The GOC's education strategic review

The consultation

The GOC recently consulted on the future of optical education as part of a strategic review of education.

The main goal of this review is to equip students to meet patients’ future needs, as technological change and the increased prevalence of enhanced services are altering the roles that optometrists and dispensing opticians play in delivering eye care.

The review covered the following areas:

• Changes in demand and in the delivery of eye care
• The GOC’s approach to education
• Content of education programmes
• Professionalism and consistent standards
• Barriers to change and other issues to consider

Process in reaching our response

• Significant discussion and workshops on the future of education at the AOP’s October 2016 Council meeting
• Formation of an expert education review group to formulate the AOP response, with representatives from across the UK and from a range of modes of practice
• Input from members from across the UK to key aspects of the call for evidence through our community forums. We raised awareness of this opportunity to all our members via email and social media
• Full consideration of the AOP response at March 2017 Council.

Changes in demand and the impact of changes in eye care delivery

Question 1. How might the needs of patients requiring eye care change over the next 20 years?

We expect to see an increase in the need for refractive correction across all age groups. Alongside this there will be an increase in eye disease and in the general vulnerability of older patients.

We are going to see a sharp increase in the prevalence of certain eye diseases. The Foresight Report¹ predicts that in the 20 year period between 2010 and 2030 AMD will increase by 80%, cataract by 64%, glaucoma by 52%, and diabetic retinopathy by 28%.

With the ageing population, there is also going to be an increase in the prevalence of visual impairment. This will mean more demand for low vision services. There could be an increase in technology for these to aid people with visual impairment such as artificial eyes, virtual headsets/specs. More people will be living with one or more long term condition such as diabetes, AMD and dementia.

Also, myopia is on the rise internationally and optometrists will become more and more heavily involved in myopia control.

We may see the demand for ophthalmic surgery rise. The demand for cataract surgery will rise due to the larger numbers of older people. Innovations in refractive surgery will make it more easily accessible for patients. We are currently waiting for the results of trials but optometrists may well be using laser procedures for instance SLT (selective laser trabeculoplasty) and iridotomies as a first line in treatments for glaucomas.

There is no reason why in the future specialist optometrists cannot perform these procedures. As patient access to technology increases, people will increasingly be encouraged to take more responsibility for their own care and prevention of illness. We are likely to see self-monitoring and self-measurement of intraocular pressures. Patients could also be using technology to be able to take their own retinal photos or even carry out OCT for themselves.

The role of the healthcare professional may therefore increasingly include using their knowledge and expertise to interpret and treat and support patients who are already self-managing their healthcare. Patients will need expert advice and guidance from registrants on use of available eye health technology.

Question 2. What changes in how and where eye care is provided will be required over the next 20 years in order to meet patient’s needs, and what are the barriers to these changes? 

As people live longer and the NHS will deal with more patients with co-morbidities, registrants, and all health professionals, will need to deliver more public health advice and intervention. Optics can play a part in a general shift towards whole population health promotion and disease prevention with an emphasis on healthy living, diet, smoking cessation and alcohol reduction.

More eye care will move from hospital settings into primary care, where it is more convenient for patients and more cost-effective for the NHS. Primary ophthalmic services need to integrate with the NHS “right care” agenda and care needs to become more patient centred. There will be new drug treatments for chronic eye diseases eg wet AMD and glaucoma.

The recent Royal College of Ophthalmologists report, The Way Forward² shows that in the future that there will not be enough ophthalmologists to meet demand. It has recognised multi-disciplinary working as key to managing current and future demand in eye disease. Optometrists will need to be involved in delivering this care, both in hospitals and in the community as the prevalence of these conditions increases.

Greater inter-disciplinary working will be needed with good systems of communication; crossreferral and shared records. More health care advice to patients may need to be delivered remotely (virtual care). Patients will increasingly care for their own health and wellbeing with remote support from healthcare professionals.

