The GOC's consultation on standards of practice

The consultation

Consultation on proposed new standards for individual registrants and students.

The AOP's response

Introduction

The GOC has now agreed to the new standards that will come into effect in April 2016. We’re pleased that the GOC took on board a number of our concerns and we look forward to working with them. However, the standards still do not reflect the reality of today’s optical practice. By imposing stricter duties on individual registrants without updating its code for business registrants, the GOC is making the system more unfair. In addition, we do not believe that the new standards for students are appropriate for their level of experience.

Our responses to the consultation questions are set out below.

Question 1. Does the new framework for standards as outlined in Figure 1. make clear the GOC’s new approach to setting standards and how these standards are distinct from the guidance provided by other organisations?

Yes.

Question 2: Do you support the GOC’s new approach to setting standards?

We do not believe the GOC’s approach is proportionate, consistent and targeted. It is unclear what risk has been identified which needs to be tackled by the introduction of new standards. The consultation document says, for example, “when compared to the standards of other healthcare regulators, the GOC standards are less detailed ........which may lead to uncertainty and inconsistency”. Is there any evidence that the difference between the level of detail in the GOC’s Code of Conduct and the standards of other regulators has led to uncertainty – and that this alleged potential uncertainty has led to risk to patients?

The GOC’s approach involves implementing new standards for individual registrants, both qualified and student, before introducing standards for bodies corporate. Ideally standards for all registrants should be introduced at the same time. If this is not possible then standards for corporate bodies should be introduced first.

There is no reason for standards for all registrants not to be introduced at the same time.

• There is no urgent need for the introduction of standards. If the problem is that
  standards for bodies corporate are not yet ready there is no reason or evidence why
  public safety would be in any way jeopardised by waiting until they are
• This would be equitable, ensuring that all registrants had the same obligations
• The consultation process would be simpler, allowing easier scrutiny of consistency
  across the standards
• It would be easier, if any inconsistencies are identified, to make appropriate changes to
  whichever standards need to be amended
• Bodies corporate, being employers, set standards of performance and create protocols
  to be followed within their practices by their employees. If standards are not 
  implemented simultaneously, it is possible that a situation may arise where an
  employed practitioner is required by his or her employer to behave in one way while the
  GOC standards insists that he or she behaves in a different manner. This would put the
  employee in an impossible position with consequent risks to patient safety.

Because employers have the power to set standards of performance and create protocols within their practices, standards set for bodies corporate will immediately also have a knock-on effect on their employees. Therefore, if standards are not to be introduced simultaneously, the public interest would be better safeguarded by the introduction of standards for bodies corporate first.

Many of the standards seem to have been copied from the GOS contract, from the GMC standards or those of other regulators and seem to draw heavily on the Francis Report, which was aimed at medical and social care providers. Not all of the recommendations are applicable to optometry and optics. Contractual obligations are very different from standards, and it is inappropriate for them to be used in this way.

It is also unnecessary for the profession to be governed by two sets of identical obligations, imposed by different bodies. While reference to GMC standards is understandable in order to achieve consistency across the professions, they should be copied with caution, because the relative risk to the patient is different between to the two professions and because they apply to healthcare professionals with different skills, working with patients with different ailments, providing different services in a different environment. For example, reference to the sharing of patient information, while desirable, is often impossible for optometrists and dispensing opticians for reasons of IT connectivity (or the lack of it).

Question 3: Do you support there being two sets of standards, one for optometrists and dispensing opticians and one for students?

No.

We do not believe that a set of standards for students is required. Students are working under the supervision of academic staff, or a supervisor approved by the College of Optometrists. It is unrealistic to expect them to have the experience or confidence to act against an instruction given to them by someone who has authority over them.

Adequate sanctions are already available to the University or the supervisor to ensure compliance with instructions given. If students must have standards, then they should be drafted by someone with detailed knowledge of the student experience and environment and should be developed expressly and exclusively for their needs and to ensure public safety. The proposed student standards as drafted are based on the standards for qualified registrants with a bare minimum of adaptation for their particular circumstances.

