The GOC’s consultation on CET: Lifelong Learning Review

The consultation

In July 2018 the GOC issued a consultation seeking stakeholder views on its Continuing Education and Training (CET) scheme.  Its aim was to gather views on how the CET scheme can successfully evolve to help meet the challenges of the future.

The AOP's response

We welcome the opportunity to respond to the GOC’s consultation on CET - Fit for the Future: Lifelong Learning Review. Our response is informed by our members’ views, including through discussion at a meeting of the AOP Council, input from our Policy and Membership Committees and our Education Working Group, and comments from our wider membership through our online community forums. 

Our consultation response follows the structure of the substantive questions set out by the GOC. We have only responded to the tick-box elements where this was appropriate. 

Key points we make in our response include:

• The GOC should urgently review whether the CET reforms can be fully delivered by January 2020. If not, we think it would be preferable to begin another three-year cycle in 2019 rather than risk needing two transitional years before the next cycle
  
  
• The current CET system provides enough assurance for the main risks in the optical sector. However, the inflexibility of the system means that it is not good at meeting skills needs arising from evolving service delivery, or giving individuals the ability to tailor learning to their scope/mode of practice and the risks involved
  
  
• Moving to a more flexible and self-directed system of learning should support registrants in taking professional responsibility for their own learning, to enable them to maintain the appropriate skills/competence for their mode of practice
  
  
• To support self-directed learning, we think the GOC should allow individual registrants to decide on their own learning outcomes after they have accessed CET content from providers – giving personal responsibility for demonstrating learning and better supporting reflection
  
  
• We are in favour of peer review (both in the form of practitioner-led peer review, and provider-led peer discussion) as learning methods. However, we know from our members that some registrants find this difficult to engage with. Reforms are required to make peer review more accessible and meaningful as a learning experience
  
  
• Alongside other stakeholders, the GOC should encourage culture change to support practitioners in taking responsibility for their own learning
  
  

Section 1: Views and understanding of the current CET scheme 

Question 7. To what extent do you agree or disagree with the following statements. The GOC’s current CET scheme:

When the AOP Council discussed the current CET system in October 2017 the consensus was that the system was too inflexible and needed reform in order to meet the learning and professional development needs of individual registrants. We have summarised this feedback below, along with member comments on the specific points on which the GOC has invited comment. 

    1.  Allows registrants to develop their skills and knowledge in order to keep pace with the changes that are happening in the optical sector
    2.  Allows registrants the flexibility to undertake CET in relation to their individual scope of practice 

• The current system is relatively easy to access, but overall is inflexible to changing needs. The onerous CET approval system for providers, and the tightly defined points system are examples of this inflexibility and make adapting to change more difficult 
• The CET points system does not allow enough flexibility for individuals to meet the needs of their own scope of practice, as there are tick-box elements that limit this 
• Because of the lack of flexibility in the system there may well be areas of practice that are over-catered for while other areas do not have enough CET coverage

    3.  Helps encourage professional development
    4.  Helps improve registrants’ practice

• The feedback on points 1 and 2 above also applies here
• The CET system does have scope for improved practice but is too focused on maintaining existing knowledge, and not enough on professional development  
• There is not enough self-directed learning to allow individuals to take responsibility for their own development and learning. The current tick-box approach does not support an ethos of professional development
• To inform debate on point 4, the GOC should assess trends in fitness to practise and other regulatory action since the current CET scheme was introduced 

    5.  Helps registrants to keep up to date with good practice
    6.  Helps registrants to plug gaps in their knowledge 
    7.  Helps to build and maintain public trust and confidence in the optical professions

The CET system does better on these points than on points 1-4 above, but the same issues also apply to some extent.

• The well understood points system, working across a three-year cycle with some CET needed in each year, can help registrants to keep track of good practice and there is adequate assurance in the system. However, it is hard to meaningfully assess the impact of the scheme on public trust  
• Peer review/discussion is particularly good at plugging gaps through peer learning and mitigating isolated practice. Peer learning can be the most valuable part of CET. However, as we discuss later in this response, the structure of the CET scheme can make it difficult for registrants to engage with, and as a result our members are not always positive about their experience of peer learning in the current scheme
• Whilst CET may help to ‘plug gaps’ in some areas of knowledge, the current scheme does not give individuals responsibility for focusing on the right priorities for their learning and development. A more flexible system that encourages learners to set their own learning goals would be preferable 
  

Understanding risks in the optical sector and the role of revalidation 

Question 8. What do you think are the riskiest areas of work carried out by optometrists and dispensing opticians? How well does the CET scheme address these risks? 

We understand that the GOC carried out an assessment of risk in optical practice before the introduction of the enhanced CET scheme in 2013. The GOC have previously said that they would undertake a similar exercise before further reform to the system. Such a risk-assessment would be a helpful reference to inform changes to the CET system as well as wider reforms as part of the ESR. 