We will see greater use of technology for diagnosis and analysis, and perhaps the use of big data will increase in future medicines and health management. Technological developments may facilitate more remote and tele-health practice. The optometric role should be taking overarching responsibility for primary eye care, treatment and disease management and we will see more optometrists working in hospitals and in domiciliary care.

We also believe that optometrists will increasingly deliver part of an episode of care rather than a complete ‘sight test’ or ‘eye examination’. Education and regulation need to recognise the optical professional as part of the wider healthcare team, rather than primarily as a tester of sight and issuer of prescriptions.

Barriers

Differences in commissioning across the UK, especially within England, have slowed progress towards more comprehensive community eyecare.

As MECs and other schemes develop they need to cover costs and indeed compete with the dominant optometric business model, which subsidises clinical work through the sale of appliances. The clinical contribution within an optical practice needs to be given its proper value and the business model needs to adjust to reflect that.

The Royal College of Ophthalmologists, as already mentioned, has published guidance based on best practice and innovation in ophthalmology. This practice is not yet comprehensive, although we are confident that others will follow suit and that the recent reduction in the follow-up tariff may encourage a shift in care from acute to community settings. We hope that ophthalmologists will increasingly feel confident in moving work into the community, given appropriate oversight and governance arrangements.

Referral between primary eye care services and to secondary care is made more difficult by the lack of connectivity with NHS IT systems. Also as there are a myriad of NHS IT systems (EMIS, System One etc). There are numerous examples in local health economies (between primary, secondary, community, social care and voluntary sector providers) of different IT systems being additional barriers to effective care for patients.

A further barrier is that patients and other health and social care professionals do not have a full understanding of the evolving roles of eye health professionals. Members of the public still see themselves as customers in relation to optical practices and their visit to an optical practice as a retail experience³ . There will need to be considerable work done by the sector and regulator to change the public perception.

Question 3. How are the roles of optometrists and dispensing opticians likely to change over the next 20 years, and what are the drivers for these changes?

Optometry as a profession is well placed to take on an extended role that will include clinical tasks in therapeutics, disease management and some aspects of surgery. There should be greater involvement by registrants in all the components of primary eye care, especially services for minor eye conditions, glaucoma and cataract. This is already starting to take place.

Technology will enable some tasks to become more automated, which could in time be done safely by others, under the supervision of optometrists. We believe that prescribing optical appliances should remain within the optometric role to ensure patient safety, clinical governance and accountability. Likewise in all roles and functions the ultimate responsibility for the patient needs to be clear and rest with an identified individual.

However we recognise that optometrists and dispensing optician could work increasingly with other eye health professionals including orthoptists, ophthalmologists and ophthalmic nurses. We can see the value of fewer divisions between professional groups. There is already considerable overlap between optometrists and orthoptists.

This should not just extend to eye care professionals but also our other primary care colleagues (GPs, Pharmacists etc). There is a common prescribing competency framework for all independent prescribers (GPs, dentists, nurses, pharmacists etc) which was developed by the Royal Pharmaceutical Society in collaboration with NICE⁴. There is scope for joint education which could facilitate inter-professional working and mutual respect and understanding.

We feel that a greater number of optometrists may also be working in hospitals in the future. There could also be a continuing trend towards more part-time and locum working. This could have a number of implications. If an optometrist’s role becomes more clinical, then perhaps the locum role will change and become more like medical locums, who take on placements to cover for holidays, and illness, rather just for a day a week etc. Clinical qualifications will be much more important and relevant certification and experience is vital for these locums.

Drivers for change

There are a number of factors that will be driving these changes over the next 20 years. Hospital eye departments are over burdened and additional ophthalmologists are expensive to train. The evolving eye care needs of an ageing population can only be addressed by widening the role of registrants and moving more services into primary care. The recent work of the Royal College of Ophtalmologists both on a competency framework for non-medical optical professionals⁵ and on innovative pathways for the main eye diseases⁶ are both important contributions to the debate on this change.

Question 4. How should the education of optometrists and dispensing opticians be structured to enable continuing professional development throughout their careers, eg core training followed by general or specialist practice? 