Looking at the GMC standards and outcomes for 'Tomorrow's Doctors'' (which is being overhauled at the moment) the main focus on that is the educational standards the student should be experiencing, rather than the onus being on the student to "must do". What the medical student should do is encapsulated on one page of this document. For the current optical students, much of this is way beyond the student's control or experience. In section 9 for example, how is a student to ascertain whether their supervisor has the appropriate training and experience to supervise them?

We are not aware of any significant risk posed to the public by students which would justify the introduction of their own standards; therefore, their introduction is not proportionate. As it is, optometric students are already, uniquely, subject to registration, which is hardly evidence of an approach consistent with that of the other regulatory bodies in the health sector. Imposition of standards as well is heaping Pelion upon Ossa.

The remainder of the questions relate to the standards for optometrists and dispensing opticians and standards for optical students. Please indicate whether you are responding with respect to just one set or both sets of standards.

• Optometrists and dispensing opticians
• Optical students

Question 4: Do the standards make it clear what the GOC expects from our registrants?

No.

The standards impose requirements that are not within the authority of some registrants – notably, employed practitioners, locums and students – to meet. In such circumstances, those practitioners will have no clarity about what they should do.

For example, some of the standards require the registrant to take responsibility for things that are beyond their control. For example, standard 15.2: “Ensure that all staff you....work with are aware of their obligations in relation to maintaining patient confidentiality”. How is a locum, attending a practice for which he or she has not worked before, supposed to do this?

Or standard 15.7: “Securely store and protect patient records to prevent loss, theft and inappropriate disclosure, in accordance with data protection law.” How is a locum, as above, supposed to ensure that the data storage in the practice meets the requirements of the data protection act?

These are just two examples of standards that should be applicable to bodies corporate and to practice owners and managers but are beyond the control, and even knowledge, of many registrants, especially locums and employed staff.

Question 5: Do the standards cover all relevant areas of optical practice and/or optical training?

No.

It’s not so much that they don’t cover all relevant areas, but that they go beyond what is relevant into areas that are not relevant for all practitioners.

Question 6: Are the standards sufficiently flexible to accommodate any changes in practice and education that may occur in the next five years? 

Yes.

Question 7: Are the standards presented in a way that is clear, accessible and easy to use?

No.

When looking at the headings of each standard, the sub-headings do not necessarily support what would be considered to be good practice. It may be sensible to redraft the standards and then give a general explanation of what is meant, with sub-headings giving examples of such practice. As drafted, lacunae may exist and the registrant may be misled in their understanding of what is required practice.

Overall the language used in the drafting of these standards is imprecise and unclear. We agree the sentiment of the proposals may be acceptable but significant redrafting and review will be needed before these standards can be presented to the profession for further review in advance of their enactment.

Question 7: Is there anything missing, incorrect or unclear in the standards? 

Yes.

Standard 2.1:
“Use appropriate language and communications skills to give patients information in a way that they can understand”.

What is appropriate language for a patient who cannot speak English? Surely this should be “use your best endeavours to...”

Standard 2.2:
“Ensure your patients know in advance what to expect from the consultation, giving them the opportunity to ask question or change their mind before proceeding.”

How is a practitioner to do this? What does “in advance” mean? How far in advance? How can a locum meet this standard when he arrives at a practice on the day of work? This is more appropriate for a body corporate.

Standard 2.4:
“Ensure that you and everyone you are responsible for have the appropriate language skills to communicate and work effectively with patients and their carers, colleagues and others.”

Once again, how does a locum or an employed practitioner meet this standard? This is appropriate for a body corporate, not an individual.

When it says “others”, what does that mean? This standard could be interpreted to impose an obligation on a practitioner which goes well beyond the Equalities Act’s requirement for “reasonable adjustment” and could allow a deaf or non-English speaker to insist on the provision of a translator.

Standard 2.5:
“Ensure that patients have all the information they need about their prescriptions, optical devices, drugs and eye conditions.”

This is a wide and ill-defined standard. What does “all the information they need” mean?

Standard 2.6:
“Ensure that patients or their carers have shown the ability to use, administer and look after any optical device, drugs or other treatment that they have been prescribed or directed to use.”

