Future gazing: what will optometry look like in five years’ time?

Where do you see optometry in five years’ time?

Prinal Patel (PP): Already, we’ve seen universities produce optometrists who are therapeutically endorsed. So, I think it will be a process of seeing how existing optometrists can upskill to that level.

In 2015, I did my Australian conversion. Over there, all optometrists coming out of university are therapeutically endorsed. I foresee a very similar pattern happening here.

However, the big question is whether there will be a separation between the refractive services that we offer, and, if deregulation does go ahead at any stage, whether we will start to see more of a European model. In places like France, you go to a shop to get your glasses, with the prescription checked, and to an ophthalmologist for your eye health check. Obviously, here optometrists would do that side of things.

Also, where hospital departments are starting to struggle, we are seeing a lot more ophthalmology on the High Street. In Tunbridge Wells, ophthalmology centres have been set up locally. They are all private currently, but are accessible for patients to see an ophthalmologist the same day.

I envisage a bit more of that happening, particularly as we look at our overall health system. I do see parts of it becoming more privatised. I see more patients saying they don’t mind paying, because they are fully aware of the pressures on the system.

Helen Tilley (HT): I’ve been in optics for over 30 years now. I’ve worked within Optometry Wales, our Regional Optical Committee, and the General Optical Council, to make sure the profession moves with the times.

We foresaw that, if the profession clinically skilled up, it would be much better prepared. In Wales, the Government understood this, and that’s why we have the new contract – because it believes glasses sales are not going to sustain businesses.

If we had carried on as we were, we probably wouldn’t have a profession. There is unlikely to be an absolute necessity for optometrists to test eyes. Certainly, booths are taking over the refraction side of things. Glasses can be made on 3D printers. The only way that the professional will survive, further down the line, is by upskilling clinically and taking work from the hospitals. The hope is that this will continue.

Andy Britton (AB): I want to be practising at the top of my optometry game. We should be aspiring, within the next couple of years, to more routinely be doing lacrimal lavage. More of us should be fixing punctal plugs. We should be looking at new technologies, including intense pulse light for meibomian gland dysfunction, and at whether the evidence base is growing so that we can offer red light therapy for myopia management.

We need democratisation of myopia management, because 50% of the world’s population is going to end up myopic – but the cost of providing it is beyond the will of governments, in the current economic climate. Unfortunately, it is also beyond the financial threshold for many families.

I wrote a paper on behalf of the Welsh Optometric Committee, which was then picked up by one of the clinical advisers to the Welsh Government and taken to Health Technology Wales. They established that myopia management is a valid and economical intervention for children with myopia, and that there should be a degree of funding on the NHS for orthokeratology and multifocal soft contact lenses. Myopia management is something that has to be mainstream within five years.

HT: In Wales, it will become evident over the next few months that we can operate at the top of our licence. We are already doing independent prescribing clinics. We are taking work away from the hospital. We have been doing a glaucoma clinic for years now. That will become more autonomous, because we have higher qualifications. We have a low vision clinic within practice. For about 15 years, the low vision clinic has not been in the hospital. We’re doing a lot more clinically. A decade down the line, the businesses who don’t evolve may struggle.

Myopia management is something that has to be mainstream within five years

 

What is the biggest change that optometry needs to see in the near future?

HT: It needs to accept that spectacles sales may no longer be viable to support business. Look at taking on more clinical work, and upskilling. For the past five years, my clinical fees from various sources have been higher than my spectacle sales. I know it’s more difficult in England, because there isn’t the funding there. But in Wales, optometrists need to really upskill.

PP: We are the key to making the profession valuable. A few weeks ago, I was in a nail bar at 10am on a Friday, and I still had to wait half an hour before I was seen, because of how full it was. Everybody there was spending £30, £40, £50. They all seemed like regulars, meaning they are paying that at least once every month. In that context how are we, as practitioners, struggling to get across the importance of eyes and vision that patients don’t want to pay for a private eye test, or the additional cost for optical coherence tomography (OCT)?

There is monetary value to it, but people will spend the money on their nails, or they will spend £5 a coffee. All we’re asking for is healthcare across two years – probably 50 pence per day, if that. Patient education is something the profession has to work on, and I think every optometrist and dispensing optician is key to that message getting across.

I would also say liaising more closely with ophthalmology and other services, to ensure optometry does have those connections within the community, and is referring to the local pharmacist, for example – building and growing those stronger roots with allied health professionals within the community, to allow for intra-community referrals. It’s something we have been working on for years. It works in some places; it doesn’t in others.

What are your thoughts on the future of auto-refraction, and the potential of artificial intelligence (AI) in practice?

