Prospect Ophthalmic

Latest Public Updates

04/03/21

ESR Review: GOC Approval of Training

We hope you are well and managing to stay safe.  Due to our concerns and what we are receiving from members, we believe it’s useful to provide our initial position with regards to the Education and Training Requirements that have recently been approved by the GOC.

The General Optical Council announced the approval of the new Education and Training Requirements (ETR) as part of the Education Strategic Review (ESR) during their public Council Meeting (10^th February 2021). This is despite many registrants, within academia and community practice raising overwhelming concerns. The Optometry Schools Council sent a letter to the GOC directly raising their concerns, many of which have been echoed by registrants since. Whilst some points have been addressed, the responses have not been to a satisfactory level and there are still many unanswered questions.   The Union would like to highlight some of these questions below on behalf of its members.

1 – Removal of the two stage qualification process

2 – The 48 week training placement and quality assurance processes

3 – Lack of professional and clinical autonomy

4 – Transition period between old and new courses and how graduates will be affected

5 – Increase of the Regulated Qualifications Framework for GOC professionals

6 – Changes to Independent Prescribing

7 – Funding concerns

8 – The Apprenticeship

1. Members rightly expressed grave concerns that the removal of the two-stage qualification (university degree and final stage OSCE assessment) in favour of a single qualification can lead to an inconsistent standard of knowledge within newly qualified registrants. This is due to allowing the provider to award the final qualification, rather than keeping the consistent national end-stage assessment that the College of Optometrists currently provides. There is a risk that different providers will set not only their pass criteria inconsistently to others but that they may also deliver a different curriculum entirely. This worry is exacerbated especially if there is pressure to pass individuals before the next cycle of students. Contingencies must be put in place to avoid this otherwise a varying level of knowledge will be applied amongst graduates.
2. The requirement to undergo a ‘48 weeks learning and experience in practice’ placement may seem a positive addition on the surface. However, members believe this can lead to a potential conflict of interest whereby placement providers may influence students on commercial interests over clinical aspects. The Council papers suggest the GOC have addressed this with a requirement that providers must have;

 “policies and systems in place to ensure the supervision of students during periods of learning and experience in practice safeguards patients and service users and is not adversely affected by commercial pressures.” (S4.9). 

However, this appears to be placatory as there is little detail on how any quality assurances will take place and what the reviews will assess. The real worry is that placement bodies will have the power to dictate terms to the education providers on aspects of education that should not be influenced by any retail interest. For example, the very quality assurance that is meant to be installed to prevent any undue commercial pressure. Most of the training is provided in the placement so the onus is on the GOC to make sure that the training provided is meeting the requirements. However, due to every student needing a placement, this will not be physically possible as things currently stand. The GOC are aiming to conclude the draft deliverables by September 2021 which will include an update on quality assurance and enhancement methods for each qualification. The GOC are also aiming to establish the entry criteria to courses by this date to allow the first cohort's entry in the 2023-24 academic year.

3. The GOC’s Standards for Optical Businesses 3.1.3. states that businesses must;

 “Makes sure that operational and commercial pressures do not unreasonably inhibit the exercise of professional judgement.” 

Despite this, the Union is aware that there can be a lack of professional autonomy within some practices, as commercial requirements can be prioritised over clinical expertise. There is little consequence for businesses that do not follow this standard, putting the GOC’s authority to ensure commercial interests do not affect a student’s learning into question. A qualification in which student practitioners are exposed to such environments from an early stage, questions the fitness of the approved changes, is contradictory to the GOC’s mission and may end up harming the public.

Further inconsistencies are likely as some practices (by the same or different providers) would have different education systems and priorities. This may lead to some students having an unfair advantage if they secure a favourable placement relative to others that are available.

4. One concern that does not seem to have been addressed is the transition phase from the old system to the new education system. Graduates who are due to undergo their pre-registration may find it difficult securing positions if practices have already agreed to take on students for their 48 week placements. The pandemic highlighted a shortage of pre-registration positions with some graduates unable to secure positions soon after completing the undergraduate course. There is no clear guidance regarding this matter and no contingencies put in place. We await more information from the GOC regarding this.
5. We welcome the implementation of a RQF of level 7 for optometry and an increase from level 5 to level 6 for dispensing opticians as it provides for a minimum standard of knowledge. However, if providers are providing the knowledge, then this may inevitably lead to discrepancies and gaps in student knowledge as some providers may prioritise certain aspects over others. This difference may be exacerbated if the education and 48 week placement are provided by one commercial provider.

The ESR was an opportunity to upskill and develop the profession to be recognised as true healthcare providers, but we believe an opportunity to do so has been missed. One particular concern from the original consultation was of providing clinical content guidance for both optometry and dispensing optics. However, we feel the GOC’s response is vague and not dissimilar to the current pre-registration requirements. It is lacking in detail and needs amending to direct more towards practitioners who have access to modern imaging techniques and are likely to take on more responsibilities regarding shared schemes with secondary care.

