The long view: what’s ahead for independent optometry?

Emerging from an undoubtedly difficult period, the independent sector might, as 2021 draws to a close, allow itself a period of reflection – as well as a tentative look at what the next few years might bring.

In the context of technology, education, sustainability, practitioner upskilling and a changing retail landscape, OT hosted a roundtable discussion in partnership with five Hakim Group practice owners on what the landscape will look like in a decade, and what lessons we can take into the future.

Technology, education, opportunity: optometry in 2030

Game-changing technology

Technology is a key driving force for optometry over the next decade, with forward-thinking equipment heightening the level of service that independents can offer.

Neil Hilton, who owns four independent practices in Merseyside, is clear about the opportunities available, citing Optomap as “a game-changer” in terms of safety during the pandemic and ortho-k as a highlight of his 20-year career.

He also pointed out the fact that optical coherence topography (OCT) was once on a pedestal, before being installed across various multiples – something that he believes should make independents want to “take it upon ourselves to go one step further.”

“As the independent sector, we absolutely have a duty to stay ahead of our multiple counterparts,” he said. “I absolutely believe technology is imperative to us moving forward as a profession.”

Investing in services like ortho-k, he said, should not instantly lead to questions about how much money can be made per patient. Instead, he offers a different way to assess value: “It’s not just about making money off that particular individual. It’s about drawing the families in and doing something cool and special, that the multiples don’t always want to.

“I think that’s what the independent sector should be aiming towards. We absolutely should be investing in technology.”

Martin Steels believes that charging correctly for the level of eye exam that this technology can provide is the key to independents being able to compete with multiples.

“We need to be charging correctly,” he said. “These machines have to be purchased and funded efficiently so that we can use them. We are showmen, in terms of being able to use the equipment and show the patient what we can do with it. The technology is moving at pace.”

On a micro level, by 2030 Steels hopes he will have a field screener that keeps focus on the back of the eye even if the patient moves. “If we had a curved screen that could match the movement of the eye we’d always be tracking the movement, and would be able to get a more solid field screen,” he said. “That’d be great.”

On a wider scale he believes that artificial intelligence (AI) will be a bigger part of the landscape by 2030, but that there might be challenges sustaining it at High Street level. Again, the biggest challenge that he foresees is finance: “Developments to AI that already exists will be driven by appropriate funding, whether it comes from patients or somewhere else,” he said. “That hopefully will come with time.”

Nick Rumney believes that technology will impact the ‘relatively simple’ tasks of refraction and contact lens fitting, and that “within the next five years there will be deregulation of refraction, because we're already working with equipment that can give an incredibly accurate response.”

He added: “The job of the optometrist will remain maximising the optical outcome; that’s our expertise.” He predicts “a real segmentation of roles within the practice. It may well be that as an optometrist, I will end up seeing the patient for 20 minutes, not 40, and collating the information to make the final decision on the treatment.” It’s something he finds an exciting prospect.

I absolutely believe technology is imperative to us moving forward as a profession

In Ireland, Clodagh McGovern agrees that refraction is going to become more automated. She believes that this will increase the prevalence of remote clinics, also aided by AI.

“On the telehealth side of things, I definitely see stronger connections building between hospitals and primary care,” she said, “and that will be aided by better technology. That will have a positive impact on the development of optometry, because patients will have to travel less, and optometrists will oversee their eye care by connecting digitally with ophthalmologists. It’ll free up hospitals and allow ophthalmologists do their surgery.”

Although McGovern believes that technology can greatly assist working practices between primary and secondary care, she cautions that it needs to “become more intuitive and faster” to be effective. Sometimes staff can find themselves battling with technology, she said, “when their time should really be focused on the patient.”

She added: “The optometrist needs everything to be moving much more smoothly in the test room.” Technology’s key role, she emphasises, is to give us more time.

Steels agrees: “Joined up thinking is what we need, between the machinery and the people who are actually looking at it.”

Business innovation

Business-wise, by 2030 McGovern believes that support functions, such as HR, IT and digital marketing, will be faster and more intuitive, which will “ultimately free up our biggest resource, which is time, allowing us to focus on the clinical and customer service aspects of business. I think that in the future as technology improves, all of this will become much easier.”

