The cover story

The IP crowd

OT  talks with clinicians about how independent prescribing has changed their practice – and explores how the qualification can develop in the future

IP illustration

An emergency eye department is a study in the vulnerability of the sense that people cherish the most.

Patients present with disease and injury afflicting every aspect of the ocular anatomy and visual system. Clinicians must stay calm while assessing where the problem is, what has caused it and how they can help.

Independent prescribing (IP) optometrist, Daniel Todd, has shown along with colleagues that well-trained and experienced IP optometrists can perform this fleet-footed detective work at a level that is on par with consultant ophthalmologists.

When Todd began working as a hospital optometrist eight years ago, a relatively small proportion of IP optometrists worked in emergency eye departments in England.

“There was a limited evidence base. We wanted to look at the diagnosis and prescribing decisions of IP optometrists in that setting,” he shared.

Daniel Todd
IP optometrist, Daniel Todd
Todd and his colleagues began a study comparing IP optometrists to consultant ophthalmologists in the diagnosis and management of patients presenting at the emergency eye department.

Over a two-year period, 321 participants were first assessed by one of three experienced and well-trained IP optometrists, and then assessed by one of eight consultant ophthalmologists.

The study team found that there was “almost perfect” agreement in diagnosis between the two professional groups as well as concordant clinical decision making.

Todd highlighted that the results show appropriately trained and experienced IP optometrists can safely contribute to the multidisciplinary team in acute ophthalmic services.

“We demonstrated that patients who would have traditionally been diagnosed and managed by ophthalmologists could be managed safely by our IP optometrists. This evidence is the first to validate IP optometrists extended role in acute ophthalmic services and opens up an area where we can contribute more,” Todd observed.

The backlog

Evidence for the value that IP optometrists can offer in managing an extended range of conditions comes at a time of burgeoning wait lists within secondary care.

Data released by the NHS in July revealed that there were 5.3 million people waiting for elective care – the longest waiting list since records began in 2007.

I would hope that IP optometrists in the community would act as a first port of call to assess, diagnose and, where appropriate, manage urgent conditions

Daniel Todd

Within this group, 336,733 people had waited more than a year for treatment, while 7403 people faced a delay of over two years for treatment.

Todd shared that IP optometrists can play their part in addressing the backlog both in acute settings and in primary care through schemes such as the COVID-19 Urgent Eyecare Service.

“I would hope that IP optometrists in the community would act as a first port of call to assess, diagnose and, where appropriate, manage urgent conditions; it is a good use of resources and makes the most of our skills,” he said.

An aspect of the study that surprised Todd was how many patients were seeking care for minor conditions at the emergency department rather than visiting their local optometrist.

“At the time – this was pre-pandemic – there were still a lot of non-urgent conditions presenting – things like dry eye and blepharitis. These are really things that should be getting assessed in the community. It highlights the question ‘What is motivating patients to turn up to A & E rather than go to their local optometrist?’,” Todd emphasised.

General Optical Council (GOC) research published this year that found only one in three members of the public would visit an optometrist if they woke up with an eye problem.

Strengths and limitations

Todd observed that because the research examined the management and diagnosis of different conditions, it gave clinicians an idea of the strengths and training opportunities among the IP workforce.

Because IP optometrists have traditionally worked in glaucoma, practitioners in the study were quick to spot this condition – on one occasion identifying narrow angle glaucoma when it was initially missed by a consultant ophthalmologist.

In contrast, on a separate occasion an IP optometrist diagnosed a visual migraine but, unlike the consultant ophthalmologist, missed an associated transient ischaemic attack; such a case requires a medical work up and prescription of blood thinners, Todd shared.

“It’s important to know your scope of practice, your limitations and when to refer to other colleagues,” he said.

The findings could lead to improvement in care such as more efficient triage Todd highlighted.

“If patients are identified at triage as being manageable by an IP optometrist or an ophthalmic nurse then they can be directed as such, which frees an ophthalmologist to see complex cases requiring medical intervention,” he elaborated.

Todd is quick to highlight that the findings from this study are limited by the fact they apply to a small group of IP optometrists from one hospital, who all had at least 10 years’ experience.

The same results may not be replicated in IP optometrists who have just qualified, he added.

However, Todd would like to see more research critically examining the care provided by IP optometrists to build on the evidence base for their extended role in acute ophthalmic services.

Exploring the evidence

Dr Nicola Carey, from the University of Surrey, was part of a team examining the evidence around optometric therapeutic prescribing for the GOC.

The study was commissioned by the optical regulator to inform decisions about how therapeutic qualifications might develop in the future through the Education Strategic Review.

Carey highlighted a scarcity of evidence on the impact of optometrist independent prescribing – even though the qualification has existed for longer than a decade.

Nicola Carey
Grant Pritchard/University of Surrey
Academic and independent nurse prescriber, Dr Nicola Carey
She observed that this lack of data can be a hindrance when informing a business case of the added value that IP brings.