6. There is one point that relates to Independent Prescribing, whereby the GOC acknowledge that finding a supervisor for the clinical placement has been difficult. They are looking at replacing the current requirement of having a Designated Medical Practitioner (Ophthalmologist) with a Designated Prescribing Practitioner (Ophthalmologist or someone who is already an Independent Prescriber). This should alleviate the burden of completing their placement within the 2 year deadline as there are many more trainees than placements available.
7. A very important issue highlighted by regulators is funding. The consultation carried out showed a clear and very real concern about providers being able to fund the proposed changes to meet the new requirements. Independent research conducted by the GOC shows that Universities could only have £100 left per student for teaching. This again is a great concern as it allows another avenue whereby commercial interest can be prioritised over all else if the practices will subsidise the costs. Other alternatives are that the education provider would either close their doors as they would not be financially viable, or they would establish a partnership with a commercial provider. The Union awaits more information from the GOC to announce its plans regarding this.
8. Finally, we would like to acknowledge a key concern for members, a degree apprenticeship route into optometry. No new apprenticeship has been approved or submitted to the GOC as of yet, however the new education training requirements have opened the doors for an apprenticeship qualification. The Union continues to support its members’ views on a degree apprenticeship in which we strongly oppose and reject the proposal and will endeavour to call a stop to advancing any such proposals in the future.

The new standards are set to allow the first intake of students for the 2023-2024 academic year so we await further clarification on how current providers of optometry and dispensing optician courses will adapt to the new standards without encountering the problems listed above. 

We will be launching a number of surveys soon to obtain feedback across areas of the sector which will include the ESR review as well, but please engage with us on the link above so we can understand your views.

15/02/21

Practising in a Pandemic: Workplace Safety

The global Covid-19 pandemic has presented us with many obstacles which we have all been forced to accept as the 'new normal'. There are in the workplace of the ophthalmic profession where close proximity with patients in an enclosed space is unavoidable. One of the most pressing concerns is the ability to minimise the risk of transmission of Covid-19 and ensuring practitioner and patient safety are not compromised. During each stage of the pandemic, practitioners and their staff were at the forefront of providing essential eye care to everyone - from NHS frontline staff to those in self-isolation. This paper aims to highlight some of the key issues faced by GOC registrants encountered during the outbreak in relation to workplace safety during the pandemic.

Whilst very little was understood regarding virus transmissibility during the initial stages of the pandemic, GOC registrants found themselves in a very difficult position. Attempts were made to protect themselves and their family members from contracting covid-19, given the close proximity to patients in their job.  Many practitioners chose to wear personal protective equipment (PPE) such as face coverings and masks before any official guidance to do so was published and there were reports where use of PPE could affect the daily routine in practice and so was advised against initially. Many registrants called for the GOC to announce that PPE be made mandatory for practitioners.  No official guidance from the optometric bodies was issued during the early stages of the pandemic (prior to national lockdown announcement) which made it extremely difficult for GOC registrants to provide evidence to their employer supporting the need for PPE.

On the 23rd March 2020, a national lockdown announcement was made by the government, urging the nation to stay at home and help reduce the spread of the virus.  Many optometric practices were forced to temporarily close their doors, cancelling any appointments until further notice. Guidance was then issued by the College of Optometrists (CoO) on the 23rd of March effective immediately¹. The CoO adopted a traffic light system based on the lockdown level to guide practitioners on what changes to implement². The “Red Phase” was a very strict phase during which only emergency and essential eye care was to be provided. CoO also advised to modify the eye examination to exclusively perform symptom-led assessments and omit routine tests unless clinically necessary. As the lockdown restrictions eased, the CoO moved to the “Amber Phase”, opening up the opportunity to see more patients and accommodating routine visits to practices while still prioritising urgent appointments.

Practices were advised to conduct workplace safety assessments to follow government guidelines³. One of the key government guidance to reduce spread of Covid-19 is social distancing. “When with people you do not live with, you should also avoid: physical contact; being close and face-to-face….Where you cannot stay 2 metres apart you should stay more than 1 metre apart, and take additional steps to stay safe”⁴. Practitioners have been required to wear PPE typically consisting of face mask, face shield, gloves and apron according to risk assessments. This was supplied at the cost of the practice initially, however later on the NHS paid for and supplied all optometric practices with complete PPE.

