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During 2011-12, 481,674 NHS domiciliary sight tests were carried out in the UK.1 These took place for patients who were eligible for an NHS sight test, but unable to attend an optometrist’s practice unaccompanied, due to a physical or mental illness or disability. This document outlines details of the NHS provision for domiciliary eye care and discusses the professional, legal and ethical responsibilities of optometrists working in this area.
NHS provision
NHS domiciliary eye care falls under the umbrella of the General Ophthalmic Services (GOS) and as such, is commissioned at a local level throughout the UK. In Scotland, NHS Boards issue contracts and optometrists are paid via Practitioner Services, In Wales, the NHS Wales Business Services Centre supports the Local Health Boards, providing contractor services for primary care optometry including contracts management and payment processing. In Northern Ireland, the Health and Social Care Board has responsibility for the provision of General Ophthalmic Services.
Prior to April 2013, primary care trusts (PCTs) were responsible for GOS commissioning in England. Since that date and the enactment of the Health and Social Care Bill, abolishing PCTs, NHS England has taken over this role. NHS England is now central to commissioning Primary Health Care in England. It operates nationally (with a central office in Leeds), regionally (being split into four sectors) and is represented locally by 27 area teams.2
Regulations stipulate that GOS sight tests may only be provided at a listed practice, at a patient’s normal place of residence (including residing at a residential home), or at some day centres.3,4,5,6 Although possession of a contract to provide ‘Mandatory Services’ is sufficient if sight tests are to be carried out at a practice address, a separate contract to provide ‘Additional Services’ must be obtained in order to carry out domiciliary sight tests. Any provider wishing to offer NHS domiciliary sight tests must apply for a contract with their relevant local body. It is also important to note that a separate ‘Additional Services’ contract must be held for each area in which the contractor wishes to carry out domiciliary visits.3 Applications for ‘Additional Service’ contracts can be made by individuals or partnerships, or corporate bodies or limited companies.
A minimum standard of equipment is required for ‘Additional Services’ contractors and ‘Additional Services’ applicants are asked to bring their mobile equipment into the area team office of NHS England so that it might be checked and approved. If this is likely to prove problematic, the area team should agree with the applicant a suitable time and place for inspection and approval. During this meeting, the applicant has the opportunity to answer pertinent questions about their facilities for record-keeping and their staffing arrangements.7 The minimum equipment for ‘Additional Services’ contractors can be found in Table 1.
Before visiting patients, contractors are required to inform the appropriate area team or health board of their intent to provide domiciliary services. In England and Wales, 48 hours’ notice must be given if one or two people will be visited at the same address, whilst if three people or more are to be visited, three weeks’ notice should be provided.3,4,8 In Scotland, the relevant health board should be notified one month in advance of any proposed visit to three or more people at the same address, while in Northern Ireland, 48 hours’ notice is required except if the situation is urgent, when no notification is needed.5,6,8
In England and Wales, any changes to the original notification given by the contractor may be made, providing that this takes place at least 48 hours before the intended visit. Up to three changes (additions or substitutions) may be made on the day of the visit, but only if it would not have been possible to give 48 hours’ notice, eg in respect of a new resident or a person who has only just developed an eye or vision problem.3,4 In Northern Ireland, 24 hours’ notice is required for any changes to a planned visit. However, if circumstances arise which mean that it would not have been possible to notify the Social Care Board in advance, it is possible to add up to three patients to those being tested.6 In Scotland, substitutions can be made on the day of the visit, providing the health board had received notification, at least a month in advance, of the substituted location or patients.5
When an NHS domiciliary sight test takes place, both the optometrist and the patient have a responsibility to ensure that the domiciliary visit is necessary. The optometrist should ask the patient to specify the specific illness or disability which prevents him/her from attending a practice and this should be noted on the relevant GOS form (Table 2).
Generic terms such as ‘housebound’, ‘immobile’, ‘wheelchair-bound’ or ‘resident of a home’ are insufficient. Giving the reason why the patient cannot leave home unaccompanied is the patient’s responsibility rather than the practitioner’s, and there is, therefore, no issue of medical confidentiality. Having a role as a carer for a person who is housebound, does not make that individual eligible for an NHS-funded domiciliary sight test, even if it is difficult for the carer to leave their house, due to their caring responsibilities. When completing the GOS form, the optometrist should also indicate whether the patient was the first, second, or third or subsequent person seen at that address on that visit.4,5,6,7
Current (April 1 2014 to March 31 2015) NHS domiciliary visiting fees paid to the contractor are set at £37.19 for first and second patients and £9.31 for third and subsequent patients.9 This amount can be claimed in addition to the sight test fee for each patient seen.
