Key concerns

The Association of Optometrists (AOP) is the leading membership organisation for optometrists. We represent over 80% of the UK's optometrists. Our membership also includes registered optometry students, pre-registration trainees and some Dispensing Opticians.

This paper sets out our response to the GOC's 2020 consultation on revised draft Outcomes and Standards for optical education, and on a draft Quality Assurance and Enhancement Method. Our response, which focuses on the education and training of optometrists, consists of two sections. Section 1 draws together our key concerns about the overall impact of the GOC's Education Strategic Review (ESR). Section 2 gives our answers to the specific consultation questions posed by the GOC.

Our response has been developed with the AOP's Policy Committee, the Students Committee, the Hospital Optometrists' Committee and our Council, and with input from our wider membership. Given the breadth of practitioners' views that we represent, we hope and expect that the GOC's Council will give significant weight to our response.

Below are our key concerns:

Section 1: Key concerns

Financial impact of the ESR and implementation timing

Our joint statement with the College of Optometrists and the Optometry Schools Council (OSC) on 1 October 2020 set out our concerns that uncertainty over the funding of the proposed new education framework could significantly disrupt future optometry education and training, affecting patient safety and public confidence. We, along with the College and the OSC, therefore called on the GOC to:

  1. Confirm that it will work closely with education providers and other stakeholders to address the likely financial impact of the proposed new framework and the sources of funding to deliver it
  2. Commit to establishing that the new model is financially viable in all four nations of the UK before taking the final decision on approval

In this consultation response we have addressed the GOC's specific consultation questions, and we have proposed changes to improve the new framework if it is introduced. However, these changes would not mitigate our over-riding concern about the need to confirm the financial viability of the new framework before it is implemented. It is vital that we and other stakeholders have a proper opportunity to comment on the GOC's commissioned assessment of the ESR's financial impact before the GOC takes a final decision. 

Weak rationale for a compulsory integrated model

We said in our 2019 response to the GOC's last consultation on the ESR that it should set out the public protection rationale for moving to a one-stage journey to registration for all optometrists, and explain how it has balanced the benefits and risks of this change. The GOC has still not done this. 

We remain concerned about the likely costs and impacts of a compulsory integrated approach, and do not think the benefits the GOC has suggested the model will deliver can justify the risks and costs involved. We are not aware of any evidence that the proposed approach will improve patient safety, for instance by reducing fitness to practise issues. The GOC has said the integrated model would meet students' desire for more clinical content to be integrated with academic study, but this is entirely possible under the current optometry education model. 

The GOC has also said the proposal will increase student choice, but imposing an integrated model on all providers arguably reduces choice, and could also mean that students would have to decide on their whole path to registration, including the setting of their clinical placements, before starting study. The financial implications of the proposal seem likely to involve a further year of student fees for optometry training, which could make the subject less attractive to students.

A compulsory integrated model may appear to tidy up the GOC's regulatory role in education, by clarifying accountability for education delivery, but we do not think that in itself justifies imposing this model on the sector. Creating a new web of contracts between education providers, assessment providers and clinical placement providers will bring significant new costs and complexity. This will create new challenges for the GOC and may not in reality do much to resolve difficult issues, such as the current shortage of clinical placements caused by the pandemic, which can only be addressed by collaboration between all those involved.
 
As we said in our 2019 consultation response, this model also heightens the risk that employers may have undue influence over the design and delivery of optometry education. The compulsory integrated model will also increase the risk of inconsistent training and assessment, by removing the current College Scheme for Registration which most optometry students currently undertake to join the register. This could ultimately affect patient safety, as discussed below.  
 

Unclear minimum requirements to join the register 

In principle we support the move to higher-level requirements, and the current draft Outcomes are more clear, logical and fit for purpose than the drafts the GOC consulted on in 2018/19. However, the clinical content of the draft Outcomes is too high-level to provide confidence that all education providers using the new framework will train students to the necessary minimum standards to produce a 'safe beginner' optometrist.

The GOC has said it will 'co-produce' with the sector an indicative guidance document to provide more detail on required clinical skills. We welcome this proposal, which would enable guidance to be amended quickly in response to developments where needed. However, we think the guidance must be given a formal role within the new framework, to ensure that providers cover all the necessary clinical topics and to mitigate the risk of undue variability in course content. It should be possible to do this while allowing education providers to adopt innovative approaches to delivering content – for instance by adopting a 'comply or explain' approach, which would require providers either to follow the guidance, or to explain why they have departed from it.  

Risk of inconsistent and inadequate assessment of students

The new draft Standard 3.7 for education providers requires that student assessment criteria "must be explicit and set at the right standard", but does not specify what the "right" standard is. It is important that the sector has a clear shared understanding of how the GOC will ensure that appropriate standards of assessment are in place, particularly given that the proposed shift to an integrated model will remove the common final assessment that the College Scheme currently provides for the large majority of optometry students. This will allow education providers to take very different approaches to assessing student achievement, including at the crucial final stage which determines whether a student can join the GOC register. 

