On 30 October 2019 a ‘trailblazer group’ of optical sector employers launched a consultation on a draft Standard for an optometrist degree apprenticeship. The consultation can be found here. The AOP submitted its response on 9 December, the original closing date for the consultation. The closing date was later extended to 10 January 2020.
The AOP's response
The Association of Optometrists (AOP) is a membership organisation for optometrists and other optical professionals. We represent over 80% of the UK’s 15,000 optometrists, registered healthcare professionals regulated by the General Optical Council (GOC) who play a vital role in delivering eye healthcare. We also represent some Dispensing Opticians (DOs), another profession regulated by the GOC.
We welcome the opportunity to give views on the proposal for an optometry degree apprenticeship, in response to the trailblazer group’s consultation on a draft Apprenticeship Standard. The AOP is not and has never been part of the trailblazer group which is developing the proposal for an optometry degree apprenticeship, contrary to statements that have previously appeared on the consultation website.
Our response deals with the overarching proposal to create an optometry degree apprenticeship, and does not comment in detail on the Apprenticeship Standard document itself. Although we understand the Institute for Apprenticeships and Technical Education ran a consultation on an optometrist ‘occupational proposal’ in August 2019, that consultation was very brief and was not drawn to our attention. This is therefore the first opportunity we have had to consider a proposal to develop a degree apprenticeship for optometry, and to invite our members’ views to inform our response.
Summary of our view of the proposal
The AOP opposes the proposal for a degree apprenticeship in optometry because it carries significant risks, and those risks are not justified by the weak rationale for the proposal.
This view is based on an unprecedented level of feedback and concern from our members – the highly trained and regulated professionals who play a vital role in ensuring the eye health of the UK’s population. A large majority of those members who expressed a view to us firmly opposed the proposal.
In summary the key reasons for our opposition to the degree apprenticeship proposal are:
- a mainly workplace-based route to registration as an optometrist, in optical practices that have a strong retail as well as clinical focus, will not give students the necessary depth of academic supervision, or equip them with the patient-centred ethos and the full range of scientific and clinical skills needed to
- develop into a safe practitioner in a range of clinical settings
- withstand the recognised commercial pressures on practising optometrists
- the GOC has a key role in approving all new routes to registration as fit for purpose, but we doubt it could ensure appropriate standards of training and supervision if students spend the majority of their time in mixed clinical and retail settings
Given the risks to patient safety, the proposal would damage the credibility of the optometry profession with patients and other healthcare professionals, at a time when primary care optical practices have a vital and growing role in meeting the rising demand for eye healthcare from an ageing population.
It can be hard for employers to find optometrists in some parts of the UK, and in principle we support the aim of encouraging students – including those from disadvantaged backgrounds – into the profession. But there are other ways of tackling these issues, without the risks to patient safety and the credibility of the optometry profession that this proposal creates.
Our other concerns about the proposal include:
- Degree apprenticeship training may not equip the optometrists of the future for the increasingly demanding clinical roles they will need to take on as more NHS eye healthcare is delivered in primary care optical practices, as envisaged by the NHS Long Term Plan
- The proposal could cut across the implementation of the GOC’s Education Strategic Review, and increase recognised risks already associated with the review
Degree apprenticeships involve apprentices spending up to 80% of their learning time in a workplace setting. Some optometrists work in hospital settings but the large majority work in a combined clinical and retail environment, delivering primary eye healthcare services within business models that have a necessary focus on sales of optical products such as spectacles and contact lenses.
Because of the nature of the optometry profession and the combined clinical and retail setting in which most optometrists work, a largely workplace-based route to registration as an optometrist would carry some particular risks to patient safety.
Apprenticeships and degree apprenticeships can be an effective and appropriate route into a range of occupations and professions, including some healthcare professions. And some key skills of the optometrist’s role, such as communication with patients, are best developed in a workplace setting, as they are currently during university clinical placements and the pre-registration year.
However, optometrists – like medics, dentists and pharmacists – also need a large amount of concentrated scientific and clinical training, under near-continuous expert academic supervision, in order to develop the clinical ethos, skills and understanding needed to practise autonomously and deliver healthcare safely to patients. This includes thorough exposure to the full range of patients, eye health conditions and pathologies they may encounter when practising in different clinical settings – exposure which may not be adequately provided in a single workplace setting.
