In 2014 there were more than 800,000 GOS18 referrals intended for the GP/HES1 and many HES departments are struggling to cope with patient demand.2
Many optometrists are now undertaking more extended clinical roles either under the supervision of an ophthalmologist (in acute or community settings3) or in primary care optometric practice, either privately or through CCG-funded schemes.4 Modern equipment such as OCT, SLO (eg Optomap, figure 1), corneal topographers, etc, coupled with higher qualifications5 in therapeutics, glaucoma, medical retina and contact lenses have allowed optometrists to provide safe, convenient, good quality and cost-effective care,6 beyond a routine eye test, to patients with a range of ocular conditions who would otherwise attend their GP, HES or A&E.7
GPs might not have the necessary equipment or training to make an accurate diagnosis8 whereas a clinical optometrist often can and at short notice. Also, an accredited clinical optometrist is capable of managing9 or monitoring a range of ophthalmic conditions or referring with an appropriate level of urgency to a more experienced colleague (optometrist or ophthalmologist).
So why are more optometrists not getting involved? NICE10 discusses a range of barriers to changes in clinical practice, such as practitioners might have a lack of interest, understanding, training, equipment or confidence. Furthermore schemes might not exist, be poorly funded, have an onerous remuneration process or be misaligned with the existing business model/clinic structure.11
This article draws on web resources and peer discussion to provide an overview of some common modalities of clinical optometry practice in the UK beyond the routine sight test.
Locsu
In England, Locsu has developed a range of Community Optometric Services pathways12 which allow patients with a specified range of presenting symptoms to be referred via their GP or optometrist to an accredited optometrist; these pathways, when commissioned by CCGs, are typically implemented by the LOC or an LOC-related ‘primary eye care company’.
Minor Eye Conditions Service (MECS, formerly PEARS) is a range of clinical pathways for dealing with Mec symptoms such as red eye, flashes and floaters or sudden loss of vision. Some pathways provide guidance on the history and symptoms interview and recommended clinical tests. A standardised clinical form is completed (usually online) noting findings, diagnosis and management including urgency; one follow-up visit is also funded if clinically indicated.
Other examples of Locsu pathways include glaucoma repeat readings (pathway for repeat IOP measurement and fields, disc and anterior chamber examination – figure 2) and pre/post-op cataract (pathway for referring suitable patients directly to the HES for cataract surgery and reviewing post-operatively for complications).
Despite the pathways being at core competency, a validation of knowledge and skills is required. Accreditation is granted by completing WOPEC’s online modules and an OSCE examination for certain pathways. Specsavers is in the process of accrediting its optometrists for MECS assessments having appointed a number of heads of enhanced services.13 The fee structure varies between CCGs and would typically range from about £40 to £65.35
CCG local service contracts
Some CCGs implement their own local service contracts directly with practitioners. Examples include glaucoma repeat readings, direct cataract referral and fast-track wet AMD pathways. Some administrative systems14 training might be required although there is no standardised cross-CCG requirement for clinical accreditation.
Eye health examination Wales (EHEW)
The EHEW service15 provides pathways for the examination and follow-up of patients with acute eye conditions, certain at-risk groups or those who would be at a particular disadvantage if they were to lose their sight. It allows additional clinical investigations to be undertaken which further inform referrals to the hospital eye service (eg repeated glaucoma measures) and where clinically indicated, a variety of specialist tests (eg OCT, pachymetry, gonioscopy, etc – figure 3) can be used alongside other investigations as part of the referral refinement or management. In addition to acute eye conditions, this scheme covers the monitoring of OHT/glaucoma suspects and post-op cataract reviews.
Optometrists are accredited by completing WOPEC’s online modules and attending interactive workshops. Re-accreditation is carried out every three years and is informed by new service developments and audit. The fee structure is £60 for a case-finding ‘Band 1’ examination (£20 for a subsequent follow-up) and £40 for ‘Band 2’ further investigations following a sight test.36
Scottish supplementary examination16
The NHS has funded Scottish eye examinations for Scottish residents for more than 10 years. In addition to a routine ‘primary examination,’ practitioners may perform a ‘supplementary examination’ to conduct further investigations for referral refinement, to monitor patients with suspected pathology or for ocular emergencies. The scheme also includes post-operative cataract review, cycloplegic refraction, dilated fundus examination and the use of modern equipment such as OCT.
