All change ahead

Optometrists on the High Street might, for the moment, be only vaguely aware of these changes. But inside university optometry schools, the General Optical Council’s (GOC) revised education and training requirements (ETR) have been part of a complex, ongoing conversation for the past two years.

A far-reaching plan

So, how and why have these changes come about – and how are universities planning to respond?
In 2020, in order to build on work begun in its Education Strategic Review (ESR), the GOC committed to ensuring “that the qualifications we approve are fit for purpose, meet patient and service-user needs and ensure optical professionals have the expected level of knowledge, skills and behaviours and the confidence and capability to keep pace with changes to future roles, scopes of practice and service redesign across all four nations of the UK.” 

Updated requirements were confirmed internally, and then communicated to optometry schools in early 2021.

After years of planning, in December 2022 and January 2023 respectively Ulster and Cardiff universities became the first to receive confirmation that their plans had been approved and that they would be able to start offering their new courses from September 2023. 

As the two universities prepare to welcome students to their refreshed optometry programmes, and others continue negotiations or wait eagerly for GOC approval, OT spoke to three academics about the planning process, the challenges faced, and the long-term opportunities that refreshed optometry education might bring about.

Major changes anticipated

As one of the first to have their courses approved, Ulster University is “in good shape” for its September 2023 intake, according to Professor Kathryn Saunders.

Already having an integrated Master’s helped in the planning process, she explained, as the new course is a modification of that which already existed – with the key difference being that from 2023 all optometry students, rather than only some, will be enrolled.

“We have run, since 2016, an integrated Master’s in optometry, which is essentially what the GOC has asked us to deliver. Students had to apply to do the integrated Master’s, whereas now all students will be on the integrated Master’s,” Saunders said.

She believes that the major change will be the way training is evidenced, and the documented learning outcomes that will be required. There are also increased opportunities for trainees to experience clinical practice and a stronger focus on clinical decision-making.

“Rather than a list of tick-box competencies, the GOC now requires evidence of students’ ability to enact professional behaviours,” she explained.

“The GOC’s ESR and ETR offered a chance to review and enhance the curriculum and the learning experience for trainees.

“Nonetheless, we still need to teach students the clinical skills required to be an optometrist and evidence their competency in these skills, so there are elements of the curriculum and assessment framework which will remain, because optometrists still need to do what optometrists need to do.”

The GOC’s ESR and ETR offered a chance to review and enhance the curriculum and the learning experience for trainees

Saunders added that integrating 48 weeks of professional placement into the course, which is a key GOC requirement, does not require a large shift in mindset from the current pre-registration year: for Ulster students at least, a long placement towards the end of the programme will remain, albeit not one that will be part of the Scheme for Registration going forward.

Students will also experience additional in-practice placements in community and hospital practice during the first three years of the programme, as well as providing eye care in the public and hospital outreach clinics in the on-campus eye clinic.

Likewise, at Glasgow Caledonian University (GCU), Dr Graeme Kennedy explained: “We are keen to take this opportunity to revamp our programme from the ground-up, increasing practical clinical exposure, both within our in-house eye clinic as well as in the community, to provide a tightly interwoven student experience, spiralling around theoretical, clinical and professional aspects.”

Being out in the community as a student is markedly different from the way optometry training works currently. So, what other changes does GCU have planned?

Kennedy explained that, aligning with a push for more cases to be seen by community optometry in Scotland, “we are hoping to integrate qualification as an independent prescriber (IP) within a new offering.”

This is an ambition of the Scottish Government, he believes: a letter sent out to the Scottish optometry profession in February 2022 outlined certain goals, including integration of the IP qualification into newly designed courses.

“Integrating IP and producing graduates who can meet the increasing demand to manage eye disease in the community has been an ambition of ours for a number of years,” Kennedy said. “The ETR provides an opportunity to drive this ambition forward.”

He added that, with ophthalmology departments struggling with staffing issues and a long backlog of patients, paired with a desire to have more cases dealt with by community optometry, ensuring that all optometry graduates in Scotland have an IP qualification is “probably the aspect of the changes that will make the biggest impact.”

