Community spirit

The extension of optometrists' responsibilities into new areas of clinical care has been a long time coming. Shared care schemes may have been around for more than 20 years but many optometrists are yet to play their full part in patient co-management.
Shared care of diabetic eye disease is well established, and cataract and glaucoma schemes are becoming more widespread. Yet although some areas have introduced anterior eye co-management schemes, these remain the exception rather than the rule. Instead of becoming the gatekeepers to secondary care, many optometrists have struggled to expand their responsibilities, while others have been content to retain their traditional role or develop the commercial side of their business.
But with changes to the referral system and optometric prescribing of therapeutic drugs soon to become a reality, some practitioners have been unwilling to wait for a national framework and have moved forward at a local level, working with other primary care providers to improve patient care.

northern light
One such practitioner is Australian-trained Peter Frampton, owner of Aaron Optometrists in the former coal-mining community of Ashington. Fifteen miles north of Newcastle-upon-Tyne, Ashington is known as the largest mining village in the world, or, more likely, as the birthplace of Bobby and Jackie Charlton. The last pits closed in the late 1980s and, after a period of severe depression, the 'village' is now a thriving community of more than 40,000 people, many of whom commute to the city to work.
Graduating from Brisbane in 1984, Frampton arrived in the north east 17 years ago and never went home. He bought the Aaron practice, established as a family business in Ashington since 1921, and a half-share in another practice in nearby Washington in 1993. Eight years ago, he sold his share in the Washington practice and invested the proceeds in moving to a more prominent, corner site in the centre of Ashington.
But with only two consulting rooms and limited space for frame display, the practice soon outgrew the premises. So 18 months ago, when a former restaurant became available on the first floor of the same building, Frampton decided to expand upwards. The practice trebled in size and now has a total of six consulting rooms equipped with the very latest instrumentation, including a corneal topographer, digital retinal imaging system and GDx laser scanning polarimeter. An Rx lab, meeting and staff rooms are also housed upstairs.
Elderly and low vision patients continue to be seen in the original downstairs rooms with dedicated low vision facilities, while the first-floor facilities include a contact lens room, extensive designer frame displays and seating areas. All furniture and fittings are bespoke and were designed and installed by Leicester-based specialist Christopher Rodwell.

investing in people
Faced with increasing competition on the high street, many independent optometrists have positioned their practices at the top end of the market and re-focused on patient care. So what's so unusual about the Aaron practice?
One difference is the scale of investment in the practice. Aside from the cost of buying, refurbishing and equipping the new premises, which Frampton estimates at 'more than 250,000', staffing levels have increased by four since December 2003 to take the team to 15 in total. The business has also invested heavily in training, achieving Investors in People 12 months ago.
But the principal difference is the wide range of products and services that the practice provides. Clinical techniques such as gonioscopy, optic nerve photography, punctal occlusion and syringing, eyelash removal and tear volume assessment, are among the procedures offered, alongside less mainstream services such as dyslexia assessment, orthokeratology and Chromagen colour vision enhancement.
Supplementary fees, prominently displayed in consulting rooms, are charged for each service, although many are free for patients on Eyeplan. Costs range from 5 for anterior eye photography, to 130 for inserting silicone punctal plugs. The practice's private eye examination fee for patients not on Eyeplan is 24.50, which includes digital retinal photography at the discounted price of 4.55.
An abundance of patient leaflets, produced in-house, explain in painstaking detail the services on offer. One leaflet headed 'Clinical optometrists - we are evolving, the funding is not!' details the true cost of an eye examination and how the sale of spectacles subsidises primary eye and health care.
Another compares the practice's contact lens pricing policy with mail order and internet supply. As Frampton explains: 'Internet is only a threat if patients cannot clearly compare prices. If prices are split so that patients know what they are paying for the commodity and what they are paying for professional care, they can make an informed decision on how they wish to buy the service. Some of our patients choose to buy our lenses only - we are as cheap as the internet - and they pay independently for aftercare.'