While the evidence is that adults learn more effectively in clinics than in lecture theatres, undergraduates do not generally arrive at university as independent learners, so a variety of approaches is needed.

We believe that a modular education model should be adopted. This would allow increased opportunity for optometrists and dispensing opticians to benefit from joint study alongside other eye health professionals and others where there are elements of a course in common.

Education should be structured so as to provide more flexibility for students to develop specialist interests and prepare for further specialisation after graduation.

Students should be taught to develop skills to allow them to adapt to changing professional requirements during their career. Undergraduate courses should be primarily focused on understanding 'why and to what end tests are done' as this will help practitioners adapt to changes in technology. However, the current stage 1 competency framework seems primarily focused on demonstrating 'how to' rather than understanding ‘why and to what end’.

We feel that CET ought to become CPD, in common with many other professions in order to encourage professionals to see it as continually developing their skill base as well as validating their existing one. CPD is about gaining experience and acquiring new skills, not just about maintaining current entry level skills. Peer review and discussion is also an important component. The ability critically to analyse evidence and data as well as one’s own clinical practice is also key.

Question 5. What are the implications for the GOC register of likely changes in roles and will the existing distinctions between registrant groups remain appropriate? 

As our answers to the previous questions indicate, we believe that functions rather than titles will become more important in future, although we do expect change to be slow. This may mean that in due course professionals will be registered to carry out a range of skills and functions rather than by a professional label.

One register for all eye health practitioners could act as public reassurance that all professionals are expected to act within their competence. We feel that career progression between professions needs to be reviewed and made more flexible.

GOC’s approach to education

Question 6 – What are your views on the GOC’s approach to the accreditation and quality assurance of education programmes, including on whether this is an appropriate focus on outcomes and on the use of the competency model to set the standards of education?

We feel that the GOC is too ‘input driven’. We would rather see the GOC specify reasonable outcomes. An example of an over reliance on inputs is the implementation of minimum real patient experience requirements. The provider would then be free to use its expertise to get students to satisfy the competencies.

Less specificity in the definition of the competency framework would allow it to be better integrated into the undergraduate optometry programme, avoid a ‘tick-box’ approach and allow a better learning experience to be delivered. The GOC could, for example, define a set of outcomes describing understanding and abilities that a graduate should possess. This approach would enable universities to more easily embed the outcomes in learning modules and not need to 'tick them off'.

This would mean that stage 1 (undergraduate) and stage 2 (pre-registration) competencies could also be better differentiated, with a list of specific competencies being more appropriate for stage 2 assessment. If the option for some registrants to move into a more clinical model of practice exists, then there will need to be more freedom to make clinical decisions. There is a need for a core competency where the basic role is defined but clinical freedom is maintained.

We hope that as its review progresses the GOC will investigate the approach taken by other regulators and adopt a “right-touch” approach, focussed on the need to provide a good learning experience for students and produce professionals who provide a safe, high-quality service to patients. This is the approach to regulation that is recommended by the PSA⁷ and is implicit within the Law Commissions’ recommendations for healthcare regulation⁸ .

Question 7 – Should the GOC accredit and quality assure additional or different higher qualifications and if so, on what basis?

We do not believe that the GOC should necessarily be involved in accrediting or quality assuring higher qualifications. These are covered by the service specification negotiated with commissioners which includes quality control.

The College of Optometrists has been successful at getting universities to buy in to its framework of higher qualifications, and this has been good insofar as it has given the same platform for a postgraduate refresher for optometrists providing enhanced services. Development of these qualifications has been a response to demands in the NHS. It would be difficult for the GOC, in common with other regulators, to respond in a timely way to such evolving needs of the health
system.

Greater involvement by the GOC would create confusion and potentially duplication and is unnecessary.

Content of education programmes

Question 8 – What are the core skills, knowledge and behaviours which optometrists will need to have on first joining the register in the future?

The core skills, knowledge and behaviours which optometrists currently need to have on first joining the register are outlined in the current QAA benchmark for optometry⁹ .