PP: Optometrists will have a far more clinical role. I’ve been practising for nearly 14 years as a qualified optometrist, and I’m a big fan of being a community optometrist. I enjoy looking at a patient’s problem as an umbrella of issues, trying to connect everything, and giving them an overall wellbeing report on their eyes. I think it would be sad to see refraction services potentially deregulated in the future, because I think that plays a big part in a patient’s understanding of their eyes and their vision. There is a connection there.

I have seen a lot more technology in practices. From a dispensing perspective, Rodenstock instruments can pinpoint specific chromatic aberrations, so lenses can be made up specifically to a patient’s eyes.

From an optometrist perspective, very precise auto-refractors now exist, and we have access to OCT and Optomap. I wonder whether, in the future, consultations will involve someone collecting the data and sending the reports through to the optometrist, who will then spend 15 minutes with the patient, going through everything and confirming the action plan. I think it will be a smoother transition.

It would be sad to see refraction services potentially deregulated in the future, because I think that plays a big part in a patient’s understanding of their eyes and their vision

 
AB: With the role of AI, the biggest thing protecting our profession is legislation. There are already devices out there. In some states in the US, patients can undertake the refraction-based elements of an eye examination online. I think we’re going to see more providers attempting this service, and offering patients a prescription. How long before that prescription is uploaded, without any check on their eye health, and patients get their glasses online? Patients who want to avoid coming into a practice will find ways to circumvent it.

We can hope that we’re going to see legislation, and a sensible degree of prudence about the fact that we’re not just selling glasses, we’re about the whole eye health piece – which is what we’ve seen in Wales and Scotland. But we are dependent on legislation to maintain that.

I do think we’re going to see more automation of refraction. In England, if there isn’t a commensurate rise in the value of General Ophthalmic Services (GOS) sight tests, you will see a two-tier system. If you want an NHS sight test, you will do a self-directed refraction. There will always be a place for the high-end. If you’re occupying that perilous middle space, you’re potentially going to end up very threatened. That’s how I’ve justified my position on advanced eye care and enhanced clinical services.

There is going to be a big role for AI and interpretation. I think hospitals and the NHS will develop hubs that will become data capture centres, so patients can have their pressures monitored remotely via an app or go to a specific booth or clinic, and then AI will crunch it and flag the problems.

The beautiful thing for us as a profession is that eyes are complicated and slightly weird, and there are many nuances. So, I think there is going to be a role for the more advanced practitioners for the foreseeable future. If you don’t have these advanced skills, particularly with the education review and students graduating with at least the theory of independent prescribing, you’re going to be left behind as a generation of optometrists.

HT: In our practice, we have visual fields machines, OCT, and slit lamp cameras, all connected through to the electronic record, which is all readable anywhere within the practice. We already are connected electronically.

The next step is connecting using AI. In the future, AI could be used to help practitioners gain knowledge of risk levels and of what they’re seeing.

PP: Optomap and OCT have improved our relationships with ophthalmologists, and have also made our clinical awareness better and our referral processes easier. Before, we might have said, ‘I think there might be macular oedema.’ Now we can say, ‘yes, there is X amount of macular oedema; the vision has dropped by X,’ and we’ve got proof via OCT. There is value in that.

The beautiful thing for us as a profession is that eyes are complicated and slightly weird, and there are many nuances

 

Do you have any plans for your own career development?

AB: [Because I have] glaucoma and independent prescribing qualifications, I can supervise the placements required for these qualifications. This co-management with the hospital means that in my practice, I’m investing in space that allows me to invite other optometrists to gain their higher qualifications under my supervision.

It’s trying to remove some of the bottlenecks that hospitals have in place, which has stifled the ability for optometrists to get higher qualifications. I’m keen to avoid a situation where optometry devolves into two separate streams, with hospital optometrists and primary care optometrists. We need to have a profession that is able to go between the two spheres.

We have to aspire to be indispensable to the NHS. My big mission in five years is to come up with a pathway where we can safely deliver laser treatments in a primary care setting. Access to an argon laser might not be in your direct practice; it might be in a shared clinical hub for the local NHS. There are some difficulties, but I don’t believe they are insurmountable. If you live in a remote rural location, what could be better for the patient?

There may also be advances in glaucoma management, with self-monitoring, contact lenses, and home OCT. It’s going to be whether we can get our foot in the door with that sphere of technology.

PP: Multidisciplinary centres, with ophthalmology and cataract services, are popping up everywhere. There is room for optometry to develop within them. If I had a big enough house, I’d probably have an outbuilding, where I could set up my own clinic. I think there’s a lot of scope for optometry to provide those independent, individual services. There are some great optometrists out there, who have done a very similar thing. I think there is room for that.

The new education and training requirements, set by the GOC, will mean optometry students graduate with a higher level qualification than they have in most cases historically. What do you think the benefits of that will be?

