Supporting IP in optometry

Each change brings a new dimension to the IP discussion and for this final instalment in the series, OT heard insight from representatives in England, Wales and Scotland on what these changes might bring for those either working towards, or who currently hold, the qualification.

Referral pathways into IP

Enacted on 20 October 2023, the Optometry Contract Reform in Wales saw the formation of five levels of Welsh General Ophthalmic Services (WGOS) relating to core services for optometry practices and opt-in services that require the completion of additional clinical qualifications.

Sharon Beatty, optometrist and clinical adviser for Optometry Wales, told OT that the organisation negotiated for an Independent Prescribing Optometry Service (IPOS) as part of the national reform.

IPOS was originally established in three health boards in 2020.

“I was fortunate to be involved with establishing the service with four wonderful IP optometrists in Cardiff and Vale University Health Board,” Beatty explained. Research demonstrated that 92% of patients attending the service did not require onward referral to the hospital eye service.

“The service brought immediate benefits to patients, optometry, and GP practices, and the hospital eye service,” she added.

As of mid-March 2024, WGOS level 5 IPOS Urgent became operational in all seven health boards in Wales.

This service enables non-IP practitioners to refer, following a WGOS 2 (urgent eye examination), to an IP practitioner where this is appropriate. Both intra-practice and inter-practice referrals are supported under the service.

In a webinar introduction to WGOS 5 IPOS Urgent by the NHS Wales Shared Services Partnership, the service was described as a “precious limited resource” requiring triage at WGOS 2 level (previously Eye Health Examination Wales).

Patients are directed to attend their own optometry practice for urgent eye problems under the WGOS 2 urgent eye care appointment. At this stage, if a non-IP optometrist determines that an IP assessment is required, a referral is made.

The pathway aims to reduce demand on secondary care by filtering out those patients who can be managed by IP optometrists.

Beatty added: “There will be a formal addition shortly to the WGOS 5 clinical manual to specify the IPOS Discharge service, which means that the patients who do actually require hospital treatment can be discharged from hospital eye service sooner to an IP optometrist as part of WGOS 5.”

Describing the “steady” introduction of this pathway across Wales, she explained: “Optometry Wales has been delighted with the engagement between practices, health boards, regional optical committees and the Welsh Government to ensure that this change has been manageable for practices, hospitals and patients.”

“All stakeholders have agreed a national approach to the service specifications to ensure consistency for practices and patients,” Beatty added.

The Wales General Ophthalmic Services national clinical leads oversee the implementation programme, she added, sharing that optometrist Mike George, one of the national clinical leads, described the pathway as “the culmination of years of collaborative working between stakeholders.”

Practices engaged in the pathway are able to manage their diaries in a way that best suits their business, informing the health board of the day or days they are available to receive referrals from other practices. Through the pathway, the IP examination is supported by a fee for the initial assessment and any follow-up assessments required.

Beatty explained that, as part of the Optometry Contract Reform, there is an agreement for an ongoing future quarterly payment to all practices as part of quality assurance.

“Optometry Wales is liaising with stakeholders to ensure that future quality assurance mechanisms are workable for busy practices,” she said. “Health Education and Improvement Wales is overseeing the optional offer of funded Silver Quality Improvement training for practices, which includes completion of quality improvement projects.”

Reflecting on what is ahead for IP, Beatty commented: “We are really excited about the future of IP in optometry in Wales. The support from the profession has been outstanding. All IP optometrists can now fully utilise their advanced skills to work at the top of their clinical licence so that patients can access this service across Wales.”

“The support from ophthalmology colleagues and the Welsh Government has also been instrumental in services evolving for the benefit of the citizens in Wales,” she added.

Supporting training with simulation

Accessing clinical placements to complete the requirements needed to gain the IP qualification has proven to be a hurdle for many.

NHS Education for Scotland (NES) has been exploring the applications of simulation technology in healthcare training, and identified postgraduate independent prescribing as an area of optometry that could stand to benefit from the approach. Senior specialist lead, Erica Campbell-Walker, leads the workstream. “Optometrists were wanting to upskill during COVID-19, so a lot of them had been completing the IP training and there was a backlog in accessing clinical placements,” she explained.

NES already facilitates Teach and Treat clinics that support IP placements, and simulation offers an additional avenue for training opportunities.

Dr Lesley Rousselet, associate director optometry for NES, identified that with growing challenges in hospital eye departments securing placements had become “harder than ever.”

Simulation offers a high quality IP training experience, the team shared. A Haag-Streit UK EyeSi Slit Lamp Simulator, with a range of pre-programmed clinical conditions, along with a professional actor to support scenario building, enables IP trainees to examine and manage specific eye conditions in a safe, quality assured environment, with no burden on ophthalmology clinics.

Campbell-Walker pointed out: “If you have an ocular emergency coming in, the practitioner can’t necessarily take the time to talk trainees through everything. This is a safe environment for learning.”

The benefit of simulation is that the complexity of the case can be adjusted, whereas, in a Teach and Treat clinic, the conditions that an IP trainee is exposed to will depend on the appointments that are booked in.

“This supports learning, providing a safe place to practise new skills, have discussions, and try new communication styles,” Campbell-Walker said.

During the simulation experience, a group of three trainee IP optometrists enter a case history conversation with a professional actor playing the role of a “patient.” The actor is briefed on the information they will share, what details to hold back, and the emotions to portray.

The group then spend time with an IP optometrist facilitator, examining the eye condition presented through the EyeSi Slit Lamp Simulator, deciding on a differential diagnosis and developing a management plan to deliver to the patient.

“We have some scenarios that are quite straightforward so that we can help optometrists get used to this new way of learning,” Campbell-Walker said.

