Training, progression, and advanced practice in hospital optometry

Balancing community and hospital practice

The typical path into a hospital optometry career might begin with a pre-registration placement that captured the individual’s passion for the role and saw them stay on for years to come, qualifying in new skills, and moving into different sub-specialties.

Dr Waheeda Illahi, consultant optometrist and head of optometry services at Birmingham and Midland Eye Centre (BMEC), reflected: “A lot of hospital optometrists were traditionally ‘homegrown,’ with a career in optometry following hospital pre-registration training.”

This might then evolve into a balance of community and hospital practising for many optometrists.

Illahi observed: “A more recent and surprising trend I have noticed over the past 10 years is for community optometrists associated with High Street multiples to apply for hospital positions on a part-time basis and then go on to dedicate their careers to the hospital eye service, with commercial pressures often being cited as the main reason for changing career paths.”

“Those from independent practices tend to continue with a part-time hospital and community mix,” she added.

The General Optical Council’s (GOC) Registrant Workforce and Perceptions Survey 2024 explored the settings in which optometrists are currently working and the days worked across the week.

Scaling up the results to help inform workforce planning, the GOC found that there are approximately 2700 optometrists working in hospital settings, with 1512 of those full-time.

It is not unusual for hospital optometrists to divide their time in the HES with roles in primary care, universities, or other organisations across the profession.

Patrick Gunn, consultant optometrist and head of optometry at Manchester Royal Eye Hospital, said: “I think that only adds value and expertise to the department. It also makes it a much more enjoyable job when you have opportunities to work in different environments.”

With NHS trusts recognising the importance of flexible working, this is a working pattern that is becoming easier to achieve.

Gunn said: “I think that creating an environment where people feel encouraged to do more – engage in research or academia for example – and to push themselves outside of their comfort zone, helps services progress.”

Elizabeth Cave, head of optometry at University Hospitals Plymouth NHS Trust, pointed out that a role in primary care optometry can be beneficial for maintaining skills.

“It can be useful to keep your hand in routine sight testing and contact, if this is not part of a hospital role, because it is a major skill that is easy to lose if you don’t practise it regularly,” she shared.

The benefit of variety

Optometrist Irinder Khakha is an ophthalmic director at Specsavers Hayes and Hayes Lombardy, and also a specialist optometrist at the Hillingdon and Mount

Vernon Hospitals, part of The Hillingdon NHS Hospitals Trust.

He said: “This variety allows me to experience a diverse range of cases, environments and complexity, ensuring that I stay well-rounded and adaptable. It keeps my work fresh and engaging, preventing it from ever becoming mundane. The constant change in setting and patient needs ensures that each day brings new challenges and learning opportunities.”

It keeps my work fresh and engaging

Khakha suggested this pattern of working is becoming more common among optometrists, sharing: “Many see the value in diversifying their professional experiences and skillsets by working in different settings.”

“Hospitals are increasingly utilising optometrists who are working more autonomously in specialist clinics and employing advanced diagnostic and therapeutic techniques,” he said.

Hear more from Khakha in OT’s Q&A, available in the ‘Our Journal’ section of the website.

Career progression

The GOC registrant survey explored respondents’ perceptions regarding career development opportunities at their place of work. 

The survey found that those who worked in a hospital, in education, or academia generally expressed more positive experiences of opportunities to develop. 

In the survey, 81% of hospital optometrist respondents agreed with the statement: ‘I have opportunities to improve my knowledge and skills,’ 61% agreed that ‘there are opportunities for me to develop my career,’ and 51% agreed that ‘I feel supported to develop my potential.’

In comparison, 56% of optometrists in multiple settings and 50% in independent practice agreed with the statement: ‘There are opportunities for me to develop my career.’ Around 70% of optometrists in both settings (72% multiple and 73% independent) agreed that ‘I have opportunities to improve my knowledge and skills.’

Meanwhile less than 50% (45% multiple, 43% independent) agreed that: ‘I feel supported to develop my potential.’

Gunn explained that education and training is vital for team development, adding that many colleagues have completed independent prescriber and College of Optometrist qualifications. 

Describing what goes into this, he said: “It is important to consider what qualifications are relevant to a colleague’s current role, and what is going to help support develop in the future.”