Examination considerations
Guidelines issued by the College of Optometrists are clear that, regardless of where an eye examination takes place, an optometrist has a responsibility to carry out whatever tests are possible to determine the patient’s needs for vision care as to both sight and health.10 Additionally, individuals who have protected characteristics, defined by the Equality Act (2010), are protected from discrimination. Characteristics which may be relevant when considering providing domiciliary eye care are age and disability. In particular, service providers should not offer a lower standard of service to anyone with a protected characteristic.11
Joint guidance from ABDO, FODO, the AOP and the College of Optometrists lists the tasks that a practitioner providing mobile ophthalmic services would normally be expected to perform and examples of equipment considered suitable to perform these tasks (Table 3). However, it is acknowledged that there may be occasions when it may not be appropriate or feasible to carry out all the tasks outlined, because of a patient’s disability.12
Following considerable debate regarding the assessment of visual fields in a domiciliary environment, the Domiciliary Eyecare Committee issued guidance on this matter.13 This guidance recommends that the safest requirement for domiciliary patients is for all mobile providers to ensure that a portable means for testing visual fields, either manual or electronic, is routinely available (in addition to confrontation targets) for all patients.
Particular attention should be paid as to whereabouts in the residential environment the sight test will be carried out. Information available to those who wish to arrange a domiciliary sight test advises that a room with good lighting and blinds or curtains to allow the room to be darkened should be available. The availability of easy access to a plug socket is also emphasised. Additionally, it is recommended that the optometrist should be able to get to both sides of the patient and that three metres of space should be available in front of the person’s bed or chair. Rearrangement of a room’s layout can sometimes be distressing for an individual so if this is necessary, it can be beneficial for this change to be explained in advance of the sight test and for the person to be reassured that it is only temporary.8
It is also important to ensure that the patient’s dignity and privacy is respected within the domiciliary setting14,15 and the Care Quality Commission have emphasised this need in care homes.16 The sight test should take place in an area where patient confidentiality can be maintained and where interactions between patient and practitioner cannot be observed or overheard by other residents. Each patient should also be treated as an individual14 and group testing is, therefore, not condoned.
Patients should have a free choice as to which practitioner is consulted.3,10,14 and it is suggested that limiting patient numbers to five to seven per session (morning or afternoon) will ensure that patient care is not compromised.17 These points are of particular relevance in a residential home or day centre setting.
Consideration of the Mental Capacity Act (2005) may be appropriate when working with some domiciliary patients (Table 4).
This Act, which applies in England and Wales, provides a comprehensive framework for decision making on behalf of adults aged 16 and over who lack capacity to make decisions on their own behalf. Scotland has its own legislation, the Adults with Incapacity (Scotland) Act 2000, and in Northern Ireland, the approach is currently governed by the common law.18
The Mental Capacity Act affects anyone with an impairment of, or a disturbance in the functioning of, the mind or brain.19
A fundamental principle of the Act is that people over the age of 16 are presumed to have legal capacity to make decisions for themselves, unless it can be shown that they lack the capacity to make the decision for themselves at the time the decision needs to be made. The Act also states all appropriate help and support should be given to enable people to make their own decisions or to maximise their participation in the decision making process. This could mean supplying relevant information in alternative formats, eg pictorially, or delaying decision making until a time when the individual is more able or more alert. It should be remembered that individuals who do not possess the mental capacity to make major decisions (eg giving consent to being referred to an ophthalmologist) may still be able to make more straightforward ones (eg colour choice of a new spectacle frame).
However, if a decision is made, or action is taken, on behalf of someone who lacks the capacity to make the decision or act for themselves, then the decision or action should be carried out in their best interests.18
If a doctor or healthcare professional proposes treatment or an examination, they must assess the person’s capacity to consent (Table 5).
Additionally, as a healthcare professional, an optometrist should work within the Code of Practice which accompanies the Mental Capacity Act.21 This Code explains that a person must not be assumed to lack capacity because of their age, their appearance, any mental health diagnosis they may have or any other disability or medical condition they may have.