A GOS competency training assessment is required for accreditation which involves a virtual visual fields lecture and a practical assessment in indirect ophthalmoscopy, contact tonometry and slit lamp use.17 Fees for the primary eye examination are £37 (£45 if over 60 with a fundus photo) and £21.50 for a supplementary exam.37
Evolutio care innovations ltd18
Evolutio provide electronic referral management services to a range of CCG’s across England. All non-emergency GOS referrals within a CCG are assessed by a team of clinical readers who determine the most appropriate tier of care based on risk (triage). The patient is then offered a choice of provider within Evolutio’s clinical network; this could include the HES, community ophthalmology (either led or delivered by a consultant ophthalmologist), GP with special interest, or clinical optometrist. In addition to providing access to consultant telemedicine services, Evolutio’s CCG-accredited pathways allow clinical optometrists to maximise use of their specialist equipment and skills (eg OCT, SLO, topographer, gonioscopy).
Optometrists are accredited by completing an HES-led training course/OSCE exam. A live PDP with regular peer review and clinical audit are required to maintain accreditation. Fees range from approximately £38 for an anterior eye pathway to £48 for a posterior pathway with digital imaging. Fees for OCT telemedicine partners are £115 (first or follow-up appointment).38
Ophthalmology-led service
Some optometrists work under the supervision of a consultant ophthalmologist, with direct or remote telemedicine access, in community ophthalmology clinics (such as Newmedica,19 Anglia Community Eye Service20 and eCare21) or in acute hospital settings.22
A wider range of conditions can be investigated and managed under an ophthalmologist’s supervision.23 Written protocols specify the conditions and required investigations. An optometrist would typically undertake a range of clinical tests, formulate a tentative diagnosis and propose a management plan which the ophthalmologist would approve or modify after reviewing the clinical data (either in person or remotely).
The optometrist must ensure the tasks delegated to them are within their limits of competency and are performed safely and accurately. It is important to have a clear line of accountability (clarify who is responsible for the outcome) and a reporting process.
Optometrists are ‘accredited’ after being trained and validated by an appropriate person, often a consultant ophthalmologist; relevant higher qualifications are generally encouraged. NHS optometrists’ salaries are banded and equate to approximately £26,302 at entry-level (Band 6), £31,383 for a specialist (Band 7) and up £82,434 for a consultant (Band 8).24 Sessional rates might be offered for part-time work in the NHS or private sector, often commensurate with conventional locum fees.
Private clinical optometry
Optometrists are expected to recognise signs and symptoms which require further investigation and decide whether they are able and willing to manage these in practice. They are expected to offer clear advice on appropriate management options and refer the patient appropriately if necessary. Irrespective of whether CCG-funded schemes exist, some patients might opt to pay privately for investigation, monitoring or treatment in practice. In many cases this can provide a diagnosis and treatment sooner and closer to home than non-emergency HES care and it is entirely reasonable to be adequately remunerated for this service.
A sight test must include ‘such examinations of the eye for the purpose of detecting signs of injury, disease or abnormality in the eye or elsewhere as the regulations may require,’25 therefore additional diagnostic tests, monitoring and treatment fall outside the scope of a ‘sight test’. The practitioner and patient should understand that such ‘privately funded medical services’ are not a statutory sight test nor a full eye examination and the patient should be advised to have a sight test at the appropriate time (routinely or sooner if indicated).
Clinical optometrists are expected to be familiar with the College of Optometrists’ Clinical Management Guidelines26 which provide information on ‘the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.’
Optometrists must explain the proposed procedure and its scope, gain consent and explain the results with an appropriate management plan.27 Where onward referral is indicated, agreed local HES referral protocols28 should be followed and a good working relationship with your local ophthalmologists (including telemedicine access) can be beneficial.
Experienced clinical optometrists may receive referrals from their colleagues for investigative procedures/treatment, advanced contact lens fitting etc. College guidance29 states that ‘when you refer a patient, you also transfer responsibility for the relevant part of the patient’s care’. It is therefore important for both practitioners to have a clear understanding of the extent of their responsibilities and to maintain a clear line of communication with each other and the patient.
College guidelines30 also state that ‘if you receive a referral, you should address the reasons for referral and advise the patient to consult their regular practitioner for routine eye care’. When receiving a referral through a CCG-funded scheme (eg MECS or GRR) there may be written protocols which a practitioner should follow. Like our medical colleagues, private practitioners may have a greater level of flexibility in deciding which investigations are indicated and have the opportunity to be remunerated appropriately.
