DOMICILIARY RULES ARE EXTRA BURDEN
I would just like to endorse Robin Dawson's well written letter (July 1) which questions the sense of the new rules requiring prior notification of domiciliary visits. I too undertake home visits to individuals, both through our busy town-centre practice and also occasionally as an individual practitioner covering the area around my home on odd days or evenings after normal practice hours.
Until now the arrangement of relatively impromtu visits, obviously comensurate with the patient's convenience, has worked well. The short notice did depend on factors such as lack of late bookings at work as well as residual energy reserves!
Without this additional burden of long-term planning and extra bureaucracy, the unwillingness of optometrists to get involved with domiciliary work no doubt includes reasons such as: initial outlay and maintenance costs of specialised mobile equipment, challenging working conditions, often difficult patients to communicate with (typically necessitating a patient, imaginative approach).
Add to this relatively poor remuneration - short of being professionally satisfied with a cursory eye examination, individual patients in their own homes can often be seen at no more frequent intervals than around an hour or more (allowing for travel time, finding the address, often moving furniture and setting up/packing away heavy equipment) with the end result quite often being referral and/or no improvement possible or just advice on improved lighting etc - and it is easy to understand why there is such a dearth of domiciliary practitioners.
I would imagine that only the larger domiciliary companies, who in any case have to plan some weeks ahead for staff cover etc, will not be further deterred from continuing home visits. It would certainly be interesting to learn of the views of organisations such as the Macular Disease Society and the Association for the Prevention of Blindness regarding existing domiciliary arrangements and their particular take on these new rules. Personally I find it hard to accept that this further disincentive to take on domiciliary work can possibly help elderly and other housebound people to receive the service that they deserve.
Mike Vickers
Nottinghamshire
QUESTIONS OVER DUTY OF CARE
With regard to the domiciliary regulations two problems have occurred so far which concern me. One whole day's work was lost recently when a clinic cancelled on the day of the visit when a previously arranged visit could have been brought forward. At a visit this week four people presented themselves for eye examinations who were not on the list sent to the PCT.
The last person had little symptoms of concern except red eyes and variable vision throughout the day. A decision was made to examine the patient who was found to have eye pressures of 46mm Hg and an emergency referral was made via fax to his GP.
He was seen at the Milton Keynes eye department the next day and prescribed eye drops for glaucoma. The patient was very pleased with the outcome, but this situation asks serious questions.
In what order do we have liability? If he was refused an eye examination could the optometrist have been prosecuted either by the GOC or under the Disability Discrimination Act? Does duty of care come first? Does the optometrist have a responsibility to examine patients who cannot be claimed for? The nature of domiciliary work often encounters routine check-ups for people who are less aware of changes to their eyesight (due to their age, illness, dementia etc) when a problem is detected and they are referred for assessment.
The current regulations would appear to be based on a financial constraint, to reduce payments and to reduce the level of service to the patient. I would suggest that every domiciliary company make notes of this type of occasion and email Derek Busby at dhmail@dh.gsi.gov.uk and telephone him on 020 7210 4850 as ultimately it would appear to be his responsibility.
John Snelgrove
Watling Street, Herts
IS FIELDS TESTING MANDATORY?
Congratulations to Brian Suttie, who was found not guilty of serious professional misconduct as reported in optician (July 15) after completing a sight test without a fields test. This case is a perfect example of being 'damned if you do, and damned if you don't'.
Is a fields test part of a routine examination? Probably not. Does the NHS fee include for a fields test? Not in my world. Does the NHS pay extra for supplementary tests? Again, not in my part of the world. Does the GOC expect the optometrist to include a fields test in a routine
examination? Obviously yes, as they wouldn't have charged Mr Suttie with misconduct.
Would the GOC and NHS like optometrists to continue quietly doing it for nothing or risk being taken to court in a black lottery if they don't? You can answer that one.
Can we therefore please have a clear directive that fields testing is mandatory in an eye examination, and an NHS sight test, so that we can plan our appointments and fees to accommodate it?
And another thing. In this particular case the patient was referred to a neurologist three months after the sight test in question, and six months before another eye examination where Mr Suttie referred her for glaucoma. Did this neurologist also fail to notice glaucoma, or does optic nerve damage fall outside the remit of a specialist medical practitioner?
Kennedy Rath
Grays, Essex
DISCOUNT STRATEGY WON'T MEET THREAT
Max Davison's letter (July 15) puzzles me. Only two weeks ago he struck a forlorn figure wondering whether there was anyone in the profession ready to lead the way to the Promised Land where optometrists earned their income not from selling products, but by charging appropriately for chair time. Now he has had an epiphany - that day is only around the corner!
I wrote to optician years ago advising that optometrists must charge for their time rather than try to compete on price with the emerging internet. My advice was not heeded then and there is no indication that optometrists today realise what is necessary to do to fight off the new and far more dangerous threat from Tesco and the like.
Most multiples and too many independent optometrists still think that the best way to promote business is continually to discount professional time, let alone charge a realistic fee. Why else is my local multiple now advertising half-price sight tests (ie £7.50!) and another group always running a 'free contact lens fitting' promotion?
I'm genuinely pleased that Mr Davison is feeling settled in his profession and content that all will be fine in a little while. If I were an optometrist I would not be so sanguine.
David Levy
Radlett, Hertfordshire