Using IP to future-proof your optometry practice

The long-term business benefits of IP  

Ian Cameron (IC): There are direct and indirect benefits of having a fully independent prescribing (IP) workforce. In terms of recruiting and retaining good optometrists, having a strong IP basis is quite an attractive feature. We are a team of eight resident IP optometrists, including myself, at this practice. You create a real team that you can work and learn from. 

I qualified as an IP optometrist in 2010, so I’ve been doing it for a long time, but I’m still asking questions of my colleagues and considering what I would do in certain situations. This process makes me a better prescriber. Having that kind of team is a powerful thing, and we all benefit from it. As an experienced prescriber, I still benefit from having somebody who I can discuss cases with and get a second opinion from. That leads to job satisfaction. 

It also opens up opportunities. We’re about to begin providing a national glaucoma service in Scotland, and you can only do that course if you’re IP-qualified. The Scottish government has also just agreed higher fees for inter-optometrist referrals, so if we get other optometrists referring into us, we can attract a higher NHS fee than we would otherwise for certain conditions that require IP. There is a premium for being an IP, and for using your IP skills to treat more complex patients. 

Jane Smellie (JS): I have a practice in Wrexham, North Wales, as well as one in Cheshire and one in Shropshire – so three different counties, in two countries. I was using my IP under the old Eye Health Examination Wales system, but not being paid enough for it.  

Now, we have WGOS5 for IP, and that’s brilliant. There are tricky things in Wales, for example in terms of cataract waiting lists, but it is a joy that they can negotiate for the whole country. 

As part of the new contract, the Welsh government increased our General Ophthalmic Services (GOS) fees, but decreased voucher values. The point was that we wouldn’t have to rely on selling spectacles to stay afloat as a business, and that has absolutely happened. In Wales, we don’t sell nearly as many spectacles, but it’s now turning more profit than the English practices. In the past six months, that has been obvious. In Wales, we get paid a lot better for the initial consultation, and we get paid more for our follow-ups than England pays us for our initial assessment. 

It’s very difficult to put a value on being a specialist practice. I saw a patient yesterday who had had a massive inflammation of her lid. I treated her two weeks ago, and she came back today for the follow-up. I was astonished with how much better her eye was with a bit of Maxitrol ointment. She then asked if she could move here for her eye examinations, which I of course said yes to.  

I’ve always offered enhanced services; I’ve always been a specialist practice. I always make sure I’m the most expensive eye examination in the area, because I really feel people need to understand the value of good clinical care. 

In Wales, we don’t sell nearly as many spectacles, but it’s now turning more profit than the English practices

IC: There is now more of a business case for IP than ever before, because we’re receiving decent funding. It opens up new revenue streams, such as glaucoma services. They are a diversification, and I think that’s very important for optometry these days – that your practice isn’t dependent on selling glasses. We know that can come and go and is a fickle market, so we do want to diversify and have as many different income streams as we can. 

It also opens up ideas for the future. Myopia management and atropine is around the corner – it’s not available yet, but when it is, you’ll have to be IP to prescribe it. IP is becoming a standard requirement in optometry, in order to practise at the top level of clinical optometry. 

JS: I’m the only practice in the Betsy Cadwaladr region that is offering IP, hydroxychloroquine, and the glaucoma service moving forward. You can’t just suddenly go: ‘Oh gosh, I better get my glaucoma higher certificate.’ You’ve got to do your IP, your professional certificate, and then your higher certificate, before you can prescribe.  

It’s future-proofing. I feel so proud at what the practice is doing, and I’m very grateful to Wales that they are allowing me to use my skills. 

IP is becoming a standard requirement in order to practise at the top level of clinical optometry

Upskilling an IP-ready workforce 

JS: I talk to my optometrists, at least once every two months, about what we are doing next. IP iss next on the list for our former pre-reg, who qualified last year. Another newly-qualified optometrist is working towards their IP qualification at the moment, and is looking at the glaucoma professional certification too.  

The absolute theme of all my practices is, ‘What are we going to do next? Who can we upskill?’ I’ve got 22 members of the team, and they all know that if they want to take the next step to upskill, I’m there to encourage that completely. 

IC: There’s having IP, and then there’s using IP. In the first instance, we want to encourage people to use it, and use it often: prescribing as much as they possibly can, and then taking steps to prescribe in more complex cases, and to be referring fewer and fewer cases to the hospital. If a condition can be treated medically, we shouldn’t be referring patients from this practice, except where it’s a very complex case. We should be treating it here.  

