11 August 2021
In 2009, 33 trailblazing optometrists were the first in the UK to become independent prescribers (IP). Among them were Susan Bowers, a practice owner in England who was then 34 years qualified; Ross Henderson, a practice owner in Scotland who was then 18 years qualified; and Martin Hood, a community and hospital optometrist in England who was then 22 years qualified.
Each had previously completed their additional supply and supplementary prescribing qualifications but had a thirst for continued professional development and felt that IP would afford them the opportunity to provide patients with a full circle of care, offering faster access to treatment closer to home.
“I wanted to be an IP optometrist as it would mean that I could do more,” Bowers told OT when asked why she completed the qualification, explaining: “It was very satisfying as an optometrist to do my IP qualification as it meant I would have a larger sphere of expertise and it gave me a unique selling point in that I was different to my peers.”
For Hood it was about expanding his skills and helping to ease the burden on the hospital eye service (HES). “I was curious and wanted to extend my professional expertise – I felt it would enable me to deal with more patients in practice who I may have otherwise had to refer into the HES,” he said.
He explained that, over the years, being able to provide a wider service for patients has allowed them to receive their care locally, while offering him a more interesting variety to his day and taking stress off eye emergency services. “I felt an onus to provide that service,” he said.
Scottish-based optometrist Henderson agreed, sharing that, for him, “it has always been about the patient.”
“Practically, if you see a patient and you make a suggested diagnosis about their eyes, the next step is to be able to do something about it, offering them the healthcare they require from start to finish.”
Three years prior to the IP qualification being introduced, NHS eye examination regulations in Scotland changed, Henderson highlighted, explaining that “the examination became much more healthcare focused and flexible to the patient’s needs. I felt that I needed to step up my abilities to prove that I was providing value for money.”
The IP qualification was established for optometrists in the UK in 2009, allowing practitioners who completed the qualification to officially prescribe any licensed medicine for conditions affecting the eye and surrounding tissues within their recognised area of expertise and competence.
Prior to its introduction much went on in the background and, in fact, a chance meeting at a clinical conference in Athens, Greece between Bowers and the ophthalmologist teaching the course at City, University of London, Roger Buckley, may well have played a pivotal role in what the qualification looks like today.
“I unexpectedly met the ophthalmologist who I knew would be lecturing on the course at City – he was a guest speaker at a conference I went to. Speaking to him, I explained how I felt that applying for optometrists to have access to a closed list of drugs would handicap us; I had seen this happen for nurses and had experience of how the tiny list of drugs that we could use for additional supply had shackled us,” Bowers told OT, sharing: “He explained that he had applied for the controlled list as he didn’t think that we would get anywhere with an open list, but that he would look into it further and winked. Today we can prescribe everything in Chapter 11 on the BNF, so he must have listened.”
“It was quite a lot of hard work going through the process as one of the first because you often don’t have a structure of support in place. It has been a steep learning curve, but it has also been very rewarding,” he shared.
Working in independent practice, on qualification, Henderson decided not to market his skills, but instead to allow it to evolve slowly. “Initially I was mainly prescribing for dry eye and minor eye conditions, which allowed me to build up and develop my skills. Then, with time, I started to see more complex patients. I developed my confidence slowly and I am now confident to prescribe oral aciclovir and systemic antibiotics when needed,” he shared.
Today he writes about 150 prescriptions a year, which he says is “not a high number,” and feels he would have “built up and developed my skills a lot faster if I was working in accident and emergency, or something like that.”
This is a notion that Hood agrees with in both theory and practice, describing working in hospital eye emergency as “invaluable” for enabling him to use and expand his IP experience.
Having worked in eye emergency for at least one day a week since his training, Hood explained: “Working in eye emergency with my IP qualification, I can act independently and don’t have to get a senior colleague to check and sign my forms. Importantly, being in that environment also means that some of the things that come through the department are on the edge of my competency and while there are lots of things I can deal with, there are also strange or quirky things that I am sometimes uncomfortable with. You have to be aware of what you don’t know and what your limitations are and learn by experience. In those instances, colleagues are always helpful and happy to give me a second opinion. I find that really helpful as an ongoing CPD educational experience.”
Hood also highlights the benefits that his experiences in eye emergency provide him in community practice. “I know what happens in eye emergency and how the system works. I have a better understanding of the mechanics; what is an emergency and what is a priority,” he said.
“I can also transfer my experiences back into my practice. 12 years ago, for example, I wouldn’t have dreamt about some of the things that I am very relaxed about dealing with in the community, such as taking foreign bodies out,” he added.
