The specialist optometrist

Although ophthalmology does not feature in the national enhanced clinical areas, it is, for many PCTs, a major local problem. Management of cataract has, however, been given central funding and is a priority for local health economies.
PCTs can include ophthalmology as part of their local delivery plans (LDPs) as a local enhanced service, to enable to deliver the care required particularly in the areas mentioned previously. However, where are the trained healthcare professionals going to appear from in order to manage these services? An opportunity exists for optometrists trained in focused aspects of ophthalmology to offer their services to primary care organisations.
By December 2005 all PCTs should have at least five providers for each speciality from which a patient can choose, if a specialist opinion is required. The Government has also indicated that
8 per cent of such referrals must be to the independent sector.
It is likely that ophthalmologists will form consortia or chambers to bid for this work. This may offer an opportunity for optometrists and ophthalmologists to group together and offer PCTs a comprehensive specialist service out of the NHS.
The caveat is that the optometrists must be suitably trained in those clinical areas in ophthalmology which they will be asked to deliver.
This policy, rather similar to patient choice, will allow money to follow patients. More importantly, general medical practitioners will lead the commissioning, as they did in the far flung days of Fund Holding. The need to access enhanced services will be considerable, with ophthalmology being a major requirement.
Here again a professional link between optometrists and ophthalmologists would provide a strong contender to bid for work. The base requirement will be that the individuals have the requisite skills to deliver the skills. Optometrists will have to have specific ophthalmological skills. The most difficult component to find in all this is the individual who has the skills to work in new ways and under novel circumstances. Apart from the limited number with the required experience and/or training, there is a severe national shortage of manpower.
Practising in new ways must adhere to the standards of clinical expertise, clinical governance, accountability, audit and many other aspects of modern clinical practice. It would appear sensible and financially prudent to encourage those with a wealth of experience in eye care - optometrists - to engage in some additional training in ophthalmology to assist in filling this large skills gap.
What is required to be a practitioner with a special interest in ophthalmology?
The Royal College of General Practitioners (RCGP) indicated that for GPs this would be the possession of a set of skills that would allow management of care over and above that which is normally delivered. This could be in the area of diagnostics or may be procedural-based skills. For optometrists the same definition would apply if they wished to work as a practitioner with a special interest. These special skills would have to be demonstrated by suitable documentation if based on experience or evidence submitted on completion of an accredited training programme.
It is paramount that any practitioner delivering care at this intermediate tier level has in place a robust clinical governance framework. This is best achieved by locking into systems already established by colleagues in the local acute sector provider. This will also maintain the essential clinical links and allow access to continuing professional development opportunities.
To date, defence unions have not required a hike in fees as the delivery of care should be provided to a level comparable to other clinicians practising at the same level. That is the same parameter that is already used in relation to clinical practice across all professional groups.

training for Optometrists
The prime requisites in developing 'Special interests' are to gain the required knowledge and acquire the practical clinical skills. The former is achieved primarily through paper-based studies and forms the foundation on which to build the clinical skills. The latter can only be attained by formal clinical attachments with consultant and other specialist colleagues. During these clinical sessions the student is gradually allowed to work independently but very much supervised. This element requires regular activity to gain the skills in history taking, examination, investigation and formulating management plans.
How can this training be structured and delivered in ophthalmology? First, any training needs to be of sufficient length and regularity to allow skills acquisition. In this respect the equivalent of one day a week over about 10 months for the purposes of developing a special interest in ophthalmology appears adequate. One half day a week should be dedicated to the knowledge base (written material and case study presentation) component and the other half day to formal clinical training with specialist colleagues. These ongoing elements are 'formative assessments'.
There should also be a 'summative assessment' (clinical examination and viva), which is externally validated. This provides additional quality assurance for those who are given postgraduate awards.
Middlesex University, London has, with one of its collaborative partners, produced a resource-based postgraduate training programme in ophthalmology. This Postgraduate Diploma is also accredited by the Royal College of General Practitioners and recognised by the College of Optometrists for CET. It is at present under consideration by the College for accruing credits towards its fellowship.
The diploma runs over about 10 months, with five days only where the participant is required to attend workshops in London. It is otherwise delivered locally to the student. The programme incorporates all the elements outlined above in terms of assuring the acquisition of the required knowledge and clinical skills, coupled with an end point externally validated examination.
Several optometrists, either supported by PCTs or self funding, have already completed this postgraduate diploma. Many are now working with consultant ophthalmologists and PCTs along agreed care pathways for certain eye conditions.

The Future
The future in eye care is bright. An ageing population coupled with the predictions of a rising incidence of diseases such as diabetes and glaucoma ensures the absolute need for professionals with a special interest in ophthalmology. I would strongly encourage optometrists to consider developing enhanced ophthalmological skills.
Further information on www.pgdip.com The next course commences in October.