“Unless you have data on the uptake, use and impact on patient care from service delivery you are not in a negotiating position to say, ‘This is really working for us’,” Carey emphasised.

Carey highlighted that that challenges for IP identified in the research include fragmented commissioning within England, a shortage of clinical placements and issues around the funding of training.

“My feeling is that optometrists are keen to realise their professional aspirations and it’s clear that it does work well but there are challenges in implementation. There are practical challenges with respect to getting people trained and practical challenges in providing the service if it is not commissioned,” she said.

Carey, who is a qualified nurse independent prescriber, shared that therapeutic prescribing within optometry has several key differences when compared to non-medical prescribing in other professions.

Unless you have data on the uptake, use and impact on patient care from service delivery you are not in a negotiating position to say, ‘This is really working for us

Dr Nicola Carey

For example, other healthcare professions complete the practical and theoretical elements of their qualification concurrently in contrast to IP optometrists who complete a placement that is separate to their coursework.

There is also a requirement for IP optometrists to be supervised by an ophthalmologist, whereas for other healthcare professions they can be supervised by any other non-medical prescriber.

“One of the challenges that people shared is that there is a shortage of ophthalmologists and there is quite a big backlog. They were talking in terms of thousands of people waiting to get clinical placements. If you adopted a new model, you wouldn’t be reliant on having to be signed off by an ophthalmologist you could have it done by an optometrist or pharmacist,” Carey shared.

A Glasgow Caledonian University study published in 2011 surveyed 38 IP optometrists – which at the time represented 60% of all registered IP optometrists within the UK.

Within the group, half of respondents reported referring patients less frequently after they became IP qualified.

IP infographic

Survey respondents reported issuing 10 prescriptions per month on average, with 87% prescribing on a daily or weekly basis.

Only one in three IP optometrists had access to a prescription pad. The remainder either requested prescriptions by written order or through a GP/ophthalmologist.

IP and referral rates

Glasgow consultant ophthalmologist, David Lockington, contributed to research that was published in July last year assessing the distribution of IP optometrists within Scotland and referral rates.

“There appears to be an ever-increasing number of optometrists achieving IP which is great for them and the patients they evaluate in primary care. IP optometrists seem to be well-distributed across Scotland, and they seem to increasingly be using their skills,” he told OT.

However, the study did not find that increasing numbers of IP optometrists was reducing referrals to secondary care – in fact, since 2010, referrals to hospital eye services have increased by 118%.

The traditional eye care pathway has been a one-way conveyor belt to the hospital, with no exit door

David Lockington

Since 2013, Lockington has taught and supervised optometrists undertaking clinical sessions for their IP qualification in the West of Scotland Optometry Teach and Treat Clinic.

“Without doubt, every optometrist presenting themselves for IP training with me has been keen to learn and engaged to use their skills appropriately,” he said.

However, Lockington has concerns that the current system does not permit the skills of IP optometrists to flourish post-qualification.

“The traditional eye care pathway has been a one-way conveyor belt to the hospital, with no exit door,” he shared.

“We need to have a system which is more like a revolving door, where the appropriate patients can be seen, investigated and treated by the competent eye care professional and returned back into primary care for monitoring where possible,” Lockington emphasised.

IP programme lead at Glasgow Caledonian University, Mhairi Day, shared that following the outbreak of the pandemic NHS Education for Scotland (NES) and the Scottish Government funded an additional 70 training places for IP optometrists.

As a result, Glasgow Caledonian University had an intake of 220 optometrists studying IP – more than double the usual number of trainees.

Optometrists from across the UK completed the training which was offered online due to the pandemic. 

Glasgow IP optometrist, Dr Stephanie Kearney, observed that IP enables optometrists to manage more complex conditions within the community rather than referring to hospital.

“Patients therefore have a less stressful experience as they are able to be managed by their familiar and local optometrist. As IP optometrists are able to prescribe from an extensive range of drugs, this also allows for individualised treatment for each patient,” she said.

Kearney, who is an AOP Councillor, added that Scotland has a significant number of optometry practices based in rural areas.

“Having a local IP optometrist improves the accessibility and quality of care in these areas,” she emphasised.

Within Scotland, an FP10 prescribing pad can be obtained from the NHS Health Board the IP optometrist works in.

Locums can obtain an FP10 pad from the health board they most frequently work for – which can then be used across all NHS Health Boards within Scotland.

Kearney shared that, as an IP optometrist, it is rewarding to be able to diagnose and manage patients in practice rather than refer them.

“Before qualifying as an IP optometrist, I would know what treatment the patient required but would be unable to prescribe it which was frustrating. As I am able to manage more patients in practice, this saves time within my clinic which may have been spent on the phone organising referral to the local HES,” she said.

Stepping up during COVID-19

In Wales, following the outbreak of the pandemic the unique skillset of IP optometrists was harnessed to ease the burden on secondary care.

The Cardiff and Vale University Health Board introduced the Independent Prescribing Optometry Service (IPOS) one day after the first lockdown on 24 March, 2020.

Four optometry practices with IP optometrists provided emergency eye care within the community, managing 92% of cases without an onward referral.