In our members’ view, based on their wide variety of first-hand experience in practising optometry, the high level of academic training and contact needed to become an optometrist means that initial professional training is best suited to delivery through a primarily university-based programme, with a strong focus on evidence-based practice. Training optometrists in settings which do not provide this level of university-based contact will reduce the educational effectiveness of the training programme, with a potential impact on patient safety and clinical standards.
Our members’ responses to us on this included:
“You need good foundations for this job and the first step of building that is through appropriate learning, which should be done at university where it can also be done in a safe environment.”
“If the course content and assessment/competencies is going to be the same, then I don't see why we need to develop an entire new programme aside from the current university ones”
“Dealing with people with serious pathology as part of daily practice requires a solid foundation that I believe is better achieved through university teaching.”
“ Apprenticeship would only work if there is still the deep theory given to each apprentice, to gain this it would mean at least 2-3 days at university [per week], with a longer time to qualification.”
“Rather than building on the strengths and weaknesses of existing courses of study, this proposal looks like a hastily prepared effort with little evidence of clear, consistent academic input or direction. It would do little to enhance training for the future, promote safety or promote high standards in the profession.”
Most current routes to registration involve a three year BSc followed by a pre-registration placement that often takes well over a year. The trailblazer group is proposing that degree apprenticeship students would complete study leading to a level 7 MSc degree, and registration as an optometrist, in four years.
Many of our members have questioned whether this is feasible for students who are mainly based in busy workplace settings – even allowing for the fact that students will be working and learning all year, and not just in term times. If the time allowed for study is insufficient, there will be a risk of corners being cut and of students burning out. It is not clear that the current proposal has addressed this.
The quality of training that degree apprenticeship students would receive in the workplace would depend heavily on the skills (both clinical and educational) of their workplace supervisors, and on the amount of time that supervisors can dedicate to the student’s learning experience. AOP members who currently work in mixed clinical and retail settings have strong concerns that the standard of supervision available to degree apprenticeship students may not be adequate. The quality and nature of supervision required would be more challenging than when supervising current (undergraduate and pre-registration) students on clinical placements, who receive a strong grounding in clinical skills before entering workplace settings.
Our members’ responses to us on these issues included:
“Even pre-reg students struggle to find time with their supervisor let alone trying to teach an apprentice the deeper knowledge behind most of the decision making in optometry.”
“I am concerned about the level of supervision and who will be directly supervising someone who has had no formal education in the use of 'specialised equipment' etc. and how this will impact patient care.”
“What happens when you're struggling? You may have your store supervisor / mentor but they're busy trying meet the demands of the business. They can only give you a set amount of time with perhaps their own referral to think about in the background. What if the supervisor / mentor cannot teach a topic in a clear and concise way to someone who is struggling with an element of the apprenticeship?”
“How could it be possible to guarantee the same level of teaching in so many different practices where there are so many variable factors: the size of the practice, the supervisors, how busy a practice is, regional variations?”
It is not clear that the proposal for a degree apprenticeship in optometry has addressed the major challenges that would be involved in:
- identifying, recruiting and training workplace trainers and supervisors with the right experience and aptitude to take on the important role of supervision
- giving them enough time, free of their own workload and pressures, to work with students
As we discuss further below, the risk of problems with supervision may be magnified by the wider changes to optometry education being introduced via the GOC’s Education Strategic Review. This will increase students’ clinical exposure during their early years of training, and will itself require more supervision capacity in optical workplaces.
We have assured our members that if the degree apprenticeship proposal goes ahead despite our opposition, the AOP will support and defend them if they are asked to take on a supervisory role and believe that it is not appropriate or clinically safe for them to do so.
All UK optometrists are highly regulated healthcare professionals, and all the evidence shows that they provide safe and high quality clinical care for their patients, wherever they work. However, there is also evidence that optometrists working in a combined clinical and retail setting find their work environment can lead to some challenges and risks for their clinical practice:
The GOC’s 2016 survey of optical registrants (p.57-58) found that 47% of optometrist respondents had experienced pressure from an employer or business to sell a product or provide a service which was not needed by a patient, and 52% had felt under pressure from an employer or business to meet commercial targets at the expense of patient care.
Trainee optometrists currently receive university-based training which provides a strong clinical foundation and patient-focused ethos, before they spend significant time in the combined clinical and retail environment. We are therefore confident that our members have the experience and confidence to resist and challenge these pressures in the best interests of patients, and provide excellent clinical care in all the settings in which they work. Indeed, this is a key consideration for the AOP as the leading provider of indemnity cover and legal support to optometrists in the UK.
