The theme of last month’s Verum column highlighted the worrying number of patients suffering from glaucoma whose follow up appointment is delayed or worse lost completely. This appears to be a common occurrence across the country that is well known to all concerned, except perhaps the patient, who may be blissfully unaware their vision is being lost as inevitably delays in investigation and identification of deterioration in a condition will contribute to visual loss.
Despite this, the perception is that the problem is getting worse and yet urgent action does not seem to be being taken by appropriate bodies; clinical commissioning groups, CCGs and trusts. To my thinking the obvious solution is to have more optometrists involved in routine glaucoma follow up, either in the community or working within the hospital alongside an ophthalmologist. Since the previous column was published I have received anecdotal comments on the obstacles that exist to addressing the situation and I wanted to explore these in greater detail.
A common theme around the country is that there are not enough optometrists who have the required qualifications to undertake ocular hypertensive and glaucoma monitoring. The Royal College of Ophthalmologists sets out the level of competence required and this is fulfilled by the optometrist undertaking the College of Optometrists certificates, such as the Professional Certificate and Higher Professional Certificates in Glaucoma. There may be a number of reasons why some optometrists do not come forward for this training. There is a cost and time commitment. There is also the requirement for the optometrist to undertake a placement, which will need to be paid for in addition to course fees, under the guidance of a consultant ophthalmologist. A major obstacle is that a placement may be impossible to find.
A colleague recently observed there is a certain irony to the situation where an ophthalmologist knows they cannot cope with demand, they need to do something different, their College sets up pathways and training to bring on new people and yet the ophthalmologist points out they are too busy to adequately look after an optometrist who is training. I wonder if the ophthalmologist has heard the common analogy of a woodcutter who is sawing for several days and is becoming less and less productive. The process of cutting dulls the blade and so an onlooker suggests that, as the woodcutter looks exhausted, he takes a break and sharpens his saw. To which the woodcutter replies, he does not have time to sharpen the saw as he is too busy.
In addition to a lack of time, ophthalmologists may be sceptical of optometric ability to adequately manage patients in the community, a view that will be reinforced by some of the poor referrals they receive. Training places may also be limited by space within the hospital setting. Looking elsewhere, CCGs may be uncertain about entering into new arrangements due to uncertainty of the future cost due to initial capital outlay or increasing the number of patient episodes.
Whatever the reason for a lack of placements, if there was positive ophthalmology engagement in having optometric manpower involved in pathways these obstacles could and would be overcome. I suspect there is some deep-seated aspect of human nature reluctant to give up a part of their job to others, akin to ‘taking the food off my plate’, even where objectively it looks to be the right thing to do. It follows that any case for change put forward should not appear threatening to ophthalmology, but should paint a picture where ophthalmologists are able to use their unique expertise to best effect in a service that is producing excellent outcomes.
There are, of course, examples of great practice around the country where ophthalmology and optometry work excellently together. The frustration is that these are pockets of excellence and not the norm. It would be attractive to think there would be a national body to implement change across the board. Unfortunately this is not how the NHS works. It will take a lot of effort, through LOCs, Locsu and Eye Health Networks, in each area around the country to get to a point where there is significant change.
We will have to have local conversations with ophthalmologists as they will be key influencers of CCG commissioners and trust managers. We will need to build a persuasive business case for the CCG commissioners and the trusts that sets out what is currently going wrong, the patient benefits that will be realised, the impact on the public health outcomes framework and cost savings that can be achieved. Finally is there influence the Royal College of Ophthalmologists can bring to bear on their members?