The window for responses to the General Optical Council’s (GOC) call for evidence on the Opticians Act closed on July 18 and optical professional bodies have published their feedback.
In the section about testing of sight, the GOC asked should dispensing opticians (DOs) be able to undertake refraction for the purposes of the sight test? It noted that this would only be possible if the GOC amended or removed its 2013 statement on refraction.
Patient safety
In response to the question, the Association of Optometrists (AOP) said DOs should not be able to refract and highlighted that the Opticians Act does not permit the delegation of the sight test.
The professional body said allowing DOs to refract, without supervision, would create a significant risk of missed pathology that could endanger the nation’s eye health.
An AOP survey, which was conducted as part of its response to the call for evidence, asked its members if they thought elements of the sight test could could be appropriately delegated to another professional, such as a DO? It received 2,449 responses of which 4.6% said they definitely could and a further 28.9% said they could but only within strict guidelines. However, 64.41% of respondents felt that no elements of the sight test could be safely delegated.
The AOP said refraction within the sight test was integral to the overall eye health assessment and went beyond the simple identification of a patient’s need for visual correction. When asked to provide feedback, AOP members shared examples of where a subtle change in refraction in conjunction with clinical experience alerted them to identifying an asymptomatic disease. Concerns were also raised by members that separating refraction from the sight test would weaken the ability to detect general health conditions.
A scenario where a DO performed refraction under the oversight of an optometrist or registered medical practitioner would serve to partially mitigate the risk of missed pathology, the AOP said. However, this scenario could create increased pressure on optometrists who would provide this oversight. AOP members expressed concerns about being provided with shorter appointment times that would be insufficient to check the refraction.
If the GOC decided to withdraw and update the current statement, the AOP said it should be clear that: optometrists and medical practitioners remained responsible for the sight test as defined by the Act; and, an optometrist or medical practitioner may, at their discretion, be supported by other staff members in the testing of sight but the decision around what support is provided must remain with the person conducting the sight test.
The GOC also asked what would be the advantages, disadvantages and impacts of amending or removing its refraction statement to enable DOs to refract for the purposes of the sight test? The AOP said there were no advantages and highlighted there was already a large optometry workforce with sufficient capacity to provide high quality eye care to the population. It added the limited additional capacity that would be provided by DOs who could refract would serve no practical purpose and deliver no obvious benefit to patients.
Refraction was a central element of the sight test, the AOP said, and allowing DOs to refract was a clear breach of the Act and would risk patient safety and the integrity of the sight test.
Suggested updates
FODO, the association for eye care providers, said DOs should not be able to undertake refraction for the purposes of the sight test. Its members and sector partners were in strong agreement that the sight test should remain as it is and not be split into a refraction and separate eye health examination.
The professional body saw no merit in the simple removal of the GOC’s 2013 statement because it would create confusion and result in the same question that led to it being published in the first instance. However, it noted that optometrists and medical practitioners would increasingly need to work as part of a multidisciplinary team to meet growing patient needs in a sustainable way. In addition, each member of a multidisciplinary team would need to be appropriately trained, overseen and competent in any support they provide to an optometrist or medical practitioner who performed a sight test.
In recognition of this, FODO suggested an update to the GOC’s statement on testing sight, which stated sight testing was the responsibility of an optometrist or medical practitioner but did not prevent them, while working in a multidisciplinary team, to test sight and meet patient needs in a safe and effective way. This could include trained staff who collected initial clinical information, such as fields, pressures and refractive data, for an optometrist or medical practitioner to use and interpret as part of the sight test.
FODO said the sight test was a major benefit to public health and few countries in the world have an eye care service that was as accessible, safe and cost-effective as primary eye care in the UK. It said there was no evidence to suggest sight testing legislation needed to change and the sight test was one of the few healthcare services that has been able to innovate over time while keeping costs down for patients.
Quality control
The College of Optometrists also said no in its response to the question about DOs undertaking refraction. It said the testing of sight must remain a protected function of the Act that can only be performed by an optometrist or medical practitioner.
