The Francis inquiry into the Mid Staffordshire NHS Foundation Trust recommended that all organisations providing NHS care should be required to be candid as soon as it becomes clear that a mistake has happened, and not wait for a complaint before communicating with patients. This is of course most important and relevant when there has been or could be serious harm as a result.
THE AOP'S RESPONSE
Section 1: Our guidance
The Association of Optometrists (AOP) is a membership organisation for optometrists and other optical professionals. We represent over 80% of the UK’s 13,000 optometrists.
We responded alongside the Association of British Dispensing Opticians to the GOC to express constructive concerns about its supplementary guidance on candour. We advised that the guidance should be better designed for the situations in optical practice, and use language that is appropriate to the procedures carried out.
The obligations on registrants need to be proportionate to the risks in practice and the guidance should explain this. For example, the discussion of risks with a patient when instilling eye drops will be different to those involved in undergoing a visual acuity test.
Our responses to the consultation questions are set out below.
Question 1: Do you support the GOC’s approach in providing supplementary guidance on candour to support registrants in meeting their obligations in the Standards of Practice for Optometrists and Dispensing Opticians and Standards for Optical Students?
No. Whilst guidance for registrants to interpret the duty of candour is helpful, it would be better if this was produced by professional bodies. However, if the GOC decides to issue guidance then we would ask it to take on board these comments in order to improve the content.
The guidance needs additional work to ensure that it is clear, and applicable to the clinical situations within optical practice. For example the interpretation of ‘treatment’ referred to within the guidance needs clarification and would benefit from the use of examples and additional explanation.
Question 2: Does the new supplementary guidance on candour make it clear what the GOC expects of its registrants?
No. Further clarifications are required to the guidance to achieve this. The guidance should describe better the particular situations that apply in optical practice. The form of words used in the guidance at the moment is more appropriate for a high risk clinical environment such as a hospital.
Obligations need to be explained in a way that is appropriate to the lower risks that are present in optical practice. Otherwise there is a risk that the guidance is too widely applied and could get in the way of practitioners meeting patient care needs.
Question 3: Is the guidance presented in a way that is clear, accessible and easy to use?
Question 4: Is there anything missing, incorrect or unclear in the guidance on candour?
Paragraph 10 (advice on what to do before beginning treatment) states that patients must be, “fully informed about all the elements of their treatment”. While optometrists and dispensing opticians should explain what they will do, to explain fully the options available to patients in terms of their entire treatment whether by an optometrist, dispensing optician or another clinician in an appointment slot is impractical. For the most part the length of appointments is outside the control of the optometrist.
Further, the use of the term “treatment” in the specific context of the optical environment is confusing and either needs replacement with a term more suited to this professional context or more explanation. In general, optometrists and dispensing opticians do not consider they are “treating” patients, even when prescribing spectacles or fitting contact lenses. This is especially important as registrants are asked to also have a “comprehensive conversation” about risks of treatment options with the patient. The GOC needs to clarify which kinds of optical care processes fall within this obligation.
The framing of this should also be proportionate, taking into consideration that the GOC commissioned research Risks in the optical profession has not identified any “major risks in the optical profession”1.
The use of the word “comprehensive” is not appropriate and could be over-interpreted – leading to distress for the patient. It should be removed. The General Medical Council guidance Openness and honesty when things go wrong2 simply refers to clear and accurate information about risks needing to be provided.
Issuing a prescription for spectacles may or may not be considered treatment. It is not in common practice a situation where a comprehensive explanation of risks would be required. Instilling eye drops for diagnosis would not usually be considered as treatment, but is a procedure of which an optometrist would expect to discuss the small risks with a patient. The guidance does later refer to investigation (in paragraph 11) needing a discussion of risks before consent. However undertaking a visual acuity check using a standard letter chart is an investigation but not one appropriately associated with a discussion of comprehensive risks.
