Dispensing opticians and optometrists are voicing frustration at GOC competency regulations that obstruct their need to adapt as the profession considers how best to manage the Frankenstein of emerging technology in optics.
A panel of leaders congregated at last week’s Eye to Eye discussion arranged by the Worshipful Company of Spectacle Makers. Representatives from ophthalmology, dispensing and optometry were invited to engage with the WCSM’s provocative question: ‘Will we need optometrists in 2020?’
Held at AOP headquarters in London, panellists discussed how technology, notably portable refraction testing equipment and OCT scanning, will change the role of optometric staff in practice.
With optometrists and dispensing opticians working in UK communities taking on patients from overloaded hospital eye departments and stretched GP appointments, the claim is being staked for competency regulations to shift.
Such changes could see high street trained dispensers permitted to refract and take on eye testing responsibilities in practice. Meanwhile, optometrists seek to take more eye care service competencies into local community practice, and allow ophthalmologists to focus on specialised eye conditions consultation, referral treatment and surgery.
Professor David Thomson, former head of optometry and vision science at City University London, opened the discussion by demonstrating the burden of patient numbers on GPs and hospitals while there are overlapping competencies that could be provided in local optometry and dispensing.
He said: ‘One of the problems with this territorial model is that it is not the most flexible when fulfilling the need for eye care in our local patient base. Around 100 million people attended outpatient consultations in hospitals last year, and 10% of those were for eye appointments. Eye departments are swamped and that is not going to improve in the future with the demands of an aging population.’
Newly available hospital treatments for eye conditions were expected to further exacerbate the issue.
Prof Thomson said: ‘Unless there is a big increase in the number of ophthalmologists it seems that the way this is going to go is that ophthalmologists will have to retreat to the complex stuff. This will leave a vacuum in their wake that will need to be filled. Each of these areas demands completely different training, where we form our professional tribes.
‘We are all guilty of wanting to protect our own territory. Optometry is very protective of refraction and contact lenses. Orthoptists are protective over binocular vision and seeing children for screening. Ophthalmology is very protective over surgery and therapeutics. We have developed these barriers.’
However, he also made the point that market forces will drive changes that will work into the hands of optometrists.
He added: ‘The reason I am optimistic about the future as there are two market forces converging. One is that ophthalmology is completely overloaded and will continue to be overloaded. The other one is that we have this vast resource of optometry, and a lot of our core function is likely to be taken over by technology. We can’t bury our heads in the sand and say it’s not going to happen. Responsibilities are going to be delegated and at the very least we are going to see more patients.
‘This brings an untapped resource and as a profession we have to be selfish here to avoid large scale unemployment in the future. We must make sure we position ourselves so that we are able to fill that vacuum. We need to make sure that all our undergraduates leave with all the skills that will underpin that future in optometry as it will be in another 10 years’ time.’
Meanwhile, Professor Carrie MacEwen, president of the Royal College of Ophthalmologists, highlighted the importance of keeping eye consultations face-to-face and increasing competencies available in community practices.
She said: ‘We are talking about technology and making it your friend, not your enemy. We need to communicate with the patients because otherwise it does not work. Optometrists and dispensers have to make the patient feel that they are important, cared for as a human.
‘The discussion that has been raised about barriers within the sector reflects the training. Primary and secondary care are not joined up so people are not being invited to go between the two. What we need is for optometrists to come and work in hospitals on a regular basis to see what’s done. I think that if people were trained appropriately, different fields of optics could provide primary and secondary care in practice.’
Working under one roof
The panel’s dispensing representative, Abdo president Fiona Anderson, told the discussion that giving training and extended responsibilities to professionals stationed in the dispensing area has improved patient engagement in Scotland. She said: ‘DOs are in the perfect place to communicate with patients as we often have much more contact time with the patients. The optometrist has a whole raft of tests that they must do each day. We have got quite a different contract in Scotland but DOs do much more for the Scottish system. Often it is the DO that the patient is handed over to after testing.’
She also offered a case study from her volunteering stint at the 2014 Commonwealth Games in Glasgow. She said: ‘I was in the athlete’s village in the polyclinic, and it just showed how easily all the professions can work under the one roof and we all pass patients between each other. It must be acknowledged that crucially it wasn’t a business, but on every clinic there was a dispensing optician, an optometrist and an ophthalmologist.’
High street optometrists at both multiples and independents were seeking to specialise and fully define their role, according to Ben Fletcher, managing director of Boots Opticians.
He said: ‘How do we liberate our optometrists to do the job that only they can do? I think that involves the embracing of technology. Refraction can be done in a more automated, technological way. Technology will blow through the optometric industry and drive change in a way we’ve never seen before. We are quite hamstrung by the sheer cost of responding to that because you have to invest in technology yourself and secondly because regulation makes it almost impossible to manage.’
Former Optical Confederation chief Don Grocott, who chaired the panel discussion, said: ‘I get the feeling that one of the things that gets in the way is narrowing by regulation and narrowing by commercial self-interest, which is not an unreasonable thing.’
Grocott also added that the current regulatory environment was resulting in ‘a significant tendency to over-refer’. Prof MacEwen agreed, adding that optometrists required upskilling with extra competencies and new regulation to prevent over-referrals.
Prof MacEwen said: ‘The OCT has caused all sorts of havoc – it picks up something that no one knows what it is and you are sent to hospital. Before you know it you have a worried patient who requires communication and it’s a false positive, there is nothing wrong with them in the first place.’
As for patient experience, digital technology will become increasingly significant according to Fletcher. He said the first place that people now go for medical advice is a website.
‘I believe that technology will transform the patient experience, the ease of the journey. As much as we talk about shared care and pathways, there is also destructive self-diagnostic technology being developed that raises fears the role of optometrist would become redundant,’ Fletcher added.
Therefore, the panel argued for more effective cross-competency regulation and training in order to help practitioners adapt their individual roles in both community and hospital settings.
Prof McEwen added: ‘What we need to do is develop more community care, there is no shared care plan on the GOS, that has to be changed. We [ophthalmologists] can’t discharge patients. With shared care and some training, the patient experience of eye care would be very different.’
GOC responds to calls for change
‘All regulation should be proportionate and should not act as a barrier to practitioners delivering safe, innovative care for their patients. We are keen to see new models of care develop and many of the barriers to this are not regulatory, for example the provision of education and training, and funding to commission services. Nonetheless we are happy to hear ideas and specific examples from stakeholders where they believe regulation impedes the development of new models of care that would be in patients’ best interests.
Stakeholders must also remember that our regulatory framework is put in place by government and changing the law is a matter for it rather than the GOC. For example, we do not believe it is proportionate for us to continue registering undergraduate students but unless the government amends the Opticians Act the law will continue to require us to do so.’