On qualification, Bowers felt excited about using her new skills. “I had done all of the training and I knew what I was doing. I was excited to be able to use my abilities to the full,” she shared. However, she was disappointed that while glaucoma had been an area covered by the qualification, it was not an area that IPs could prescribe for. “I felt, ‘crickey,’ another thing that they are telling me I can’t do, so I immediately started the glaucoma training,” she told OT.
As a clinician, it was important for Bowers to continue with her education and she subsequently went on to complete her certificate, higher certificate and diploma in glaucoma. “Education is the most important thing; you need to know what’s coming up and what’s in the future. You shouldn’t stand still,” she emphasised.
“If I wasn’t IP qualified, I wouldn’t have been open during the pandemic,” Henderson shared. “Working during lockdowns was a very rewarding time due to the volume of patients who were coming into practice who needed a prescription and therefore really needed you. We saw a lot of patients who would have normally gone directly to the hospital and, mostly, we were able to manage them. It was very challenging as I saw a much wider range of more serious pathology than I ever had before,” he added.
Hood also saw a large number of patients who may have previously gone directly to the HES but “didn’t want to go into the hospital setting and were more comfortable staying locally and visiting us,” he shared.
Hood emphasised that the pandemic has also created a large backlog of patients waiting to be seen by the HES and explained that in his experience, some of those patients are turning to their local optometrist for advice. “Being IP qualified, we are almost acting as a virtual clinic,” he explained, highlighting: “I think that there is a lot of good will being offered by community optometrists doing this currently and that is not always recognised or funded. Long-term, if we are doing more clinical work, how we are recognised and remunerated by the excellent NHS has to be resolved and that is all a work in progress.”
Being an IP optometrist made a “huge difference” to Bowers during the pandemic. “I could use all my skills,” she said. “The hospital was shut down for three months doing telephone triage only and emergencies only. But we could continue to see real life patients when wearing PPE. If you have a piece of metal embedded in the eye, for example, you need it taken out and that can’t be done over the phone,” Bowers stressed.
For Bowers, having her glaucoma certificate proved invaluable during the pandemic. “I wasn’t seeing glaucoma cases in my practice previously, but with the hospital not seeing many patients that all changed and they were referred to my practice. There I was able to see patients who felt that their medication might not be working or that their pressures were high, and managed them in the community.”
Bowers stressed that there are so few ophthalmologists, who are even busier than ever before, and “they need independent prescribers to help them.”
How an IP optometrist can secure an FP10 pad in England differs from one region to the next and of this trio who have been IP qualified for over a decade, not all have always had access to one.
Henderson, who practises in Scotland, received a GP10 pad, the Scottish equivalent, in 2014 when the country rolled out access nationally. To have a GP10 pad was one of the primary reasons he trained as an IP in the first place. “It took time but it works really well and means that everyone gets treated equally,” he shared.
In the area that Bowers practises in, Coventry and Rugby, every IP optometrist has an FP10 pad. However, this has not always been the case, and is certainly still not the case for those practising across England, she stressed.
It took Bowers herself 11 months from the day she became IP-qualified to receive an FP10 pad. “I was making all the GPs locally prescribe everything for me and driving them up the wall. It ended up being their idea to get me an FP10 pad to save them time.”
The value is now recognised and funded locally, as Bowers confirms that all IP optometrists in her area now have access to the pad. Despite this, Bowers is clear that long-term FP10 pads should be provided via a national system in England, just as it is in Scotland to ensure all IPs have access.
Sharing advice for IP optometrists trying to secure an FP10 pad, Bowers said: “Pester your local GPs and insist that you have an FP10 pad to save them having to write prescriptions for you all the time – pester, pester, pester.”
A primary reason relayed by all is the impact it can have on supporting the HES and providing patients with quicker care closer to home.
“The more IPs there are, the wider schemes such as CUES can be rolled out and in turn we can help free up the HES for more emergency cases,” Hood emphasised, adding: “I think contact lens practitioners, especially, should consider IP to enable them to extend their clinical armoury and experience in dealing with contact lens-related complications.”
“Being an IP optometrist allows you to offer the best care for your patients, and if there are more things that we can provide and deal with for our patients more locally, I think there should almost be an impetus to try and do that,” he added.
Encouraging others to consider IP, Hood reflected: “I find it really interesting to have a variety of things on the go. In this realm we are part of a much bigger picture in the health service and we should be thinking about how we can work more efficiently as part of that organisation and be better qualified.”
For Henderson, IP is for the many rather than the few: “I think it would be nice to see more optometrists doing this and developing their professional skills.”
