“Domiciliary is a chance to add some real variety to your working week”

How long have you locumed for?

Nikesh Lad, domiciliary optometrist at OutsideClinic (NL): I first started locum work in April 2019.

Hector Marcos, domiciliary optometrist and owner of Home Optika (HM): I started domiciliary work in 2007. I was employed in the south west of England. I was there for a year or two, and then I took another employed role in south Wales, which I later left to become a locum.

Has domiciliary always been part of your locum career?

HM: Yes. Since I started locuming, I’ve always done a few days of domiciliary – sometimes for other companies, and I also have my own small domiciliary business, Home Optika. The majority of my work now is in south Wales.

NL: Previous to moving to locum work, I had already been employed in domiciliary. I switched to locum work to allow me to have the balance of being in practice and being on the road. I wanted to keep up my contact lens skills, as well as working with children and younger patients, which you don’t get exposed to as much in domiciliary.

I first tried domiciliary as I needed to change up the day job and challenge myself. I had worked in numerous practices beforehand, and realised domiciliary was an area that would challenge me. That was in 2015, and I still love the challenge.

How does domiciliary work fit into your locum portfolio, and around your other projects?

NL: Domiciliary makes up the most of my working week, as it offers me the flexibility of balancing my family life. I keep up with working in practice on occasions, but I have also had the chance to explore some professional service work, delivering training to colleagues.

HM: I do a mix of everything. I do some work in-store, and until recently, I was doing half a day in the hospital. Also, I do domiciliary for my own company, to fill gaps in my diary, whether it’s on days off or after work. I also work certain days for domiciliary companies on a locum basis.

What makes domiciliary special?

NL: It allows me to make a real difference to people who might otherwise not have their eyes checked. A lot of people I see want to keep their independence, and don’t always want to trouble their family to attend for their eye tests. Domiciliary allows me to provide high quality eye care to these patients in their own home.

HM: First of all, it is the service you provide to patients who are often stuck in their homes, unable to leave the house. Sometimes they’re quite worried: ‘how am I going to fix my vision? How am I going to deal with this eye problem, if I cannot leave the house or go to the hospital?’

That’s the most rewarding aspect of domiciliary – trying to help the patients a bit more than you can when you’re in practice.

A lot of people I see want to keep their independence, and don’t always want to trouble their family to attend for their eye tests

Have you encountered any misconceptions about domiciliary from other locums?

NL: Many optometrists I have met are scared of the unknown. Of course, anything new takes a period of adaptation, but once you have tried it you realise that it is not that different to working in practice.

A lot of people are worried they will miss their equipment, such as a slit lamp or fundus camera. So many people are surprised that we have access to portable versions of a lot of equipment, which gives us more tools to help provide a high level of care.

HM: I’m not sure if I would call them misconceptions, but there are always challenges. Sometimes you come across people living in very poor conditions, so that aspect can be challenging.

Domiciliary can be difficult both mentally and physically. Obviously, you have to carry all your equipment in and out of the car several times a day, sometimes in the cold weather or the rain. It can be tough in that way.

Only 2% of optoms in the UK work in domiciliary – what would you say to encourage people to consider it?

NL: Domiciliary is a chance to add some real variety to your working week. Moving from store to store, it is essentially the same job, however domiciliary is a real chance to try something new.

HM: I think it’s a growing market. You can learn a lot from providing eye care services in people’s homes. You can make your own decisions, and tailor your tests to the patients.

The volume of patients is still there, and sometimes as a locum you do have to deal with extra commercial pressures, no matter where you work, even in domiciliary. But I think you have a bit more flexibility. You often have a bit longer for testing, so you can chat with the patient and help them if needed. Sometimes they might feel a bit lonely. It’s a different pace.

It’s also nice to be out and about. Sometimes you encounter patients who are quite elderly. It’s very interesting to hear about their lives, about their life experiences.

Could you speak about the variety of patients you see as a domiciliary optom?

