For employers: clinical governance

Optometrist examining patient

This page covers good governance in following up on patients.

Deferred procedures

It is not unusual for an optometrist to need to ask a patient to return for further tests or procedures (eg visual fields, tonometry) because:

  • A need for a further procedure has been identified during the test
  • A need to repeat a procedure at a different time has been identified owing to, eg:
    • An equivocal result
    • An abnormal result
    • A possibly erroneous finding
    • An instrument not functioning on the day in question

In some cases the procedure, or repeat procedure, may be performed immediately following the consultation. In other cases the patient may return at a later date. In some cases the repeat procedures may confirm a normal finding; in others they may lead to further tests or referral. Practices should ensure they have failsafe procedures for ensuring follow-up of these patients and hence continuity of care. In many cases in England and Northern Ireland, the sight test will not be able to be concluded until the repeat procedure has been completed.

In the case of an NHS-funded sight test this means that all relevant boxes on the GOS form must be completed (including whether a referral has been made). In the majority of cases, until the outcome of a necessary repeat test is known and reviewed:

  • A prescription should not be issued
  • The GOS form cannot be completed or submitted for payment
  • Spectacles should not be dispensed

If the above presents problems for the organisation of the practice, internal practice referrals offer a possible solution.

The situation is different in Scotland. There, some repeat procedures (eg IOP or visual fields) may be claimed as a supplementary eye examination following a primary eye examination. If all of the required procedures for the initial examination have been carried out, that test has been completed and a prescription can be issued.

For guidance on the rules for making claims in each of the four nations please see the relevant Making Accurate Claims.

Making Accurate Claims in Scotland

Making Accurate Claims in Wales

Making Accurate Claims in England

Making Accurate Claims in Northern Ireland

Did not attend (DNAs)

Inevitably some patients will fail to return for repeat tests for a variety of reasons ranging from simply forgetting to deciding that the tests are not necessary once they have left the practice. In such cases it is the practice’s and practitioner’s professional duty to make reasonable efforts to ensure that the patient is contacted and can make an informed decision about the risks and whether to return to complete their sight test. DNAs for repeat tests are therefore a shared responsibility of both the practice and the optometrist. Failure to follow up repeat procedures is a growing cause of complaint, litigation and GOC fitness to practise investigations.

To minimise the risk to patients and public health, practices should have a fail-safe system in place to:

  • Identify patients who fail to attend for repeat procedures
  • Follow them up
  • Record both the facts of the lack of follow-up and the outcome

Such a system may be as simple as tracking the practice diary and routinely alerting the optometrist to DNA cases. If a non-diary system is in place (eg marking that the test should be completed on collection of spectacles) that system must ensure this happens.

Some optometrists also keep a personal log of patients for whom further or repeat procedures have been requested. This is particularly useful for locum optometrists who, despite the difficulties involved, may wish to phone practices to check a patient’s status after their engagement period has ended.

If the patient cannot be contacted or refuses to attend for a necessary repeat test, the practice should send them a letter explaining:

  1. The practitioner’s findings (eg intra-ocular pressures appear to be raised); and
  2. The practitioner’s advice (eg book an appointment for repeat measurements); and
  3. The possible consequences of not following this advice (eg sight-threatening pathology is not diagnosed, leading to permanent loss of vision); and
  4. What to do if the patient changes their mind (eg contact the practice to arrange an appointment)

Additionally, if appropriate, a referral letter can be enclosed and the patient advised to take this to their GP instead. This would count as a referral for the purposes of completing the test. Note that you cannot refer a patient without their permission so you should not send the referral direct to their GP unless the patient has agreed to this.

Member resource: Did not attend letter

We've created a template letter to help you when contacting DNAs:

Internal practice referrals

Internal referral template

See our internal referral template and guidance notes

Internal practice referrals between optometrists is one option to enable the completion of the test, issuing of a prescription and submission of forms. This involves transferring the clinical responsibility formally to another named optometrist within the practice by way of a referral in line with the GOC rules on referral. A practice protocol should make clear that the details of the referral must be recorded, the referral must be in writing and must indicate what has happened so far and what needs to happen next (in line with the GOC rules for referrals). This is the same basis as referrals to yourself as part of an enhanced or community service, eg to repeat pressures or counsel regarding cataracts.

As an example, if a visual fields test shows a few missed points, then the record should note that fact and whether there are any other suspicious findings. The referral report to the colleague might indicate the state of pressures and optic nerves and the reason for requesting a repeat of the visual fields, with advice that if the field defect is repeatable then the patient should be referred to the HES. Whatever the advice of the referring optometrist however, the final decision taken and responsibility for the patient, including whether any other tests should be repeated, lies with the last optometrist to see the patient.