specialist services
In terms of co-management, Aaron's is already participating in the local diabetic monitoring scheme, which was piloted for one year and has now been active for a further nine months. But the practice's plans for eye triaging and a comprehensive low vision service in the coming year are what distinguish it from most other practices.
'From April, we hope to have direct referral from GPs, self-referral and maybe through NHS Direct as well, where patients with a problem will be given the choice of attending an accredited optometrist who will do the triaging,' explains Frampton.
'We've budgeted to have one initial check and two follow-up checks. If after two follow-ups we haven't resolved the problem then the patient will go on to secondary care. Initially we will treat through the GP - we'll recommend an appropriate care management plan. Even if we never get independent prescribing, we'll still have a nice system which fundamentally we already have but the difference is we'll be getting paid for it.'
In developing the triaging proposal, the practice looked at other schemes established around the country, such as the PEARS scheme in Wales and a similar service in Glasgow (GIES). A good relationship had been built with local GPs over many years and the experience of Aaron locum optometrist Duncan Clark as optometric advisor to the Northumberland Care Trust also proved invaluable.
Frampton says that most local ophthalmologists are happy with the proposal but the care trust has been the driving force. The local glaucoma specialist would also be very keen, in principle, to develop a scheme for glaucoma shared care and is interested in cooperative research using the practice's GDx system.
Although the triaging scheme is open to all practices to participate, only five of the 135 optometrists on the ophthalmic list in Northumberland are known to be undertaking prescribing courses which will potentially receive GOC approval and three of them work at the Aaron practice. Frampton and Clark both attended the University of Bradford MSc course in advanced clinical techniques and therapeutics, getting up at 5.30am to drive to Bradford and back in a day. Along with optometrist Craig Sixsmith, they have also completed five of the 15 modules of the Institute of Optometry's internet-based course on supplementary prescribing.
Frampton says he had no misapprehensions that doing either course would bring him more money or more patients, but further training has given him insight into new clinical areas and, although hard work, has been enjoyable. 'Optometrists seem to want the money on the table before they'll actually do anything. My argument always is that any course is good and whether we end up with independent prescriber status or not, we'll be able to manage our patients better.'

local links
The ability to sort out patients' problems regardless of their requirements is also the driving force behind Aaron's low vision work. Over the past 10 years, the practice has developed close links with a group in nearby Morpeth called NCBA (Northumberland County Blind Association), a charity partly funded by social services.
For each low vision patient seen, the practice would send a detailed letter to the NCBA so that when the association's rehabilitation officer went out into the community she was not working from scratch.
Then, 18 months ago, the local optometric committee started looking at a formal low vision scheme for Northumberland. The LOC's detailed, fully costed proposal was accepted by the care trust and the scheme will hopefully begin next year. Frampton points out that although optometrists will be at the core of the service, other professionals must also be involved. Aaron's already has its own rehabilitation officer, Jen Oliver, working on a voluntary basis one day a week, with the expectation that, once the scheme is up and running, there will be longer term employment opportunities.
More controversially, Frampton also plans to offer counselling to LVA patients, as part of an integrated service. 'A bunch of optometrists doing technical low vision things is not a low vision service. It has to be integrated with rehabilitation, counselling and education. When you lose something - whether it's a loved one or a leg - you go through a grieving process. We find we spend a heap of time just talking with patients to help them come to terms with their disability. To offer a holistic service you really have to think along those lines.'