It could be a challenge for some trusts and smaller hospitals to secure funding, Gunn acknowledged, adding: “We’ve always been very lucky here in Manchester to be able to do that. I think that it’s vital to be able to deliver the services that we do; that we invest in staff training, not just to develop skills and knowledge but to help them feel valued and supported.”

Rebecca Ellis, associate director for education at Moorfields Eye Hospital, and advanced practice training programme director, ophthalmology for London, NHS England, said: “We are now in a time where optometrists can truly be autonomous in secondary care in multiple of our subspecialty services. Whether that is paediatrics or cataracts, almost every subspecialty has some element of non-medical advanced practitioners working within it.”

Until recently, Ellis suggested, advanced practice roles have focused on clinical work, but there is now greater recognition for – and opportunities to progress into – areas such as leadership and management, or research and education. 

The education team at Moorfields is committed to ensuring it develops education that is relevant to the staff in the roles they carry out, and the services delivered for patients.

Education is divided into single academic modules supporting practitioners training in subspecialist interests, continuing professional development, and internal training and development.

Ellis said: “Our education team, particularly within optometry, has its finger on the pulse when it comes to what is required, and is very responsive.” 

I think that it’s vital to be able to deliver the services that we do; that we invest in staff training, not just to develop skills and knowledge but to help them feel valued and supported

Advanced clinical practice

In the first feature of this series, OT heard from hospital optometry leads about the myriad ways the role of the hospital optometrist is expanding, including into extended, and even advanced clinical practice roles. 

Ellis explained: “Advanced practice is something that has been pretty well embedded in many specialties in medicine, and ophthalmology has been quite late to the game with this.”

Advanced clinical practitioners (ACP) are educated to Master’s level or equivalent and take on an expanded scope of practice to meet patient needs. Advanced practice comprises four pillars of clinical practice, leadership and management, education, and research.

The NHS Long Term Workforce Plan highlighted the important role played by growing numbers of advanced practitioners, and the need to offer more opportunities for enhanced and advanced practice. 

The ACP retains their core professional identity, but Ellis points out: “It is the skills that they have, not necessarily the previous roles they have had, which is important. Advanced practice has the opportunity to level the playing field to support and allow services to benefit from the truly multi-professional nature of the care that we deliver.”

The education for advanced clinical practice is carried out in multi-professional programmes, Ellis explained. 

“We’re not just working together, we are now learning together, being taught by a mixed professional faculty, which is really very new for us, and it’s something that I think will change the way we approach true multidisciplinary working,” she said. 

The NHS England Centre for Advancing Practice provides support, including funding advanced practice training programmes. An apprenticeship route is also available for the ACP qualification. 

The logistics can pose the greatest challenge to introducing ACP roles or enabling team members to pursue the qualification. 

Ellis said: “Asking working people, often in full-time roles, to undertake a Level seven Master’s programme on top of their busy working and home lives is difficult. There will be an expectation for some time away from work to be able to undertake the learning. That is more of a challenge, and it is about planning ahead.” 
This means identifying a need for an ACP role and recruiting three years ahead of time, to allow the practitioner to work and train in the intervening years, with time ringfenced to support their academic learning. 

Ellis suggested that ACP training highlights the unique skillsets of the different professions. 

“One of the big driving forces for me is to create this multi-professional education faculty where we can work, learn, train, and support each other, because that is mirroring the way we are working in our clinical settings,” she said. 

ACP in the community

Rebecca Ellis explained that advanced practice is not limited to within the hospital setting, sharing: “When we talk about moving care into the community, the role

for advanced practice is only going to grow.”

A number of trainees in London are on advanced practice training programmes to deliver NHS services in primary care as ACPs.

This required forward-thinking about the skill mixes in the workforce in the community.

When we talk about moving care into the community, the role for advanced practice is only going to grow

“If we’re thinking about, in the long-term, taking patients out of secondary care settings and moving them into primary care, we need to make sure that our optometry colleagues – who are going to be responsible for some elements of that – are prepared, trained, and ready, and have the recognition and accreditation to be able to do it,” she said. 

Ellis added: “I think if we are really committed as a profession to making sure that we’ve got high quality local holistic care for our patients, then this is all part of that.”

Capacity to train

The development of ACP roles is currently a priority, and a work in progress, at BMEC. 