The professional body said refraction was a key component of the sight test and that clinical decision-making, ascertaining a person’s ocular health status and issuing a final prescription was of higher quality and improved patient safety if carried out by one individual.
Patient outcomes could be harmed if refraction, the ocular health check and assessment of a person’s binocular vision status were delegated, the College said. It recognised that DOs and other health professionals could adequately conduct an objective and subjective refraction with appropriate training and may already do so outside the context of a sight test. However, without one person conducting all components of the sight test there was a risk of not identifying clues to the condition of the patient.
The College conducted a literature review and found no evidence that enabling DOs to perform refraction for the purposes of a sight test would result in more sustainable or accessible means of delivering population-led eye care. Of the College’s surveyed members, 85% thought DOs should not be able to undertake refraction with patient safety and the need for a holistic sight test given as key reasons.
Disadvantages to amending the or removing the GOC’s statement of refraction were outlined by the College and included repeated aspects of the refraction being carried out where ocular health or binocular vision impacted on refraction, which would increase the time of appointments and reduce patient satisfaction. The College’s members were concerned that this change had only been suggested because it could reduce business costs, rather than improve standards of care or patient outcomes.
Appropriate training
The Association of Independent Optometrists and Dispensing Opticians (AIO) said DOs should be able to undertake any activity, including refraction, provided they received an appropriate level of training and were overseen by an optometrist or medical practitioner.
It outlined that DOs should be permitted to refract under the following conditions: they do not issue a prescription; demonstrated their competency after being awarded speciality in refraction by a GOC approved provider; refraction was not performed as part of a patient’s regular eye examination as a delegated function; refraction was not in place of a patient’s eye examination; the patient was seen within the last two years and not within the last six months of prescription expiry; or under the current care of an ophthalmologist.
The AIO provided examples of when it would be appropriate for a DO to carry out refraction, such as: to triage a patient on collection of spectacles when the test visual acuity was not met; to verify an in-date prescription that does not meet BS EN standards prior to dispensing; and to monitor the progression of myopia at a shorter interval than recommended recall. Examples of when refraction would not be appropriate were also outlined by the AIO and included: to verify an out-of-date prescription prior to dispensing; and to recommend whether an examination may or may not be necessary.
Unwarranted restrictions
The Association of British Dispensing Opticians (ABDO) supported the idea of DOs refracting for a sight test but only under the oversight of an optometrist or a registered medical practitioner. It said the current unwarranted restriction on the ability of DOs to extend their scopes of practice should be removed from the GOC’s statement on sight testing.
The professional body commented that the change would not compromise patient safety and would enable patient care to be provided in a more flexible way. ABDO’s response challenged concerns among other eye care professionals and asked if these practitioners held the same concerns about the use of auto-refractors in practice. ‘We note that survey data gathered by another optical body suggests concern among optometrists about delegation of elements of the sight test to other professionals, such as dispensing opticians. However, this is not relevant to the question of whether dispensing opticians should be allowed to carry out refraction under the oversight of an optometrist rather than as a delegated function, which would involve the optometrist discharging their responsibility for the refraction element of the sight test.’
ABDO said there should be confidence in DOs’ ability to carry out refraction accurately and safely, including flagging any concerns about pathology or binocular vision for the overseeing practitioner to consider. It cited how DOs already learn to refract as part of their education and how the GOC’s statement allows DOs to refract to verify a prescription. In a survey that received 1,350 responses from ABDO members, 9% already carried out refraction, which the professional body said equated to around 600 DOs.
ABDO noted: ‘Enabling DOs to refract as part of the sight test would form part of the wider and positive trend towards a multidisciplinary approach to delivering primary eye care. By optimising the use of the primary care workforce rather than seeking to maintain outmoded professional boundaries, we can help to relieve the strain on hospital eye departments and improve the quality of eye care which we provide for the UK public.’