However, degree apprenticeship students would be exposed to the risks discussed above from the start of, and throughout, their journey to registration. They would receive the majority of their formative learning in the workplace, so would be likely to be strongly influenced by the professional culture of their employer – perhaps more than by the culture of their academic education provider, which will only provide a minority of their training time.
As discussed above, we also have concerns about the likely standard of supervision and training in the workplace. Degree apprenticeship students would have less access to supervision and feedback in a financially unpressured setting than current students; and the fact that their experience will be so concentrated in a single workplace may affect their expectations of what good-quality workplace supervision and training should involve.
Our members’ own experience of the mixed clinical and retail working environment has left them with strong concerns that degree apprenticeship students would be vulnerable to pressure to prioritise commercial considerations over their responsibility for patient care, and potentially even to provide patient care outside of their competence and/or without adequate supervision.
Our members’ responses to us on these issues included:
“An optometrist has a clinical role, which sometimes clashes with retail targets in high Street practice. I do not feel the high street is an appropriate environment to be training a potential future Optometrist. Surely a university environment focused on the clinical duty of care is much better. There is a conflict of interest.”
“In a large proportion of [corporate high street] practices the Optometrists are judged by employers based on their commercial performance rather than their clinical abilities. I say this having worked in a significant number of such practices (over 10 practices as an employed Optometrist and a locum).”
“Multiples focus on volume and conversion rates above clinical excellence. Never once has a manager congratulated me on saving someone’s sight or life via emergency referral. But I get thanked on a regular basis whenever I meet target. The values placed in the impressionable students mind about what optometry is all about would be commercial above the needs of the patient.”
“As a locum optometrist with experience of many practice settings I do not believe it is the correct environment to teach a lay person to become an optometrist. It is a steep learning curve for current pre registration optometrists, often conflicted by the retail nature of the work environment, let alone for someone starting from scratch.”
“Particularly concerning is the incorporation of business needs and commercial aspects of optometry into the core competencies of the apprenticeship. Sales pressure is already a significant issue within many practices. This places the optometrist in a difficult position where the needs of the patient are secondary to KPIs and sales targets.”
“We are the only health professionals judged by the performance of our sales.”
Given our members’ views based on their first-hand experience, we are concerned that this proposal would create significant risks for patients receiving care from practitioners trained through a degree apprenticeship in a combined clinical and retail setting. The risks may be more severe for elderly or vulnerable patients who require longer test times. They could also become more significant over time, as optometrists trained via this route themselves start to supervise future students.
GOC approval and oversight
As the trailblazer group has noted, the GOC has to approve all education courses that can lead to registration as an optometrist. In principle, that should provide an assurance that standards will be maintained – the GOC’s ultimate role is to ensure patient safety.
However, the role of ensuring the quality of education provided in a largely or entirely university-based training programme is very different to the role of quality-assuring education provided in a workplace setting. Aside from the wider points discussed above, the sheer variety of locations in which training will be provided is likely to make it difficult for the GOC to provide effective and consistent oversight of the quality of training under a degree apprenticeship.
For instance, AOP members have asked whether the GOC would be required to treat any workplace in which a degree apprenticeship is offered as an “approved training establishment” under s.13 of the Opticians Act 1989. We do not know if the GOC has reached a view on that question, but it is a point that needs to be considered, and an example of the potentially resource-intensive implications of the degree apprenticeship proposal for the GOC’s education function.
These concerns are heightened by the other ongoing challenges facing the GOC’s education function, notably the implementation of the GOC’s Education Strategic Review (ESR) which we discuss further below.
Many of our members have expressed concerns about how optometrists trained through a degree apprenticeship may be perceived by patients, other healthcare professionals and other optometrists – and about the knock-on impact that this could have on perceptions of the whole profession.
In principle this should not be a concern, because the GOC would have to approve any training programme based on the degree apprenticeship standard, and has the role of guaranteeing standards. However, given the risks to patient safety discussed above, we share our members’ concern that over time, patients may come to regard optometrists trained via this route as less clinically robust than their peers – and that ultimately this could affect their perceptions of all optometrists. Any such development will inevitably undermine the trust within the patient-clinician relationship that is so important for care delivery and shared clinical decision making.