The document should use language appropriate to the optical context, such as “investigation”. Terminology needs to encompass and distinguish a range of procedures including things like the instillation of eye drops, contact lens fitting or supply/prescription of medication. Given this difficulty in interpretation the GOC should provide clinical examples to allow registrants to understand their obligations in relation to patient communications before beginning procedures.
Case examples should also be used to explain how registrants should interpret the full scope of the guidance on candour in a proportionate way. It would for example be helpful to describe clinical situations that would constitute a near miss and when to report these to the patient.
Paragraph 13 states that registrants should be candid when a patient “has suffered physical or psychological harm or distress, or where there might be implications for their future care.” Again this needs to be explained within the context of a low risk optical environment. Examples of situations that cause harm and care implications need to be given here.
Paragraphs 15 and 16 are confusing to interpret. It is difficult to see why a registrant is asked to find out why a patient might not want more information about what has gone wrong. If a patient does not want more information it should be enough to let them know they can change their mind about this. The final sentence of paragraph 15 states that if a patient wishes not to have more information their wishes should be respected “having explained the potential consequences”.
It is not clear to the consequences of what the guidance is referring. We also note that the GMC guidance on candour referred to earlier does not include similar content to that covered here. It would be better for the GOC guidance simply to state that a registrant should check whether a patient would like information about what has gone wrong. It is implicit that if the opportunity for this has been offered then the patient can still ask for this information in the future.
The obligation at point 21a to see a patient at a time when they are best able to understand and retain an explanation should be amended. The guidance rightly says this need only be done when it is “possible”. The word “reasonable” should also be inserted here. For example the best place to discuss a situation with an elderly patient may be at their home, however it would be more reasonable to do this over the telephone or when they are next able to come into the practice.
Question 5: Are there any specific issues or barriers that could prevent stakeholders from implementing or complying with the guidance on candour?
Individual registrants will need to be provided with sufficient time and support by employers to ensure that they are able to comply with the duty of candour. This will be particularly important when the registrant is a locum. This need should be considered as part of the GOC review of its Code of Conduct for business registrants. Ideally the GOC should fulfil the undertaking it made, during the consultation process on the Standards of practice for registrant, to develop and implement equivalent standards for business registrants.
The guidance correctly encourages registrants to seek advice from senior colleagues and allows for a healthcare team colleague to communicate with a patient when something has gone wrong. The guidance should also say that, as well as seeking advice from a senior colleague, registrants can seek advice from their professional representative body. This may be more appropriate for a locum in particular.
Larger practices should consider appointing a duty of candour officer to support less experienced colleagues and locums in meeting obligations. It is also important that locums are not put in a situation where they have to take responsibility for discussing something that has gone wrong when they are unfamiliar with the patient’s case. In a larger organisation where locum work is common, a duty of candour officer could ensure that communication with patients to meet obligations is properly handled and registrants not put in an unreasonable position.
Question 6: What action should the GOC (or other organisations) take to help registrants to implement the guidance on candour?
As explained in earlier answers there are sections of the guidance that would benefit from additional clarification. The GOC should also produce clinical examples to support registrants in complying with the guidance.
Section 2: Impact
Question 7: Overall, do you expect the guidance on candour to be beneficial to, or have a positive impact on, the protection of the public?
This will depend on how successfully registrants can be supported in meeting its obligations.
Question 8: Are there any aspects of the guidance that could have an adverse or negative impact on certain groups of patients, optometrists or dispensing opticians?
Yes. Some locums may find difficulties as discussed in the answer to question 5.
Question 9: Are there any areas of the guidance that could discriminate against stakeholders with specific characteristics? Please consider sex, age, race, religion or belief, disability, sexual orientation, gender reassignment, pregnancy or maternity, caring responsibilities or any other characteristics
Question 10: Do you have any additional comments you wish to make on the guidance for candour?
Association of Optometrists (AOP)
Association of British Dispensing Opticians (ABDO)
September 6, 2016.
If you would like any more information, please contact a member of the policy team on firstname.lastname@example.org.
1 European Economics Foundation. “Risks in the optical profession”. (2010).
2 General Medical Council. Openness and honesty when things go wrong.