There has been very little guidance set out on face covering use for patients by optometric governing bodies. Government guidance released on 24^th July 2020 stipulated that face coverings are not mandatory in opticians⁵, whilst being an obligation to wear in supermarkets. This is contentious due to the fact that one can socially distance themselves from other members of the public in a supermarket but not in an optometrist's testing room, where close proximity is unavoidable when assessing ocular health. Prior to this date, CoO had advised that face coverings for all patients were compulsory in practice and subsequently changed their advice to align with government guidance⁶. There is an argument to suggest that governing bodies could have decided not to accept the government guidelines on this matter, instead they could have challenged the government due to the risk taken by practitioners in carrying out their duties. Furthermore, many practitioners believe that face coverings should be mandatory at their request due to the close proximity and duration of eye examinations and dispenses, however are being told by managers that patients without masks must be seen in order to fulfil duty of care to all patients. No optometrist has refused to abide by the GOC standards, which state that a “safe environment is provided to deliver care to your patients”⁷. Asking all patients to wear a mask is trying to achieve this.

There have been cases of practitioners refusing to see patients without face coverings due to themselves, their family members and their patients being at a higher risk and clinically vulnerable to severe symptoms. Some have been threatened with disciplinary action while others have had no choice but to see these patients. Health and safety assessments should have been conducted and practices must have a policy in place for exempt patients who refuse to wear a mask. The previous guidance has been vague and a more proactive and clear guidance is required on how to support exempt patients in the workplace without the practitioner feeling pressured and fearing for their own and their patients' safety.  This could be looking at what additional measures can be put in place including a defined process for these unique situations.

Many practices operated an appointment-only system to allow better control of the number of people within a store to maintain social distancing. Closed door policies have been implemented in some practices, whereby patients can only enter with an appointment. We welcome this change; not just for the obvious benefits it brings to the working day, but because it helps to greatly reduce the risk of transmission of Covid-19 to staff members, as all patients can be triaged first. Personal hygiene and sanitising were also emphasised by the government therefore practices were modified to accommodate this. Perspex screens were set up where patients would normally be face to face with staff and hand washing areas or sanitising hand gels were made readily available for staff and patients. These additional measures were put in place to reduce the risk of transmission and provide a safe environment for practice staff and patients. There was also a need for practice staff to demonstrate increased hygiene awareness in common areas of the practice, such as staff rooms and also during breaks.

To accommodate many of the CoO guidance, eye examination times were extended throughout the UK. This resulted in fewer patients being seen, reducing the number of patient-practitioner interactions, whist allowing additional time for practitioners to familiarise themselves with the modified routine and allow for replacing PPE and additional cleaning between patients. On booking appointments, triaging was recommended prior to booking to ensure no patients were seen presenting with symptoms of Covid-19³. Additionally, case history was taken over the phone to reduce the time practitioners spent with patients.

Telephone consultations became a new way of working for many optometrists, dispensing opticians (DOs) and contact lens opticians (CLOs), in which they have had to adapt and work off detailed history and symptom questions and previous notes. If suitable management could not be achieved remotely, the patient would be asked to attend the practice or directed to an appropriate healthcare practitioner.

Many optometrists are still reporting difficulty with VOLK, spectacle lenses and trial lenses steaming up due to masks being worn. This interferes with the practitioner’s time keeping when performing an eye examination; extra time is required to clean trial lenses and breaks needed during fundus checks to allow VOLK lenses to de-steam. With practise, optometrists became better at managing these issues by keeping VOLK lenses warm using heat mats or keeping the room temperature warm to avoid lenses steaming up. 

Extended test times were a welcome change during the initial lockdown and helped reduce pressure on practitioners. This was widespread throughout the nation to facilitate the need for PPE changes, additional cleaning and overcoming the difficulties testing with PPE as mentioned above. However more recently, many practices reduced their testing times back to pre-covid levels, or even less, due to increased patient demand for eye tests once routine testing was advised. Practitioners are now expected to deliver the same services that were provided at the start of the global pandemic, but are no longer given adequate time to fulfil the additional duties without compromising on the quality of the eye examination. This leads to undue stress on practitioners to omit various tests. There are anecdotal reports that regional managers have been arranging one to one discussions on which tests to exclude and how to "speed up the test". This undermines the clinical judgement of the practitioner and affects the quality of care as extra tests that are carried out on a case by case basis are being pressurised against.

Extra tasks being given without additional time allocated have put unnecessary strain on practitioners in an already stressful working environment. A survey conducted by the Ophthalmic Trade Union stated that out of 634 respondents, 91.5% feel stressed because of work. Unfortunately, we are aware of many complaints from practitioners regarding issues that have led to poor job satisfaction. Each working day can seem to be a battle between practitioners and practice management.

Furthermore, increasing capacity to increase patient footfall has had an impact on the amount of social distancing that can take place at a particular time as more people are in the practice. Staff members are seeing the same number of patients, if not more, as they were before restrictions were in place; this increases the risk of transmission compared to early lockdown when appointment times were lengthened. This risk is heightened with the multiple new strains of Covid-19 that are now in general circulation around the UK.