Perceptions amongst other healthcare professionals and service commissioners could also be adversely affected. Whilst apprenticeship programmes exist in other health disciplines, these are currently focused in roles and professions where workplace training and supervision is largely or wholly delivered in NHS clinical settings, rather than mixed clinical and retail settings.
We note that a proposal to create a degree apprenticeship for pharmacy, a healthcare profession partly conducted in mixed clinical and retail settings like optometry, has already met widespread opposition from pharmacists. We are not aware of plans for degree apprenticeships for the entry level training provided to doctors or dentists. The perception of falling standards in optometry caused by apprenticeships could affect optometrists’ working relationships and credibility with other health professionals, including ophthalmologists who are the most important route for clinical referral from optometry.
It is already clear from the reaction to the current consultation that existing optometry registrants will have largely negative perceptions of the degree apprenticeship as a route into the optometry profession. Apart from AOP members’ views in their comments to us, we note that an online petition opposing degree apprenticeships in optometry has been signed by over 11,000 people at the time of writing, although the signatories will not all be optical professionals.
Given the significant risks discussed above, it is important to consider whether the rationale for this proposal justifies the risks involved. The rationale given in the consultation survey is “to meet the growing needs of the optical sector”.
The trailblazer group has suggested that the proposal will help to address problems including difficulties in attracting people into optometry and retaining them, a shortage of optometrists in the employment market, and the high cost of training as an optometrist which may prevent students from disadvantaged backgrounds. As many of our members have pointed out, the evidence for these assertions is mixed, and it is not clear that a degree apprenticeship is the only or best solution for the problems that have been identified.
There is certainly strong anecdotal evidence, including in the AOP’s 2018 workforce member survey, that optical practices in some parts of the UK can find it difficult to recruit and retain optometrists. However, there is also some anecdotal evidence of an over-supply of optometrists in some areas. Unfortunately there is limited hard evidence about the current overall workforce needs of the sector; a College of Optometrists workforce survey in 2015 found differences in regional supply across the UK, but could not say whether there was an overall under- or over-supply.
Given the limited evidence, we do not think the stated rationale for this proposal is sufficient to justify the risks associated with it. Local recruitment and retention challenges could be better dealt with by improving incentives for practitioners to take on and retain roles, and through agile provision of university-based training programmes. Since the 2015 College survey that found no evidence of overall under-supply, several new university optometry programmes have opened, partly to encourage students to train and locate in areas with current recruitment challenges. The GOC’s Education Strategic Review should provide more flexibility in how optometry education programmes are designed and run, and so may also help to address workforce issues.
We are aware of little evidence that a degree apprenticeship in optometry is needed to encourage disadvantaged students into the profession, or increase social mobility. There are already opportunities for students to enter optometry through blended learning, combining work and academic study, such as the University of Central Lancashire programme which launched in 2019. Our members have also noted that many optometry students work part-time in non-clinical roles in optical practices, during their course and in university holidays, to supplement both their academic study and their finances. Degree apprenticeship students will be full-time and will not have that opportunity.
Our members’ comments on this issue included:
“As it stands, UK Optometry degrees are very accessible for students without traditional qualifications. They can qualify as a Dispensing Optician via distance learning and then enter a fast track degree in Optometry. This route has been available for some time and is well proven.”
“A bursary/scholarship for the University Degree could entice the least represented whilst upholding the integrity of the education and keeping a uniform standard of qualification for the public and other health professionals to trust in.”
Increasingly demanding clinical roles
Optometrists working in primary care already have the clinical skills to deliver a range of eye healthcare services beyond the sight test, and deliver such services for the NHS in many parts of the UK – playing a key role in relieving pressure on overstretched hospital eye departments. The services that optometrists provide include: care for minor eye conditions; repeat testing to identify disease; monitoring low-risk glaucoma patients; and pre- and post-operative cataract care. Some of these extended services require optometrists to obtain higher qualifications, such as in independent prescribing and glaucoma management.
The work of optometrists is also changing as a result of advances in technology. Optometrists need sound theoretical and scientific knowledge and critical thinking skills to use sophisticated testing equipment, interpret the results and make appropriate clinical decisions. The prospect of healthcare professionals making increasing use of artificial intelligence to provide patient care will put even more of a premium on those skills.
Our members are concerned that a degree apprenticeship in optometry is likely to focus more than current optometry degree courses on the basic elements of optical practice, with training in scientific skills and critical thinking less central. This may make it more difficult for optometrists trained by this route to obtain higher qualifications, make full use of evolving technology, and play a full part in meeting the growing demand for eye healthcare.
