The GOC's education strategic review - phase two

The consultation

In December 2017 the GOC issued a consultation setting out a set of concepts and principles it is exploring as part of its Education Strategic Review. This followed an initial call for evidence, to which the AOP submitted a response in March 2017.

The AOP's response

Overview

Our response to the consultation questions is set out below. Key points include:

• We agree that the GOC should focus on high level learning outcomes when setting education standards
• We think the required outcomes for new registrant optometrists should focus on intellectual, clinical and communication skills
• There should be common national standards for the registration of optical professionals, and robust, externally monitored verification that prospective registrants have the necessary skills and experience
• The potential changes will have cost implications, and the GOC should assess these and involve funding providers in any detailed redesign of education requirements.

Concept 1: Standards for education provider

Q1. Do you agree or disagree with us further exploring the concept of new Education Standards in the way we describe above?

Agree/Disagree/Don’t know - “Agree”

Q2. Please tell us more about your views, including any opportunities or risks you foresee

We agree that the GOC should further explore new high level Education Standards. We said in our response to the call for evidence that the current GOC requirements are too input driven. We think the proposed new Education Standards should be more focused on the achievement of learning outcomes. The requirements should encourage evidence-based learning and be constructed in a way that allows education providers to meet the evolving learning needs of students in an agile and responsive way.

The GOC consultation paper suggests that the new Standards could cover the design and delivery of programmes, policies, procedures and course content, which are inputs rather than outputs. We think new Standards should avoid prescribing inputs as far as possible, although we acknowledge that some input requirements may be needed in order to ensure that education programmes are of adequate quality.

The current optometry accreditation and assurance standards¹ set out six sets of requirements for ongoing accreditation. The GOC could simplify these in a new set of Standards to be consistent with an outcomes-based approach and avoid unnecessary repetition. The current requirements cover:

4.1 Public Protection
4.2 Student Experience
4.3 Student Assessment
4.4 Monitoring and Evaluation
4.5 Facilities and Resources
4.6 Professional Requirements

Public protection is also covered in Standards for Optometrists, DOs and Students². Student experience is already measured by a number of other bodies. Facilities and Resources is prescriptive and could be made less specific, as it is not consistent with an outcomes-based approach. Professional Requirements contains arbitrary patient contact minima and describes outcomes in terms of detailed competency statements rather than a higher-level approach.

A set of standards that would be consistent with an outcomes-based approach could be, for example:

• Public Protection – with emphasis on supervision of any patient contact, and the inclusion of course content on ethics and patient safety
• Assessment Methods 
• Monitoring and Evaluation 

These would need to be constructed so as to cover all levels and types of practice and all professional groups.

High level Standards may be difficult to assess consistently. The GOC will need to put in place robust assessment and quality assurance mechanisms, including course visits, to ensure that the Standards are applied consistently by different education providers. Visitors will need to be highly skilled, and the GOC will need to ensure that the assessment system encourages appropriate and consistent interpretation of the Standards. A visit by GOC education visitors should feel, as far as possible, like a collaborative partnership. It should be an opportunity for the education institution to share its thinking, including about innovation, and for the visitors to share their experience of good practice and innovation elsewhere.

We note that this change, and other potential changes discussed in the consultation paper such as enhanced clinical experience for students (concept 6), may have a range of cost and funding implications. We therefore think the GOC should involve education funding providers in any detailed redesign of the current education arrangements for the optical professions and should assess the cost impact of changes on prospective registrants and on education providers. This should include consideration of the funding that universities receive for teaching optometry, the fees paid by university students and the salaries received by pre-registration students.

Concept 2: Education Standards and Professionalism

Q3. Do you agree or disagree with the concept of informing our education requirements by our professional standards?

Agree/Disagree/Don’t know – “Don’t know”

Q4. Please tell us more about your views on this concept, including any opportunities or risks you foresee

We agree in principle that the proposed new high-level Education Standards should be informed by the existing standards of practice for registrants. We have answered “don’t know” to question 3 because we are unsure what “directly linking” the two sets of standards would mean in practice, given that the Education Standards apply to education providers rather than individual registrants. 