“We are care professionals and clinicians when we qualify, and IP allows us to expand on that. There are so many potential routes in our profession nowadays, but when you are working in a practice like mine and can follow up on your patients from start to finish, it’s such a rewarding thing to do,” he added.
When discussing the future for IP, Bowers is passionate that this network of optometrists is key to the HES.
“Ophthalmologists are so busy, they need independent prescribers to help them. They will never cope if we don’t.”
In the future Bowers would like to see a five-year doctorate in optometry introduced that allows graduates to “qualify and be able to prescribe.”
“It would mean that optometrists could start prescribing privately and in the community straightaway, reducing the demand on hospitals,” she said, adding: “We can and should be looking to develop our profession and IP helps us do that.”
Each had previously completed their additional supply and supplementary prescribing qualifications but had a thirst for continued professional development and felt that IP would afford them the opportunity to provide patients with a full circle of care, offering faster access to treatment closer to home.
“I wanted to be an IP optometrist as it would mean that I could do more,” Bowers told OT when asked why she completed the qualification, explaining: “It was very satisfying as an optometrist to do my IP qualification as it meant I would have a larger sphere of expertise and it gave me a unique selling point in that I was different to my peers.”
For Hood it was about expanding his skills and helping to ease the burden on the hospital eye service (HES). “I was curious and wanted to extend my professional expertise – I felt it would enable me to deal with more patients in practice who I may have otherwise had to refer into the HES,” he said.
He explained that, over the years, being able to provide a wider service for patients has allowed them to receive their care locally, while offering him a more interesting variety to his day and taking stress off eye emergency services. “I felt an onus to provide that service,” he said.
Scottish-based optometrist Henderson agreed, sharing that, for him, “it has always been about the patient.”
“Practically, if you see a patient and you make a suggested diagnosis about their eyes, the next step is to be able to do something about it, offering them the healthcare they require from start to finish.”
Three years prior to the IP qualification being introduced, NHS eye examination regulations in Scotland changed, Henderson highlighted, explaining that “the examination became much more healthcare focused and flexible to the patient’s needs. I felt that I needed to step up my abilities to prove that I was providing value for money.”
Practically, if you see a patient and you make a suggested diagnosis about their eyes, the next step is to be able to do something about it, offering them the healthcare they require from start to finish
The IP qualification was established for optometrists in the UK in 2009, allowing practitioners who completed the qualification to officially prescribe any licensed medicine for conditions affecting the eye and surrounding tissues within their recognised area of expertise and competence.
Prior to its introduction much went on in the background and, in fact, a chance meeting at a clinical conference in Athens, Greece between Bowers and the ophthalmologist teaching the course at City, University of London, Roger Buckley, may well have played a pivotal role in what the qualification looks like today.
“I unexpectedly met the ophthalmologist who I knew would be lecturing on the course at City – he was a guest speaker at a conference I went to. Speaking to him, I explained how I felt that applying for optometrists to have access to a closed list of drugs would handicap us; I had seen this happen for nurses and had experience of how the tiny list of drugs that we could use for additional supply had shackled us,” Bowers told OT, sharing: “He explained that he had applied for the controlled list as he didn’t think that we would get anywhere with an open list, but that he would look into it further and winked. Today we can prescribe everything in Chapter 11 on the BNF, so he must have listened.”
You have to be aware of what you don’t know and what your limitations are and learn by experience
Experience
There can be benefits and drawbacks of being early adopters in any field, and being among the first to practise as IP optometrists came with its challenges and rewards, Henderson highlights.“It was quite a lot of hard work going through the process as one of the first because you often don’t have a structure of support in place. It has been a steep learning curve, but it has also been very rewarding,” he shared.
Working in independent practice, on qualification, Henderson decided not to market his skills, but instead to allow it to evolve slowly. “Initially I was mainly prescribing for dry eye and minor eye conditions, which allowed me to build up and develop my skills. Then, with time, I started to see more complex patients. I developed my confidence slowly and I am now confident to prescribe oral aciclovir and systemic antibiotics when needed,” he shared.
Today he writes about 150 prescriptions a year, which he says is “not a high number,” and feels he would have “built up and developed my skills a lot faster if I was working in accident and emergency, or something like that.”
This is a notion that Hood agrees with in both theory and practice, describing working in hospital eye emergency as “invaluable” for enabling him to use and expand his IP experience.
Having worked in eye emergency for at least one day a week since his training, Hood explained: “Working in eye emergency with my IP qualification, I can act independently and don’t have to get a senior colleague to check and sign my forms. Importantly, being in that environment also means that some of the things that come through the department are on the edge of my competency and while there are lots of things I can deal with, there are also strange or quirky things that I am sometimes uncomfortable with. You have to be aware of what you don’t know and what your limitations are and learn by experience. In those instances, colleagues are always helpful and happy to give me a second opinion. I find that really helpful as an ongoing CPD educational experience.”