Sufficient time should be allocated to provide a proper diagnosis and treatment. Referrals can be broadly classified into anterior and posterior pathways. In clear-cut cases of anterior segment pathology (eg blepharitis, superficial non-metallic foreign body, dry eye, etc), practitioners might choose not to examine the posterior segment. Others might take a more cautious approach by conducting a cursory examination through an undilated pupil (with dilation as indicated). In unilateral posterior segment pathology (eg floaters, choroidal naevus or a suspicious optic disc) most practitioners would undertake a dilated fundus examination of both eyes following an anterior segment examination.
Optometrists should not practice outside the realms of their expertise or qualifications. Indemnity insurance usually covers any work done which is ‘within the scope of normal optometric practice’ but it is advisable to discuss your individual circumstances with your insurer if there is any uncertainty. In the event of a GOC complaint, you are judged against the standard of a reasonably competent optometrist;31 if the procedure is outside core competency you would be judged against the standard of an optometrist with whatever qualifications you currently hold (eg IP, Prof Cert etc);39 opinions are usually provided by an experienced clinical optometrist known as an ‘expert witness’.
We must make the care of the patient our first and overriding concern.32 Clinical optometrists can often see patients sooner, closer to home, at a reduced tariff (compared to acute HES ophthalmology) and refer to the HES with fewer false positives and appropriate levels of urgency. Through our PDPs we can become confident with our core competencies33 then expand our clinical skills11 and scope of practice34 with postgraduate education, training and modern equipment to reach our full potential as clinical optometrists. We have more opportunities to work and be paid as clinicians now than at any time in the history of our profession.
The author is an optometrist with experience in HES clinics, community ophthalmology and clinical and retail optometry. He is a MECS assessor and referral reader (triager).
Acknowledgements
I would like to thank the following individuals and organisations for their views and contributions:
- Locsu – Trevor Warburton (clinical advisory group chair) and Katrina Venerus (managing director)
- EHEW – Dr Nik Sheen (clinical lead)
- Optometry Scotland – Nikki McElvanney (chair)
- eCare Eye Services Ltd – Mr Simon Hardman-Lea (consultant ophthalmologist) and Peter McElduff (clinical optometrist)
- Evolutio Care Innovations Limited – Peter Price-Taylor (CEO) and Lyn Price (clinical lead – optometry)
- Clinical optometrists – Ian Cameron, Peter Frampton, Dr Adrian Jones, Kevin Lewis and Nick Rumney
- Professional bodies – Association of Optometrists
References
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27 College of Optometrists (2016) ‘Guidance for professional practice – Gaining consent to treatment from adults’, [Online] Available at guidance.college-optometrists.org/guidance-contents/communication-partnership-and-teamwork-domain/consent (Accessed 28/8/16).
28 College of Optometrists (2016) ‘Guidance for professional practice – Working with colleagues (C149)’, [Online] Available at guidance.college-optometrists.org/guidance-contents/communication-partnership-and-teamwork-domain/working-with-colleagues/#open:234 (Accessed 29/8/16).
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30 College of Optometrists (2016) ‘Guidance for professional practice – Working with colleagues (C142)’, [Online] Available at guidance.college-optometrists.org/guidance-contents/communication-partnership-and-teamwork-domain/working-with-colleagues/#open:234 (Accessed 29/8/16).
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34 Hawley, C (2011) ‘UK Eye Care Services Project – Phase One: Systematic Review of the Organisation of UK Eye Care Services’, [Online] Available at college-optometrists.org/en/utilities/document-summary.cfm/4783B5BD-51D2-4C3E-916EE02F6230CB21 (Accessed 28/8/16).
35 Email and verbal correspondence with a sample of MECS providers (August-September 2016) Locsu do not publicly comment on fees due to regulations surrounding competition law in the absence of a national tariff in England for primary eye care services.
36 Email communication with Dr N Sheen, EHEW Clinical Lead (30-8-16).
37 Email communication with N McElvanney, Optometry Scotland Chair (5/9/16).
38 Email communication with P Price-Taylor, CEO and L Price, Clinical Lead – Optometry, Evolutio Care Innovations Limited (27/9/16).
39 Email communication with Association of Optometrists (29/8/16).