New General Optical Council research into current and future risks posed to patients and the public by optical professionals has highlighted serious concerns among registrants about the commercial target pressures and time constraints they face in everyday practice.
Worries over targets and time constraints topped the list of contextual concerns, which, if they occurred in practice, could place patients and the public at risk. Data from the online survey component of the research showed limited chair time with patients was perceived to be the most likely contextual risk (3.75 out of 5) and was also viewed as having a high level of severity (4.16) if it occurred in practice. Risks relating to commercial and performance target pressure were viewed as being above average likelihood (3.61) and just below average potential severity (3.79).
Underlining the results of the data, the issue of time constraints was the most widely discussed during the qualitative research and many agreed with the survey’s results. The report also said it was often suggested by participants that this risk was more common in multiples, particularly in comparison to independent practice settings, with many participants having experience of working in this type of setting. ‘Reinforcing this view, some organisations have introduced measures to combat the issue of time constraints in order to guarantee that patients receive sufficient “chair time’,” said the report.
Catch 22
Analysis showed that optometry and dispensing optics remained low risk when compared to other healthcare professionals such as doctors and nurses. However, the research also showed that the risk profile of the professions could increase in the future as registrants take on more clinical work and encounter patients with more complex needs.
This was not lost on registrants during discussions around time constraints in the qualitative research phase. According to the report, multiple participants said this risk was becoming more likely for optometrists, because, as their role expands and they take on more responsibilities such as enhanced services, they were expected to do more things with patients, but often within the same timeframe as before.
Time constraints with patients was generally seen as a high severity risk by participants, as there was consensus that as time pressures increased, mistakes became more likely to occur. In the less severe cases, it was suggested that time constraints and pressure could lead to poor levels of customer service, poor administration and record keeping, poor communication with patients and colleagues or incorrect prescribing and dispensing. However, at worst, participants suggested that it could lead to severe mistakes such as misdiagnosis and missed or inappropriate referrals.
‘If you’re stressed, you’re more likely to miss things. You’re going to not do certain things. You might make poor management decisions because you haven’t had time to get all the facts and assess everything, which could lead to a different outcome for the patient,’ a Leeds-based optometrist told researchers.
The concerns around time constraints were not shared by all stakeholders, as two had implemented measures that they said would prevent risk to the patient. These included having no minimum length testing time or having variable testing times based on the type of patient, allowing individual stores to manage this based on the requirements of patients or the demographics of the population.
These stakeholder submissions were from Vision Express and another multiple. ‘There is guidance on the minimum things that you should be doing in a consultation – investigating the patient’s symptoms, history, vision and severity of condition, etc. There isn’t a time policy. Individual directors assign that for their practices,’ said an ophthalmic director for a large multiple.
Targets
The risk of commercial and performance target pressure was viewed by practitioners as being above average likelihood (3.61) and just below average potential severity (3.79) and many held the perception that commercial and performance target pressure was prevalent in the optical sector, particularly within multiples.
This perception was touched upon in 2016 registrant research conducted by the GOC, which found that 41% of respondents had experienced pressure from an employer or business to sell a product or provide a service which was not needed by a patient, and 45% had felt under pressure from an employer or business to meet commercial targets at the expense of patient care.
‘I work for a multiple and we do have targets, but luckily I work in a practice that is very much patient based. If the patient needs the time, we will give them the time. Even if there is a huge queue at the desk and the phone won’t stop ringing, the patient will still be our priority,’ a London-based dispensing optician told researchers.
But the report said perceptions in the new data were typically based on second-hand experience of colleagues who worked elsewhere under commercial pressure, or based on previous jobs that respondents had held in the past. ‘Very few registrant participants had current direct experience of working under commercial and performance target pressure, and many explained that while they perceived this risk to be an issue within the profession, it was not a problem where they currently worked,’ noted the report.
The risk of commercial pressure was less likely to occur in independent opticians when compared with national or regional chain practices, suggested participants. This perception was backed up by survey results, where the likelihood of the risk was scored more highly by those who worked for a multiple (3.84) or regional chain (3.97) when compared with those who worked for an independent optician (3.38).
Ethics
When discussing the severity of the risk target pressure, several participants felt it presented little or no risk of harm to patients and had no real impact on patient safety. They explained that, while the patient may be upsold products they did not necessarily need, this would not place them at risk. Instead, participants suggested that commercial and performance target pressure presented more of an ethical issue for practitioners, resulting in patients paying more for products or services that they did not necessarily need.
A Leeds-based dispensing optician told researchers: ‘You need an average order of over a certain amount, otherwise you’re not seen as a good dispensing optician. It’s things like selling unnecessary coatings and stuff. It’s not putting them at risk, they’ll still be able to see. But you’re selling them 1.6 index lenses that they don’t need because their prescription doesn’t warrant it. It’s not ethically or morally great, but it’s not a safety risk.’
The risks associated with this type of selling make themselves known slightly further down the line, as the real risk of commercial and performance target pressure comes in the form of damage to the reputation of the profession. Participants highlighted that, as a result of increasing distrust of the profession, the public could well be deterred from visiting an opticians to have their eyes tested, as they would be viewed more as retailers rather than healthcare professionals, therefore increasing the potential risk to health. A stakeholder from the RNIB also suggested commercial pressure in the optical sector had created a perception among patients that they may be pressured into buying expensive spectacles which they may not be able to afford, and therefore this poses a risk to economically disadvantaged members of the public who may be deterred from visiting an optician for this reason.
Charity stakeholder Patient Safety Learning summarised the pressures and constraints argument by saying: ‘Clinicians being expected to meet increasing volume targets with fewer resources is something we’re hearing more and more about. Often these pressures are being balanced by the individual clinician, and we think that’s a system issue when such safety trade-offs are being made. The commercial environment provides additional pressure and challenges for professionals.’
In Focus will cover additional elements of the risk research in forthcoming issues.
The research
The risk analysis used a mixed method approach with primary research based on an online survey with 2,610 respondents, and qualitive research in the form of focus groups with Council registrants and other stakeholders. Secondary research looked at data from the Optical Consumer Complaints Service (OCCS) and GOC fitness to practice records from the period April 2016 to April 2018. Results were graded on a scale of one to five, where one was very unlikely or of no impact to patients or the public, and five was very likely or very high severity.