Hood also highlights the benefits that his experiences in eye emergency provide him in community practice. “I know what happens in eye emergency and how the system works. I have a better understanding of the mechanics; what is an emergency and what is a priority,” he said.
“I can also transfer my experiences back into my practice. 12 years ago, for example, I wouldn’t have dreamt about some of the things that I am very relaxed about dealing with in the community, such as taking foreign bodies out,” he added.
On qualification, Bowers felt excited about using her new skills. “I had done all of the training and I knew what I was doing. I was excited to be able to use my abilities to the full,” she shared. However, she was disappointed that while glaucoma had been an area covered by the qualification, it was not an area that IPs could prescribe for. “I felt, ‘crickey,’ another thing that they are telling me I can’t do, so I immediately started the glaucoma training,” she told OT.
As a clinician, it was important for Bowers to continue with her education and she subsequently went on to complete her certificate, higher certificate and diploma in glaucoma. “Education is the most important thing; you need to know what’s coming up and what’s in the future. You shouldn’t stand still,” she emphasised.
The hospital was shut down for three months doing telephone triage only and emergencies only. But we could continue to see real life patients when wearing PPE. If you have a piece of metal embedded in the eye, for example, you need it taken out and that can’t be done over the phone
COVID-19
Through the pandemic a light has been shone on the value of IP optometrists as they have been able to support the HES and deal with a wider range of patients in the community. For this trio, the pandemic has provided the opportunity to use their skills to the fullest, while expanding their experiences.“If I wasn’t IP qualified, I wouldn’t have been open during the pandemic,” Henderson shared. “Working during lockdowns was a very rewarding time due to the volume of patients who were coming into practice who needed a prescription and therefore really needed you. We saw a lot of patients who would have normally gone directly to the hospital and, mostly, we were able to manage them. It was very challenging as I saw a much wider range of more serious pathology than I ever had before,” he added.
Hood also saw a large number of patients who may have previously gone directly to the HES but “didn’t want to go into the hospital setting and were more comfortable staying locally and visiting us,” he shared.
Hood emphasised that the pandemic has also created a large backlog of patients waiting to be seen by the HES and explained that in his experience, some of those patients are turning to their local optometrist for advice. “Being IP qualified, we are almost acting as a virtual clinic,” he explained, highlighting: “I think that there is a lot of good will being offered by community optometrists doing this currently and that is not always recognised or funded. Long-term, if we are doing more clinical work, how we are recognised and remunerated by the excellent NHS has to be resolved and that is all a work in progress.”
Working during lockdowns was a very rewarding time due to the volume of patients who were coming into practice who needed a prescription and therefore really needed you
Being an IP optometrist made a “huge difference” to Bowers during the pandemic. “I could use all my skills,” she said. “The hospital was shut down for three months doing telephone triage only and emergencies only. But we could continue to see real life patients when wearing PPE. If you have a piece of metal embedded in the eye, for example, you need it taken out and that can’t be done over the phone,” Bowers stressed.
For Bowers, having her glaucoma certificate proved invaluable during the pandemic. “I wasn’t seeing glaucoma cases in my practice previously, but with the hospital not seeing many patients that all changed and they were referred to my practice. There I was able to see patients who felt that their medication might not be working or that their pressures were high, and managed them in the community.”
Bowers stressed that there are so few ophthalmologists, who are even busier than ever before, and “they need independent prescribers to help them.”
Pester your local GPs and insist that you have an FP10 pad to save them having to write prescriptions for you all the time – pester, pester, pester
FP10 pads
Once qualified, while IP optometrists are able to officially prescribe, securing an FP10 pad to allow them to write and sign an NHS prescription for their patients seems to be a contentious topic. Without an FP10 pad, they can prescribe privately or choose to refer the patient to their GP, for example, for an NHS prescription.How an IP optometrist can secure an FP10 pad in England differs from one region to the next and of this trio who have been IP qualified for over a decade, not all have always had access to one.
Henderson, who practises in Scotland, received a GP10 pad, the Scottish equivalent, in 2014 when the country rolled out access nationally. To have a GP10 pad was one of the primary reasons he trained as an IP in the first place. “It took time but it works really well and means that everyone gets treated equally,” he shared.
In the area that Bowers practises in, Coventry and Rugby, every IP optometrist has an FP10 pad. However, this has not always been the case, and is certainly still not the case for those practising across England, she stressed.
