The discussion

Demystifying domiciliary

Three early career optometrists tell OT  how their experiences of domiciliary care have outshone industry perception

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With domiciliary optometry rarely being taught at university, it does not come as a huge surprise that those OT  spoke to did not have a strong awareness of it, either whilst they were studying or during their pre-reg years.

For Tehreem Ali, a domiciliary optometrist with Specsavers Home Visits, it was a chance meeting, rather than direct teaching, that led her down the domiciliary path. “During my pre-reg, a patient told me that their husband was a domiciliary optometrist for Specsavers,” she explained. “This was the first time I really thought about exploring domiciliary. That night I went home and researched the job, watched some YouTube videos with domiciliary optometrists, and had a look at the Domiciliary Eyecare Committee website.”

Whilst Ali might have felt domiciliary was the right path for her early on, Frank, who has worked both in domiciliary and on the High Street, had more reservations. “I was aware of the concept, having spoken to a domiciliary optometrist at one of the conferences I attended during university,” she said. “It wasn’t something I considered doing when first qualified, though, as I wanted to get more experience in a High Street practice first. I knew domiciliary may be more challenging and require more advanced clinical skills.”

She added: “I felt like it would be a rewarding but challenging job. I was uncertain as to what types of equipment would be available, and I had become quite reliant on the modern technology available in my High Street multiple, so I was apprehensive about this.”

Decide for yourself, and you’ll be amazed how far from the truth what you’ve heard about domiciliary is

Rishi Bhogaita, domiciliary optometrist with OutsideClinic

Likewise, OutsideClinic domiciliary optometrist Rishi Bhogaita had “very minimal awareness” when he qualified in 2019. “When we’re at university it's not spoken about much, and pre-reg is usually done in a High Street store, so my awareness wasn't high,” he said. “That's a big shame. In our company we see about 100,000 people a year. So, it's a very big market. It came as a shock to me that this isn't spoken about more.”

He believes that the level of learning needed during the pre-reg year – “contact lenses, visual fields, etc” – means that domiciliary is not a primary focus, but that this lack of attention means missing knowledge when it comes to the possibilities that are available.

“They want you to experience all aspects of optometry,” he said. “But branching out from there, there should be a lot more awareness of domiciliary. I think if people know about it, they’re educated about the sector, they realise there’s more they can do with their degree than work on the High Street. It gives people that information, where they can make their own decision about whether or not to try domiciliary.”

Motivation for choosing domiciliary

With a lack of awareness of domiciliary amongst those starting out, OT was interested in uncovering our panel’s motivations for taking the leap.

For Frank, the demographic of domiciliary patients and the knowledge that she could help them, once she felt she had a strong enough skillset from her work on the High Street, was key.

“I wanted a job that felt more rewarding, where I could offer help to patients who would not be able to receive it otherwise,” she said. “I felt like I had the necessary patience and compassion needed.”

Rishi Bhogaita
Rishi Bhogaita
She added: “I also liked the idea of working somewhere different every day to give more variety than being in the test room. Salary and Monday to Friday working hours were a big appeal too.”

The variety that a domiciliary role could offer, out on the road rather than in the test room, was important to Bhogaita too: “Once I was nearing the end of my pre-reg,” he said, “I’d started finding it very repetitive. I was in the same room, test after test. In the High Street, you see many people – in my case, up to 25 a day.”

He described feeling like he was on a ‘conveyor belt’ of patients, which he felt wasn’t good for his mental health.

“I think this is a big issue with many people, and it’s not spoken about much,” he said. “Seeing so many people in one day, in the same room, is not necessarily good for your mental state.”

In domiciliary, he saw a way to break away from this: “I realised that when you’re in domiciliary you’re out and about, in different people's homes, and you have more time testing,” he explained. “That’s what interested me. I did my pre-reg year, and one year afterwards on the High Street, and then I made the change to domiciliary. I couldn’t be happier.”

Tehreem Ali
As was the case with Frank, it was the chance to help vulnerable patients that sparked Ali’s interest in domiciliary. Her previous experiences had made her realise that caring for people in this way was something that she was passionate about.