NL: The majority of my patients have full mental capacity but struggle with their mobility. They want to maintain their independence, but are not always able to access the High Street easily.

I also see patients from all different backgrounds. Each day will hold a different challenge. I can see patients who are wheelchair-bound or bed-bound. Some patients are living with dementia, which affects everyone differently. I have also seen people struggling with their mental health. Every day is different, and the job has taught me to not pre-judge anyone.

HM: When I work as a locum, I go more to people’s homes than care homes, although we do visit care homes sometimes. The variety of patients are home-bound, for medical reasons, whether physical or mental. We see patients with mental health conditions as well.

You see more elderly patients than you might see in the practice. More frail people are, in general, more vulnerable anyway, no matter what age they are. You have to have a little bit of extra care with them – a gentler manner, because of their condition. Sometimes, unfortunately, some of them are at the end of their life. Mentally, it can be quite challenging seeing these patients.

At the same time, it broadens your perspective. Life is short. Patients at the end of their lives might have a quite positive attitude. It gives you more of a perspective on how people live around you, especially in deprived areas. It’s interesting to learn how people live in society in the UK. Sometimes, that is a bit hidden.

It gives you more of a perspective on how people live around you, especially in deprived areas

What are your thoughts on career progression, both as a locum and in domiciliary?

NL: Being a locum gives flexibility. There are often opportunities to explore areas such as professional services, helping with training and developing colleagues. However, career progression can be difficult as a locum, as you may not be exposed to the senior management teams who make some of the decisions regarding progression opportunities.

HM: I think the way forward is independent prescribing services – bringing more services to the community, in terms of people who are home-bound. Being able to treat pathologies, and trying to keep these patients out of hospital, from a logistic point of view, from a finance point of view, from a comfort point of view for the patient, from a safety point of view in terms of, for example, risk of falls. It’s trying to care for these kinds of patients more at home, and trying to tailor their eye care to their needs.

A lot of the time, their main need is to be kept comfortable. You might not be able to treat certain conditions, but at least you know you can make their life easier.

How do you feel being a locum domiciliary optometrist improves your clinical knowledge/skills?

NL: Having a background in domicilliary allows me to have an added string to my bow. But also, it provides a different mindset. In practice, we are aiming for 6/6 or 6/5 vision, and for all tests to be ‘passed’. In domicilary, you often have to take a more holistic approach. I soon learnt that ‘6 over happy’ is what you aim for with patients. Sometimes, being able to see the patient in their home environment allows me to give more dedicated and personalised recommendations.

HM: You see a lot of pathology, compared to the typical refraction a practice-based optometrist might see, with more routine patients.

When you’re doing domiciliary work, there’s always something going on there. People have certain health conditions affecting their eyes. Sometimes people are elderly and they have cataracts or glaucoma or other eye conditions. The majority of patients will have a certain degree of eye pathology. It’s a good learning experience, from that point of view. Sometimes, it’s very different management compared to what you would do if this patient came to you at a practice.

What is your favourite thing about domiciliary locuming?

NL: Being able to make a real difference to someone’s day. That can be something as simple as a chat, as they may not have spoken to anyone face-to-face for a few days.

But more importantly, [you are helping to] maintain the patient’s independence for as long as possible. A lot of my patients want to remain in their own home for as long as they can, as that is what they know, and where their memories are. Improving their vision can help them to do that for as long as possible. As a domiciliary optometrist, you can offer advice on contrast in the home, on lighting, or even on things as simple as sitting closer to the TV. You would be surprised how many people have a small TV, and sit on the other side of the room struggling to read the subtitles.

HM: I like being out and about. I like my car journeys. I always listen to books in the car, so it’s quite mindful to be in the car in between visits.

The other aspect is the flexibility to be able to spend as long as I want with a patient. In practice, you can feel a bit restrained if the next patient is there already. There are several very good things about domiciliary.