It took Bowers herself 11 months from the day she became IP-qualified to receive an FP10 pad. “I was making all the GPs locally prescribe everything for me and driving them up the wall. It ended up being their idea to get me an FP10 pad to save them time.”
The value is now recognised and funded locally, as Bowers confirms that all IP optometrists in her area now have access to the pad. Despite this, Bowers is clear that long-term FP10 pads should be provided via a national system in England, just as it is in Scotland to ensure all IPs have access.
Sharing advice for IP optometrists trying to secure an FP10 pad, Bowers said: “Pester your local GPs and insist that you have an FP10 pad to save them having to write prescriptions for you all the time – pester, pester, pester.”
Why IP?
Gradually over the last decade, more optometrists have become IP qualified, with schemes such as Minor Eye Conditions Services and COVID-19 Urgent Eyecare Services (CUES) demonstrating the value of the qualification to the profession.
Having a network of IP peers around him is something that Henderson feels is of particular value. “We network locally, which has been really important for me. It provides me with colleagues to bounce ideas and views off.”
“Similarly, a WhatsApp group for all the local IP optometrists acts as a useful forum to get advice when I’m stuck,” he added, something that he encourages IP optometrists to set up in their local areas too.
For this trio there are a number of reasons why it is important for optometrists to consider IP training and beyond.
The more IPs there are, the wider schemes such as MECS can be rolled out and in turn we can help free up the HES for more emergency cases
A primary reason relayed by all is the impact it can have on supporting the HES and providing patients with quicker care closer to home.
“The more IPs there are, the wider schemes such as CUES can be rolled out and in turn we can help free up the HES for more emergency cases,” Hood emphasised, adding: “I think contact lens practitioners, especially, should consider IP to enable them to extend their clinical armoury and experience in dealing with contact lens-related complications.”
“Being an IP optometrist allows you to offer the best care for your patients, and if there are more things that we can provide and deal with for our patients more locally, I think there should almost be an impetus to try and do that,” he added.
Encouraging others to consider IP, Hood reflected: “I find it really interesting to have a variety of things on the go. In this realm we are part of a much bigger picture in the health service and we should be thinking about how we can work more efficiently as part of that organisation and be better qualified.”
For Henderson, IP is for the many rather than the few: “I think it would be nice to see more optometrists doing this and developing their professional skills.”
“We are care professionals and clinicians when we qualify, and IP allows us to expand on that. There are so many potential routes in our profession nowadays, but when you are working in a practice like mine and can follow up on your patients from start to finish, it’s such a rewarding thing to do,” he added.
When discussing the future for IP, Bowers is passionate that this network of optometrists is key to the HES.
“Ophthalmologists are so busy, they need independent prescribers to help them. They will never cope if we don’t.”
In the future Bowers would like to see a five-year doctorate in optometry introduced that allows graduates to “qualify and be able to prescribe.”
“It would mean that optometrists could start prescribing privately and in the community straightaway, reducing the demand on hospitals,” she said, adding: “We can and should be looking to develop our profession and IP helps us do that.”
Comments (3)
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Paddy Optom12 August 2021
"supporting the HES and providing patients with quicker care closer to home."
"optometrists could start prescribing privately and in the community straightaway, reducing the demand on hospitals"
Am I missing something .....the consistently underfunded HES is to be supported by patients obtaining private care in the community?
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John Gurney11 August 2021
Intersting stuff, I feel we have come some way but are not there yet. I dont get the focus on MECS with minor eye conditions. WE are the Primary care Eye Docs . I have been practicing 100% community ophthalomolgy for pretty much 10 years, my last refraction in practice over 3 years ago. We dont have to limits ourselves with MINOR. Our service have shown that 95-97% of all eye acute presentations can be autonomously diagnosed,manged and treated by us including AAU, corneal ulcers,preseptal cellulits,herpetic eye disease etc . We need more commisioned direct with the CCGs community Ophthalmology contracts.
Leave the surgery to the ophthalmologists and ALL the other treatments including very soon the delivery of ,SLT,YAG PI ,YAG Caps to us in a community setting . Its how we do it in Kent
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Nicholas Rumney11 August 2021
Of course I endorse every word. I was on the side pushing Prof Buckley and others (notably the ex head optom of Moorfields and head of city in the late 90’s) away from an immediately redundant formulary. We got it wrong on glaucoma but the big fear (unnecessary as it happens) was that every concession needed to be made to avoid the risk of alienating Ophthamology. Hindsight suggests and going forward, continues to suggest that we should be more aspirational and clear (single voiced) in our vision.
It’s not possible to see that, even now, when too many (individuals and professional bodies) are happy with seeing basic MECS as the blue sky and not a step in the road BEHIND US.
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