Marc Drake
IP optometrist, Marc Drake
IP optometrist at Osmond Drake in Penarth, Marc Drake, shared with OT that IP optometrists in Wales gained access to W10 prescribing pads in February, 2020, one month before the first lockdown.

Working in a practice involved in IPOS, Drake received referrals from other optometry practices as well as the emergency eye clinic at the University Hospital of Wales.

“We were able to see patients promptly in the community and thus reduce the need for patients to travel to hospital during a pandemic. Patients really valued being seen in the local community in a quieter, safer environment compared to a trip to the hospital during the pandemic,” he said.

Drake shared that he was proud his team were able to provide a meaningful service to patients during the pandemic.

The initiative also fostered closer ties with ophthalmology – which Drake hopes to see continue into the future.

“IPs should develop their skills in a way that suits them and their patients but at the same time we need to continue to build bridges with our secondary care colleagues,” he said.

Pervaze Jan, an IP optometrist at Direct Eyecare in Cardiff, told OT that many of the conditions that he managed through IPOS were complex.

“On reflection, it was the best way to learn as we were thrown in at the deep end,” he said.

“For me personally, seeing patients’ conditions resolve as a result of our unique skill set in diagnosis and treatment from initial presentation to discharge is very rewarding,” he added.

In the future, Jan would like to see optometry evolve clinically to reflect the unique skillset of the profession and the advanced diagnostic equipment that optometrists have access to.

He noted that IPOS has gained recognition among his peers who are now confident to refer patients to the service rather than hospital.

“I know that IPOS has inspired other optometrists to study for the IP qualification,” Jan said.

IP in NI: “a sounding board” for other optometrists

Brian McKeown, an IP optometrist and AOP Councillor based in Northern Ireland, shared with OT that being IP qualified has given him the confidence to diagnose and treat conditions in practice, saving his patients a trip to accident and emergency or their GP.

“I can also act as a sounding board for the other optometrists in the team to help manage patients,” he shared.

Since COVID-19, a group of more than 40 IP optometrists in Northern Ireland have kept in touch through WhatsApp, seeking guidance on cases and organising Continuing Education and Training.

“There is a real belief that IP optometrists are able to manage more conditions in the community and there is a lot of goodwill which has come out of the pandemic,” McKeown emphasised.

In terms of future development of IP within Northern Ireland, McKeown would like to see an IP-specific pathway commissioned.

“To reach our full potential in Northern Ireland there needs to be a pathway to let us work and grow  to allow us to manage those more acute conditions and continue to build a great relationship with secondary care,” he shared.

“It happened during the pandemic when we were needed and there was real hope that change would happen to utilise these skills,” he added.

Easing the burden on secondary care in West Kent

In West Kent, IP optometrists helped to ease the burden on secondary care through the Acute Primary Care Ophthalmology Service (APCOS).

The number of monthly cases seen through the service increased from 371 in January, 2020 to 641 in June, 2020.

Over the same period, the number of patients seen through the hospital’s rapid access clinic declined from 861 in January to a low of 372 cases in April.

Cases at the rapid access clinic rose to 610 by June. However, this is still lower than pre-COVID attendances – with more patients seen in the community over the same month.

Professor Ejaz Ansari explored the effectiveness of the service alongside IP optometrists Manish Patel and Dr Deacon Harle in their research published in Journal of Optometry in January this year.

Harle told OT that it is important to show that IP optometrists can be commissioned to safely manage a broad range of conditions and support the hospital eye service.

“This has implications not only for crisis situations, but locally it has made the hospital trust realise that there are many more suitable cases that can be repatriated to this community service to help share the increasing burden of cases,” he said.

Harle shared his hope that the APCOS model could be rolled out within other areas of the UK.

“There are as many therapeutic IP registered optometrists in the UK as there are ophthalmologists. If we don’t use these skills effectively, beyond simple primary eye care services, then patient care will be delayed and significant avoidable blindness will occur,” he emphasised.

UK IP optometrists will learn from their US contemporaries about the use of lasers, injections and minor surgery at an event in December.

Dr Michael Johnson, an IP optometrist involved in organising the course, shared with OT that the foundations will be taught to enable clinicians to work within their scope of specialist practice more comprehensively.

“International experts will cover treatment decisions, consent, management of complications, and relevant law,” he said.

Johnson noted that the traditional centralised model of delivering ophthalmology has left many people unable to access eye care.

“There is a clinical and human need for another way. It is not simply a matter of expanding capacity, but an opportunity to improve how things are done.”

He shared his view that there is a need for teams based in the community, who autonomously manage a wide range of eye disease – not just minor eye conditions.

Johnson added that optometrists must trust themselves to take responsibility for doing what is in the best interests of their patients.

“Waiting to be told what to do and shying away from challenges will cause optometry to become a simulacrum of a profession,” he said.

The event will run from December 9-12 at BMA House in London. Although the event was fully subscribed at the time of going to print, a limited number of additional places will be made available. Contact [email protected].