“During university my summer job was with the National Citizen Service (NCS) as a practitioner, taking groups of 16-year-olds into care homes,” she explained, “helping them learn more about the residents and planning activities to help entertain them. This meant care homes were an environment I was already comfortable in.

“Later, during my pre-reg and my voluntary experience in hospital paediatric clinics, I just couldn’t see myself in a store test room in the long run. I really enjoyed my pre-reg, being in store and working within such a caring team, but I missed working with vulnerable people the way I used to with NCS and within the hospital clinics.

“When I realised that, I realised domiciliary was the best fit for me. I could use my new skills as an optometrist, as well as my previous experience.”

Myths vs reality

Misconceptions about domiciliary were a recurrent theme brought up by those OT spoke to. “There are a lot of misunderstandings about it,” Bhogaita said, including “that we don't deliver a good service, or that we might not have the top equipment.”

He wants to emphasise that: “These are all myths. We have portable cameras, portable slit lamps, I-care tonometers. I'm able to deliver a good service. I think it’s something that people should be aware of.”

Starting out in domiciliary, his biggest surprise was “that what people were saying was so far from the truth.”

“When I saw the technology the company had and how my test was exactly the same as High Street, it came as a surprise that I could provide exactly the same level of quality,” he said. “What people had told me was incorrect.”

He was also pleasantly surprised by the level of support for domiciliary optometrists employed by OutsideClinic, when the traditional impression might be that those performing home visits might be working entirely alone.

It’s a worry that he understands. “I work by myself and I can see why, when newly-qualified, the fear may be that you are on your own,” he said. “In your pre-reg you had your supervisor next door so you could knock for help. That might be something, as a newly-qualified optometrist, you might be a bit scared of – going off by yourself.

“But this is where we need to educate people, that you’re not by yourself. We've got an amazing professional service team, which is our senior optometrists, and we're here to help and support anyone at any time. You should never feel like you're alone.”

For Ali, the biggest surprise that domiciliary has afforded is the flexibility within her day. “It’s not your typical workday, as on different days you are in different areas,” she said. “Some days I’m close to home; some days I’m a bit further out.”

She added: “Typically, you start and end from your home, which I found quite nice. There is no real commute at the end of the day, and that’s a benefit I didn’t think I’d have as an optometrist.”

Most enjoyable aspects

With any previous misconceptions busted, what are the most enjoyable aspects of working in domiciliary as an early career optometrist?

Ali emphasised how “there are truly so many factors to enjoy” in her role with Specsavers Home Visits.

“Firstly,” she said, “helping to make one part of a vulnerable person’s daily life a bit easier. Sight is important to everyone, but it is especially important in helping maintain an individual’s independence if they are vulnerable or elderly.

“A lot of patients I meet start off anxious. They tell you they wouldn’t have been able to get into a store and are so grateful we can come to them, so that they can still 'take care of their eyes'. By the end of the exam, getting them reading what they wanted to, such as a medicines box, or just having a chat with them to alleviate concerns, really is what makes my day.”

She added: “There is also the satisfaction of refracting non-verbal and complex needs patients. When you put their prescription in, seeing their face light up or their family or carers noticing they are fixating better, or that the patient is looking around more and interacting more. How can you not enjoy sharing that experience?”

You meet people from all walks of life: not just the patients, but so many individuals involved in patient care. You learn a lot from these interactions. It never gets boring

Tehreem Ali, domiciliary optometrist with Specsavers Home Visits

Frank agrees, identifying “the feeling at the end of a sight test, when you feel like you can really make a difference to a patient’s quality of life with your findings” as the highlight of her time working in domiciliary.

Bhogaita noted the independence he is afforded.

“The company doesn’t micromanage,” he said. “They appreciate that you've got the degree; you know what you're doing. You’re your own boss, in that sense. You get given your patients and they trust you to do the job.

“I feel much more autonomous than I did on the High Street, where you’re in the same building as your managers and directors.”

Ali added: “I also really enjoy meeting a large variety of people. You meet people from all walks of life: not just the patients, but so many individuals involved in patient care. You learn a lot from these interactions. It never gets boring.”

