Updating the exemptions to the Human Medicines Regulations 2012 to match the clinical training of optometrists and dispensing opticians

Executive summary

The exemptions list that allows optometrists and dispensing opticians to sell and supply certain medicines direct to patients in certain circumstances is 20 years old and not fit for purpose. We are calling for the list to be revised, as we believe this will revolutionise the delivery of minor eye conditions services (MECS) and community urgent eye care services (CUES), streamline patient access to medications, and improve efficiency and reduce the pressure on GP colleagues.

What’s happening?

For over 20 years, undergraduates on optometry degree courses have received training in pharmacology and medicines to ensure that they understand how common anti-infective, anti-inflammatory and anti-allergy medications work.

Once qualified, there is a limited range of therapeutic drugs that are available to all optometrists via exemptions to the Human Medicines Regulations 2012. These exemptions allow optometrists to sell and supply certain medicines direct to patients in certain circumstances.

This has many benefits for patients; enabling them to access care close to home, to be examined by an expert optometrist utilising specialist equipment, and to avoid the potential wait for an appointment with their GP.

However, the list of exemptions has not been updated since 2005. Some of the medicines that are on the exemptions list are no longer available, have been superseded, or are now prohibitively expensive due to changes to the supply chain.

The current state of the exemptions list mean that despite the training and level of knowledge that optometrists and dispensing opticians possess to supply medicines, most patients who require a medication for an eye condition have to be referred to (or via) their GP so that they may access these medications. This approach is inefficient, inconvenient and, for already overburdened GP colleagues, unmanageable.

Compounding this issue, where minor eye conditions services (MECS) or community urgent eye care services (CUES) are commissioned, optometrists and dispensing opticians are increasingly the first port of call for eye problems. Currently many are hamstrung by the out-of-date exemptions list. While they have the knowledge and skills to examine, diagnose and manage the eye conditions of many patients, optometrists and dispensing opticians are limited by the range of treatment options that are routinely available to them.

As an example, freely available GP prescribing data shows that there were 1.1m prescriptions¹ made by GPs in England every year for chloramphenicol eyedrops, a basic anti-bacterial, and 0.6m prescriptions each year for sodium cromoglicate a drug used to treat allergic eye disease such as hay fever. We believe this means: either GP colleagues are prescribing millions of medications each year taking up valuable appointments that could be better used by other patients; or these prescriptions are being made on an administrative basis, without proper oversight. Neither scenario represents good patient care or use of resource.

In recognition of the problems, a sector-wide working group was convened with unanimous agreement on a range of proposed changes to the exemptions list. Unfortunately, that work was sidelined first by Brexit and then by the Covid pandemic.

What impact does independent prescribing have?

Independent prescribing (IP) optometrists can prescribe, with one or two caveats, all medications for the eye and surrounding it (adnexa).

However, various barriers mean that many optometrists in England have not gone on to qualify in IP because:

• There is a significant cost burden for the optometrists to take the qualification – typically £4800. We estimate that to train the 16000 optometrist workforce currently without IP to attain an IP qualification would cost £80m
• The training requires a hospital placement. The need for a placement has so far acted as a bottleneck to training more IP optometrists.

Additionally, we believe that most eye conditions that present within MECS and CUES do not require full IP for them to be managed. Indications from prescribing data in Scotland, where IP optometrists are far more prevalent, suggests that most optometrists with IP prescribe medicines that would be suitable for an updated exemption list. Therefore, while IP is an important and growing part of the optometric landscape, in our view a change to entry level exemptions would have more immediate and effective impact.

What needs to change?

We are calling on the following:

• The list of updates to the exemptions to the Human Medicines Regulations 2012 is revised and a new list of entry level medicines exemptions is published as soon as possible
• Confirmation that the list will as a matter of course be reviewed regularly.

Reference

1.  www.openprescribing.net