Again, our concerns are about the use of a degree apprenticeship route for the initial training and professional formation of optometrists. Advanced courses using apprenticeship-type structures and funding, such as the Advanced Clinical Optometry and Ophthalmology MSc offered by UCL and Moorfields Eye Hospital, can enable registered optometrists to develop their skills and obtain post-graduate qualifications. Such courses are very different from the optometry degree apprenticeship proposal; they are only open to qualified healthcare professionals, they deliver learning that has an established framework for delivery via clinical placement, and they are provided in an NHS rather than a combined clinical and retail setting.
Impact of the Education Strategic Review (ESR)
There are already plans for major changes to the education and training of optometrists in the next few years. The GOC’s Education Strategic Review (ESR) will lead to new high-level education Standards and Learning Outcomes for optometry, changes in the structure of education provision and the accountability of providers, and more clinical experience during undergraduate training. The GOC expects new courses under this model to begin from 2022 onwards.
We are concerned that the introduction of a degree apprenticeship at a time when the whole design of optometry education and training is going through a major transition could pose significant challenges for the GOC, education providers and employers, and may pose wider structural risks.
The GOC must ensure that any route leading to registration as an optometrist meets safe standards and maintains adequate consistency with other programmes. Given the concerns we have already set out in this response, it may be difficult for the GOC to determine with a high level of confidence that every student optometrist trained through a degree apprenticeship is meeting appropriate standards consistent with conventional programmes. This would be particularly challenging during the phased implementation of the ESR, when for several years the GOC’s education quality assurance function will need to assess and monitor the quality of courses being delivered through the old and new university education frameworks, as well as the degree apprenticeship.
A paper on ESR implementation considered by the GOC’s Council in November 2019 suggested that the GOC could manage the quality assurance pressures created by the ESR through improved operational efficiency. However, degree apprenticeships would add to those pressures – and if they cannot be managed effectively, the overall timetable for the ESR changes could be affected. At worst, the GOC may struggle to meet its obligation to ensure the quality of education programmes.
The ESR envisages earlier and more frequent clinical placements for students in conventional optometry programmes. This will in itself create more demand for trained clinical supervisors in optical workplaces, and that demand would be raised further by the introduction of a degree apprenticeship, as discussed above.
The rising demand for clinicians to supervise students in workplace settings will require more training in clinical supervision. This may be challenging for education providers and optical employers to arrange and fund, at a time when the wider UK education system is facing heightened financial pressures; a November 2019 GOC Council paper on ESR implementation evaluated the likelihood of education providers facing budget pressures as ‘medium’ and the impact on the ESR as ‘high’. It will be vital that supervisors are properly trained so that their educational and clinical skills are strong enough to give students proper support. This is a particular concern for students using a degree apprenticeship route, because so much of their learning will take place in the workplace.
Undue employer influence
There are already widespread concerns in the optical sector that the ESR may give large optical employers significant tacit influence over the way optometrists are trained. A GOC ESR consultation response report published in August 2019 identified ‘power and influence of large employers’ as one of the main risks and impacts identified in the consultation process.
This risk arises from the fact that under the ESR model, education providers will be accountable for the entire journey to registration, including the time students spend gaining clinical experience in the workplace (which at the moment usually takes the form of a pre-registration placement after undergraduate training). A small number of large optical employers currently provide over 80% of these placements. The AOP and other stakeholders are concerned that under the new model, optometry education providers will effectively only be able to function if their course is supported by these large employers. Employers’ needs should of course be taken into account in the education of optometrists and other healthcare professionals, but we think the GOC needs to do more to manage the risk that the ESR proposals would give employers too much influence.
A degree apprenticeship in optometry would be likely to amplify these concerns, because large employers will be directly responsible for most of students’ learning time, and will effectively be sub-contracting the remainder of their learning time to universities. This may put further pressure on education providers to tailor the academic aspects of the degree apprenticeship programme structure, course content, and even course entry requirements, to meet the wishes of employers.
We think the risks of undue employer influence from both the implementation of the ESR and the proposal for a degree apprenticeship will be difficult to manage safely – especially if the GOC’s education approval and quality assurance function is under pressure. Even if these risks can be mitigated effectively, there may be damaging perceptions within the profession that the wishes of employers have too much influence over the way the optometrists of the future are trained.
Published: 10 December 2019