We would broadly describe the education domains needed as prescribing, public health, technology, communication skills, detection and management of pathology, refraction, patient management, decision making and consistency with other health professionals.

We would argue that in the future greater emphasis will need to be placed on the ability of graduates to utilise primary research as an evidence base for practice, and apply this in conjunction with sound clinical skills, a problem-solving approach to clinical care, and the ability to self-reflect and critically analyse. This needs to be done at the same time as maintaining core clinical skills, which are best embedded through practical experience.

Question 9 – How should the content and delivery of optometry programmes change to ensure that students gain the skills, knowledge and behaviours that they will require for practice and for new roles in the future?

As we have explained above, we believe that some elements of common core education in optics and eye health should be provided alongside other eye health professionals in training. We believe that the future optometrist undergraduate degrees should adopt the medical and nursing approach which focuses on general education that allows professionals to develop and work within their own set of competencies.

In our discussions we have found some members advocating much greater amounts of patient contact time in the optometry degree and suggesting that lack of practical experience hampers preregistration students’ effectiveness. The contrary argument is that the pre-registration year is precisely for learning how to use skills learned at university in patient-facing work. In other words there is a lively debate about the correct balance between practical clinical experience and the learning of technical skills and underpinning theory in the undergraduate degree.

In preparing our response we have considered a number of suggestions such as that all optometric undergraduate courses should become 4 year MOptom or even 5 year courses in which the fifth year is the pre-registration year. We have also considered the US model of a Doctor of Optometry. We are not advocating these models at this time as standard, although we do feel that the course length might have to be extended if there is more content to cover and in order to achieve the right balance between theory and practical experience.

We do feel that pre-registration training should cover all aspects of optometry, and that the preregistration year should cover all modes of practice.

Question 10 – How might post-registration training and registrable higher qualifications for optometrists need to change in the future? 

The GOC should ensure that a suitable and widely accessible therapeutics qualification is available for all optometrists as a stepping stone towards the full IP qualification. This could be achieved by making the AS qualification more achievable, although it also needs to have a useful purpose. Placements required for IP should be able to be carried out with suitably qualified IP optometrists, not only with ophthalmologists. We also feel that there is potential for modular education to enable access to specialist roles.

We would argue, however, that IP should not be part of undergraduate education, because there is not enough IP work for such a large number of practitioners to remain current.

Question 11 – What are the core skills, knowledge and behaviours which dispensing opticians will need to have on joining the register in the future?

We have described above our view that there should be elements of common joint study for eye health professionals where possible.

We have also said that while prescribing should remain the responsibility of an optometrist, we think that some other clinical processes could be delegated under the supervision of the optometrist, and with the necessary clinical governance.

Skills in occupational health and rehabilitation will be important to allow registrants to make dispensing decisions for patients with these needs. Given the ageing population and the consequent likely increase in people living with sight impairment, we would like to see the role of Eye Care Liaison Officer (ECLO) added to the core skill set for dispensing opticians.

For the same reason, the skills within the existing LVA higher qualification could be added to the set of core skills for dispensing opticians. Skills and knowledge in the use of highly customisable eyewear are likely to be needed as these devices become more prevalent. This may for example include Computer Aided Design (CAD) to place dispensing opticians as the first port of call for customised eyewear.

We believe that the titles of optometrist and dispensing optician will continue to be used for some time. However, as we have said above, we think that in due course professionals will be registered to carry out functions that they are trained and qualified to do, rather than be defined by their title. As a separate matter, the process for overseas applicants joining the register should also be improved and simplified, whist ensuring that new registrants are fit and competent to practise.

Question 12 – How should the content of dispensing programmes change to ensure that students gain the skills, knowledge and behaviours that they will require for practice and for new roles in the future?

Practice-based training is an important part of training but there currently exists a great variation in delivery on programmes. The supervision element potentially falls between two groups: the training provider and ABDO as the gateway to entering the register. Better clarity on the role of ABDO in this would be helpful. 