It is unrealistic to expect registrants to “ensure patients have shown the ability .....”; “have been shown how to use .....” would be a more sensible alternative. As an example, if a patient has been given eyedrops, are optometrists expected to open the pack and get the patient to instil a drop whilst they watch and record this fact? If they get it wrong, do they repeat the process until it is correct (potentially instilling more drops than is safe)? If we advise a patient to perform eyelid scrubs and hot compresses, should we watch them perform this in the practice? This seems impractical.

Also, it is unclear whether this relates only to optical devices, drugs or other treatments that they have been prescribed or directed to use by the practitioner in question. This clause could apply to drugs and treatments prescribed by medical practitioners.

Standard 3.1:
“Assist patients in exercising their rights and making informed choices.”

Should we not define which rights we are referring to?

Standard 3.6:
“Support patients in caring for themselves, including giving advice on the effects of life choices and lifestyle on their health and well-being and supporting them in making lifestyle changes where appropriate.”

Is this really to be a requirement? To what lengths does a practitioner have to go to support a patient in caring for themselves? Optometrists and dispensing opticians, unlike GPs, have no ability to invoke services to assist in lifestyle choices at primary care level. This standard requires either removal or significant rewording to understand the extent of this obligation.

Standard 4.1.2, 4.1.3, 4.1.4:
4.1.2 By the patient or someone authorised to act on the patient’s behalf
4.1.3 By a person with the capacity to consent
4.1.4 By an appropriately informed person

Is this one person? Should we insert “and/or” in between each sub-paragraph?

Standard 4.2:
“.....Also be aware of differences within the four nations of the United Kingdom.”

Why should a practitioner be aware of the differences within the four nations? What relevance does the situation in Scotland have to a practitioner in Cornwall? And vice versa? Surely a practitioner only needs to be aware of the legal and regulatory environment in which they operate?

Standard 4.4:
“Ensure that the patient’s consent remains valid at each stage of the examination, treatment or during any research in which they are participating.”

What does the GOC intend by this standard? That the practitioner, during a sight test, asks for permission before each procedure? This is completely impractical. If this standard remains, then clarity is required on how consent is obtained and what elements of the tests they have concerns about.

Standard 5:
“Show care and compassion for your patients”

Standard 5.1 should be sufficient to cover the whole of standard 5.

Standard 5.2:
“Respond with humanity and kindness to circumstances where patients, their family and carers may experience pain, distress or anxiety.”

Respond with “humanity”? Humanity covers a multitude of sins. Perhaps substitute “professionalism”?

Standard 5.4:
“Ensure that you demonstrate equal care, empathy and compassion for your colleagues.”

While being nice to your colleagues is obviously desirable, it seems beyond the remit of the GOC to regulate on this matter.

Standard 6.3:
“Be aware of current best practice, taking into account relevant developments in clinical research, and apply this to the care you provide.”

Replace “best” with “good”. It is not reasonable to expect all practitioners to be up to date with all the latest academic research. At what point do recent developments into clinical research become safe to apply to all practice? What about the peer view? Greater clarity is required here. This standard is potentially a risk to patients.

Standard 7.2:
“Be able to identify when you need to refer a patient to another practitioner in the interests of the patient’s health and safety and make appropriate referrals.”

After “practitioner” add “or service”.

Standard 8.1:
“Conduct an adequate assessment, taking into account the patient’s history, including symptoms, personal beliefs, and psychological, social and cultural factors.”

It would be inappropriate for practitioners to ask patients about their personal beliefs and asking about psychological, social and cultural factors could be seen as intrusive and offensive.

Standard 8.2:
“Provide or arrange any further examinations, advice, investigations or treatment if required for your patient. This should be done promptly so as not to compromise patient safety and care.”

Insert “Use your best endeavours to” at the start of the first sentence. A practitioner cannot “arrange” all further examinations, investigations or treatments if the patient is being referred. The word “promptly” should be replaced with a phrase that is clearer and more flexible – “within an appropriate timescale”.

Standard 8.5:
“Provide effective patient care and treatments based on current best practice.”

Replace “best” with “good”. Practitioners are required to practice to the standards of their peers

Standard 8.7:
“When in doubt, consult with professional colleagues appropriately for advice on assessment, examination, treatment and other aspects of patient care, bearing in mind the need for patient confidentiality.”

