“The million-dollar question”: an insider’s guide to GOS negotiations
OT talks with the chair of the organisation responsible for negotiating the General Ophthalmic Services fee
20 May 2022
In March, the Optometric Fees Negotiating Committee (OFNC) announced that the General Ophthalmic Services (GOS) fee would rise by 2% from April 2022.
The OFNC, which comprises the leaders of UK representative bodies within optics, expressed disappointment with the level of increase.
The marginal rise follows rising inflation and cost of living pressures within the UK.
This comes within the broader context of a fee that has stagnated as the service offered by optometrists has become more advanced.
OT talked with OFNC chair, Gordon Ilett, about the challenges and opportunities for the profession amid ongoing efforts to negotiate appropriate Government funding of primary eye care.
How would you summarise the key points you put forward as part of the GOS bid this year?
This year, following some limited success with last years’ bid, OFNC decided to focus on two key areas. The first was the effect of inflation, which, at the time of writing the bid documents, was predicted to be around 5% for a short period before falling back to around 2%. The other was addressing the historic funding gap.
Put simply, there is a difficult balance to be struck when coming to a decision about what level of increase to propose. The undeniable importance of sight testing must be balanced with realism and the context of what the rest of the NHS and other primary care professions will receive. The metaphorical elephant in the room is that the profession has consistently over-performed, offering an improving service year-on-year. However, the NHS can counter this by noting that it never asked for this increased level of service, although it now both happily accepts, and expects, these increased standards to be maintained.
The balance of these factors means that if we ask for what is perceived to be too much of an increase, the bid may appear detached from reality and lack credibility, but as we know the profession offers an important service that deserves to be fairly funded.
In our view, that appropriate and balanced recommendation was this year to ask for a 7.1% increase in the sight test fee. This was broken down as 2% to reflect inflationary pressures and 5% to close the historic funding gap.
While some practices had handed back their GOS contracts and become private only, the overall trend in the number of NHS contracts was broadly stable, if not increasing
I’m aware that many would say that 5% doesn’t even get close to the historic funding gap. I’m inclined to agree, but there is a difficulty that can’t be ignored: there hasn’t been a mass exodus of the profession from the GOS contract, and the NHS perceive this as tacit agreement that the NHS sight test fee that is being offered is acceptable. Any arguments about inflation cannot rest simply on calling for an uplift based on a reference point in the distant past.
OFNC took the view that given the period of austerity that started around 2010, that was a reasonable place to start. Using the accepted measure of inflation over that period gave a 13% real term reduction in the sight test fee, and while many may ask why we didn’t suggest a 13% rise, this is where pragmatism and realism becomes important. Given the wider pressures on the health system in a post-COVID world, the OFNC view was that asking for 13% would fail to recognise those wider pressures, and as such 7.1% was considered an acceptable compromise.
What trends are you seeing within the optical workforce regarding the decision to move away from a GOS contract? What factors are driving these trends?
We were aware that the suggestion that practices are handing back GOS contracts in their droves has become a common narrative and OFNC considered putting this forward as part of the process of making our case with NHS England. To fact check this, the variation in contract numbers was obtained. This in fact revealed that while some practices had handed back their GOS contracts and become private only, the overall trend in the number of NHS contracts was broadly stable, if not increasing.
There are a number of reasons the move away from GOS hasn’t been more pronounced. It may reflect the socio-economic constraints that are a reality for many practices based on their location; a concern about the impact that this change may have on their businesses; or a concern about how patients who cannot afford to pay will be able to access eye care.
How does under-funding the GOS sight test affect patients and the profession?
The underfunding of the GOS sight test places the profession in a difficult position. To deliver the standard of care that patients deserve, and that practitioners want to provide within the current fee on offer, is challenging at best, and some would say it isn’t possible. We know that most practices cross-subsidise clinical care from the retail portion of the business, which raises in turn ethical questions and contributes to the false perception with many of the general public that optometry is a retail profession.
I know that cross-subsidy may not be sustainable as the world evolves and, if that happens, the question of how patient care is funded becomes even more problematic. Some practices are moving to a subscription service based model, and while this will be suitable for those that can afford it, there is a risk of increasing health inequality for patients without the means to pay for care. As healthcare professionals, that leads to hard decisions that many of us would rather not have to make.
It is worth keeping in mind the value that GOS brings to the nation’s eye health. I would not want future generations of patients, or practitioners, to find themselves in a position where GOS sight testing had suffered a dramatic decline and that any potential replacement was now unaffordable, far less effective or both.
What is needed to achieve a higher GOS fee?
This is the million-dollar question – and each of the answers to it come with significant downsides. Simple modelling suggests that doubling the GOS sight test fee in England would require around an additional £280m of funding; with the pressures on the NHS including the backlog in patient care at the moment, that could be difficult to find.
Could we look at other ways to increase the fee? We could limit who has access to NHS funded sight tests, or seek to restrict the number of NHS funded sight tests, but what cost does that mean in terms of equity of access to care, disease detection and prevention? We know that most glaucoma is picked up opportunistically at a sight test and the cost of not doing so could have severe implications for patients. There is also the cost of providing ongoing care and support to patients who may suffer avoidable sight loss or visual impairment that shouldn’t be underestimated.
I’m sure that, to the minds of many optometrists, these arguments supporting the case to increase the sight test fee are persuasive, and reflect reality. Unfortunately, the way health and social care budgets have been split over the last few years means that the big picture view is lacking. Faced with a limited pot of money available in health, we are in effect asking the NHS to defund other areas of care to fund eye care. What makes us more important than, for example, cancer treatment, heart disease or dementia care?
Not only can those areas of care make equally compelling arguments, those arguments will resonate with the public.
I’ve seen some suggest a work-to-rule type approach with regard to GOS, or even strike action. It is worth noting that as most optometrists are now employees, that is unlikely to be successful. As long as the business they work for continues to pay their wages, I don’t see this being a viable option.
To achieve a higher fee we must make sure that the NHS and the public are aware of the importance of what we do as a profession. We need advocates and champions for the importance of eye care – and then hopefully we can see the funding that would give us the basis to take an already excellent service to another level.
How do you think the rapidly increasing cost of living will affect the optical workforce and consumer behaviour in optical practices?
The rising cost of living poses a significant challenge, and the optical workforce will be noticing that their wages aren’t stretching as far as previously and will be looking for increased salaries or locum fees to maintain current standards of living. This will particularly impact the less well-paid staff members who might even be struggling to make ends meet.
For business owners, the increased cost of fuel, shipping, materials, and component parts will make it harder to maintain current spectacle and contact lens prices. Patients will be under the same pressures and will be looking to limit costs where they can, and this may mean they will be less willing to purchase new frames or lenses unless they are deemed an essential purchase.
As clinical care is cross subsidised in many cases by retail, the cost of living crisis adds increasing pressure to focus on the retail side of the business and may prevent practices from investing in, or focussing on, clinical services.