‘Keep your friends close and your enemies closer’ is often attributed to Sun Tzu or Niccolò Machiavelli, although the first instance is probably Michael Corleone in Godfather 2 (a rare case where the sequel was better than the original). It’s certainly unfair to pitch ophthalmology, optometry and dispensing optics as enemies, we are all ostensibly after the same thing; better patient care. Nevertheless, there is certainly a political angle to how organised medicine deals with allied professions outside its direct control.
At 100% Optical the new president of the Royal College of Ophthalmologists (RCO) discussed plans to resolve issues with the ophthalmology workforce. This was followed by news that the RCO had received funding to develop the Ophthalmology Common Clinical Competency Framework (OCCCF). The press release clearly stated this would be through the development of an ophthalmology-led multi-disciplinary workforce. Optical representation appears to involve only the College of Optometrists (CoO), leaving the sector wide body (Optical Confederation (OC)) aside and ignoring dispensing opticians entirely.
This funding appears to have arisen from the recent Health Education England workforce planning review,1 which is currently out to consultation. Previous brushes with the DH workforce planners might raise an eyebrow. In the early 2000s the profession was assured that workforce planning was going to help fund optometrists into non-medical prescribing. By the time it came to ask for it, what little that had not been Blackaddered (found it, pinched it, spent it) by GPs and others was only to be used for direct NHS employees and not mere contractors like optometrists.
In any case, there is no mention of optometrists or optometry in this 142 page document, save the news about the involvement of our College in the projected OCCCF. Interestingly the call for national consultation on this document has not yet appeared in any of the optical press.2 It goes without saying it would be nice if our 20,000 strong combined profession could comment?
The RCOphth has (with obvious CoO input) altered its understanding of matters optical.3 For example, there is now tacit recognition of the limitations of what a GOS sight test is, and is not. Nevertheless the OCCCF is a concern. Maybe it is pertinent to look at the existing published OCCCF documents4 and review the current state of play. Structurally it envisages a pre-existing ‘core’ of skills before moving on to its Level 1, 2 or 3. There are documents on acute care, cataract, glaucoma and medical retina specifically as well as a general introduction. All start with the following assertion.
‘The basic skill set of an ophthalmic non-medical health care professional (qualified optometrist, orthoptist, ophthalmic nurse or ophthalmic clinical scientist) is to:
- Perform basic clinical ophthalmic assessment
- Follow protocols within their scope of practice under appropriate supervision
- Detect abnormalities through assessment and act on these findings
- Not make a diagnosis or treat.”
Most optometrists in primary care will fundamentally disagree with all bar the assertion on detection, although few will disagree that these do not form part of the core contract with the GOS ST. As has been said in these and other pages time it ill-behoves our representatives to accidentally or mischievously misrepresent this position as being an absence of competence as opposed to an inadequate contract.
Moving on from what is mistakenly detailed as ‘core’ the documents list areas of competence in Level 1, 2 and 3. Some of these are just plain nonsense. Accident, deliberate or misunderstanding ? I will highlight a few.
Using a ‘device to measure intraocular pressure’ is listed above core, at Level 1 in acute eye care, while in the glaucoma document GAT is listed as Level 1. However, while it may be sensible to list gonioscopy as Level 2 in glaucoma listing the ‘use of stains’ and ‘arranging appropriate and timely referral for patients outside scope of practice’ is Level 2 in the glaucoma document. Even more bonkers at Level 1 in cataract is the competence ‘ability to recognise the signs of cataract’ while Level 2 includes undertaking YAG laser.
I could go on. The important thing from our perspective is that this set of documents, while it does possibly detail the specific competencies that may be required for different patients at different times in the HES process, it is clearly not mapped to optometry or dispensing optician competences as they presently exist, let alone what they might be. The impression given is of a ‘smoke and mirrors’ approach to retaining control entirely within the ophthalmology-led HES.
It certainly does not reflect any of the core competencies of optometrists at registration and piles Pelion on Ossa on the mess that has pushed basic optometric core competencies, tested at registration, into higher certificates for glaucoma and medical retina. The very concept of an autonomous independent prescribing optometrist is not remotely recognised in these documents though is presumably level 2 or 3.
Mike Burdon is to be supported in his efforts to continue to facilitate the interdisciplinary working developed by his predecessor. In his press release he states: ‘While the hospital eye service and its workforce continues to be overwhelmed, we are constantly looking for solutions. The welcomed HEE funding will ensure we can now develop a curriculum that will have many benefits for both the HCP ophthalmic workforce and, importantly, for patients.’
This is where the political nous of our representatives becomes vital. It is no longer satisfactory (if it ever was) to assume that what takes place in terms of investigation, diagnosis, treatment and management is always, by definition, right when it occurs within the HES and treated with dismissal or at worst contempt when such a process is undertaken by an optometrist in primary care.
In recent months I have personally handled a frank visible retinal tear imaged on Optos that was not found in two ophthalmic A&E units, two cases of frank repeatable visual field defect with visible structural damage on OCT nerve fibre layer and ganglion cell loss, yet discharged, and umpteen symptomatic cataracts denied listing on spurious visual acuity grounds. In all of these cases I have had to re-refer or contact senior consultant staff.
The fact is that while the diagnostic and management learning curve of ST junior ophthalmologists is meteoric and that of the average community optometrist tortoise-like, we simply need to work together and respect what each profession is capable of when supported by appropriate education, training, experience and contract. Sometimes, just sometimes, that requires the admittedly junior partner profession to gird its political loins and stop doffing its cap.
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