Steels expects increased demand for optometry services in the coming decade, but has concerns about whether practices in their current form, with commercial pressures and compact sites, often located on High Streets, will be able to meet this need.

“I fear for the fact that there is all this demand for our services, which we’re not going to be able to fulfil unless we go out of town, open a branch next door to a B&Q, and have multiple eye examination rooms and a car park,” he said. “That’s one of the big issues. Our mindset is to be on the High Street. Maybe we don’t have to be.”

Rumney cautions against decisions that might cause practices to lose engagement with inaccessible groups who are potentially at risk from vision problems, warning that “it becomes difficult as an organisation or as a profession, if you’re moving away from being able to access those particular people.” Vulnerable people, he pointed out, are most likely to attend a practice in a market town or a secondary shopping centre, where independents are still most likely to be found. Cross-subsidies, he said, can help ease the shortfall that might come from General Ophthalmic Service fees: “If we’re on a strong economic footing as a practice, we can start to look at cross-subsidies for people that can’t otherwise afford it… I think we need to be cautious.”

Returning to the subject of refraction, Brian Tompkins also believes that technology will speed up the process. This will allow greater communication with patient, he said, allowing practitioners to “give them full education about what's going on.” This will be especially important for speciality work such as contact lenses and myopia management, where technology is already allowing cuts to waiting and consulting times. He believes that 10 years will see further improvement in technology, which will “make the efficiency of the process better.”

We're not testing eyes, we're examining them. I think to say 'eye test' suggests that it's a quick test, not a thorough, comprehensive review and examination

He added: “It’s not that we will have to charge less because we’re spending less time. It’s our years of education and knowledge that is going into our fee structure, not the 10 minutes it takes for us to take that scan and pass it to the lab. It’s the problem solving. The more complex the patient, the more skillsets are going to be utilised.”

Tompkins believes that communication will be key over the next decade, and that the way optometrists speak about appointments should change to encourage loyalty. “We’re not testing eyes, we’re examining them,” he said. “I think to say ‘eye test’ suggests that it’s a quick test, not a thorough, comprehensive review and examination.”

He added: “Language is going to be important. The more the patient is educated about what we’re doing, how we’re doing it, and why, the more compliant they become and the more loyal they’ll be, so we’ll retain those patients for longer.” He is, he said, currently seeing his fourth generation of patients – the grandchildren of those he saw when he first started working in practice.

Changes to education

Education is a vital part of the coming decade, with the GOC’s Education Strategic Review and a proposal for optometry apprenticeships both hotly debated topics.
Rumney believes that the conversation around apprenticeships, which he feels are unlikely, is a distraction, and that actually “we’ve missed a golden opportunity to push the case for reclassifying optometry as a clinical discipline, so university fees could fund an appropriately trained clinician.”

He outlined an alternative process for optometry education, where students qualify at one level, then go on to graduate with their independent prescribing (IP) at the next. He believes that universities can deliver these changes, and that the challenge lies in funding.

“I’m not convinced that carrying on with the system we’ve got at the moment is good enough,” he said. “I think the universities have been enabled in regulatory terms to be able to change it, but I don't think anybody’s sorted out the funding. I think we missed a trick.”

He also believes that seeing fewer patients with more specific pathology would lead to more focused learning, using the long-standing Australian model as an example.

Much like learning to drive, Steels believes that real optometry education comes post-qualification – including from conferences, manufacturer courses and others in the industry. Technology offers better diagnostics and acts as a profit generator (“each instrument we utilise is part of our business plan”) but isn’t something that formal education can teach.

“The fact that a lot of the new stuff isn't taught in universities isn't going to necessarily hold things back,” he said. “Where we have evolved is where we have embraced the technology, taught ourselves, and demonstrated that we can perform an eye examination and put value on that by explaining what we're doing. You can't teach that, necessarily, at university. That's what these young bright things will come out and learn - how to convert that brilliant knowledge into communication with the patients.”

IP, he said, is the one thing that needs to be factored into university courses: “Without IP in the practice, I don’t think we’d be surviving as well. We are very lucky to have our IP optometrists. I think that’s absolutely a way forward, and if it was taught in university, the whole optometry profession would be in a better place.”

