There was once a time in optometry when the bodies seemed to represent their members well, whatever their background or mode of practice. The Association of Optometrists (AOP) and the College of Optometrists did well by the profession and fought against oppressive employers and dispensing opticians with delusions of refraction.
The profession has been able to get substantially to where the Establishment wanted it to be – qualified with core competencies to provide primary eye care in the community. Yet core competencies don’t seem to be enough.
The work of the Local Optical Committee Support Unit (Locsu) developing pathways for enhanced optical services (EOS), shared care and community monitoring, has been instrumental in engaging independent optometrists and members of FODO (Federation of Ophthalmic and Dispensing Opticians – the employers’ body for opticians in business) who have suddenly woken up to EOS and with the help of the Welsh Optometric Post-Graduate Education Centre (WOPEC), started training optometrists by the thousand.
But now, just as EOS seems to be gaining momentum, the Establishment seems to have changed its mind.
In quiet corners at both the College and the AOP can be heard mutterings that there isn’t enough Mecs (Minor Eye Conditions Service), EOS, therapeutics and shared care work to go round. Having every optometrist qualified to do all this work could endanger the public because it would be spread too thinly and practitioners wouldn’t get the experience they would need to keep up to date.
No matter that there are only 15,000 optometrists and that a lot of the work is currently split between well over 10 times that number of doctors, nurse practitioners and pharmacists. Nobody seems to worry about them getting enough experience. Nobody worries either about their ability to deal effectively with patients with eye problems given their comparative lack of training compared to optometrists or even dispensing opticians.
Could it be that the power in the optometrist bodies has swung too far towards hospital optometrists and independent prescribers and that they see enhanced optical services and community monitoring services as something they would like to keep for themselves?
Is this why the College offers additional post graduate qualifications in subjects that are supposed to be, or at least should be, core competencies? Health care commissioners need to be satisfied that practitioners are competent but it seems the profession is putting barriers up before it has gotten started with enhanced services.
For a practice to offer the main enhanced optical services each optometrist needs to carry out so much additional learning and assessment they may as well have spent an additional year at university.
Mecs is the most widespread service, commissioned in around 60% of CCG areas, other services are less widespread, ranging down to low vision and special school services at something below 10% each. No surprise that the disabled are discriminated against, or that there is a postcode lottery for eye health care.
What is surprising is the lack of evidence for the quietly whispered position that community optometrists don’t get enough experience. Where the majority of services are commissioned and most practices engaged, then it seems that the concerns of the Establishment are unfounded.
Certainly practices need to adapt to a new business model. This may mean utilising unused capacity where optometrists are not fully booked. It may mean recruiting additional practitioners to satisfy demand. To be sure adding enhanced optical services to practices that don’t have the capacity to deal with them means lost sight tests and lost spectacle sales.
However, by increasing optometry cover, most practices can obtain better utilisation of their fixed costs – rent, rates, heat, light, pre-screening equipment, etc – and thereby enhanced services can make a significant marginal contribution to the overall wellbeing of the practice.
In deprived, inner city, and remote rural areas enhanced optical services could be the difference between the survival and the closure of a practice. It should be a priority for commissioners to ensure these areas have services commissioned, not because it helps optometrists earn a living but because all the evidence suggests that where people struggle to access services they will put off dealing with problems until it is too late for them to receive early and cost effective interventions and treatment.
Most practitioners have stories of patients who have experienced microbial keratitis or the tell-tale symptoms of retinal detachment but didn’t seek eye healthcare advice or intervention until, say, after the weekend.
The promise of a four-hour wait at Accident & Emergency, or a two-hour trek into the nearest large town is enough to prevent many patients seeking appropriate eye healthcare. Knowing their GP can’t see them for several days, makes it all the more vital that local enhanced optical services are commissioned everywhere as soon as possible.
Or is the Establishment right when it says there isn’t enough EOS to go round and optometrists need to see hundreds of patients with each eye condition (glaucoma, diabetic retinopathy, cataracts, minor eye conditions, etc) each year to stay competent?