03 November 2022
With a new Health Secretary in place and the Government back at work after a summer recess and succession of leadership changes, OT asked three High Street optometrists what they’d ask for if they had Steve Barclay’s ear.
Dr Valarie Jerome, Berkshire
“I’d like to see my patients get the care that they need much more quickly, to preserve their vision and maintain a good quality of life”
I would give optometrists in the community more ability to provide primary eye care for patients, by making it easier for all optometrists to become IPs.
I would walk the new Health Secretary through the journeys that my patients have had in accessing basic primary eye care. I would walk him through my corneal ulcer patient, and how it took her four days to see the consultant because of letters ping ponging back and forth, and arriving at the hospital to find that the consultant wasn’t there, for something I should have been able to treat her for on the day. I’d walk him through the journey of a retinal detachment patient, where it took three days to find a consultant who could operate on her. I would walk him through the simple case of an allergic conjunctivitis patient who has a chronic condition, who could have been treated by me in the chair months before they finally got to see the consultant. I’d walk him through a patient with a visual field defect, who I referred in March, who was just in this week, for a sudden loss of vision.
I would walk him through those journeys, and say, “it seems like you’re playing with fire here.” It seems that primary eye care is being thrown on consultants at the hospital. Consultants need to focus on surgical procedures; they don't have time to be seeing all these primary eye care conditions.
I’ve come from a country where you would never go to a hospital for a corneal ulcer – you would see your local optometrist
I come with a different perspective, because I’ve come from a country where you would never go to a hospital for a corneal ulcer – you would see your local optometrist. It frustrates me, having practiced as a therapeutic optometrist for over 10 years in the United States, to come here and be unable to qualify because it’s too difficult to be taken on for the hospital placement days. To see these patients and know I could treat them in the chair, and to know that they might fall through the cracks and not get the treatment that I refer them for, is extremely frustrating. My focus, if I had his ear, would be: “let’s work on getting primary eye care into our communities and out of the hospital, because the hospitals can’t see everyone.”
I’ve lived in this country and practised here as an optometrist for 13 years now, and for 13 years I’ve been very frustrated, especially when I’m purely doing refractions and referring patients. Would I like to be able to use the knowledge in my head to sign a prescription and do that part of my job? Yes. But the bigger thing is, I’d like to see my patients get the care that they need much more quickly, to preserve their vision and maintain a good quality of life.
Martin Smith, Lincoln
“If you funded primary care properly, you'd get a lot fewer referrals into secondary care and it would save money in the long run”
I think there are two issues. One is the utilisation of optometrists for more advanced practice. So, using optometry practices in the community, particularly IPs to treat patients who would otherwise be referred to hospital.
There are a lot of schemes around the country, but it’s very disjointed. Lincoln has got quite a good scheme. We see pretty much all suspected glaucoma rather than it being referred to the hospital, and we only refer on people who need hospital treatment.
I feel there is an underutilisation of optometry skills. I think that optometry should be structured for the future, so that all optometrists should be IPs on qualification. It would be a sea change for the profession, for those skills not to be confined to six or seven people in the county.
All optometrists should be IPs on qualification. It would be a sea change for the profession
The other major issue is the underfunding of primary care optometry for routine care, and the knock-on consequences that has. If primary care was funded properly, you’d get fewer referrals into secondary care and into the schemes and it would save money in the long run – but they don't look at it that way. So, proper funding, if you want optometrists to do something other than a refraction, checking if there’s something wrong, and referring it on.
Ophthalmology has the biggest referral rate of any speciality, because they don’t pay optometrists to do anything other than refer people on. I don’t do GOS: I practise privately, and I manage huge amounts during those appointments. People don’t need to go to secondary care the vast majority of the time, and they wouldn’t have to if the system was sorted out.
I think the utilisation of IP optometrists in the community to manage those referrals is already happening, and it could happen to a greater extent if we have more optometrists with more qualifications. Everything is going that way. Some harmonisation of these schemes, and funding for them, would be nice.
There is also the issue of segmentation. I’m in Lincolnshire, but I live in Nottinghamshire, so we’re not far away. If someone has a GP in Nottinghamshire, I don’t know what I’m referring them into. I can’t refer them and know that they're going to see an optometrist, and they can’t come back and see me because their GP is five miles in the wrong direction. That just seems nuts, to me.
The new contract in Wales looks promising. These schemes obviously work. The number of IP optometrists in Scotland far outstrips the proportion in England, and it’s because there's an incentive to do it. These schemes will, maybe, result in a change in the attitude in the government.
Tushar Majithia, Nottinghamshire
“There isn't uniform access to urgent eye care within community optometry”
One of the things we see in day-to-day practice is that patients are having to wait. The waiting times for cancelled appointments have gone up, because there isn’t the capacity in secondary care. It would be nice to see action to try to bring down those waiting times and make the best use of primary care optometry, to try and reduce the burden on the hospital eye clinics.