Incorporating audiology

Another opportunity comes from audiology, which more optometrists are incorporating into their practice. Hilton has been using Amplify Hearing for five years and has seen year-on-year growth.
“The challenges that we face in optometry are just mirrored in audiology,” he said. “With an ageing population, eye and ear problems increase.”

He believes that, as optometrists upskill and take on more work from primary care, the same is true within audiology: “As an independent sector, we should absolutely embrace it. The feedback we have is nothing but good. Patients love that they can come here for their eyes and ears.

“We’ve started moving into a subscription-based model, tying in audiology. Again, that’s working well. I think there’s a perfect opportunity for optometrists to get involved.”

Patients ask Steels if he offers an audiology service daily. As a result, he is about to roll out Amplify in his Emsworth branch. The similar business models, he says, mean the two services are “absolutely perfect bedfellows.”

Rumney has a further endorsement for branching out in this way: “Two years ago, there were a few months where we actually sold more hearing aids than glasses.”

External factors impacting optometry

Customer service-savvy

When OT asked the panel about the external factors that are likely to affect optometry over the next decade, the changing retail landscape and what that might mean in terms of customer service was a clear theme.

McGovern believes that there will be no place for average practices in a challenging retail environment, and that being savvy about the patient journey is key to ensuring they do not look elsewhere. At the same time, she believes that online will not be as much of a threat as might be predicted.

“We’re a service industry,” she said. “Patients still like that touch and feel; they like to have products fitted. But I do think we need to be very, very good at it. It’s all about having the right team that can deliver that journey and that connection. If we can do that, I think we're on a winner.”

Tompkins agreed that high-quality service comes from “the attitude of the team, the practitioner, and front of house. Service comes from the person. In 2030, we will still be people-centric.”

Rumney has found that joining the Hakim Group has allowed him to focus more fully on the patients. Previously, he might have found himself having to “firefight operational issues in between patients.”

Having a function in place to manage this side of things – pension, holiday allowance, and so on – has offered a financial benefit: “Average transaction values have risen, because the focus is much more on the person that’s in front of you. They’re taking time out of their day, often spending money to come and see you. You need to be 100% focused on them.”

From a business perspective, will mergers that have taken place in recent months cause changes to the way that practices operate in the coming years?

Steels is concerned that when brands amalgamate, “they tend to simplify the offer, and so product quality dips.” He is not overly worried about the impact on his own business, though, as his demographic “don’t want what everybody else has got. They want something a little bit unusual. They’re fed up of looking like everybody else.”

He values independent brands, and believes that large-scale manufacturer mergers are more likely to impact larger groups, whose customers might value labels more highly: “That’s what my patients tell me. They don’t want anything with diamonds. They want something more niche. We’re fortunate to be in an area where that works.”

Hilton agreed: “We’re not limited to key brands. The more mainstream and commercial it becomes, the less our customers want that. You’ve got to be agile.”

Competing on price alone, he emphasised, will not work in the long-term: “It’s common sense to differentiate yourself; any decent independent business owner will realise that. It’s all about the experience when it comes to an independent brand. If you believe in something enough, then nothing else matters.”

For Tompkins, the only brand that will really endure is that of the practice itself. “We’ve put our personalities into our practices,” he said, “and that’s the brand we put forward. As to what our brand then recommends for our patient, it’s an important factor: that they will trust us because they believe in our brand.”

The future of shared care

On a more clinical note, what does the panel make of the sector’s increasingly close links with, and perhaps movement towards, ophthalmology?

Rumney has a cautionary tale of referral, which he believes highlights the importance of Montgomery consent: where the referrer has an obligation towards the outcome. It is something he doesn’t believe optometry has yet fully embraced.

“We’ve had two very poor outcomes,” he said. “We felt obliged to refer these people because during lockdown their vision had become significantly impaired through cataract, and they were no longer able to drive.”

He explained that the local hospital was unable to see the patients within a reasonable timeframe, so external practitioners were brought in to perform the surgery. The negative of this, he said, was that the practitioners had not seen the patients beforehand and were not around for aftercare.

The future of independent practice lies in people

Unfortunately, there were complications, “and our local trust is now picking up the pieces.”

The lesson here is about communication: the optometrist being clear with all those involved about the required result.

“It’s down to us to tell the ophthalmologist what the end stage outcome ought to be,” Rumney said. “If we’re not doing that, we’re causing problems. And I don’t think that we’re educating our optometrists to be argumentative enough over that. We’re still kowtowing a little bit to the senior doctor.”