The GOC’s Standards of Practice for Optical Students reflect the current requirement for students to be registered with the GOC. We share the GOC’s view that this is unnecessary. Linking education requirements to the professional standards that apply to optometrists and dispensing opticians would strengthen the case for removing the requirement for student registration.

Concept 3: Learning Outcomes

Q5. What are your views on the concept of system-wide learning outcomes for optometry and dispensing optician education and training, instead of an educational competency-based approach?

We support the idea of focusing on higher level learning outcomes rather than the current competency-based approach. As discussed in our response to question 1, we welcome a more outcome focused approach to the regulation of professional education. We think high-level outcomes should focus on intellectual skills, including the ability to think critically and independently, weigh evidence and understand concepts from first principles. This will allow practitioners to practise confidently in a variety of settings and adapt to changing technologies and service delivery in the course of their careers. 

The existing competency framework for optometrists certainly needs to be changed. The current stage 1 competencies do not effectively describe the skill set, understanding and abilities required of a graduate entering a pre-registration placement. They are intended to be outcome based but set requirements out in too much detail and may in fact demand too much of students at too early a stage. Students should be expected to reach a certain level before seeing ‘real patients’ without direct supervision in the pre-registration year (or any equivalent stage of learning in future). This could be achieved via a modified version of the stage 1 competencies. The stage 2 competencies to be demonstrated by the end of training would also benefit from review. 

New outcome requirements should give educational providers the flexibility to meet changing demands and developments. The requirements should enable innovation while ensuring that common learning outcomes, including clinical and critical thinking skills, are embedded across course content – within and across different institutions. 

In practical terms we are not sure how these learning outcomes would fit within the high-level Education Standards that the GOC is proposing (concept 1). More explanation of this detail will be needed.

Concept 4: Links to Continuous Education and Training

Q6. What do you see as the merits to removing the current link between CET and our education requirements, if any?

We support the removal of the link between CET and education requirements. The CET system overall needs to be reformed, as the GOC already accepts. It makes sense to focus the CET scheme on the Standards of Practice as this is the framework within which all registrants must practise. This is also consistent with setting education learning outcomes which are linked to the Standards of Practice and would provide a common approach to learning requirements for registrants and students.

Removing the link to education requirements could also help the CET scheme to foster professional development amongst registrants. The continuous education requirements on registrants should build and develop new clinical skills, as well as maintaining and validating existing skills. 

Q7. Do you envisage any disadvantages or risks in this approach, and if so, what are they? 

We do not see any specific disadvantages to this approach. Its success will depend on how well the new CET scheme is designed and operated.

Concept 5: Educational content

Q8. What do you see as the key changes needed to the current content of optometry programmes and dispensing optician programmes to ensure our future requirements are fit for purpose?

Our response to the call for evidence argued that course content for optometry should cover core clinical and scientific skills, and enable the evaluation of evidence, critical thinking and self-reflection. This is still our view.

The GOC has said that it is exploring certain cross-cutting aspects in advance of stakeholder consultation. Of the list of cross-cutting issues set out on page 20 of the consultation paper, we believe that the most important for the education of optometrists are:

• The skills of confident clinical decision-making and application of evidence-based practice
• The need for professionals to communicate effectively with patients, carers, other professionals and the wider health system and optical sector; and
• monitoring and promoting public health

We think the GOC should construct its future education requirements in a way that puts these skills and priorities at the centre of professional training for optometrists. It should avoid specifying curriculum content in any more detail than is required by outcome-based high-level standards. Education providers should be able to develop innovative course content in collaboration with the sector, as long as this is consistent with the GOC’s education standards and learning outcomes. Over-specification could restrict innovation and might not keep up with changing practice and technology.

Concept 6: Enhanced clinical experience for students

Q9. Do you agree or disagree with the concept of embedding clinical elements of education and training progressively from the outset of programmes? 

Agree/Disagree/Don’t know – “Agree”

Q10.Tell us more about your views on this concept

We support an approach that would provide students with a more varied clinical experience in different modes of practice during their education. Working in different clinical environments should better prepare students for future changes in service delivery and different career paths. We would not support an approach that relied on experience of a limited range of clinical environments.

However, there are a number of practical factors to consider in any move to widen students’ clinical experience in this way. Educational institutions would need to build relationships with a diverse range of employers and would need to work closely with these employers to ensure that students are appropriately supervised, that they reflect on their practice and that learning from clinical experience is embedded. This in turn would have cost implications.