One of the things that’s needed for that is a wider commissioning of services. Services in primary care at the moment are not equitable. There isn't uniform access to urgent eye care within community optometry. Enhanced services need to be commissioned throughout the country to allow people to access eye care, rather than patients having to be referred to hospital eye clinics for assessments.
Enhanced services need to be commissioned throughout the country to allow people to access eye care, rather than patients having to be referred to hospital eye clinics for assessments
[I would ask the Health Secretary] to utilise the skills and resources within primary care. What needs to happen is to engage with primary care optometry and look at allowing the commissioning of services throughout the country, with a more uniform approach to eye care pathways. At the moment this type of service is very scattered around the country, so there isn’t equity to access it.
It needs to be more equitable throughout the country. For example, in our area, there’s no access to urgent eye care in primary care, so patients who need urgent eye care have to go to accident and emergency or pay privately to have an assessment within an optical practice, which isn’t ideal for patients who need to be seen quickly for urgent eye care problems.
We do have an advanced service in the county, but that doesn’t include urgent eye care, so it excludes services such as assessment of flashes and floaters or red eyes, painful eyes – certain eye conditions that ideally need seeing straight away. Patients are having to pay privately to have those assessments, because those are the kinds of things that are not covered by GOS.
Having a review of GOS like they have done in Wales and Scotland to improve and modernise it would be a good start, so patients can get a better service. GOS in England is very underfunded. So, a better funding of the GOS scheme and an overhaul so that we can make use of the technology that we have in practice, as well as being better funded for the services that we can offer.
There’s an emphasis in the new Welsh contract on prevention and self-care, which is interesting, and that’s something that needs to be looked at in England. Many optometrists have tried to offer it within their practices, but it’s not something that’s funded.
Other aspects are things like the Low Vision Service, for which they have a really good service in Wales. Once again, in England there isn’t an integrated Low Vision Service that has a multidisciplinary approach to provide that service. Some areas provide a Low Vision Service, but it doesn’t allow for a partnership working with different areas of care: social care and hospital eye departments, working together with practices to provide the optimum service for patients.
The other thing is the integration of IT with primary care optometrists. We don’t have access to hospital records or patients’ NHS records, so when patients do come and see us for an eye problem, there’s no way of knowing their previous history. Our records are not linked to theirs. Quite often that can lead to referrals for issues that patients have already been seen for by the hospital eye departments. It can lead to inappropriate referrals if we don't have access to the records. It would be a be nice to have a more integrated IT system where we can have access to patient records.
Comments (10)
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Anonymous16 December 2022
I dream of the day when I wake up to the new Specsavers has decided to ditch the NHS contract and go completely private. Boots and Vision Express will follow suit. Followed by all the independents. A life free from NHS bureaucracy. Form filling. Chasing up GOS 3 vouchers. Being forced to carry out early nhs st because the gp recommends one. All the useless audits and training modules. Getting to set your own prices. Getting paid on the day for your services. I dream of such a day.
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Anonymous13 December 2022
The more difficult the patient, the more we should be getting paid. Claiming £21 for a child with no Rx isn't the same as dealing with a 80 year old with Alzheimers, hearing problems, ARMD, Cataracts, poor mobility, abnormal head posture.
Older Px's take up more time, they are more stressful, they require more care, they require more work up...dilations, referral to the HES...we are dealing with an ageing population, they don't always buy glasses. Especially when you have to refer them.
You can't expect practitioners to provide all this care for the current GOS fee. It's not sustainable. Not for Independents.
Specsavers tends to attract a younger crowd. Patients who don't have problems or pathology tend to go to specsavers for a quickie eye test. When they develop eye problems they go to an independent.
Hence Independents deal with a a disproportionately greater number of difficult and needy patients.
So the independent, clinically led practice deals with all the flack, whilst Specsavers continues to profiteer from the easy straight forward subjects.
The industry is a mess. It's been a mess for years. And nothing will change because there is no desire to change the status quo.
Meanwhile independents continue to close down. And the GOC continues grandstanding, prosecuting individual optometrists rather than dealing with the core root of the problem. The culture of quick sight tests fostered by Specsavers bonus driven payments.
It's completely at odds with health care. But 20 years I've been practicing nothing has changed, and nothing will change.
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Anonymous13 December 2022
I currently provide CUES and most of my day consists of dealing with Px's calling up wanting to be seen because their eyes are 'smarting', or because their eyes are pulsing, or their eyes are 'dry'. Or their eyes are aching, they've been told to wear glasses but 'they didn't notice a difference' or didn't want to spend so much money on a pair of glasses. They all want to be seen in practice. They ring the GP's and get batted by the receptionists straight to the Opticians..HA's? ring the optician....gunge in the corner of the eye? ring the optician...corner of the eye red? ring the optician...we get so many of these timewasters...it kills your morale....the thought that these tools used to and continue to go to A&E before the CUES pathways sends shivers down my spine...no wonder the NHS broke. No I don't want to upskill because I don't want an influx of timewasters flooding my practice. The answer isn't upskilling. We need to privatise CUES and any other bright idea the think tanks come up with so people think twice before abusing it.
