Running a successful optical practice : Part 10 - Operating as a business within the NHS

Regardless of the nature of your practice, all practitioners can benefit from a healthy relationship with the National Health Service. This side of our business has developed rapidly over the past 20 years, from the days of limited frame ranges and free eye examinations for all, through the Thatcher government's deregulation of the industry, to new and upcoming services such as NHSnet and the very real threat of the Government's reform of General Ophthalmic Services (GOS).

Clearly, there is a need for all of us to understand the relationships, opportunities and threats that exist for a modern practice in operating within the NHS.

CURRENT GOS ARRANGEMENTS

Our industry has become very accustomed to the ability to earn an income from the NHS by the provision of GOS to patients eligible for help. While we all hope that this will continue, it is unlikely that things will stay the way they are.

Under the current rules, to provide GOS it is necessary to be registered with the General Optical Council as an ophthalmic optician or an ophthalmic medical practitioner and be listed by a primary care trust (PCT) on either its ophthalmic list of contractors or its supplementary list.

The difference between these lists can be confusing. Simply put, the ophthalmic list is designed for optometrists and optometric companies that provide the premises and equipment used to offer the services and who are referred to as 'contractors'. The supplementary list is designed for employed opticians and locums, who are referred to as 'assistants'.

As either a contractor or an assistant, the latest regulations give optometrists the ability, once registered with a local PCT, to work within other PCT areas without the need to register on other lists (this excludes Scotland, Wales and Northern Ireland which have alternative arrangements).

This means a contractor registered on a PCT ophthalmic list will be able to work within other contractors' practices in other PCT areas. Likewise, an assistant, once registered on a supplementary list, will be able to work in contractors' practices in other PCT areas. This is termed by the PCTs as 'passporting'.

Remember that if you intend to be listed as a contractor, all elements of your practice must comply with the GOS terms of service, including premises, record keeping and equipment.

A full list of GOS regulations can be found at: www.assoc-optometrists.org/uploaded_files/consolidated_gos_regulations_1986.pdf

Along with ophthalmic lists, new GOS form-signing arrangements have also been introduced. These now detail the requirements, taking into consideration the roles of contractors and assistants:

GOS1 forms
The optometrist who carries out the sight test will sign as the practitioner taking clinical responsibility for the conduct of the test. If he/she is the also the contractor, one signature will be sufficient.

 If the optometrist who carries out the sight test is not the contractor, then the contractor (or his representative nominated in advance) will countersign in relation to the financial and regulatory responsibilities of the contractor under the GOS terms of service.

GOS3 forms
These may be signed by any optometrist on either an Ophthalmic List or Supplementary List. Needless to say, the correct signatures on forms will ensure swift and prompt payments are made. Sadly, all could be about to change.

REFORM OF GOS

As we all know, the Government's review of GOS as part of The Health Improvement & Protection Bill, if passed, will change the situation dramatically.

Although the review of GOS is only part of the bill, which also covers other areas such as making enclosed public/work places smoke-free zones and the implementation of recommendations from the Shipman inquiry, all optical bodies including the Association of Optometrists, Federation of Ophthalmic and Dispensing Opticians and Association of British Dispensing Opticians have voiced their concerns about the proposals.

A key issue is the lack of involvement and representation of any of our ophthalmic bodies as part of the consultation process. This is viewed by many as contradictory to the Government's policy of inclusive consultation in all parliamentary proposals and differs from the high level of joint working involvement enjoyed by GPs, dentists and pharmacists.

The main issue involved in the debate is the restriction of funding and the introduction of local commissioning. If approved, this would, in turn, give the PCTs the responsibility to budget accordingly and so have the ability to limit funds available. By implementing this level of control, the PCTs would move away from the current arrangement where optometrists registered with the GOC are able to register on an Ophthalmic or Supplementary List and then provide GOS. This would be replaced by a 'performer list' arrangement that would require practitioners to establish a contract with a PCT through negotiations before undertaking GOS work. Clearly, as part of this process, price would be a key issue and there are fears of 'sweetheart deals' that would be awarded to one practitioner in an agreement to exclude another.

To defend our industry against these reforms, as pointed out by AOP chief executive Bob Hughes in the Association's newsletter in August, we must make sure we are proactive in the way that we canvass support and influence our MPs as they debate the reforms this autumn. Building relationships with the PCTs has traditionally been widely ignored by many practitioners but embraced by other healthcare providers who have nurtured communications and involvement in local representation in all areas of their practices. It is worth reading this article and it can be found in full at: www.assoc-optometrists.org/uploaded_files/blink_aug_05.pdf

Over many years, the optical profession has become accustomed to surviving in a highly competitive market. Since deregulation, each of the multiples, groups and independents has had to find an area in which to provide a service and make a living. For some it has been high volume at a reduced level of margin, while for others it has been a low volume but a high margin business.

