Sight test by subscription

Switching to private care was a conversation that had rumbled in the tearoom for years before the Exmouth independent made the change in July 2020.

But following the outbreak of COVID-19, falling patient numbers as a result of social distancing restrictions and the added cost of personal protective equipment reignited conversations about changing the practice business model.

Underlining these considerations were frustrations with the administrative burden and scant reimbursement from General Ophthalmic Services (GOS).

“It was an opportunity to take ownership of our business model rather than continue putting up with something that wasn’t sustainable,” Sejpar said.

The practice now offers two options for patients – a pay as you go model and a payment plan, where a monthly fee covers all of a patient’s clinical care.

Sejpar shared that the vast majority of patients have signed up for the payment plan, with less than 10% opting for pay as you go.

“Nowadays, there is familiarity with subscription models almost across the board,” he shared.

In the year leading up to February 2020, around 81% of examinations performed at McAusland Optometrists had a GOS component.

Nowadays, there is familiarity with subscription models almost across the board

However, Sejpar calculated that he could afford to lose 40% of patients receiving solely GOS services and still break even. In the first year, he estimates that he lost fewer than 10% of patients following the switch.

He described the change to a private model as liberating – enabling all members of the practice team to focus on what is best for the patient.

“It has empowered everyone in the team, from the receptionists to the optometrists and the dispensing opticians, to say ‘You don’t need to worry about the money element of this, just do what is best for the patient’,” Sejpar said.

I-Care Optometry in East Grinstead chose to end its GOS contract on 1 January 2021.

Practice owner, James McAlinden, explained that while GOS fees had previously accounted for around 7% of practice turnover, they were responsible for roughly half the practice’s paperwork.

The initial response to the practice’s subscription model has been positive, McAlinden shared.

“It is early days, but it is building in a healthy way,” he added.

In the 35 years that McAlinden has been working in optics, he highlighted that the GOS fee has changed relatively little – despite advancements in technology and the quality of eye examinations over that time.

“The NHS fees didn’t reflect the level of expertise, the level of equipment and the amount of time and care that we provided,” he said.

In the clinics where you are seeing 20 patients a day, people are stressed and there is more capacity to miss something

He believes that optometry should have a fee structure that reflects the expertise and clinical standing of all the eye care professionals involved in a patient’s care.

“I feel that in my own little way I would like to contribute to that idea. I am 52 this year, so it is not necessarily my future, but I think it is the correct way for optometric practice to go,” McAlinden said.

Changing to a private model has also provided benefits to staff. Optometrists take their time with patients, with between six and eight appointments a day.

“I have worked for many different companies over the years in optics. In the clinics where you are seeing 20 patients a day, people are stressed and there is more capacity to miss something because you are running at full tilt. This is to my mind a better environment,” he shared.

For David Bennett, of Brooks and Wardman Optometrists in Nottingham, the decision to switch to a private model of care was a straightforward one.

“During the first lockdown in 2020 we realised that the underfunded GOS amount was never going to cover the practice needs, and more importantly the patient needs, as we emerged slowly from lockdown,” he shared.

Patients pay a monthly fee for unlimited clinical care. Bennett described the switch to the subscription model as a matter of “professional pride.”

“The government has no desire to increase the GOS amount when they see practices giving away free eye tests and we will never get beyond that situation until something really radical happens,” Bennett emphasised.

GOS and public health

While many practices have experienced challenges around the administrative burden of GOS and inadequate levels of reimbursement, Professor Darren Shickle has examined the public health implications of the way sight test funding currently operates.

A trained medical doctor, the University of Leeds academic does not have a background in eye care. He became interested in the public health issues surrounding GOS after he received a knock on his university office door from an ophthalmologist over 15 years ago.

“At that time there was concern within the primary care trusts in Leeds around the relative number of GOS sight tests that were being provided relative to the rest of the region and the rest of the country,” Shickle shared.

He has since worked on a portfolio of research including work that examines the true cost of a sight test and analyses disparities in eye care access linked to areas of deprivation.

The work was at times painstaking – combing through boxes of paper GOS forms to extract relevant information – and revealed stark differences in eye care access.

For example, in 2011, people aged 60 and older living in the least deprived areas of Leeds were 71% more likely to access an NHS sight test than those in the highest areas of deprivation.