Illahi agreed that one of the challenges is delivering training, and carrying out competency assessments during busy ophthalmology clinics, without overburdening practitioner workload or significantly impacting service delivery. 

However, with the pressures of current and future demand on eye care services, she said: “HES providers recognise the need to develop extended and advanced roles for optometrists, orthoptists, and ophthalmic nurses.”

Illahi highlighted that the Ophthalmic Common Clinical Competency Framework provides standards and guidance for the knowledge and skills required for non-medical eye healthcare professionals to deliver patient care in the HES in four subspecialties that are most under pressure – glaucoma, medical retina, cataract, and emergency care.

“The ACP role ensures standardised and recognised competencies across all ophthalmic secondary care locations in the UK, and it is important that optometrists form part of this recognised, trained workforce,” she added.

Manchester’s optometry department has four ACPs, with Gunn suggesting: “I’d certainly like to see more in the future. I think it’s good for optometrists to be able to develop, progress, and be rewarded for that in a clinical role.”

Learning to navigate the different routes available to ACP qualification might have held some departments back, he suggested, adding: “But I think the process is becoming a bit clearer.”

Implementing ACP does require making the roles available. Gunn said: “If you’re training somebody through an ACP programme, you need to make sure you have the roles in place once they are qualified. We’ve had some successes up to now in creating some of these posts, but to be able to upscale that, more needs to be done.” 

The ACP role ensures standardised and recognised competencies across all ophthalmic secondary care locations in the UK, and it is important that optometrists form part of this recognised, trained workforce

Upskilling and transitioning

As roles expand and grow in the hospital eye service, how accessible is it for optometrists in community practice to take the step into secondary care?

Illahi shared: “I do believe the specialised hospital roles are difficult to access for community optometrists due to internal HES competition from existing hospital optometrists, orthoptists, and ophthalmic nurses.”

“I would encourage community optometrists to apply and show willingness to learn, and be flexible in their approach and willing to consider applying for core optometry HES sessions in the first instance to get their foot in the door,” she said.

Onboarding and training is key to ensuring a smooth transition. This is one benefit of moving into hospital optometry, Cave suggested, with the hospital funding courses and extended qualifications, “whereas, if you’re in the community, unless you have a scheme with the Local Optical Committee, you might be self-funding a course.”

“When you look at hospital roles, you are moving further up the ladder in terms of clinical management and seeing patients who would have traditionally only been seen by an ophthalmologist,” she said. 

“They are very interesting and challenging cases,” Cave said, emphasising that practitioners who are interested in this should consider contacting their local HES. 
Ellis shared: “In my experience, as secondary care hospital optometrists have become more specialist and even more highly-skilled we are seeing this mirrored in primary care.”

“We see a much broader scope of practice in the community. I think we can say there has been a change in workforce dynamics in primary care – the two have a knock-on effect on each other,” she said, adding: “We are recruiting from a more highly skilled and specialist workforce.”

A dedicated onboarding programme, as well as strict protocols and procedures ensure everyone is working to expected standards.

The growing number of optometrists accessing higher qualifications is facilitating career movement between primary and secondary care, Gunn suggested. 

He said: “In the past, not having hospital experience might have been a bit of a barrier, but I think that primary care optometrists are engaging in so many advanced practices and higher qualifications, moving between the two is now easier.”

One barrier has been the differences in salary between primary and secondary care, making it a challenge for optometrists in primary care to switch to hospital optometry without a financial impact. 

“I think some hospitals might have undervalued the skills you have working in primary care and expect those individuals to go into lower banded roles, which is a big salary cut,” Gunn shared. He added: “It’s really important that secondary care providers value the skills and experience that optometrists with primary care experience have.”

The optometrist continued: “I think in more recent times, particularly with the availability of more higher-banded roles, there has been less disparity between the two and I think that is helpful to encourage those interested in a hospital career.”

OT will continue to explore the hospital optometry workforce in future Special Report features, including care in the community and the role of independent providers. To share your views on the topic, get in touch.

“Each day brings new challenges and learning opportunities”

Irinder Khakha, ophthalmic director at Specsavers Hayes and Hayes Lombardy, and specialist optometrist at Hillingdon and Mount Vernon Hospitals, on working in community practice and HES