27 October 2022
The reforms, which include increased fees for sight tests and additional services, were confirmed by Optometry Wales on 26 September.
Optometrists have welcomed the increased fees that will be rolled out in the coming months, as well as highlighting concerns around a reduction in voucher values, and the spread of the workforce across large rural areas.
Speaking to OT after the details were published, Evans, director of Gwynn’s Opticians, said: “Being rewarded for the clinical work that we do and the clinical skills that we’ve got is something that has been discussed for the 20 years I’ve been practising. So overall, I think it looks really positive and exciting.”
He added: “There’s a lot that’s going to benefit patients, to enable them to get care closer to home, within a more appropriate timescale than is possible at the moment.”
Tilley, who until recently was a senior council member at the General Optical Council as well as previously chairing Optometry Wales, believes that the reforms are the first step in the profession’s ambition to “try and get people to be more highly qualified, more professional, [and to] take more responsibility.”
She added: “This contract is doing exactly that, so people can practise at the top of their game and provide the services, which I’ve been saying for 25 years of working on the political side of optometry, that we can do. I’m delighted.”
It’s really crystallised the requirements that a few of us have been saying for many years: that we need to be upskilling
Andy Britton, director of Specsavers in Haverfordwest, was also positive about the changes.
“It’s really crystallised the requirements that a few of us have been saying for many years: that we need to be upskilling; we need to be doing the clinical aspects well with the right training and accreditation in place,” he said. “For that we’re going to be fairly remunerated, which is good.”
Britton added: “Obviously, it’s going to change people’s business models and what they’re able to offer, and I think that’s going to be the big picture over the next couple of years, as we prepare for the new whilst running the old systems. The two are very different.”
A changed way of working
The optometrists that OT spoke to have already upskilled or are in the process of doing so, meaning they are in many ways prepared for the changes that are about to come into place. As Andy Britton, who started upskilling six years ago, said: “It feels like it’s rewarding my style of practice.”
In Monmouthshire, Tilley undertook her independent prescriber (IP) qualification five years ago, and has since also completed her higher certificate in glaucoma.
She said: “It’s the way to go. I’ve armed my practice with people with medical retina, glaucoma, and low vision qualifications. We will enable ourselves to be prepared when the new contract arrives.”
Tilley’s practice has run the Monmouthshire area virtual glaucoma clinic for six years, due to a lack of capacity in the hospital. In Gwent, she believes that “2000-3000 patients a month are seen in the community for glaucoma. So, it already happens. It will just be more of those services rolling out. We’re ready.”
I’ve armed my practice with people with medical retina, glaucoma, and low vision. We will enable ourselves to be prepared when the new contract arrives
Evans has also “gone a fair way” on his higher qualification journey, adding that “We’ve got lots of optometrists who are at different stages, so we are hopefully going to be in a good position to be able to start offering services as the details become available, to enable our patients to have a really good level of care.”
“Other than that, it’s looking at where and when things are going to come in, and trying to put ourselves in the best position to look after our patients and use the skills that we've got.”
Andy Britton acknowledged, though, that the change is unlikely to be plain sailing for everyone.
“The biggest challenges are going to come for businesses that haven’t got people with the higher qualifications,” he said, “because it’s going to take a mindset of inter-professional working. We're not used to sending people to other practices for management.”
He added: “I put myself on the journey with higher qualifications six years ago, and I encourage my team, so I’m on the front foot when it comes to things like this. There will obviously be people who will be a lot more nervous about it, maybe those at the end of their careers, who haven’t felt the need to upskill.”
Britton offered a warning to practices that potentially haven’t made use of the region’s extended service provision: “At the moment some practices have chosen not to engage with the Eye Health Examination Wales (EHEW) schemes. But if you want to deliver NHS services in Wales, you will have to deliver the EHEW levels of service. That’s non-negotiable now. So again, there will be some businesses that have to make fundamental changes.”
Challenges and opportunities
AOP councillor for Wales, James Brawn, is optimistic, but highlighted that ophthalmologists will need to be on board with the increased services that optometrists will be providing in order to make the new system successful – especially as part of that success is likely to be measured in the new contract’s ability to remove the need for some patients to attend hospital.
“In the past decade or so, there has been a push to bring more services into the community and to lighten the workload of secondary care,” Brawn said. “We want to have these patients. Wales is a predominantly rural country. I used to work in west Wales and the closest ophthalmology unit was an hour and a half drive away. On a Saturday, I’d be referring people to Aberystwyth, which was two and a half hours.”
Brawn believes that “Glaucoma is a big one, because if you have an IP optometrist with a diploma in glaucoma, they can pretty much manage patients independently of the hospital. Pulling those patients out of the hospital, into primary care and seeing them locally, would cut down on lists and be better for them, especially if they can go to their local practice five minutes up the road as opposed to travelling for an hour and a half.”
I can see some of the practices I’ve worked in closing, unless we manage to upskill our optometrists to a higher clinical skill so they can compensate, and unless we can do that quite quickly
Brawn also has concerns about the reduction in voucher values that will come as part of the new contract, and what that will mean for the practices that rely on them.
“My concern, having worked in some practices in very deprived areas, is that they were kept viable by the voucher values for lower value sales, in areas where there’s a high level unemployment,” he said. “Having the lower voucher values drop by a significant amount makes me concerned about the viability of some smaller practices, because it will be such a massive change in their business model. I can see some of the practices I’ve worked in closing, unless we manage to upskill our optometrists to a higher clinical skill so they can compensate, and unless we can do that quite quickly.”
Another point Brawn raises is over the spread of a highly qualified workforce across Wales, and how this will be organised.
“I’m wondering how we will match optometrists who have the skills with the workloads or waiting lists,” he said. “It would be wonderful to have lots of very highly qualified and trained optometrists, but if there’s not enough work to go around, I’d be worried about people keeping up their skills. If you are highly qualified, you need to see complex cases regularly to maintain competence.”
At the same time, Brawn emphasised, “We can’t expect everyone to be at the highest standard. So, I’m wondering how they’ll match people with clinics and workloads, which will be very different in different geographical areas, hospitals and health boards. You don’t want a scenario where you have a patchy service because in some areas you have no optometrists who are Level 5, for example, whereas at the next health board you could have tonnes of people at Level 5.”
The AOP has also raised concerns over the provision of domiciliary eye care within the new structure. Conversations with Optometry Wales to clarify certain aspects of this are ongoing.
Looking ahead
Overall, Brawn believes that the new contracts are “just common sense,” and that the remuneration offered will be greatly welcomed across Welsh optometry practices – especially because increased fees for clinical services mean businesses will no longer be relying on spectacle sales.
“We know as optometrists what we can do,” he said. “We are highly qualified individuals. We can manage patients, and those with higher qualifications can do it to a very high standard. It makes sense to let us do it. It’s of benefit to no one to not let us do it.”
Evans is looking forward to the changes, and hopes that optometrists who might be worried will find that they can get on board too.
“Change always is difficult, and I think people are going to need to take time to look beyond the headline numbers and sit down with their own books and their own figures,” he said. “I hope it’s going to really benefit the people of Wales and benefit optometry in Wales, and set us as an example that the other home nations might want to follow.”
Andy Britton added: “I’m hopeful that Wales is going to be an exciting place to practise, and that this is going to tempt people to come and practise in Wales, because they’re going to see their clinical skills remunerated and valued.
“Obviously, it will mean more responsibility. I think as we see a maturing of the profession, hopefully we will see Wales as a bit of a torchbearer for the rest of the UK.”
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