Other scenarios are designed to present a higher degree of challenge. Campbell-Walker explained: “Some of the “patients” will not agree with the management plans, so the optometrist gains experience of considering how to work with the patient to find something that will suit their needs in order to achieve buy-in.”

The training is followed by a debrief incorporating feedback from the actor on communication, rapport, and any history details missed, as well as guidance from the IP facilitator on clinical skills and the management plan.

Peers are also encouraged to provide feedback to each other and reflect on their experience.

Currently, the simulation training is delivered as six day-long sessions, equalling 12 of the clinical placements required for the College of Optometrists’ logbook.

Campbell-Walker explained that the next stage of the project is to explore how simulation technology can be expanded to remote and rural areas of Scotland. In the meantime, NES is also establishing a faculty of accredited educators to facilitate these training sessions.

Dr Kathy Morrison, associate director optometry, NES, explained that in looking across the NES Clinical Skills Managed Education Network: “We’ve known for some time that simulation was being widely used in other healthcare professions – and used really well – as a safe, educational tool that is evidence-based, and that we, as a profession, seemed to be playing catch-up on.”

Introducing simulation into IP and NES Glaucoma Award Training, is just the start of the huge potential for eye care.

“Simulation allows us to develop the profession in a very safe and quality-assured way,” Morrison continued, adding that it allows for consistency and evaluation.

Rousselet added: “We are excitedly looking forward, both expanding what we are doing specifically in optometry, but also looking for opportunities to diversify our training. In Scotland, we’ve been working at increasing the amount of training that we have together with other professional groups. There are good examples of where that is starting to happen through simulation, and it is something we will be looking to do more of.”

Reflecting on the potential for the technology, Campbell-Walker added: “There is not really a limit of what we can cover. We are only at the very, very start because the scope is so huge. We are dipping our toes in.”

Expectations for FP10 access

In the latter months of 2023, the Local Optical Committee Support Unit (LOCSU) and the Clinical Council for Eye Health Commissioning (CCEHC) were tasked with developing a national standard specification for minor and urgent eye care.

The creation of this specification for Integrated Care Boards aims to improve consistency and reduce unwarranted variation in services across the country.

As part of the development process, the working group engaged stakeholders including Local Optical Committees (LOCs) in consultations on desired improvements.

Zoe Richmond, clinical director of LOCSU, explained that the topic of access to FP10 prescription pads for optometrists with IP qualifications was a common theme raised in the feedback.

“Access to prescription pads for optometrists with IP qualifications is a known issue, so it was no surprise to us that this was one of the things brought up,” she said.

This feedback was one of a number of improvements incorporated into the specification.

“Within the new standard specification, we have written that there is an expectation for optometrists working within a commissioned service who hold IP qualifications to get access to FP10 pads,” Richmond explained.

“We think there will be wide benefits in making this available: benefits for the patient, the practitioner, and the system,” she added.

The expectation that IP optometrists have access to FP10 pads could improve access to treatments for patients.

Richmond shared: “Through independent prescribing qualification and increased clinical exposure, we can enhance clinical decision-making regarding patient management on the High Street. We can improve access to treatment but should remember that it’s sometimes as much about knowing when not to treat as it is being given the authority to treat.”

This inclusion was important in recognising the role of optometrists with additional qualifications within local provision.

“The involvement of optometrists with higher qualifications and experience, such as independent prescribing, should help to broaden the range of conditions that we can treat through to resolution within primary care,” Richmond said.

Setting this expectation goes beyond the provision of prescribing resources, however – Richmond emphasised the need to make better use of the optometry workforce.

“Recognising IP within the standard specification provides better recognition of their qualification and experience and, through that, their ability to offer peer support, advice, and guidance to clinical colleagues delivering within the local service,” she shared.

Through the national standard specification, it is hoped that commissioners considering services for minor and urgent eye care in the community would recognise the “whole of the workforce in primary care, including those optometrists with higher qualifications such as IP and, in fully recognising those individuals, allow them to work at the top of their licence,” she added.

The provision of the minor and urgent eye care services remains within local commissioning decisions.

“For all that we are clearer on what the process for accessing FP10s for IP optometrists looks like, there is still work to be done on the ground. By setting out the expectation in the standard specification, we have by no means brought the entire solution, but it is good to have the expectations set out very clearly,” Richmond said.

The developers also recognise that local systems bring innovation, and this is something that they hope to encourage.

“We want local stakeholders to own this, continue to innovate and develop those areas of excellence. In areas with commissioned services, we’re inviting people to review the national standard service specification and look for areas of opportunity and improvement within their local service,” Richmond explained.

In those areas without existing services, it is hoped the specification will support local leaders to engage commissioners.

Richmond said: “With the new specification, LOCs and local commissioners have a framework that has been co-produced by the eye care sector and clinically endorsed by the Clinical Council and Colleges, that they can have confidence in.”

Recognising that reducing variation in provision across England will take time, Richmond shared: “I hope that this is not only about reducing unwarranted variation across the existing services but reducing unwarranted variation in access. I would like to see more of the population of England have access to minor and urgent eye care on the High Street as we move forward.”

As the profession works towards this goal, Richmond highlighted a need to gather evidence demonstrating the effectiveness of commissioned services: “To show that delivering more care in optometric practice, optimising that first contact care, not only has a benefit to the patient but to the wider system – in the service of minor and urgent eye care – alleviating some of the capacity pressure across hospital emergency departments and general practice.”

“We need to continue doing what we’re already doing really well, and collate the evidence base to strengthen our case, share best practice and keep on improving outcomes for patients,” Richmond said.