Visus writes: It’s better that we act
Sometimes it takes a major shift in policy to initiate change, usually it’s slow burn. The dissonance in optometric scope and delivery of practice has been evident for many years yet three things stick out as high impact catalysts; the 1989 removal of the universal right to an NHS Sight Test, the expansion of eligibility to include over 60s in 1997 and the 2009 NICE CG85 Guidelines on the secondary care of glaucoma.
Interesting in these times of government rebellions, back-bench machinations and abrupt changes in policy the first item was responsible for one of the few Commons defeats by MPs and the second was Gordon Brown’s unique change to the previous administration’s spending plans as Chancellor in 1997.
Tim Manners’ article last week on glaucoma referral was illustration of the slow burn theory of evolution. While I find little to factually disagree with in the article the underlying message and slant of the paper was upsetting to practitioners who have been delivering the sort of enhanced glaucoma case finding now advocated by professional bodies and some commercial organisations after some sort of Damascene conversion.
This exists at two levels. First the benefits of an appropriate full data set of GAT (including repeat), repeatable fields and disc analysis before referral are incontrovertible and have been known since the late 1990s. Though some assessment of anterior chamber and angle is also needed, this is hardly rocket science. It is 100% absolutely within the remit of every optometrist registered in the last 25 years and many of us have been doing just that for longer. Unfortunately, the GOS contract directly mitigates against such behaviour and the intransigent behaviour of practices that preferred to refer rather than charge an investigation fee (or absorb the cost of delivering a professional service) was counter-productive. Although even in those days a full two thirds of all referrals were justified (glaucoma being confirmed in half and enough suspicion to merit further HES testing in the other half) optometrists were unduly criticised for a mythical high false positive referral rate.
This problem was compounded by the College, working alongside the Royal College of Ophthalmologists, misunderstanding the difference between competence and contractual liability. This has resulted in tiers of higher qualifications that have confirmed what optometry has known all along. Managed properly in primary care there is no high false positive referral rate at all.
NICE CG85 (2009) was a double-edged sword. It was purely related to secondary care and taught some ophthalmologists to up their diagnostic game by adding routine gonioscopy and being more strategic in their treatment. Nevertheless, despite criticism, it was correctly interpreted by the optometric defence bodies as a political weapon to highlight the stupidity of the GOS.
Where are we 10 years later? Aside from Scotland our profession has simply failed in all its attempts to press the national political case for a decent clinical role for optometrists in glaucoma management, whether in referral or monitoring. There is some hope in this being brokered between Locsu and Newmedica although there will be considerable disquiet if this requires existing schemes to re-accredit, or worse for the schemes to be branded under a corporate banner requiring individual optometrists or practices to sign exclusivity deals. We all remember the gross unfairness of the DVLA contract.
So back to Manners and others who have proffered advice on field testing in optometric practice. We need to be clear about the different sectors we serve. The a priori probability of a field defect in an outpatient HES clinic is way higher than that of an optometry practice, even those specialising in medical optometry. Thus the method of choice for us is supra-threshold static perimetry undertaken alongside tonometry, and perhaps imaging, by a clinical assistant prior to seeing the optometrist. It is no accident that the UK optometrist method of choice is the Henson instrument algorithm. The optometrist can then exercise judgement on the possibility of artefact and the need for further directed investigation (at someone’s cost for sure but this does not need to be a referral). This preliminary assessment, incorporated into routine sight testing, acts as the trigger to further investigation and almost never referral (barn doors excepted) on fields alone.
Having picked up unexpected RP, hemianopia, vessel occlusion, etc, by utilising field testing I believe it should be done more not less, but as Manners points out it must never be used in isolation. We are not technicians, we are scientist-clinicians (and most can exercise sentient judgement). More people lose vision or go blind through not being found at all or inadequate follow-up within the HES than ever do in poor or delayed optometric referral. There is simply no problem in deferring a decision and reviewing before making a referral decision.
The law on referral and exercising judgement changed in 2000 and the onus should be on optometry not referring unless outcome (such as initiation of glaucoma treatment) change is likely. This pre-supposes a few things, direct HES communication, appropriate NHS funding in primary care and a decent contract for optometrists (pigs might fly) and less overcomplication of the process. Apart from the Department of Health intransigence this should be national – it was needed 10 years ago.