AB: I’m visualising my practice operating almost like an eye department, with everyone practising at the top of their licence. I would like to have optical assistants able to check vision accurately, getting patients to the point of having drops in their eyes and doing all the diagnostic tests, so that when I see them as a glaucoma specialist, I don’t need to do anything else. Patients will move within the pathway based on what they need to engage with.

To me, that’s how we need to evolve as a profession. The technology is helping in some respects, but with the vagaries of patients you’re always going to need that human touch, and there are always going to be patients who want that; who aren’t going to want to sit in a booth and press the buttons themselves. They want to talk about it; they want to have that relationship. It’s going to be an interesting model with funding, because the cost of doing business is going up: minimum wage, living wage, equipment, rent.

HT: I’m passionately behind it. If we don’t start producing professional optometrists who are able to take on the work that is out there straightaway, we will get left behind.

I took the decision in 2017, when I was 50, to do IP. It was a big ask, because I hadn’t done any studying since I was 21. After doing IP, which was the hardest thing I’d done in a long time, I was persuaded to do higher certificate glaucoma, which was equally as hard. It’s difficult going back to studying later in life. If you have the skills earlier on in your career, that’s great. The Welsh contract is utilising all those higher skills – we’re not just getting them for the sake of getting them.

Through COVID-19 I was running an eye casualty clinic, almost, in my practice. We are now looking towards autonomously triaging glaucoma referral, so patients don’t need to be seen by the hospital consultants.

We already have a link to the Royal Gwent Hospital. We can see everybody's clinical records. For our glaucoma clinic, we have a direct link to the NHS network – a separate phone line that was put in by the NHS. They see it as a benefit, so we should too. We’ve also got Open Eyes installed in the practice, so we will be able to directly refer to consultants and they’ll be able to come back to us directly.

They see that we are an untapped resource, but we will have to step up and make decisions rather than going through our routines. To make those clinical decisions, you need the knowledge to back you up. I don’t think we can do things by a tick box approach anymore. We need to take responsibility and make the decisions ourselves. If we sit still and say we don’t want to, I’m afraid there won't be a profession for those sorts of people in the future.

PP: I think there’s a lot to be done in the community in terms of education and monitoring. In the long-term, if you can save sight, it’s going to have a positive impact on the economy. You will also introduce independence to patients. From a holistic perspective, that’s good for the soul.

It’s difficult going back to studying later in life. If you have the skills earlier on in your career, that’s great

What do you think is the most important skill for optometrists of the future to develop?

AB: Communication. Too many medical professionals might have been the smartest cookies at school, but we need to see an improvement in ability to communicate with people. If you communicate well, you get much more out of your patients.

On a purely practical note, I think we’re going to see an explosion in independent prescribing. I think we can almost take that for granted.

I’ve been qualified 27 years. We all go in wanting to be clinicians, not wanting to do the commercial side, but there has to be a healthy balance. You don’t meet GPs who can’t run a business. An ability to understand business is going to be important, along with more of an understanding that you can’t be just clinical or commercial. You’ve got to get that balance right.

In England, it’s unfortunate that eye care is still heavily funded through selling glasses, and that is going to skew the relationship. If we can move more towards a clinical picture, we’re going to see more optometrists wanting to work in Wales, because the clinical opportunities are going to be amazing.

HT: Taking responsibility, making decisions on clinical events that come through their practice, and having the knowledge to back them up. It’s a skill I am passionate about. If somebody refers something because they don’t know what to do with it, I don’t think that's going to be acceptable anymore. Taking responsibility is a big sea change that needs to happen within the profession.

What is your last word on where optometry should go next?

AB: Ophthalmology is understaffed, and in some areas virtually broken in terms of its ability to deliver the care that is needed of the population. We need our professional bodies and leaders to be pushing our boundaries. It should be a pathway of care, and you manage that pathway of care up to the level that you’re competent and confident with. You should be able to practise at the top of your competence, and we should be challenging any impediments to improving care. If it is being safely delivered in a hospital, it can be safely delivered in primary care with the appropriate safeguards.

I am quite old now, in optometry terms, but I still feel I’m practising at the top of my licence. I’m not trying to see as many patients as I can to get a conversion rate. I’m trying to do the best by every patient I see and trying to use my skills, and that has enabled me to have a job I still love after 27 years. I'm proud to call myself an optometrist. Specsavers has enabled me to develop my skills, see the patients that I want to see, and to formulate a model of eye care that’s going to deliver enough capacity to make a real difference to secondary care. That’s key.

HT: We believe in looking after patients, and the best thing for patients is having care near to home, on time. That is what I’ve always believed in, in the 16 years of this practice: put patients first, look after them, and try and provide care close to home, within a reasonable timeframe. We do anything we can to help.