“We need a change in legislation to allow providers to be able to see patients at short notice”

It all began back in January 1995 when I sold my High Street optometry practice – I had two small children and wanted to spend more time with them. After the sale, I began locuming. One of the locum jobs I got was with the only national domiciliary eye care company in the UK at the time. During this experience I realised what an important service domiciliary eye care was, and I found it so much more satisfying than just sitting in a consulting room all day. I was offered an employed role, and I did not hesitate to accept.

Patients in England cannot access a same day service anymore, even if the provider has the ability to attend on the same day

The evolution of domiciliary

During my three decades in domiciliary, the type of patients we see and where we see them has changed greatly. Back in 1995, we really only saw patients in care homes; there were a lot more care homes then, ranging from ‘retirement homes’ where people chose to live so they were not alone, to nursing homes for those who needed nursing care.

We would spend a full day in a care home, testing everyone who needed it. Now there are far fewer care homes; successive governments have championed care in the community and so people stay in their own homes for much longer than used to be the case. This means that we now do more visits to individuals in their own homes than we do to care homes.

In terms of regulation, by far the biggest change, and a constant challenge, has been the implementation of the notification requirements.

Patients in England cannot access a same day service anymore, even if the provider has the ability to attend on the same day. Also, patients must state the illness or disability that prevents them from leaving home unaccompanied; that was not the case when I started.

Notification requirements were first introduced in 2005. They were changed and further strengthened in 2008, with the advent of the General Ophthalmic Services (GOS) contract. Prior to this, patients could have a domiciliary sight test without the requirement of the provider to pre-notify the NHS. This meant that urgent cases could be seen quickly, as providers allocated diary spaces freed at short notice when pre-booked patients were unable to have their appointment.

This pre-notification legislation in place in England means that no patient can have a home visit sight test until the provider has given a minimum of 48 hours’ notification to PCSE. This also impacts people experiencing homelessness who may be staying in homelessness shelters or visiting day centres.

In Scotland and Wales pre-notification is no longer required. In Northern Ireland, patients can be seen if it is urgent, and notification given retrospectively. Pre-notification is a frustration for both patients and providers in England.

The third legislative change that altered the face of domiciliary is the fee structure. In 1995 the fee was the same regardless of how many patients you were seeing at a venue; now, particularly in England, domiciliary fees are structured so that providers are paid more for the first and second patients at the same venue, and less for the third and subsequent patients.

On a positive note, there is much more awareness of the availability of a domiciliary eye care service than there ever was, with TV and radio adverts regularly broadcast.

I do not think that in England we are fully prepared... I think we need a change in legislation to allow providers to be able to see patients at short notice

Breaking the barriers

The main barrier that must change for domiciliary eye care in England is the notification requirements. However, there is also a lack of acknowledgement by the NHS of the importance of domiciliary eye care. For example, when Enhanced Eye Care Services are implemented in areas, usually they do not include the ability for domiciliary providers to join them. Other than simple services such as direct cataract referral, most services either require equipment that is not available or not suitable for domiciliary care, or it is not possible for a domiciliary service to comply with the timescales. I am thinking about minor eye condition services, glaucoma refinement and ocular hypertension services.

The new Welsh contract shows that, with proper funding and a bit of thought, domiciliary providers can be part of such services to benefit their patients.

I do not think that in England we are fully prepared when it comes to delivering domiciliary eye care for the growing ageing population. I think we need a change in legislation to allow providers to be able to see patients at short notice, not only at their normal place of residence like we do now, but also in respite care, when they are staying with relatives or in hospital. As the population ages, and families struggle to cope as unpaid carers, they will need services to be provided flexibly, when they need them and where they need them. The current structure only allows an NHS sight test to be provided at the normal place of residence, or at a recognised day centre.

The opportunities within domiciliary eye care are huge. Domiciliary providers could take a lot of pressure away from secondary care if they were allowed to provide enhanced services everywhere.

In my opinion, to prepare for the future, domiciliary optometrists should be developing their skills, gainingfurther qualifications in order to be ready for the ability to provide a wider range of services. Independent prescribing would be a fantastic addition to domiciliary eye care, and we may need to think about contact lens services as the current contact lens wearing population ages and becomes unable to access High Street services. After all, they should not have to give up wearing contact lenses just because they cannot get out anymore, should they?