If the proposed reforms are designed to make our industry more competitive, we have to ask the question: are we not one of the most competitive sectors of health care in this country already? This is a view shared by many - why do we need to fix something that is far from broken?

NHSnet

As the NHS develops and new technology becomes available and more widely used, the way that optical practices interact with the service will change. The biggest change that has started over recent years is the development of NHSnet.

Despite the claims of many computer software companies, it is generally accepted that even encrypted email is not secure. Therefore, there is a need to create a secure way of transmitting data throughout the NHS and the service providers. Many commercial companies have similar problems and usually deal with them in the same way - the development of an 'intranet'. This should not be confused with the internet.

Like the internet, an intranet system shares information. However, it only shares and passes information within its own domain, therefore eradicating the problems associated with sensitive information falling into the wrong hands.

Although the overall responsibility for NHSnet lies with the National Health Services Information Authority, the security of the systems and equipment used will be initially checked by the information technology department of the local PCT. A 'Code of Connection' has been established to ensure the ongoing security of the system.

In February 2004, health minister John Hutton announced that BT had been awarded a contract to provide and manage a broadband network to link all NHS organisations in England. The New National Network, also known as N3, will provide a fast, reliable network on which to run the new IT systems being delivered by the National Programme for IT. This will make the NHS the first major user of significant broadband capacity in the public sector.

The number of sites served will be increased from 10,000 under the current NHSnet contract  to all 18,000 NHS locations and sites. The network will also provide the technology to benefit patients by significantly speeding up the transfer of key clinical data between NHS organisations. In addition, it will enable much faster electronic transmission of visual data, such as video and X-rays. As the system develops, online activities such as booking and referrals will become more and more common.

Although it is unlikely that optical practices will be able to secure funding, N3 connections will be offered to all NHS healthcare providers in the PCT areas. As your practice is individual, only you can decide the need for connection to NHSnet. You will also find that a number of commercial equipment and service providers integrate connectivity to their ranges.

Consider the benefits of online referrals and being able to transfer images to GPs and ophthalmologists. While this will no doubt have a cost, your practice may benefit from providing this service.To keep updated on the rollout of NHSnet, take a look at www.n3.nhs.uk/n3/ and talk to your local PCT representative.

FORMS AND RECORDS

We can all recall being told on our first day working in an optical practice that 'this form is money'. NHS forms are money if they are completed in the right way and submitted on time following the correct procedure. This is not difficult to achieve but, like many areas of business, it requires a simple system and an element of discipline. While working for a multiple many years ago, I inherited a practice that had a six-month backlog of NHS forms that had not been submitted. Once I had recovered from the shock I set about the huge amount of work needed to recoup as much cash as we could from these vouchers. Although this amounted to several thousands of pounds, the practice would have generated much more money and much less work if submissions had been made weekly.

Sight test vouchers are currently valued at £18.39 (£32.38 for domiciliary). In any business this makes it worth spending a few minutes ensuring the details on the form are correctly filled in, the patient has signed in the right place and the optometrist has completed his or her section. Voucher values can be as high as £181.40 (H - high spherical bifocal). Since this is a significant sum of money, you should work hard to ensure people working within your practice treat every single voucher the way they would if it had the Queen's head printed on it.

Needless to say, NHS documentation is not the only important form in your business. Almost every document you complete has an implication for your business, be it a patient record, a referral or an application for a new bank account. Incorrectly completed information causes delays and can, in certain cases, have a devastating effect on you and your business. I can recall listening to a very experienced optometrist impressing upon his pre-registration student how important it was to write every detail on the patient record - 'Write down everything you are told and write down everything you tell'. When dispensing, it is also good practice to write down your recommendations and your calculations (especially of price). While most patients take advice, not all listen; therefore try to ensure you have the ability to recall what you recommended if they return for further advice.

Similarly to the security issues surrounding NHSnet, there is a need to ensure that patient records and certain other documents are kept confidential. Over recent years the Information Commissioners Office has developed guidelines on how patient records and private information should be stored and maintained. These guidelines need to be adhered to, as failing to protect the privacy of your patients is not only unprofessional, but can also result in your practice being fined.

Equally important, is the need to keep records for the prescribed amount of time. Despite the difficulties and cost of storage, the NHS has a requirement that records are kept 10 years after conclusion of a patient's treatment for adults and until the 25th birthday of patients if originally treated as a child. Interestingly, the AOP recommends 12 years after treatment and the 26th birthday in the case of children/young adults. Even in the event of death or leaving the country, both the NHS and the AOP recommend records be kept for up to 12 years.