Sight tests have always been a loss leader. That is partly one of the issues that I have with the system – the business model is not really conducive to public health benefits

For the under 16s, young people were 23% more likely to attend an NHS sight test if they lived in the least deprived neighbourhoods.

Shickle and colleagues also found inequalities in uptake of NHS funded sight tests in Essex within an analysis of 2013-2015 GOS data.

Shickle emphasised that visual impairment is an important public health problem.

“You wouldn’t want people from deprived backgrounds to be at increased risk from heart disease, for example, so why would you allow them to be at an increased risk of sight loss? Both sight loss and heart disease are preventable,” he said.

A shortfall between those who are eligible for a free sight test and those who take up the offer exists at a national scale.

Shickle calculated that if all those aged under 16 had a sight test at the recommended minimum frequency, there would have been 10.1 million GOS claims over a year in 2012. However, GOS statistics revealed an uptake that was less than a quarter of this figure.

For those aged 60 and over, the estimated need was 9.2 million – with uptake higher at 60%.

The importance of proximity

Research has supported the idea that how close someone lives to an optometry practice can predict their likelihood of accessing a GOS sight test.

Work carried out by a Public Health Action Support Team in 2009 within London’s Tower Hamlets found that 13% of people living within 0.1km of an optometry practice had received a sight test in any one year.

This figure dropped to 4% among those living 1km or further away from a practice.

The traditional business model within optometry of compensating for poorly reimbursed clinical services through the sale of spectacles means there is no incentive to set up practices in economically disadvantaged neighbourhoods.

“Sight tests have always been a loss leader. That is partly one of the issues that I have with the system – the business model is not really conducive to public health benefits,” Shickle said.

“If you were to plot out the locations of practices in relation to deprived areas, you are much less likely to find a practice right in the middle of a deprived area of Leeds. At best you might have one right on the edge,” he said.

Research led by Shickle in 2014 estimated the cost of offering a sight test. While the exact cost varied depending on assumptions made within the model, every option resulted in insufficient income.

The researchers concluded that it was reasonable to assume that the GOS sight test fee only compensated for half the ‘true cost’ of the test.

Shickle is quick to point out that he prefers to remain neutral over the perennial conflict between optical bodies and the NHS regarding the GOS sight test fee.

“What I’ve always been cautious about is being a critical friend of the sector,” he said.
“The optical bodies would love for me to say ‘The GOS fee should go up’ but actually what I would want is a change in the business model rather than maintenance of the current model,” Shickle emphasised.

High Street v health

During qualitative interviews with people living in deprived areas, Shickle delved into some of the reasons that people in these communities were hesitant to access eye care.

The words of a young participant stuck with Shickle – that having your eyes tested is a High Street experience rather than a health experience.

“The things that would attract the target audience into an opticians in a shopping centre – where they are brightly lit, with high-end furnishings – might give a sense of reassurance and the quality of the experience if you are middle class. Whereas if you are from a socially deprived background, you might think ‘That is just extra cost, that is why frames cost so much’,” Shickle highlighted.

In an ideal world, Shickle would like to see the clinical services offered by optometry practices separated from dispensing services.

“I would be happy for the sale of glasses to be entirely in the private sector, although you would still want to have vouchers because there would be some people who can’t afford any spectacles,” he said.

“The important thing in terms of clinical services is for it to become a health experience. That would mean looking at the model of general practice and general dental practice. You don’t tend to find dentists or GPs in the centre of cities or towns in shopping malls, you will find them in small buildings within communities,” Shickle shared.

An initial exploratory trial of this idea in 2016 involved employing an optometrist to work part-time within a GP practice.

Patients were made aware of the service through a written reminder in a similar way to how GPs raise awareness of other screening services.

Shickle noted that in order for this model to be rolled out, the NHS would have to cover the full cost of eye examinations.

“That would be offset by patients being picked up with glaucoma and AMD at an earlier stage – there would be costs averted down the line,” he shared.

Shickle reflected on his research over the preceding 15 years.

“An aging population means that the public health importance of eye health continues to increase. While my research pointed to changes that might address this public health need, very little has changed because of the political, economic, and professional barriers that remain.”