You start newly qualified in IP, and can be quite reluctant to prescribe for certain conditions, because you haven’t seen them very much. We want to encourage people to develop their level of competence in basic IP, and then in more advanced IP.  

Then, we would want to encourage practitioners into different specialties. You can specialise in all sorts of things, some of which are related to IP and some which aren’t. There are a couple of us, in my practices, who have completed a glaucoma qualification, and we’ve got some practitioners who are specialising in myopia management, and they’re going to be the people who will move into atropine when that comes around. We sub-specialise in teams, across the eight of us, in these various areas.  

That’s why IP must become standard of practice. Whenever anything new comes around, it’s going to be the IPs who are first to get hold of it. It opens up so many more patient care possibilities. It’s the way we want to care for people. We want to avoid referring people, unless absolutely necessary, and IP is a cornerstone of that.  

We want to use the absolute widest breadth possible of our area of competence, and expand that as much as possible, so that we’re right at the fringes of what optometrists can do. That’s where it’s interesting, and that’s where new developments happen. 

JS: When I qualified in IP in 2020, I was the only IP optometrist in Shropshire, which was difficult. For advice, I went back to the people that helped me in the hospital where I did my IP training, including a brilliant specialist nurse who I knew I could email at any time. 

Now, we hold Teams meetings in Cheshire and face-to-face peer meetings, because I think learning from other IPs is so important. We secured funding, so we will have 35 new IP students coming through from Cheshire and Merseyside, so the networking side is just going to get better. The important thing is that there is no stupid question. 

Guaranteeing a consistent level of IP work 

IC: We’re a big practice, in a big city, and we’re well known for IP, so we do see a lot of IP cases. 

Because we’re big, we have one IP optometrist on call every day. There might be four clinics running, but only one practitioner is seeing the IP cases. You condense everybody’s IP clinic into one, and we all take a turn. You probably have three days where you don’t see any, and then one day where you do loads, and can be working right at the top of your practice. It means everybody gets a fair crack at the whip. 

I think it’s more difficult in smaller practices. But I think you can make the volume. You can be prescribing for dry eye, or for artificial tears. Get used to using your prescribing muscle, so it’s ready for when you need it. Even if you feel you don’t see very much, everybody sees dry eye, and you can be writing prescriptions for that.  

You can also develop links with local pharmacists and GPs. How many GPs are around you, and how many pharmacists? Have you gone in and explained to them what IP optometry is? I’ve done ‘lunch and learn’ sessions. GPs have protected education time, so I asked if I could do a session on eyes. I spoke about how they should send patients to us.  

You’re creating knowledge and awareness in your local area. If you’ve got three GPs around you, get to know every single one of them, and get them to send you their eyes cases if you want to see more of them. 

Incorporating IP into undergraduate optometry courses  

JS: Cardiff University has incorporated the theoretical side of IP into its optometry degree. The whole push in Wales is to make sure that students come out with the IP qualification. I think it can only be for the good. We just need to make sure that when they come into practice, they have the support they need.  

My one worry is, if they see an orbital tumour or uveitis, they’ll focus on that and forget that optometrists need to refract really well, too. It is important we don’t forget the basics, because in the end, it is important that people can see well.  

I think, as long as those basics are there, the fact that it’s going to be embedded will be great. But we must make sure that we have the support in place. 

IC: We should all be coming out of university qualified in IP. Obviously, you’re not going to be experienced. You’ll be like a newly qualified driver: you’ll be legal, but you’re not a very good driver until you’ve got the hang of it.  

There is a lot of learning still to do. For a lot of people, the years-long gap between university and IP makes doing IP all the harder. Doing it all together makes sense, and making it part of the course from day one emphasises that this is what being an optometrist is nowadays.  

The process of being IP-qualified makes you a better practitioner outside of it. You have this process of seeing a thing, making a diagnosis, taking responsibility for that diagnosis, and managing it accordingly. That is a key skill, as a clinician, that they probably don’t bake into you very well in optometry school, and you only really get when you’re doing IP. That makes you a better clinician when you’re thinking about glaucoma, or other things where you're not using your IP. It makes you a better clinician generally, because you’re used to taking responsibility for your decisions. 

In Scotland, where upwards of 25% of optometrists are IP-qualified, it feels absolutely natural to say that this is the standard we aspire all our optometrists to work at, and not just the leading edge. Let’s train them in that from the get-go.