The GOC is proposing that all education providers should have to offer either a regulated qualification or an academic award on a national framework. We support this change, which will help to uphold academic standards in optometry training - at present the framework would allow the GOC to approve an optometry education award offered by any provider, such as an employer. However, the external scrutiny this requirement will provide will not have an optical focus, and cannot in itself be relied on to protect patient safety. 

The GOC has told us that the requirement in Standard 3.7 for providers to use "an appropriate and tested standard-setting process" will address this issue, and that the GOC quality assurance process will pay close attention to the standard-setting process each education provider is using. This highlights the need for the GOC education assurance process to be properly resourced, expert and transparent (see below), so that stakeholders can be confident that assessment standards in each education provider are comparable and robust. 
 

Assuring the quality of workplace supervision

The new draft Standard 4 for education providers includes requirements to ensure that the supervision of students on clinical placements is of appropriate quality. These are vital requirements; a survey of AOP members we conducted this year showed that a significant minority of recent pre-registration students found the quality of supervision they had received inadequate at least some of the time. We think the requirements should be strengthened by an explicit requirement that the quality of supervision should not be affected by commercial pressures.
 
We are publishing the findings of our member survey alongside this consultation response. It shows clearly that where supervision works well in the current system, this is often due to the 'beyond the call of duty' efforts of supervisors who are not properly funded to carry out their role. This is a systemic weakness in the current funding arrangements for optometry education. Introducing tougher requirements on supervision quality – which is vital if the new framework is to work effectively – will carry additional costs for education providers and extra work for placement supervisors. This is one of our key concerns about the financial impact of the new framework.   
 

Need for effective GOC oversight and quality assurance 

In our response to the last ESR consultation in 2018-19, we said that the proposed new approach would require robust GOC validation and quality assurance processes, which must be properly resourced. 

In assessing proposed new courses and monitoring those that are approved, the GOC will need the capacity to assess whether a wide variety of providers are delivering outcomes and meeting standards that are framed in a high-level way, and that allow a great deal of variation and scope for innovation. AOP members working in education providers have told us they think the GOC will need significant extra resources, including expertise in pedagogy as well as in optics, to do this effectively. 

As well as ensuring that visitor panels have the right skills, the GOC will need to devise and support a clear and robust quality assurance process, which visitors can apply effectively and consistently when reviewing an increasingly diverse range of education programmes. Given the vital role of effective GOC oversight, the GOC must ensure that its education function is fit for the new challenges it will face, and that its decisions on education issues are evidence-based, transparent and accountable. 

The ESR and degree apprenticeships

The AOP opposed the proposal for an optometry degree apprenticeship on which a 'trailblazer group' of optical sector employers consulted last year. As we set out in our consultation response, our view is that a mainly workplace-based route to registration as an optometrist, in optical practices that have a strong retail as well as clinical focus (as most do), would pose significant risks to patient safety and public confidence in the profession.

If the ESR framework is implemented, it will set the rules under which all new proposals for optometry education are assessed by the GOC to ensure patient safety and public confidence. This could include a revised proposal for a degree apprenticeship in optometry. Given the inherent risks we have identified in applying the degree apprenticeship model to optometry, it is absolutely vital that the new framework is robust. 

Given the concerns about the ESR that we have highlighted in this consultation response – including unclear minimum requirements to join the register, the risk of inconsistent and inadequate assessment of students, the need to assure the quality of workplace supervision and fund it properly, and the challenge of ensuring robust GOC oversight – we do not think the new framework in its current form could ensure the safety of any revised proposal for an optometry degree apprenticeship. Given the inherent risks in the degree apprenticeship model, any application for GOC approval of a revised proposal should automatically be treated as high-risk by the GOC, and subject to full public scrutiny and consultation. 

Student Fitness to Train (FTT) processes and guidance 

The AOP provides legal support and representation to our student members, including in 'Fitness to Train' (FTT) investigations run by universities. Through this work we know that our members at some universities have faced unfair investigation and hearing processes. This also creates a risk of inconsistent outcomes when a student faces both a university disciplinary process and a GOC investigation, bearing in mind that the GOC is the only healthcare professional regulator in the UK that requires student registration.

In summer 2020 we proposed to the GOC that the new ESR framework should promote appropriate FTT processes within education providers, by setting out guidance covering the principles that education providers should follow when running investigations, hearings and appeals. We are pleased that the latest draft of Standard 1 includes draft guidance in its requirements on student FTT. However, the draft guidance in Annex A to the Standards does not cover the key issues around fair internal processes in education providers and will need substantial revision and expansion to be fit for purpose. We have set out later in this response the principles that we think the guidance needs to cover. 

We note that the GOC could provide appropriate guidance on student FTT to education providers in advance of the ESR being implemented, and we think this issue should be taken forward as a priority whatever the next steps on the ESR, to ensure that current and future students are treated fairly.