“It's been years in the planning”

The final week of September saw Optometry Wales (OW) announce reforms to the way sight tests and extended services are carried out in the region: five levels of service were unveiled, with revised fees that have been designed to reflect the increased scope of clinical service that is already being carried out by optometrists across Wales.

After the reforms were published and legislation confirmed by the Welsh Government, OT caught up with Optometry Wales’ chief executive, Sali Davis, to gauge the profession’s reaction and dig deeper into what the future holds.

Looking ahead

What has the reaction been since you announced the reforms?

Very positive. I was expecting a mixed reaction from the spread of practices, across multiples and the smaller independents, especially because of the rurality of Wales. But actually, the reaction has been hugely supportive.

There are some concerns about the workforce, and how the new contract will be delivered. During the webinar, being able to see the applause and the congratulations outweighed some of the meatier questions around how it will work logistically. But I think that now people have had time to let it sit, and now that they’ve gone back into practice and done the sums, they’re even happier with the package overall.

Is Optometry Wales planning to support practitioners in upskilling?

From our membership angle, we will be offering any bespoke training to practices that they want. 647 people dialled into the webinar. That has pretty much covered every practice across Wales, which is great.

There was a lot of information and a lot of questions, so I’m currently working through an FAQ list that’s about 200 questions long. Once I have that FAQ completed, I’m going to circulate it to the entire profession. The links will be on our social media and will also be sent out via email, which is the main way that we contact our membership.

Once the FAQ is out, we'll make ourselves available for virtual calls with practice teams, practice owners, individual optometrists, locums, or anybody else, so that we can check-in with them.

Following that, we will deliver a series of roadshows that will focus on managing change. It’s going to require massive cultural change. Optometrists will have to turn around what they’ve been used to doing. Instead of 80% retail and 20% clinical, it’s more likely to become 80% clinical and 20% retail.

Optometrists will have to turn around what they’ve been used to doing. Instead of 80% retail and 20% clinical, it’s more likely to become 80% clinical and 20% retail

Already, we can see requests to Health Education and Improvement Wales (HEIW) from those that don’t have higher qualifications. They were inundated the day after the webinar, in a way that they haven’t been before. Coverage across Wales is good for the higher qualifications anyway, which we know. We wouldn't have delivered a contract had we not thought we could. We know that every area, pretty much, is covered in terms of those higher qualifications. The Welsh Government is also happy to continue to fund those higher qualifications, so that’s good from our perspective.

We’re also going to offer practical sessions. Some within the profession have piloted this work already. We’ve built up that experience, and we’re going to facilitate those practices to talk to others: “This is how we do it; this is how we manage our diaries.” It will require practices to be quite vulnerable about their business models, but we’re doing that by getting somebody who is doing it currently to share best practice as to how it might work.

Securing change

How long did it take to get everything in place, and how many people have been working on it since the ideas were first floated?

Since I came into post 14 years ago, this was the main remit. No one had done the role before in Wales, and the OW board basically said “we would like a contract for the profession. We think we’re ready.” It’s been 14 years in the planning. At the time we had only recently devolved and acquired a separate health budget, so it hadn't been possible to look at a contract until then. With various health ministers, we’d never really been able to have that conversation or release any kind of funding into optometry, until we proved that services are actually working and can work in this way. It’s taken a long time to get to where we are now.

When did the legislation that has just been signed off specifically take shape?

We began to have those conversations in 2017 or 2018, and then the pandemic stopped everything. However, the services that we were able to deliver during the pandemic really showed the Welsh Government that we were able to work and clear backlogs of patients, especially those who were independent prescriber (IP) qualified.

The services that we were able to deliver during the pandemic really showed the Welsh Government that we were able to work and clear backlogs of patients

That really led them to come back to us during the pandemic and say, “I think we can deliver this contract, even if we do it virtually, and take advantage of the fact that we've now got this magnificent data that shows that primary care optometrists can see patients that could have been seen in secondary care in primary care at a better cost.”

How many people from Optometry Wales have been involved in getting the reform through?

The rules of engagement with Welsh Government were quite clear: we couldn't bring 30 people into the negotiation room. So, we had to select a very small team. My previous chairman, Andy Riley, formulated the idea for this contract and how it could work. We brought him into the negotiation room. I also took my treasurer, who works for a large multiple, my vice chair, who also works for a large multiple, and my current chair, who works for a small independent and was previously on the other side of the negotiation table during lockdown. I wanted to have a good mix of people in that room.

We engaged very heavily with the UK optical bodies. We had meetings with them every three weeks so that they were aware of everything that was being discussed. We shared all the papers, and any initial financial proposals.

How did you go about developing the positive relationships with government that could move this forward?

It’s been years in the planning. It’s me working in this full-time role, whilst for everybody on the board and council, this is something they do in the evening. It’s really required somebody working full-time to be available to quickly jump into meetings and to respond to government requests.

We’ve put money into building up an evidence base for what we do in Wales that will allow us to have those conversations with Welsh Government to say, “this is the money we save, this is what we can do.” That's been crucial. The negotiation process proved that you have to back it up with figures.

We also worked closely with David O’Sullivan, the chief optometric adviser. We already had a good relationship with him when he moved into that pivotal role.

The finer details

Some of the voucher values are going down, as detailed in the webinar. Could you explain this decision was made to reduce the value of some of those?

It was made very clear to us by the Welsh Government during the negotiation process that vouchers are a patient benefit and not a practice benefit. When the Welsh Government did their own research, they found that it was possible to dispense a pair of spectacles within the voucher value. So, they wanted to fully embed a higher clinical fee for the work that we do as clinicians, and take away in part the cost subsidy that exists on having to sell glasses and run a practice. We confirmed this with our own research. Practices will still be able to offer private sales.

Could you comment on the changes to how domiciliary is going to be funded?

Domiciliary is going to be interesting. Right now, it’s very narrow in terms of who you can see, and when you can see them. It’s going to be widened. You will now be able to deliver and claim for additional levels, such as acute eye care and follow-ups, and some of the higher qualification work. We will also be removing the advance notice rule.

Could you address the concerns of practitioners who might be worried about being asked to do higher level work than they’re comfortable with?

On our financial modelling, and backed up by the Welsh Government’s financial modelling, if as a practice you chose to stay exactly as you are and not deliver any of the any of the higher levels, you would still be better off in terms of your income coming into the practice by the sight test alone. Just your General Ophthalmic Services (GOS) work will automatically make you better off. None of the higher qualification work is mandatory. You could carry on just as you are, doing a mix of private and GOS work, and you would still financially be better off.

The webinar stated that Level 2 would be the 'baseline.' Could you clarify what that means?

We'll have Welsh GOS Level 1, which is your sight test, which is £43. Level 2 is Eye Health Examination Wales (EHEW) bands one, two and three. The expectation will be that you have to have an EHEW accredited optometrist in your practice delivering Levels 1 and 2, although I do not anticipate that we will be specifying times that Levels 1 and 2 will be available, so it could be half a day a week, but you still need to have that that baseline service. It will be taken for granted that every patient will be able to walk into any practice in Wales and have an EHEW/Level 2 service.