Montgomery consent, he believes “has not really impacted optometry yet. I think we have a fundamentally important role in guiding patients through to what the end stage outcome would be.”

Steels agreed: “You need to have that discussion with the patient before you send them away. It is very important that both the patient and ophthalmologist know what they’re dealing with.”

Tompkins has a good relationship with local ophthalmologists, so much so that “they trust us and refer things that they know we're going to work with better. We’ve even got a consulting room for an ophthalmologist once or twice a month. We're working very closely.”

He added: “I don’t think we would be threatened as independents by any multiple or link to another practice.”

Lessons from the present day

Post-pandemic priorities

As optometry looks towards a new year, and with reflections on where it might be by the start of the next decade framing the discussion, it seems sensible to reflect on the lessons that we can take from the present day. Primary amongst them is, of course, COVID-19 – and the panel is taking overwhelmingly positive lessons from the challenges of the past two years.

“It’s made us wake up to what we can do,” Rumney said. “If we can audit 500 patients diverted from eye casualty and only 50 need direct medical intervention, there’s no need to be running a 24/7 ophthalmology casualty unit. It’s the one opportunity we’ve had in our professional careers to stick a complete spoke in the hamster wheel that we were running around on. We went into a huddle, not only to run our businesses as they were, but to look at what was going to happen in three months’ time, and how were we going to reopen.”

Now, he believes, “our business is much more focused on what's in front of us.”

Steels has found that, without “a constant bombardment of patients coming through the door,” he has developed better relationships with his staff, and that they are more engaged and happier at work as a result. “Communication,” he explained, “has been a key for me during this time.”

What opportunities are there for growth in the independent sector, in this context?

Hilton believes that “it’s a really exciting time, and probably the best place we’ve been” – although he does find it frustrating that it has taken a virus to change the way that independents look at their business models.

“As independent practices, we should constantly revisit and revamp what we do to make sure it’s the best possible service for our patients,” he said.

His growth plans include continuation of myopia management, which his practices have been offering for a few years. He believes that this is one area that independents can become market leaders in, especially when larger chains might take longer to get involved. Recurring revenue streams, particularly subscription-based eye care plans, have kept his practices afloat, and he believes they are “absolutely the way forward.”

Rumney also uses a monthly, service-based approach for myopia management. He said: “It’s not a product-led approach. It’s very much a monthly payment plan approach, because it’s a service being delivered. I think the model of conventional retail practice doesn’t lend itself to that. We’re lean, in that sense. We can make decisions quickly and go in a particular direction.”

Engaging new patients, perhaps those who are still working from home and using services more locally, has also been a growth opportunity, and Hilton thinks that this will continue: “It’s up to us to keep these patients and to show them what we’re capable of. If we don’t, we’re our own worst enemies. We’ve had more new patients than ever. It’s phenomenally exciting.”

McGovern believes that “everyone has the ability to be brilliant” – and that the future of independent practice lies in people, and what they can do that AI and technology cannot. She envisages training that focuses on “connectivity, empathy and intuition. Empathy is something that machines can never do. Communication: the craft to convey a clear message. The skills we look for in people and the way we train them will be different.”

A greener outlook

Environment and sustainability are subjects that practices might only just be starting to invest time and resource in, but they will need to remain a priority going forward.

McGovern is cautious of greenwashing (effectively leading customers into thinking a product or service is sustainable when it is not), but sees sustainability as a key feature of her businesses’ future – so much so that she believes things like recycling and energy usage will become key performance indicators in the near future. She is also very aware of the sustainability practices of suppliers, and sees this as a focus up to and beyond 2030.

Steels highlights the business opportunities that come with an increased focus on sustainability: taking on product ranges that are made from reclaimed fishing nets has “resonated massively’ with younger customers, and encouraging patients to come into the practice to recycle used daily contact lenses has increased engagement and footfall.

“People are very enthusiastic,” he said. “That has a very interesting side effect, because it gets people through the door who we’d only usually see once a year. They’re coming in, engaging with the staff, looking at products. We’re having more contact with patients, more frequently.

“There are little things that you can do, and in the patient’s mind you are doing something to help the environment. I think that’s always positive.”