This is often impossible, given the lack of the IT infrastructure needed for practitioners to communicate with colleagues within the hospital eye service (HES) and the history of difficulty in getting feedback from the HES.

Standard 8.8:
“Respect a patient’s right to obtain a second opinion from another healthcare professional.”

A GOS patient does not have a right to a funded second opinion, except in certain circumstances. In this standard, what does the word “respect” mean? What does the GOC want the practitioner to do if the patient’s desire for a second opinion cannot be funded by the NHS?

Standard 9.1:
“Maintain clear, legible and contemporaneous patient records which are accessible for all those involved in the patient’s care.”

How is the registrant to make the patient records accessible to all those involved in the patient’s
care?

Standard 9.2:
“As a minimum, record the following information:”

The detail given in this standard is at odds with the GOC’s statements that “we are not prescribing how the standards should be met” and “we do not specify how you should meet our standards. In doing so, you must exercise your professional judgement, taking into account the statements contained within this document”.

9.2.7 “Consent to any treatment.”

Do GPs always record consent to any treatment they prescribe? Is this consistent?

Standard 10:
“The responsibility to ensure that supervision does not compromise patient care and safety is shared between the supervisor, those being supervised and those undertaking a supervised task.”

How is the responsibility shared? Equally? In proportion to seniority and/or experience? This is imposing a duty on the student which is not conferred by the Act. On what basis can the GOC set standards which go beyond the Act and conflict with the obligations in 10.4.

Standard 10.4:
“Ensure that no untoward consequences, detrimental to the patient, can arise from the actions of those being supervised.”

This is impossible and beyond human capability: to exclude the possibility of untoward consequences. The NHS’ patient safety website states: “patients
are sometimes harmed no matter how dedicated and professional the staff”.

Standard 11.2:
“When making or accepting a referral you must ensure it is clear who has responsibility for the patient’s care.”

Clear to whom? The patient? The healthcare professional to whom the referral is being made? The administrator working for the healthcare professional to whom the referral is being made?

Standard 11.3:
“Ensure that those individuals to whom you refer or delegate have the necessary knowledge and skills so that patient care is not compromised.”

How can registrants be sure that those to whom they refer are suitably qualified? If they refer to the HES does that mean that foundation trainees cannot see the patient?

Standard 11.4:
“Ensure that patient information is shared appropriately with others, and clinical records are accessible to all involved in the patient's care.”

How is the registrant to make the patient records accessible to all those involved in the patient’s care when a patient is being referred into hospital or to a GP, given the strictures of a lack of IT connectivity?

Standard 12.1:
“Protect and safeguard children, young people and other vulnerable people from abuse including by:”

As it stands this puts no limit on the responsibility of the practitioner. Perhaps add the phrase “during patient contact time”.

Standard 12.2:
“Promptly report concerns about your patients, colleagues, employer or other organisation if
patient or public safety might be at risk and encourage others to do the same. This is sometimes
referred to as ‘whistle-blowing’ and certain aspects of this are
protected by law.”

To whom should concerns be reported? Greater clarity here should be given; eg “Report concerns through appropriate channels in your organisation. However, if concerns persist or these channels are unavailable consider reporting these concerns to...”

Standard 12.3:
“If you have concerns about your own fitness to practise, whether due to issues with health, character, behaviour, judgement or any other matter that may damage the reputation of your profession, stop practising immediately and seek advice.”

After “reputation of the profession” insert “or patient safety”. From whom should advice be sought? What is meant by “character” in this context?

Standards 12.4 and 12.5:
12.4 If patients are at risk because of inadequate premises, equipment, resources,
employment policies or systems, put the matter right if that is possible and/or raise a
concern.

12.5 Ensure that any contracts or agreements that you enter into do not restrict you from
raising patient safety concerns including restricting what you are able to say when
raising the concern.

These standards cannot be implemented without commensurate standards being in place for bodies corporate.

Standards 13.1, 13.1.2, 13.1.3. 13.1.5

These are more appropriate for an employer than for an individual registrant, who, if employed
or a locum, will not have control over these issues.