In our response to the call for evidence we noted that views differ as to whether there should be more patient contact in educational programmes. We note that education already includes patient contact, probably more than in the past. Clinical experience needs to be phased according to the level of experience of students and their journey towards registration. The same principle would need to apply to students receiving enhanced clinical experience in different modes of practice. 

We also note that there is little evidence that more patient contact, of itself, leads to better university graduates. The current patient minima requirements are not evidence-based. They encourage box-ticking and are resource-intensive for providers, diverting resource from other valuable teaching activities. We must be careful that ‘real patient’ contact at undergraduate level is not seen as a panacea. It may not supply the range of clinical, decision-making and communication challenges that students need to be prepared for. Some real patient experience at undergraduate level is important but simulation has a number of advantages³. The GOC approach should not be prescriptive but allow providers to design learning pathways which they can show meet the higher-level learning objectives discussed in our response to concept 5.

Q11. What do you foresee as being any positive or negative impacts on students, education providers, employers, patients and carers from taking a hybrid approach?

As discussed in our response to question 10, we support students receiving more diverse experience in different modes of practice. However, there is also an argument that students undergoing more and therefore shorter placements may gain less from the overall experience, since hosting organisations may have less of an incentive to invest time in students on shorter placements. Hosting organisations may also be unwilling to pay students for their time; this would of course not be welcomed by students who currently expect to receive a salary during their pre-registration placement.

As we discuss in our response to question 10, there will also be challenges for educational institutions in managing student experience in a greater range of clinical settings. This has the risk of adding pressures and costs to the overall programme. It may be difficult for providers to deliver much more clinical experience under the current funding structures. 

Conversely, a hybrid approach which only exposed students to a limited range of clinical environments would not prepare students for the challenges they will face in their future careers.

Concept 7: National registration examination

Q12. Do you agree or disagree with the concept of a national registration examination?

Agree/Disagree/Don’t know – “Disagree”

Q13. What are the merits and risks of this concept?

The consultation paper discusses whether to “retain the principle” of a national standardised examination or assessment for registered roles. We note that at present there is not in fact a single common assessment route for optometrists joining the register. Manchester University already offers a degree which leads straight to registration, although the large majority of prospective registrants complete the Stage 2 assessment via the College of Optometrists. 

We think it is clearly necessary to have common national standards for the registration of optical professionals, and robust, externally monitored verification that prospective registrants have all the necessary skills and experience, of the kind currently provided for the large majority of optometrists by the College of Optometrists’ independent OSCE. That verification could take the form of an examination but does not have to.

In principle it could be argued that any provider that can satisfy the GOC of its competence should be able to provide the final assessment before registration. However, this would not necessarily maintain public confidence that the training of optical professionals is subject to robust verification. A more fragmented approach to assessment at the registration stage could also have the unintended consequence of affecting the viability of the current assessment routes offered by established providers such as the College of Optometrists and ABDO. That in turn might have implications for the important wider work both bodies do for the optical sector.

There is a risk that a single national examination could encourage ‘teaching to the test’ and so work against the GOC’s aim (which we support) of focusing on outcomes and promoting innovation in education. We therefore suggest that the way in which the GOC specifies and monitors any new national standard for registration should have the same focus on outcomes as the proposed new standards for education providers (concept 1).

Concept 8: Multi-disciplinary education

Q14. How feasible would it be to develop inter-professional and multi-disciplinary elements of study within optometry and dispensing optician education programmes?

As we said in the AOP’s response to the original call for evidence, we support the concept of a modular education model which would allow optometrists and DOs to benefit from joint study alongside other eye health (and other) professionals where there are genuine common elements to their training. Students should be taught to develop skills that will allow them to adapt to changing professional requirements during their career.

We agree with the comment in the GOC’s consultation paper that the practical feasibility of developing education content on these lines will depend on the existing pattern of education provision in different providers. We note that it will also be affected by any changes flowing from the GOC’s intention to review educational content (concept 5).

Q15. Tell us about any examples you know of already in other disciplines from within or outside the UK?

Education providers will be best placed to give a comprehensive answer to this.

