how they practise and the steps they take to justify this.
Optometrist Martin O’Brien is chair of the education committee at the Association of Optometrists Ireland. He is a past president of the AOI
After the publication of this article Julian Carey, Chairman of the FODO Ireland Executive, commented:
'This article was clearly written before the two recent joint statements by FODO and the AOI outlining why we were seeking to improve the legislation. Our aim throughout has been to preserve and confirm in legislation the status quo for the benefits of patients in Ireland and prevent the new rules forcing small independent practices, in particular, out of business.
The primary legislation was ambiguous, as the Government has now recognised in the amendment which has been tabled. CORU had made clear to us that it would have to follow the letter of the law whatever that letter was even if not what the profession intended.
It was important therefore that weakness in the legislation was corrected and we are delighted that both the Irish Government and the AOI have welcomed this.
Far from watering down the role of registered professionals or opening the door to partial deregulation, we have in fact done precisely the opposite and performed a major service to the optometrists and opticians of Ireland safeguarding their roles for the future.'