I guess there are a few in the optical industry who were surprised at the press release announcing that Specsavers was investing in optical coherence tomography (OCT) technology in a multi-million pound programme. However, I would not have thought this needed Mystic Meg to predict.
Perhaps it is pertinent to ask; is this further evidence of the group positioning itself to catch up with the independent sector ? Is this what is meant by ‘simply the right thing to do in terms of offering our patients a choice of the best possible technology in their eye examination’.
What is likely to be happening is that Specsavers may be expecting their franchisees to invest in a globally negotiated, take it or leave it deal, with one or two chosen suppliers. Industry speculation suggests there are already more than 500 OCTs in primary care optometry since it was first introduced in 2007. The lion’s share is already where most innovation takes place; the independent sector.
Coming so late into the game Specsavers will obviously have had the pick of suppliers and instruments but how much choice will there be for franchisees? Will the instrumentation be cutting edge new generation instruments that can talk to the HES clinics?
Specsavers says: ‘It is another major step forward in our journey to transform eye health, putting hospital grade equipment in the community and helping to close the gap between optometry and ophthalmology.’ It is an interesting implication that in these days of NHS austerity, a wealthy private business has been making do with poorer equipment than the NHS.
Will franchisees be obliged to subsume the cost and offer OCT free of charge? To whom? Will it be standard core examination or the recommendation of the optometrist? Bear in mind there is minimal cost in the scan itself, the cost is undoubtedly in optometric time to interpret and make a clinical decision. Can Specsavers create the perception of examination quality when it has made a pretty good job of it in the retail sector?
Quite apart from the issue of supply and who pays for it there are one or two very serious questions that a mass retail chain with a retail focused operation (the clue’s in the name) will need to answer before problems rapidly arise. Without a sanity check this could backfire on the profession as a whole.
First, to become familiar with OCT requires a significant amount of training and experience that has, heretofore, taken considerable time. You simply need to be undertaking OCT day in and day out and with scores of patients to become proficient at even understanding the artefacts. While there are now at least four higher qualifications in medical retina, OCT offers much more than cross sectional imaging of the posterior pole and a medical retina qualification is way more than OCT interpretation.
OCT is becoming integral to the diagnosis and management of glaucoma despite imaging being curiously omitted from the first NICE Guideline but there is no formal course teaching on this aspect. This is because there is no specific accredited training package associated with OCT. OCT is not a core competence and so few, if any, newly qualified will have had any exposure.
Some may have seen OCT in their pre-registration period but, of course, it is extremely unlikely those young optometrists will be joining Specsavers because if you have once used OCT you will probably require it as a deal breaker in any job search. Does the expertise exists within the organisation itself to deliver this training? Surely the sheer logistics will make it a challenge even if there is more than one supplier?
Secondly, and of more concern is the entirely different culture required in an enhanced role for optometry of which OCT is merely a tool, like low vision or independent prescribing. Generations of optometrists have been inculcated in the recognition and referral of abnormality and there is evidence that optometrists can do this job well with provisos. However, because of the contractual straitjacket of the GOS and the sclerotic business plans used by the majority of optometrists (multiple, franchise and dare I say it many independents) most struggle with the GOC rules on referral.
The current rules date back to 2000 and removed the 1961 obligation on optometrists to refer disease or abnormality. The corollary to this is that optometrists are enabled to diagnose and manage ocular conditions without referral. In fact the entire principle of enhanced services and independent prescribing is based on this.
Fundamentally the mind-set needs to change; to making sufficient investigation (which may need more than one visit) to making a diagnosis and in deciding to refer only those where the outcome of the referral will benefit the patient and the referral is necessary. While there will always be diagnostic challenges requiring secondary care opinion there is a lot more to this than comparing a few red lines on an OCT to normative database and making a referral.