Policy briefing: General Optical Council research on a risk-based framework for the testing of sight

What has been published

In August the General Optical Council (GOC) published research on a risk-based framework for the testing of sight so that the regulator can begin to understand the risks of separating different components of the sight test, so that the test might be conducted by different people at different times and potentially in different places.

While the GOC concludes that there may be some risks for both private and NHS patients by allowing separation of sight testing components by person, time or place, the risk is considered to be low for a routine eye examination. The report recommended further studies to determine if a personalised risk-based approach could be considered value for money and cost effective.

The GOC commented that technology continues to evolve, and new models are developing where parts of the sight test could be carried out remotely.

The GOC also recognised the significance of the issues that surround this piece of work and the diversity of views about this topic and have undertaken to convene a roundtable with stakeholders to further discuss the issues.

The research was undertaken as part of the GOC’s 2022 call for evidence on the Opticians Act 1989 to consider updating its 2013 statement on the testing of sight. The research was carried out by Sven Jonuscheit, Glasgow Caledonian University; John G Lawrenson, City St George’s, University of London; Robert Harper, Manchester University NHS Foundation Trust; Joy Myint, Cardiff University; Julie-Anne Little, Ulster University; Gunter Loffler, Glasgow Caledonian University; Anna Higgins, Glasgow Caledonian University.

What do we say

Having reviewed the research that the GOC has published, there are several interesting points raised.

We note the Delphi part of the research couldn’t reach a consensus on risk, which highlights the diverse views the GOC mention. Also, the research only included a small number of papers that met the inclusion criteria, and within those very few related to tele-optometry. Most papers focussed on tele-ophthalmology and many of these were conducted in, or shortly after the Covid pandemic.

In our view, drawing comparisons to care delivered during a pandemic when routine care was suspended, or to tele-ophthalmology, is flawed, and does not make a fair comparison to primary care, nor to the range of patients that can present for a sight test. A wide range of patients attend for a sight test and as recent consultations on vulnerable patients by the GOC demonstrates, it is not always easy to ascertain who is in need of additional support at first glance.

Looking at the workflow model constructed within the research, it places significant weight on patients being clear on why they need an appointment or expressing their concerns accurately. Anyone who has spent time in a clinical setting understands that part of the challenge when seeing patients is carefully picking up on what they say during the history and symptoms to formulate a management plan. Trying to move the burden of this process to patients, in our view, increases risk in an unnecessary way.

Our members were clear on this point when the GOC undertook a call for evidence on the proposed changes to the Opticians Act, the precursor to this latest piece of work. The proposal to risk-stratify patients into distinct groups, risks patients being bounced around the system rather than receiving timely care. We already see this happen with systems such as the diabetic eye screening service; on paper this is a success, but many patients are confused as to what has or has not been checked or examined. For example, they can be unsure if they have had a sight test, diabetic screening appointment, have been referred, or given the all-clear. The attempt to simplify complex human interactions to an algorithm, in our view, shows a lack of understanding of human behaviour and complexity.

The research highlights that there are risks with separation of the sight test, and that it may make it more difficult to see diagnostic patterns and potentially delay diagnosis. We agree there are risks. Time-sensitive conditions such as early wet AMD could be significantly affected by separation in time. While it could be said that these patients would sit in the higher risk group, we believe that arbitrary separation of patients by category simply introduces risk.

The report also highlights that there are potential benefits to separating the sight test components by person, time or place. Our view is that this broad statement fails to recognise the complex and nuanced range of situations that need to be considered, and the adoption of this approach could introduce unnecessary risk, into an already well established and safe process.

It is possible to envisage how some of the solutions that have already been tested could deliver innovative, safe care. For example, some businesses employ an optometrist who works remotely utilising a technician to cover clinics where workforce challenges exist. In this scenario there is a real time, one to one patient interaction with another clinician on site who is able to intervene if necessary. In this example, this set up is likely to be lower risk due to direct optometrist oversight. However, this is very different to an approach that was trialled in the UK where refraction and examination were separated across different practitioners and by many days, if not weeks. This second approach in our view introduced a high risk of delayed diagnosis. We are not anti-innovation but change for change’s sake risks destabilising the provision of sight tests which will ultimately harm patients.

We will continue to engage with the GOC on this matter and to represent the views of our members.