Mental health benefits

Bhogaita was quick to highlight the quality of life that working as a domiciliary affords him, with OutsideClinic allowing for flexible working patterns.

“You could work three, four, five days – there’s great flexibility there,” he said, adding: “Something that may attract a lot of people is weekends off. In High Street stores, you’ll be working either a Saturday or Sunday. The flexibility, the work life balance available in domiciliary, is very good.”

Weekends off, he said, are “good for your balance, and your mental state. Especially when newly-qualified, you will have lots of friends who are not in optometry. They might be in office-based jobs, or other jobs where you do have weekends off. This role gives greater flexibility for life outside of work.”

He also emphasises how helpful OutsideClinic was in helping him overcome his shyness when he first joined.

“This might not be a challenge for others, but it was for me,” he said. “When you first start with a new company, you might be too shy to ask questions. But on reflection, I didn’t need to be. The company is so supportive; they were more than happy to help. It shouldn’t be a challenge for anyone else: if you need help, do not be afraid. The company will be more than happy to support you.”

Challenges overcome

An initial challenge for Bhogaita was shyness, but he admits that there are tests to overcome when starting any new job. Luckily though, he was able to work through these quite quickly.

“My first challenge was organisation,” he admitted. “When you’re in a High Street practice, you will do the eye test, and other aspects – the dispense, the admin – are done by other colleagues.

“In domiciliary, you need to be organised. You need to do your own paperwork for referrals, your topping up and ordering of drops and equipment, and the charging of your equipment. It becomes routine, once you start doing it. Initially this could be a challenge, but within a month or two you settle into it.”

He adds that OutsideClinic is very aware of this domiciliary-specific aspect of the role, and is keen to ensure its optometrists have enough time after appointments to complete administrative tasks.

Ali’s biggest challenge has been managing patients for referral who are non-verbal, she explained, as this means that ascertaining when symptoms started is often not straightforward. She has learnt to try and extract this information from family or carers, and has also adapted to find different ways to work without in-store test equipment such as optical coherence tomography or advanced visual field testing.

“Ophthalmology departments are usually very understanding, and you learn to adapt and explore alternative ways of assessment,” she said.

Frank also found that perfectionism was not always the best strategy during home visits, admitting that there was a challenge in “being able to accept that I couldn’t always do a ‘perfect’ eye test and get ‘perfect’ results for all patients and learning that as long as I was offering them the best care possible, that was all I could do.”

Referrals could prove difficult too: “Weighing up the risks versus benefits of referral to secondary care, knowing that it would be extremely difficult for some patients to attend a hospital, but also knowing that I couldn’t provide the necessary treatment, for example for a bedbound patient with wet age-related macular degeneration, at home.”

COVID-19 of course, has provided ongoing challenges for those working in domiciliary – something that Frank identified. “I started domiciliary work at the start of the pandemic,” she said, “and obviously this kind of work was significantly affected. The restrictions made the job even more difficult, as although the personal protective equipment was completely necessary, it was a big barrier to interaction with patients.”

Words of encouragement

The fact that domiciliary can be challenging is not in doubt, but Frank embraced this challenge and believes it helped build her skills. “I do think you need to have good clinical experience first and you need to be a caring, empathetic person with a thick skin,” she said. “Working in domiciliary helped me improve my retinoscopy skills and confidence in completing objective tests where a subjective response isn't possible.”

For those interested in the area, Ali recommends attending a shadow day and speaking to domiciliary optometrists, because “then you can say to yourself it is something you have explored properly. You have nothing to lose, but everything to gain.”

Meanwhile, Bhogaita is looking to the future: “We need to think long-term, in terms of our profession,” he said. “We’ve got an ageing population. Many more people want home visits; it's a growing sector. It's good to have that awareness, as an optometrist, of where the future is heading.”
Domiciliary, he believes, “Is on the exponential rise. This is a big area, and your degree offers the opportunity to be part of it.”

He added: “A lot of patients don’t feel comfortable going in a High Street store. In terms of the future, this area is definitely growing.”