Research conducted by the General Optical Council (GOC) into the risk that optical professionals pose to patients has highlighted the perception that the level of this risk is increasing. Survey respondents, a 2,610 strong mix of GOC registrants and other stakeholders, were questioned on whether they agreed the level of risk to patients and the public associated with optometrists and dispensing opticians was changing. This followed questions earlier in the same survey around perceptions of risks in optics currently, which were covered in last week’s Optician (In Focus 25.10.19).
Over half of the survey respondents (52%) agreed that the level of risk associated with optometrists was rising, although a sizeable proportion (30%) stated they neither agreed nor disagreed. In contrast, just over a third (34%) of those surveyed believed the same was true for DOs, with 40% neither agreeing nor disagreeing and nearly a fifth (19%) disagreeing. This discrepancy, however, was contextualised by subgroup analysis; DOs were more likely to report that risks were increasing in the dispensing role (49%) than optometrists (25%). More recently qualified respondents were also more likely to agree that the risks for DOs were increasing, with 43% of those having been registered for fewer than two years agreeing, compared to just over a fifth (21%) of those registered for 21 years and over.
In the investigation of whether risks were increasing, respondents were asked to rank a list of factors understood to be changing the way that optical services are delivered from one to five, based on their impact. The changing scope of the role of optical professions was the factor perceived as increasing risk for patients the most, returning a ranking of 3.35 out of 5.
Widening responsibilities
Researchers revisited the changing scope of the role of optical professionals in the qualitative research, where focus groups and intensive one-to-one interviews with registrants and stakeholders were used to further examine what exactly about changing roles was leading to the belief that risk to patients would be increased. The profession broadly accepted the role of optical professionals had increased in scope.
‘Over the last 10 plus years there has been a change from the original practice, which was to provide refraction tests, glasses and screen for eye disease. Now opticians are becoming more involved in the management of ophthalmological diseases,’ commented a Royal College of Ophthalmology stakeholder. Services including the detection and management of glaucoma have been transferred from secondary care into community practice to relieve pressure on the NHS, with the report suggesting the profession believes this increases their risk to patients.
That increased responsibilities for care presented higher risks of dangerous outcomes was perhaps unsurprising, as a Leeds-based DO opined: ‘With the introduction of Minor Eye Conditions Service work we’ve got people coming in with more issues. There’s more people coming through the door with a problem than there used to be, so there’s greater risk.’ It was also reported, however, that the increased scope of professional roles could increase risk for patients because of the subsequent expectations for more training, education, skills and confidence. Some interviewees explained that they did not have the capacity for upskilling, and it was suggested that less confident or experienced practitioners may present greater risks because of a lack of training. Longer-practising professionals who had not kept up to date with training to prepare them for increased responsibilities were also mentioned as possible risks.
There was no consensus that an expanded clinical role for opticians was increasing risk; in contrast to the online survey responses, the majority of interview participants disagreed, with most believing that risk had either not increased or had actually lessened. A Federation of Ophthalmic and Dispensing Opticians (FODO) spokesperson summarised this position: ‘As a profession we’re taking on more risks and we’re managing it incredibly well. The tools that the GOC have in place to help that, such as CET, are helpful but need to be modernised and brought more up to date, which we know is in the pipeline. Changes to the structure of the workforce are also moving us in the right direction. From our point of view, it’s an incredibly positive story.’
Dispensing opticians
A larger portion of discussion around changing clinical scope focused on the optometrist role, which the greatest potential risks centre around. However, DOs and concerns about their marginalisation in favour of non-registered optical assistants also generated considerable debate. Numerous interviewees commented on the risks they felt were posed by delegating tasks, such as pre-screening before an eye examination, to possibly underqualified optical assistants.
An Association of British Dispensing Opticians (ABDO) stakeholder explained: ‘There’s a greater risk to the public. If they go and see someone at a much lower level but consider them to be a DO, then there’s a real disparity in that. There’s also a greater risk imposed upon the registrant if you have unqualified staff doing all sort of things.’
Does an expanded clinical role necessarily mean more risk?
Training and the disparities between the levels of it that DOs and optical assistants receive was also a contentious issue. It was suggested that some companies were exacerbating the risks posed to patients by underqualified staff through their provision of training to optical assistants. Though it was generally accepted that the quality of this training could be high, it was disputed that optical assistants could be brought up to the level of their dispensing colleagues, who study for three years before qualifying. Part of this disparity was also blamed on a failure by the GOC to clearly define the role of a DO, leading to confusion and inconsistent delegation of roles across the country. ‘I think the GOC have to be clearer on what we as DOs have to do and don’t have to do. It’s really quite blurred in terms of what we are responsible for. It needs to be a more defined role,’ said a DO practising in Leeds.
Positive solutions to the problem of optical assistants increasingly performing parts of the role of a DO were suggested by members of the profession. A number of interview participants suggested that DOs should be encouraged and helped to upskill themselves, taking on additional responsibilities so as to allow optometrists to do the same. Refraction, for example, was regularly suggested as something that many DOs could begin to take responsibility for. Legal changes would be necessary to amend restrictions on the delivery of sight tests, but the report mentions that this would bring legislation in line with countries with high standards of healthcare, such as the Netherlands and Switzerland. An ABDO representative also clarified that DOs should have to prove their capability to perform refraction via training and accreditation before being allowed to carry it out, so as not to unduly create more risk to patients.
Locums
Owing to a range of factors including flexibility and more independence, the proportion of the profession who work primarily as locums had increased considerably over the previous 10 years. This changing level of risk was brought up by participants in the qualitative portions of the research regularly and informs the perception that working as a locum was seen by survey respondents as riskier than full-time practice. While locum work was rated as presenting an above average risk to patients (3.01) it was the lowest ranked contextual factor in terms of the severity of such risk (2.92). Locum respondents to the survey did rate the risks of working as a locum higher (3.14) than their full-time colleagues (2.73), though they rated the severity of these risks as lower (2.59) than those same colleagues (3.01).
Higher proportions of professionals working as locums presents a number of potential risks, as the report covers. Primarily, concerns centred around the possible lack of continuity of care resulting in a poor patient experience and, more dangerously, locum workers not learning from their mistakes. ‘What tends to happen is that if an employer has an issue regarding a locum, they will just not engage with them again. The locum will go on practising the way they have been, and the concern may never be addressed,’ explained a participant from NHS England.
These potential worries were downplayed by many respondents, who were much more positive about locum working from their experience of it. A Leeds based optometrist said: ‘A lot of locums end up working in the same places, so they can potentially see their patients throughout and finish their case.’