Concept 9: Duration of education and training programmes

Q16. What do you see as the strengths and weaknesses of maintaining the current minimum duration as described above?

We note that at present there is no formal minimum duration for the education and training of optometrists. Rather, there is a general assumption that a BSc will take at least three years to complete, and the subsequent pre-registration training will take around another year. We think this will remain appropriate for most students.

In practice we can see that it may be viable to deliver the required education and training in less time than the current four years. This could be attractive both to prospective registrants (who could benefit from a lower level of student debt) and to employers. However, the potential for this will depend on how far the current requirements may change as a result of the GOC’s intention to review the content of education programmes leading to registration (concept 5), and the intention to introduce enhanced clinical experience for students (concept 6). 

As with the concept of a single national examination (concept 7), the key thing will be to ensure that education and training produces professionals of the required standard – people who are rounded, mature and have the necessary clinical, critical thinking and communication skills. It may be challenging to give students the necessary experience to meet this standard in a shorter timeframe than at present. The academic ability of the student intake will also be a consideration here.

Q17. What could be done differently in order to ensure students become competent, confident and safe beginners?

See response to question 16.

Concept 10: UK educational routes to registration

Q18. What do you see as the opportunities for more flexibility between the education of different regulated and non-regulated optical professions?

In principle we support the concept that professional education should enable people to move between different optical roles. As we said in our response to the call for evidence, we can see the value of having fewer divisions between professional groups, both in optics and in primary care more widely. Over time we think functions will become more important than titles, although the pace of change may be slow.

The opportunities for creating more flexibility between the education and training required for the regulated optical professions, like the scope for changing the duration of training, will be affected by the GOC’s intention to review the content of education and training programmes leading to registration (concept 5) and to introduce enhanced clinical experience for students (concept 6). The GOC should bear this in mind when considering how the future education of the registered professions should develop.

The scope for enabling more flexibility between regulated and non-regulated professions may also be affected by the development of training for non-regulated roles. For instance, the new Optical Assistant level 2 apprenticeship standard in England could in time be supplemented by higher level apprenticeships, potentially including an apprenticeship for a more clinically-orientated ‘clinical assistant’ role. It will be important for the GOC’s emerging thinking on this to keep pace with developments for non-registered roles.

Q19. What are the constraints and risks to this?

There may be a tension between the GOC’s intention to move to a more outcome-focused approach to education requirements (concept 3) and the aim of promoting flexibility between roles during education, unless an understanding of different optical roles is itself specified as one of the required outcomes of education and training. The scope to build links between different roles may also be limited by the differing practical and academic requirements of the training required for each role. For example, education and training that is predominantly vocational would be inappropriate in most cases for registration in an optometric role. The type of skill, knowledge and behaviours that allow clinicians to adapt to the demands of evolving technology, clinical decision making and changing service delivery are best suited to educational delivery with strong academic and scientific components.

We also note that the education and training requirements for each optical role should be proportionate and avoid unnecessary content, in the interests of students (who face cost burdens if courses are longer than necessary) and of employers. This may limit the scope for education programmes to include interesting but non-essential material which builds links with the work of other professions.

Robust, consistent and accessible systems for the accreditation of prior learning will be particularly important. The GOC will need to take into account the various different non-registration optical training programmes and qualifications that exist across the UK nations.

Concept 11: Proportionate quality assurance

Q20. Are there any other principles and concepts we should consider at this stage in exploring further approaches to our quality assurance processes?

We support the proposal that the GOC should develop a proportionate approach to approval and quality assurance. We think this should be based on careful consideration of the evidence, including the risks associated with quality assurance in this context. The GOC should also design its approach in a way that minimises unnecessary duplication, in accordance with the principles of good regulation.

1. Accreditation and Quality Assurance Handbook: Routes to Registration in Optometry, GOC, 2015
2. GOC Standards Framework, Standards for Optometrists and Dispensing Opticians and Standards for Optical Students, GOC, 2016 
3. Bokken L, Rethans J-J, Scherpbier A.J.J.A, van der Vleuten C.P.M., Strengths and Weaknesses of Simulated and Real Patients in the Teaching of Skills to Medical Students: A Review. Society for Simulation in Healthcare, 2008.