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Anonymous12 December 2022
I hope online retail takes off. I hope AI and 3D printing allows patients to putchase glasses for next to nothing. When that happens, when online retail starts eating into the green giants retail led profits. That’s when they’ll instruct their pawns the ofnc to pay a proper fee to Optometrists for sight tests. There’s no incentive atm for spec…ofnc to petition for proper remuneration…they make too much money from selling glasses, to the detriment of their competitors. But if online retail takes off, and they see their revenues drop. That’s when we will see real change in Optometry and proper remuneration for Optometrists. Optometry isn’t a profession. It hasn’t been for the last 30 years. Even the patients don’t see us as clinicians.
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Anonymous12 December 2022
"GOS underfunded" now that's an understatement. It's none existant. They should just put us out of our misery and reduce it to zero...save the admin expenses. As for upskilling Optometrists...why? Whose going to fund it? Whose going to pay for it? How will the most trusted optician in the UK fit that into their 15 minute rolling clinic? Upskilling....not if St Doug and Mary have anything to say about it.
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Anonymous12 December 2022
£25 for refraction
£50 for Ophthalmoscopy
£35 for visual fields
£20 for IOP's
£30 for typing up referrals
£50 for prismatic work up
This is how I would break down the value of my time and expertise. The NHS pays us £21....regardless of difficulty (some patients take up to an hour to test, they're also the least likely to buy glasses).
We are seeing an increasingly ageing population who require more time, we're dealing with alzheimers, dementia, body odor, hearing problems (our job is reliant on subjective responses), pathology. Every time we see these patients we run the risk of missing something or getting called up in front of the GOC. And for what? £21...yeeey!
The whole world has changed, but Optometry still seems to be stuck in some timewarp...."sell em some glasses you'll be reet" worked in the 70's and the 80's and the 90's....it no longer works in the modern world. Px's are savvy, they go online, they go to the most 'trusted' opticians 30 years in a row...smh
We should be getting paid for our time, not running a roulette hoping to recover the cost by selling glasses.
Everytime I type up a referral that takes me 15 minutes I remind myself...I'm not getting paid for this, every time I carry out a fields assessment I remind myself I don't get paid for this. We have patients who have worked out the system, "glaucoma in the family" they know nobody will check, there's no way to prove it.
The list goes on and on, the system is broken, and it will never change because those who 'regulate' the profession are at best, incompetent, at worst corrupt.
£21 for an NHS sight test...just think about that...what does £21 buy you these days? A barber charges £20 for a haircut and you'll go to him once every month, that's £400 over 2 years. We get paid £21 to see a Px every 2 years.
And why do Px's need NHS sight tests? Everyone can afford a haircut or a hair perm, but they can't afford a sight test every 2 years?
There are a lot of problems with this profession, they will never get fixed, not in my lifetime, I've accepted that. Let's stop having the same old useless discussions because we know nothing will change. Too many corrupt people in power who benefit from this retail led model. The future belongs to the (green) multiple, they played their cards well...
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Anonymous11 November 2022
Dream on. Whilst the Multiples continue to devalue the profession by offering free or cut-price “sight checks”, we’ll NEVER move forward. It’s not in the multiples’ interest to have their optoms spend more time with patients. They just want 10 minute quickies and high dispensing (flogging specs by non qualified persons) conversion rates. STOP WORKING FOR THE MULTIPLES. Just look at the way they are pushing the apprenticeship route to qualification.
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hilaryandmichael04 November 2022
Until optometrists are properly remunerated for their professional care and time
rather than the derisory and insulting fees that are paid currently- the pie in the sky aspirations of the three aforementioned practitioners will never be realised
The majority of the public will not pay the costs of the supplementary tests that we have to do during the consultation-HM government considers the GOS NHS fee scheme is considered adequate remuneration for Optometrists time and until this changes-no progress will be made
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Dave C03 November 2022
Oops, wrote that message whilst doing visual fields. Can someone delete it & I’ll tidy it up & repost!
… and yes my favourite word is ‘useful’.
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Dave C03 November 2022
This is an interesting commentary.
I think the way that the poll is set up is not particularly useful. Is it useful to have more IPs qualifying when there is nothing useful for them to do within the NHS?
This is the problem we have in Scotland [hopefully soon to be addressed]; there there are 100s of IPs who are not able to increase their competence & scope of practice, post-qualification, as there is no mechanism for the 'juicy stuff' to be directed their way. Hence, we most of them are mostly only prescribing lubricants.
You can't pull the cart without any horses!
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