“The idea is to roll that out to anyone who is qualifying, so that in the future graduates would have that qualification already and have the potential to manage a much wider range of conditions that present in the community,” he said, adding that the university has been liaising with NHS Education for Scotland, optometry employers and other stakeholder to get their views on potential challenges that might arise.

“We are fortunate to have been working with NES on gathering views from across the profession and utilising those to develop plans for a clinical placement model that would integrate elements of advance practice and be unique to Scotland,” he added.

In terms of teaching, “we’re also looking to introduce teaching that will help to tie together the content of other modules students take in each year,” Kennedy said. “So, we would envisage each year having a module that focuses on aspects of working as an optometrist: the professional obligations and how the material from the other modules fits together.”

Building on knowledge around subjects year-on-year, rather than covering one subject and then moving on from it, appears to be a popular strategy. At Cardiff University, optometry clinic director, Tristan Jones, explained that a ‘spiral curriculum’ will be introduced, “which will reallocate where the modules are in the course.”

“We will be starting with very basic clinical things, and then adding to that as the years go on,” he said. “You begin with teaching, for example, how to measure vision. The students become familiar with that concept, and then on top of that, you say, ‘Okay, this is how you measure vision in a child.’ And then you say, ‘This is how you measure vision for somebody who doesn’t speak English.’ You make it more complicated each time you revisit the topic, and it builds on top of what they’ve learned before.

“Another example might be, ‘this is how a contact lens works.’ Then they learn how a toric contact lens will work, and then how a more complicated lens like a multifocal lens will work, and then to make it more difficult they learn how to fit a contact lens over damaged or fragile corneas, or keratoconic contact lenses. It will become more and more complicated as they go on.”

He added: “The basic science and the research elements, I think, will be woven into the clinical teaching, giving our students an appreciation of the application of scientific methods in practice. The emphasis will be changing to being much more practical, and less didactic.”

Overcoming challenges

While the outlook from universities is positive, OT is interested in knowing whether there have been any significant challenges involved in restructuring their optometry degrees.

At Cardiff, Jones thinks the biggest challenge is likely to come from teaching the remaining years of the old degree scheme at the same time as the new one.

“We’re likely to find ourselves in a situation where we will have a third year doing the BSc programme, and the second years on the MSc programme coming in and doing a similar kind of thing, but against a very different curriculum,” he said. “The short-term challenge is going to be scheduling two different degree schemes within the same clinical resource, until we’ve taught out the old scheme.”

Saunders explained that the speed at which decisions have needed to be made, especially in an environment when staff still had a level of pandemic-induced fatigue, was a challenge during the planning stages.

“Change is always a challenge, and it was a very quick change,” she said, noting that to a certain extent universities are competing against each other to have their plans confirmed early so that they can attract students.

“We have a very collegiate attitude in lots of ways, but there’s a certain amount of competition as well,” she said. “You get these published requirements in February 2021, and then all of a sudden, you’re trying to hit the start date of September 2023 so you’re not the last people to adopt the new programme.

“That is a challenge, in terms of the university timescales for validating courses, changing programmes, and appointing new staff. Coming on the back of COVID-19, a lot of staff were exhausted and felt like, ‘Oh, my goodness, this is yet another thing that we’re having to deal with.’ Having said that, I think we’re all clever people, we all love the profession, we all love what we do, and we want it to be the best it can be. At Ulster, I’m proud of the way the staff have really risen to the challenge.”

We all love the profession, we all love what we do, and we want it to be the best it can be. At Ulster, I’m really proud of the way the staff have really risen to the challenge

Returning to the subject of practice experience, Saunders emphasised that to achieve the new requirement of 48 weeks in practice, in addition to short placements and on-campus eye clinic experience during the earlier years of the course, trainees will experience extended in-practice placements.

“The ‘shape’ of these extended placements may not be significantly different to the current pre-registration year, but the students will be more connected to and supported by the universities during that learning in practice,” Saunders said.