patient loyalty
With such radical changes to the practice and its services over the past year, Frampton has worked hard to keep his loyal patient base on board. 'The risk that you always run when you do something like this is that people perceive you're trying to become an impersonal money-churning machine. We've got to be sure that patients appreciate what we're trying to achieve. We haven't done this to test more patients, we've done it to give people a better service. We haven't always pulled it off - we've made some truly awesome blunders - but we're pulling it together now.'
Frampton has also relied heavily on his practice team, encouraging them to become specialists in their areas of interest. DO Gayle Watson is currently taking an ABDO low vision course and contact lens optician Andrew Watson will begin an advanced fitting course. Says Frampton: 'I like to keep my hand in everything but, both from the clinical level and the financial point of view, it becomes almost a necessity to have specialists within your team.' Contact lens patients, in particular, benefit from this type of approach, he adds.
The practice also uses qualified clinical assistants for some techniques, such as fields and photography, but only after the eye examination and under the direction of the optometrist, rather than for pre-screening. 'Pre-screening is of no worth whatsoever - its specificity and sensitivity is appalling - it's an absolute waste of time. The only point to pre-screening is to flannel the patient. Pressures could be done beforehand but they take so little time - it's a two-minute job - so we do them in the consulting room.'
'Fields have to be done afterwards because until you've talked to the patient and looked inside the eye you don't know what you're targeting. If you look inside the eye and see an optic nerve problem you would pick a particular field test to reflect that - the pattern of field loss should link up with what you see inside the eye. If you see nothing inside the eye you might want to do a neurological-level field screen which will take a lot longer. You don't want to put every patient through every one of those tests just on the off-chance that they may need it.'

Taking the initiative
The scale of investment in the Aaron practice, its involvement in co-management and the range of products and services provided may not make it unique. But two initiatives perhaps illustrate most vividly its different approach to patient care.
The practice had traditionally offered domiciliary eye tests but found that, nine times out of 10, people requested home visits because they had mobility problems rather than being housebound. Frampton's answer was to sell his car and buy a Mercedes MPV that could be converted for wheelchair access. A volunteer driver now collects these patients from their homes and brings them into Ashington to be seen at the practice.
'I decided that we should give them as much incentive to come in as possible. We could do a better job, save the care trust money and the patients love it. I used to come in the car every morning and it sat outside the practice all day - now I drive to work in the van, which also carries the practice name to promote the service, and our driver uses it during the day. Apart from driving around in a vehicle that has no cool about it at all, there's no problem.'
The service has now been running for two years and its success was recently recognised with an Innovation in Practice award from the Care Trust, although it was less well received by other practitioners in the area. 'We had a lot of negativity and downright aggression from other optometrists locally in response to the service. Some thought it was just stupid - we get paid three times the sight test fee for a domiciliary so where's the financial benefit? But I can see three people in the practice in the time that it would take me to do one home visit.'
This positive attitude was also evident when Frampton found he had a group of patients needing specialist contact lens fitting. 'Five or six years ago I attended a workshop on sealed scleral fitting run by Ken Pullum. I had 10 or 12 patients who would have benefited from this so I rang Ken up and arranged to fly him up from Hertfordshire, paid him for a day's consultancy, and brought my patients in. Duncan and I sat in with Ken and fitted the patients and then I flew him back home.'
Only two patients were successfully fitted but the day still proved worthwhile. 'As an educational day it was fantastic - so much better than sitting in a workshop or lecture. A couple of Ken's patients have since moved north and now come to see me, so in the end it's paid off.'
Initially Frampton approached local optometrists to ask if they wanted to share the costs of the training but, at the time, no-one was interested. 'Since then I've had a couple of people approach me and say can you teach me how to fit sclerals. It worked extremely well and could be applied to any sort of specialist skill.'
As to the overall direction of the practice, Frampton sums it up like this: 'Our plan for the business is to extend the role of community-based eye care and to supply every patient with the most appropriate management for their needs. Whenever a patient sits in the chair in front of me that's basically my goal. Whether we're constrained by financial considerations, like whether we're trying to flog people glasses or not, doesn't change the fact that patients come to me for my professional advice and I want to be able to give it.'
With more plans in the pipeline, it seems unlikely that developments at the Aaron practice will stand still. 'We have done some interesting things here and I'm proud of the fact that we've stuck our necks out at times. There are a lot of optometrists who think it's just going to keep rolling along, and it's not. We have to change.'