Standard 13.1.5:
“13.1.5 Dispose of controlled, clinical and offensive materials in an appropriate manner.”

Optometrists and dispensing opticians do not use controlled drugs.

Standard 13.2:
“Have adequate professional indemnity insurance and ensure that the practice in which you work has adequate public liability insurance.”

 How is a locum to ensure this? This part of the standard is appropriate for bodies corporate.

Standard 13.3:
“Ensure that when working in the home of a patient or other community setting, the environment is safe and appropriate for the delivery of care.”

What should they do if the environment is not safe and appropriate? Do they take a bucket and mop with them? How is a practitioner to do this in a patient’s home? What takes precedence in the event of the environment not being adequate? The care of the patient in less than optimum circumstances or trying to resolve the environment to deliver that care? Which has the greater overriding duty? The guidance needs to give examples to give the practitioner an understanding as to how to apply this standard to their everyday work.

Standards 13.4.2 and 13.4.3:
“13.4.2. Provide any care within your scope of practice which will benefit the patient
13.4.3. Make your best efforts to refer or signpost the patient to another healthcare professional or source of care where appropriate.”

These two sentences should be joined by the word “or”. A practitioner does not have to
“provide any care within their scope of practice which will benefit the patient”. What if the patient won’t pay and requires an investigation or treatment that is not funded by the NHS?

Standard 14:
“Show respect and fairness to others and do not discriminate unfairly”

Delete “and do not discriminate unfairly”; if you are showing respect and fairness then, by definition, you cannot be discriminating unfairly.

Standard 14.2:
“Promote equality, value diversity and be inclusive in all your dealings and do not discriminate unfairly on the grounds of gender, sexual orientation, age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief.”

This is unnecessary in a GOC standard and is already adequately covered by law.

Standard 14.7:
“Support colleagues and offer guidance where they have identified problems with their performance or health or they have sought your help, but always put the interests and safety of your patients first.”

This is inappropriate and open-ended. What if a colleague asks for your help in changing a flat  tyre on their car? There needs to be a limit put on the scope of the assistance which should be provided. Perhaps replace “help” with “professional advice” and add the word “appropriate” before “guidance”?

Standard 14.8:
“Consider and respond to the needs of disabled patients and make reasonable adjustments to your practice to accommodate these.”

Replace “disabled patients” with “patients with disabilities”. Employees and locums are unable to make adjustments to practices, so this also is a standard
which is relevant to Bodies Corporate and employers and not to all individual registrants.

Standard 15.2:
“Ensure that all staff you employ or work with, are aware of their obligations in relation to maintaining confidentiality.”

How can a locum do this? This is a standard appropriate for employers and not individual registrants.

Standard 15.7:
“Securely store and protect patient records to prevent loss, theft and inappropriate disclosure, in accordance with data protection law.”

This standard is not appropriate for individual registrants but for employers and bodies corporate.

Standard 15.8:
“Confidentially dispose of patient records when no longer required in line with data protection requirements”

This standard is not appropriate for an employee or a locum but would more properly be addressed at an employer or a body corporate.

Standard 17.3:
“Ensure that incentives, targets and similar factors do not affect your professional judgement.

Do not allow personal or commercial interests and gains to compromise patient safety.” Incentives and targets are intended to affect practitioners’ behaviour. It is not feasible or fair to impose a requirement on individual employed registrants (who, in general, have little control over what incentives and targets are set) without putting a similar requirement on employers and bodies corporate. Suggest here that we add, after “patient safety”, “or patient interests” - but this must be accompanied by a similar obligation on employers.

Standard 17.6:
“Do not make misleading, confusing or unlawful statements within your advertising.”

This is more appropriate for a body corporate and irrelevant for employed and locum practitioners.

Standard 18.2:
“Ensure your conduct in the online environment, particularly in relation to social media, whether or not connected to your professional practice, does not damage public confidence in you or your profession.”

Add “or jeopardise patient confidentiality”.

Standard 19.3:
“Respond honestly, openly, politely and constructively to anyone who complains and apologise where appropriate.”

Responding openly to all complaints and apologising may invalidate professional insurance, so this standard could conflict with standard 13.2.