The key challenge is not for students, she said, because “students don’t go through programmes twice, they go through them once. So, what is happening to them is just what is normal.”

The challenge is potentially greater for employers, and to this end optometry universities have invested significant time in talking to them about the changes that will come.

Saunders added: “Trainees in extended placements will also be engaging in university work and therefore will need to have protected time to study during this period. Closer relationships between employers and universities will be beneficial to make sure students get the best experiences and employers get the workforce they need.”

For students, Jones does not foresee changes to practical placements having a significant impact. Cardiff students will undertake their 48-week placement between their third and fourth year, he said, allowing them to return to university and complete further study that is still required before qualification.

“Although it is going to be shorter than a pre-reg year, provided that a breadth of experience is there and the assessment criteria are proportionate to the placement, I don’t think there is going to be a major issue with it at all,” he said.

At GCU, Kennedy believes the main difficulty is likely to come from registrants reaching qualification via different routes.

“I think that there is some reassurance in having a nationwide final qualifying process, and I think the potential for that to be removed will make things potentially difficult for employers to think about their new registrants, who have come from different institutions, have potentially reached that stage by quite different routes, and had quite different experiences in the latter stages of the training,” he said.

Employers are largely happy with the current system, Kennedy explained, but see potential logistical challenges with universities having integrated pre-reg style placements starting and finishing at different times, assessing students in different ways, and having them qualify at varying times.

Saunders agrees. “One of my concerns is that there will be a lot of variety across the UK and that might restrict movement of qualified registrants from, say, Wales into England or from England into Northern Ireland, or vice versa,” she said. “We don’t want to educate just Northern Irish optometrists. We want to educate optometrists, and be part of a UK and potentially even wider network of qualified professionals who can support and learn from each other.”

Long-term opportunities

Jones agreed that the long-term impact of changing optometry education will depend on how well employers adapt to it.

He cautioned against employers viewing optometry students on placements as free or cheap labour, and emphasised that students are expecting to be paid whilst working, as pre-regs currently are.

“The expectation is that the students on placements will have a good variety of experience as they will be assessed for competencies, just as pre-reg optoms are now. But it would very easy, I think, for some employers to see it as short-term labour and just have the students selling glasses. There is potential risk and challenge associated with ensuring that the placements that the students have are of equal quality,” he said.
He also hopes that employers will not value those who have graduated under the new scheme over those with the old qualification.

“That would be unfounded,” he said, “because the quality of education will be very similar, and those students who have done the older course will always have the opportunity to upskill. But I think that there may end up being a perception that there is a difference between the two, even though that perception is pretty trivial in reality.”

Saunders believes that the agreed upon changes are just the start, and that “most education processes are a little bit iterative: you do one thing, and then you have to tweak things or change things.”

“There will be unexpected surprises, both positive and negative, in what everybody is planning,” she believes. “But I think as a profession, optometrists and optometry educators are pretty good at reflecting on what is working and what is not working.

We’re all part of established institutions who monitor progression and performance very closely. We’ll be given plenty of opportunity to make changes accordingly. We’re good at looking at evidence. We’re good at looking at data and determining how to do things better, if needed, or how to promote the things that worked well.”

She added: “I think there are lots of things to be positive about. We’re a trusted group of academics. We'll do a good job of it.”

It will bring us closer to a training model that closer matches that of medicine and pharmacy. It is bringing the healthcare element more strongly into optometry

Despite cautions, Jones is also positive about what is to come. “Overall, I think it is an exciting change,” he said. “It includes changes that I feel are long overdue in the industry. My perception is that it will bring us closer to a training model that closer matches that of medicine and pharmacy. It is bringing the healthcare element more strongly into how we teach optometry, and aligns the academic side of it with the clinical side very well.”

“I think we have to be positive, because we have to do this,” Saunders added. “We have a great job; we have a great profession. We have really good institutions and colleagues working in all these different institutions. We’ve got lovely patients, and we’ve got a point to what we do. It’s an important job. We should be able to make this work.”