This can cause some practices logistical problems and where space is at a premium you may consider using external companies to assist you with document storage and archiving. One of the most popular forms of document storage is computerised record scanning <2212> there are many companies now offering solutions these days. However, make sure that if this is what you choose to use you check the regulations and that the system complies with guidelines.

RELATIONSHIPS WITH PCTs AND L/AOCs

Many practices fail to realise the importance of ensuring a good relationship is established with their local PCT. PCTs are now a central part of the Government's delivery of health policy and account for about 75 per cent of the total NHS budget. Locally based, they control and manage the frontline healthcare service providers including GPs, dentists, pharmacists and, of course, opticians.

All PCTs work closely with local/area optometric committees (L/AOC), the representative bodies for local optical practitioners. This ensures that PCTs have an understanding of the ophthalmic services and requirements within the PCT area. You should ensure that you meet with your L/AOC on a regular basis to keep updated on schemes and initiatives in your local area. As they work closely with the AOP, you will find they have a wealth of knowledge and are able to give you detailed information about optometry in your area.

The main responsibility of the PCTs is to ensure there are a sufficient number of service providers within the local area. They are, of course, not able to force an optician to open a practice in the area if they feel there is a shortage; they are, however, able to arrange more ophthalmic cover in a local hospital or NHS walk-in centre. PCTs also control co-management schemes such as diabetic screening programmes and, together with L/AOCs, work on a variety of activities and initiatives that promote eye care in the local community.

As well as being good for the community, a successful working relationship with your local PCT will be good for business. Although not as straightforward as dealing with a supplier and certainly more complex than the relationship you have with your customers, make no mistake that the need to develop and maintain communication and an understanding of your local PCT and its requirements is fundamental to the successful running of your practice.

Furthermore, the perception that the trust has of you will have an effect on that of other healthcare providers in your area. Needless to say, every optical practice will want to be the one recommended by the local GPs and pharmacists.

You will also find that your PCT and L/AOC are able to help develop relationships with your local hospital and the ophthalmologists working in your area. For example, you will often find that they arrange voluntary clinical afternoons at the local hospital's ophthalmic department.

SCREENING PROGRAMMES

For a whole host of reasons, diabetes (especially type 2) is becoming more and more common in our society and retinopathy is estimated to be present in up to 90 per cent of cases. The PCTs are clearly aware of this and, with the recognition of the effectiveness of optometric co-management schemes, continue to work hard to develop more and more screening programmes. Again this is not only a benefit to the patients but can also be a financial benefit to your practice. It is often easy to forget the simple and very real fact that diabetic patients will usually need spectacles as well as being monitored.

Over recent years, formal screening schemes designed to detect diabetic retinopathy have been introduced across the UK. Many of these use digital retinal imaging, which allow a record of the screening intervention to be retained for quality assurance purposes. At present, many areas involve optometrists in screening using slit-lamp binocular ophthalmoscopy. Others use retinal cameras, while a substantial number have no screening at all. Normally you will have to meet the standards for the programme. 

Digital photography can be an expensive option, but you may find that it is a worthwhile investment for your practice. Some patients, regardless of the health of their eyes, will be impressed by the availability and use of technology and this can often give you an advantage over competitors. You may even find that patients are prepared to pay for the service; this, together with income from the PCT for diabetic screening, may prove that the investment in a fundus camera or a slit lamp was a good move.

Other types of co-management scheme are now operating in many areas, such as glaucoma monitoring, low vision services and anterior eye referral and management, with similar benefits to practices involved. The AOP can provide more information on the types of scheme that are currently in operation around the country.

CET strength

While some may see continuing education and training as a burden, I personally believe that it is a strength within the optical business. It is essential that professionals of all disciplines review and update their skills and knowledge and there is no excuse when CET is so readily available.

As any optometrist or dispensing optician will know, achieving CET points is essential every year and continuing education is now becoming more and more a part of all healthcare providers' lives. To ensure your CET points are recorded, first register at www.cetoptics.com. This will allow you to track your progress and you will also find details of all CET events in your area.

As a reminder, the regulations now state that all registrants are required to obtain 36 CET points by the end of December 2006 to remain registered in 2007. These points must be registered at www.cetopics.com and the GOC has made it very clear that it is the practitioner's responsibility to check their points are on this website and are accurate.

The DoH has made arrangements for payments for loss of earnings in respect of CET undertaken by optometrists and OMPs on PCT lists. The payment for 2004-05 is £270 and the deadline for claims is October 31. The claim form is on the DoH website at www.dh.gov.uk/ophthalmicservices and may be downloaded for submission to PCTs. 

Richard Peck is group managing director of the Middlesex-based Optika Clulow Group and was previously store manager and area manager for several national and regional multiples