Standards 20, 20.1, 20.1.2, 20.1:
“Be candid when things go wrong”
“Be open and honest with patients when things go wrong with their treatment or care. If a patient under your care has suffered harm or distress or there may be implications for future patient care, you must:
20.1.1. Tell the patient or, where appropriate, the patient’s advocate, carer or family that
something has gone wrong.
20.1.2. Offer an apology.
20.1.4. Explain fully and promptly what has happened and the likely short-term and long-term effects.”

Responding openly to all complaints and apologising may invalidate professional insurance, so this standard could conflict with standard 13.2. Furthermore, the duty of candour was intended to relate to cases of 'serious harm’. To quote from “Building a culture of candour – A review of the threshold for the duty of candour and of the incentives for care organisations to be candid” (Sir David Dalton, Prof. Norman Williams):

8. There are a number of definitions of ‘harm’ that are used for different purposes. This can lead to confusion and some of the language of definitions can be positively unhelpful for talking to patients. We would like to see greater alignment of definitions over time. Ahead of that, we believe that it is in the interests of patients, families and providers of care that the organisational duty of candour applies to all harm that is not defined as ‘low’. Our second recommendation is therefore:

Recommendation 2: The duty of candour should apply to all cases of ‘significant harm’. This new composite classification would cover the National Reporting and Learning System categories of ‘moderate’, ‘severe’ and ‘death’; harm that is notifiable to the Care Quality Commission; and would include 'prolonged psychological harm’. This is in line with the ‘Being Open’ guidance.

Few episodes in optometry result in serious harm, so it is overbearing to expect the same duty of candour, in all cases, as from a doctor who has just removed the wrong kidney or whose patient has died because of an inappropriate use of a chemotherapy drug.

Standard 20.1.3:
“Offer appropriate remedy or support to put matters right (if possible).”

Delete “possible” and replace with “practicable”. Lots of things are possible; it doesn’t mean that they are reasonable, justified or fair.

• Student Standards:
  All the comments above also apply to the student standards, with the additional comments: The use of standards for qualified registrants for students with little amendment other than the insertion of the words “work with your tutor or supervisor to achieve this” is inappropriate
• The failure to create specific standards for students demonstrates a lack of thought and proper consideration to the special circumstances and environment which pertain to them.

Question 9: Are there any specific issues or barriers that could prevent stakeholders from implementing or complying with the standards?

Yes. 

Several of the standards (detailed above) are inappropriate for individual registrants, especially those working in employed positions or as locums, whose conditions of employment or engagement would prevent them from implementing or complying with the standards.

Question 10: Are there any aspects of the standards that could have an adverse or negative impact on certain groups of patients, optometrists, dispensing opticians, optical students, optical businesses, optical training institutions or any other groups? 

Yes.

Many of the standards currently drafted for individuals (students, optometrists and dispensing opticians) could negatively impact on them – they cannot comply and therefore would be in breach. This would have negative consequences. There are issues for patient safety on one or two points as well.

 Again, we strongly urge the GOC to consider drafting standards for body corporates contemporaneously with the current proposals (after amendments, as suggested, to address the concerns raised in this response)."

Question 11: Are there any areas of the standards that could discriminate against stakeholders withspecific characteristics? Please consider sex, age, race, religion or belief, disability, sexual orientation, gender reassignment, pregnancy or maternity, caring responsibilities or any other characteristics. 

No.

Question 12: Overall, do you expect that the standards will achieve the objectives set out in paragraph 19? 

No. Several of the standards are not achievable by all registrants. Standards for registrants must be achievable by all, not just by some.

Question 13: Overall, do you expect that the standards will be beneficial to, and have a positive impact on, optical practice and education? 

No. The standards will not be beneficial until the GOC is able to impose similar standards on employers.

Question 14: Do you have any other comments that you wish to make on the new framework for standards, the new standards for optometrists and dispensing opticians or the new standards for students? 

If new standards are to be introduced, following redrafting and further consultation, then publication of these standards and appropriate education and promotional activity should precede the ‘go live’ date after which the standards will be expected to apply. This will allow registrants time to make any necessary changes to their practice and also ensure that there is a clearly defined start date for the standard.

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