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Professional, legal and ethical considerations for domiciliary care - part 2
Model answers
(The correct answer is in bold text)
1 Which of the following is not essential in order to provide 'Additional Services'?
A Visual fields assessment means
B Colour vision screener
C Tonometer
D Retinoscope
2 For which of the following countries should the longest notice of intention to provide domiciliary services to more than three people be given?
A England
B Scotland
C Northern Ireland
D Wales
3 Which of the following would be insufficient to enter on a GOS6 as reason for domiciliary care?
A Multiple sclerosis
B Rheumatoid arthritis
C Wheelchair dependent
D Quadraplegia
4 It is recommended that the number of patients assessed in any one session should be limited to how many?
A 1
B 2 to 3
C 5 to 7
D No limit
5 Which of the following statements relating to tonometry during a domiciliary visit true?
A As non-contact tonometers are not portable then tonometry is always carried out by Perkins
B If tonometry is thought essential then refer the patient to a clinic
C Tonometry should be offered as it is in any clinical setting
D Digital palpation is acceptable
6 Which of the following statements about remuneration is true?
A There is a single domiciliary fee paid per patient
B There is a single supplementary payment for domiciliary assessment in addition to the GOS sight test fee
C There is a single supplementary payment for domiciliary assessment in addition to the GOS sight test fee which reduces after the first patient claimed
D There is no separate payment for domiciliary services
Acknowledgement
The author would like to thank David Cross, an optometrist working in the domiciliary sector, for his help in compiling this article.
References
1 Optical Confederation (2013). Optics at a Glance 2012. Accessed 10th February 2014.
2 NHS England website. Accessed 10th February 2014.
3 The Optical Confederation, AOP (2014). Making Accurate Claims in England. Accessed 14th July 2014.
4 ABDO, AOP, FODO, Optometry Scotland (2010, Updated 2012). Making Accurate Claims in Scotland. Accessed 10th February 2014.
5 ABDO, AOP, FODO, Optometry Wales (2007). Making Accurate Claims in Wales. Accessed 10th February 2014.
6 ABDO, AOP, FODO, Optometry Northern Ireland (2007). Making Accurate Claims in Northern Ireland. Accessed 10th February 2014.
7 NHS England (2013). Procedure approval of applications for General Ophthalmic Services contracts. Accessed 10th February 2014.
8 Thomas Pocklington Trust, The College of Optometrists, Optical Confederation (2013). Sight Tests at Home leaflet. Accessed 17th July 2014.
9 FODO Website. Accessed 14th July 2014.
10 The College of Optometrists (2011). C5 The Domiciliary Eye Examination. Accessed 10th February 2014.
11 Gov.uk website. Equality Act (2010) Guidance. Accessed 10th February 2014.
12 ABDO, AOP, College of Optometrists, FODO (2006) Equipment for Use in Mobile (Domiciliary) Ophthalmic Services (GOS). Accessed 10th February 2014.
13 Domiciliary Eyecare Committee (2010). Field Screening in the Domiciliary Setting. Accessed 10th February 2014.
14 Domiciliary Eyecare Committee (2014). Code of Practice for Domiciliary Eyecare. Accessed 4th September 2014.
15 General Optical Council (2010). Code of Conduct for Individual Registrant. Accessed 4th September 2014.
16 Care Quality Commission (2012). Time to Listen in Care Homes. Accessed 4th September 2014.
17 Guidelines and Audit Implementation Network – Northern Ireland (2010). Best Practice Guidance for the Provision of Domiciliary Eyecare in Nursing/Residential Homes and Day Care Facilities. Accessed 10th February 2014.
18 British Medical Association. Mental Capacity Toolkit Available online at: http://bma.org.uk/practical-support-at-work/ethics/mental-capacity Accessed 10th February 2014.
19 Mental Capacity Act 2005. Available online at: www.legislation.gov.uk/ukpga/2005/9/contents Accessed 11th February 2014.
20 The College of Optometrists 2009. The Mental Capacity Act: Application to Optometric Practice. Accessed 11th February 2014.
21 Mental Capacity Act Code of Practice. Accessed 13th February 2014.
Catherine Viner is a senior lecturer at the University of Bradford