In addition to the above, "ghost" patients have been booked into a full diary and practitioners are expected to see them without any extra allocated time. The reason given for this is to account for the regional no show rate, however no contingencies are in place and practitioners are often working beyond their contracted hours as they put patient care first. There are various issues with this; unnecessary exposure to others and additional stress on practitioners to see extra patients (who may be routine and not in need of any urgent services-this is against CoO Amber phase advice as full capacity does not allow for additional “ghost” patients). Practice management are risking patient and practitioner safety for commercial gain.

Many practices have implemented longer working hours to fit more patients in any given day. Practitioners have been unable to decline longer working hours and are working 10 hour shifts in some cases. This can have a massive impact on work-life balance and induce fatigue if the shift pattern does not allow for adequate rest. There are reports of practitioners working 6 days in a row at longer hours due to their work rota, affecting practitioners' mental health and wellbeing in an already difficult time. This is especially true if they have been forced to accept the change in working hours against their will and reluctantly accepted. 

A lot of the relaxations since early lockdown seem to be financially motivated; in an attempt to increase patient footfall with the hope of generating higher revenue. If eye examinations were appropriately charged, the additional pressure to dispense to keep businesses viable will not be necessary. This is beyond the scope of this article and the Ophthalmic Trade Union will release an article on eye examination fees in the future. However, it is evident that many years of offering free or cheap eye tests, subsidised by the purchase of spectacles or contact lenses, has had a hugely negative impact on the perception and nature of community Optometry.

The pandemic has had a huge impact in all our lives; unfortunately many of these have been negative, however it has raised awareness of some of the current issues in optometry and ophthalmic services. We have seen that even in a pandemic, practices are adopting a more commercial approach trying to influence the clinical judgement of practitioners. We feel eye examinations would benefit from minimum examination times and a change to the GOS contract nationwide is required to follow an approach like Scotland, so that professionals can be remunerated appropriately rather than rely on being subsidised by the purchase of spectacles or contact lenses. 

To support our practitioners the Union was formed and is in need of more members to grow our voice within the sector; to discuss and negotiate with professional bodies and employers for the betterment of our profession. Unfortunately, commercial gain has been prioritised over the mental wellbeing of practitioners, affecting the quality of examinations and putting the health and safety of both patients and staff at risk. Whilst on one hand the provision and use of PPE has been welcomed, reducing examination times and squeezing in ghost patients have been unacceptable. The Ophthalmic Trade Union aims to work with our professional bodies and make a challenge for a better and safer working environment for all GOC registrants.

References

1. College of Optometrists - The professional body for optometrists. 2020. COVID-19: Member Update Archive. [online] College-optometrists.org. Available at: <https://www.college-optometrists.org/guidance/covid-19-coronavirus-guidance-information/covid-19-daily-update-archive.html>[Accessed 28 December 2020].
2. College of Optometrists - The professional body for optometrists. 2020. COVID-19: College Guidance. [online] College-optometrists.org. Available at: <https://www.college-optometrists.org/guidance/covid-19-coronavirus-guidance-information/covid-19-college-guidance.html>[Accessed 28 December 2020].
3. College of Optometrists - The professional body for optometrists. 2020. The College Of Optometrists Primary Eye Care COVID-19 Pandemic Guidance. [online] College-optometrists.org. Available at: <https://www.college-optometrists.org/guidance/covid-19-coronavirus-guidance-information/covid-19-college-guidance/primary-eye-care-covid-19-pandemic-guidance.html#appendix-2-adapting-the-practice-in-response-to-covid-19>[Accessed 28 December 2020].
4. UK. 2020. Coronavirus (COVID-19): Meeting With Others Safely (Social Distancing). [online] Available at: <https://www.gov.uk/government/publications/coronavirus-covid-19-meeting-with-others-safely-social-distancing/coronavirus-covid-19-meeting-with-others-safely-social-distancing>[Accessed 20 December 2020].
5. UK. 2020. Face Coverings Mandatory In Shops, Supermarkets, Shopping Centres And Enclosed Transport Hubs From Friday. [online] Available at: <https://www.gov.uk/government/news/face-coverings-mandatory-in-shops-supermarkets-shopping-centres-and-enclosed-transport-hubs-from-friday>[Accessed 20 December 2020].
6. Optometry Today/AOP. 2020. Face Masks ‘Not Mandatory’ For Patients In Optical Practices, According To New Government Regulations. [online] Aop.org.uk. Available at: <https://www.aop.org.uk/ot/professional-support/aop/2020/07/24/face-masks-not-mandatory-for-patients-in-optical-practices-according-to-new-government-regulations>[Accessed 2 January 2021].
7. General Optical Council. 2016. Ensure A Safe Environment For Your Patients – General Optical Council Standards. [online] Available at: <https://standards.optical.org/standards/ensure-a-safe-environment-for-your-patients/> [Accessed 2 January 2021].