More parity across training programme learning outcomes would be welcome across both higher and further education providers.

Components that could be added to dispensing programmes are:

• A placement day with hospitals in low vision units or sight loss charities
• CAD training
• Counselling and modules for sight loss
• Use of new technology such as auto-refraction, imaging and glazing
• More content on eye disease, both sight threatening and minor eye conditions

Question 13 – How might post-registration training and registrable higher qualifications for dispensing opticians need to change in the future?

The contact lens specialty qualification training and assessment framework should be reviewed to ensure it meets evolving health system and workforce needs.

Dispensing opticians, in particular CLOs, are starting to be involved in the delivery of enhanced primary eye care services for minor eye conditions. Development of qualifications in diagnostic and investigative techniques, and triage would support their involvement in these schemes. However beyond the CLO qualification these should not be regulated by the GOC, for the same reasons that we stated in relation to optometric qualifications.

Professionalism and consistent standards

Question 14 – How can we ensure students have the professionalism needed to take on new roles, including through the admissions procedures used by education providers, patient experience, supervision and embedding professional standards?

Some elements of professionalism are learnt and it is probably inappropriate to select people on the basis of already possessing them. There may be a case for teaching skills such as leadership, management and communication alongside core competencies to help equip students for the working world. The selection and admissions procedures adopted by education providers should assess students’ ability to learn those skills.

If the OSCE system is examining the student, then part of the assessment should be of their approach and professionalism, though we recognise that this is harder to objectively assess than existing core competencies.

Question 15 – How should students be assessed prior to joining the register to ensure that there are consistent and appropriate standards of education, taking into account the different types of education programmes that are emerging?

As we have said before, we believe that the GOC’s approach to defining competencies is too detailed and too focussed on inputs. We believe this has led to a “tick-box mentality” among some students.

Assessment should cover the ability of students to synthesise the technical information gained from diagnostic tests with information gained from the patient, in order to make sound decisions with and for the patient.

Barriers to change and other issues to consider

Question 16 – What are the challenges and barriers to improving the system of optical education, including issues that may be outside the remit and control of the GOC, such as legislative change, workforce planning, the funding of education (including higher education, continuing education and training and continuing professional development) and the provision of student placements?

We understand that it is not within the GOC’s power to compel institutions to institute changes such as the development of common competency frameworks or joint study programme across professional groups. We are also aware that this would not be an easy change for the institutions themselves.

We would however like to see the GOC mandate that some inter-professional education take place as part of the undergraduate programme for optometry students. The GPhC mandates inter-professional study for pharmacy programmes. We are also aware of examples in other parts of healthcare education. For example St George’s University in London says “right from the start, students on all our courses learn with, from and about each other.

The aim of this inter-professional learning is to reflect the multidisciplinary nature of delivering healthcare today“¹⁰. We hope that the education review will create a platform for the GOC and educational providers to discuss these ideas, involving other regulators and professional bodies in the discussion as appropriate.

Question 17 – Are there any other issues that we should consider in carrying out our review? If so, please set out what they are.

We welcome the fact GOC has engaged with stakeholders to this point. We would like to see that continue. The AOP looks forward to continuing this engagement as the review progresses, and after its completion.

If you would like any more information, please contact a member of the policy team on [email protected].

1. 2020 Heath (2016). Foresight Project Report: A discussion of the potential impact of technology on the UK optical sector to 2030
2. Royal College of Ophthalmologists (2017) The Way Forward
3. Enventure Research (2016) “Public Perceptions Survey 2016”. General Optical Council
4. The Royal Pharmaceutical Society (2016) A competency framework for all prescribers
5. Royal College of Ophthalmologists (2016) Ophthalmology common clinical competency framework
6. Royal College of Ophthalmologists (2017) The Way Forward
7. Professional Standards Authority (2015) Right touch regulation
8. Law Commission (2014) Regulation of Health Care Professionals
9. Quality Assurance Agency. (2015) Subject benchmark statement. Optometry
10. St George’s University (2015) Boost your career