In our view, the key characteristics of optical care in relation to risk are:  

• Optometrists and dispensing opticians work across a variety of settings: primary, secondary and domiciliary care
• There is increased working across primary and secondary care and more step-down care is being commissioned, with practitioners working in a wider range of services 
• The majority of procedures carried out are of little risk to patients, but material harm can be caused if tests fail to detect signs of disease
• Practitioners are using skills and providing services within their competence, but in different ways, and with different types of risk flowing from these services, such as with the development of MECs, community monitoring and prescribing 
• As in other health settings, children and vulnerable adults are the two groups regularly seen that may carry additional risks compared to the general population 
• There are specific risks for those working in hospital settings as part of inter-professional teams supervised by ophthalmologists 
• As in other sectors, the delegation/supervision of clinical tasks can introduce risks to patient care

In general, the CET system provides enough assurance for the main risks in the optical sector, which are comparable to those in other low risk regulated health professions. However, the inflexibility of the system means that it is not good at meeting skills needs arising from evolving service delivery or giving individuals the ability to tailor learning to their scope/mode of practice and the risks involved. The current system also makes it difficult to cover important issues that do not fit neatly into a competency framework, such as clinical governance and failsafe procedures. 

Risks in clinical practice can arise from business and service models, for example a lack of time to perform tests, locums not being given enough support or commercial pressures on decision making. It is difficult to address these directly in the CET system, beyond designing a system with a culture of learning and development that empowers individuals to act professionally and take responsibility for their own learning and practice. The GOC’s proposed new standards for business registrants may also help to address some of these risks, as we have noted in our recent consultation response.

The requirement for optometrists to undertake peer review enables practitioners to reflect on their own practice with peers and learn from others – mitigating the risk of isolated practice. However, the framework for peer review could be improved, as we discuss in our response to questions 17 and 18. 

Overall, we urge the GOC not to set CET requirements that simply map to areas of high-risk care – this could lead to an inflexible and inappropriate system. Beyond identification of pathology, areas of risk in practise will vary with the care setting and type of practice. 

For example, laser eye surgery is a relatively risky area of practice but one that only a minority of registrants are involved in, providing an element of the care pathway under supervision. It would be difficult to address this type of risk in the CET system through a specific competency/learning outcome, other than by giving individuals sufficient scope for self-directed learning. The GOC should design a system that:

• empowers professionals to practice within their competence
• requires them to be prepared to demonstrate their competence where appropriate, and 
• provides the flexibility to meet their individual learning needs. 

Question 9. Do you think that there is a risk that optometrists and dispensing opticians may be de-skilling ie losing their skills and knowledge in some areas of practice? 

Any mature and evolving profession which has thousands of skilled practitioners working across various care settings, such as the optical professions, will have individuals with different skills sets based on their experience and mode of practice. This in itself is not a risk, and the focus should be on supporting practitioners to practise safely within their competence and comply with the GOC Standards of Practice. 

Underlying the question is a potential concern that optical registrants working in more diverse and specialised areas may lose skills in areas of practice that they do not engage in regularly. Although more extended eye services have been commissioned in recent times, optometrists have always practised across a range of clinical environments in primary and secondary care. Diversity in optical practice service models also helps to build the overall set of skills within the profession. Individuals have a responsibility to ensure that they work within their own competence. Moving to a more flexible and self-directed system of learning should support registrants in taking professional responsibility for their own learning, to enable them to maintain the appropriate skills/competence for their mode of practice. 

When individuals move from one mode of practice to another, they should be given responsibility for ensuring that they are equipped, through CET or otherwise, with the skills to practise effectively and safely in the new service setting. It is also the responsibility of service commissioners and providers to ensure that practitioners have the appropriate skills to meet the needs of their service. 

Providing the means to reskill

Some optometrists may lose skills in areas in which they do not regularly practice. Dispensing is one area that has been cited. However, this is not a problem as long as the CET system provides the scope for individuals to reskill when they change roles/mode of practice. Individual practitioners will have different areas of practice they need to reskill in, but under the current system CET is spread thinly in an attempt to cover a wide set of competencies. For example, being required to earn a single dispensing point in three years does very little to mitigate the risk of losing skills in this area. It would be better for CET to focus on empowering individuals to consider their own highest areas of risk through self-directed learning. Reskilling is also something that could be addressed by skills workshops or mentoring, where practitioners can learn from others who specialise in particular areas (eg dispensing, contact lenses, children’s eye tests). 

Question 10. Are there any core areas of practice that optometrists and dispensing opticians should keep their skills and knowledge up to date in?

As we have said above the current CET system does not offer enough flexibility for individuals to determine their own learning. Defining too detailed a set of core areas would not be consistent with the flexible and self-directed learning approach which we think is needed - and which the GOC has also identified as the desired direction of travel.

Our members had a mixture of views as to whether any core areas should be defined. A risk of identifying core areas for CET is that this could limit the space that is available for individuals to develop skills that are more suited to their learning needs and area of practice. However, there are some skills that it is important for all practitioners to have. 

One example is skills linked to the identification of pathology and especially sight threating eye disease. This is an area that presents the highest material risk of harm to patients and is therefore something that all registrants need to be skilled in – performing further tests or referring on as clinically necessary. 

It should be possible to design a system in which such skills are core elements, but also giving enough scope for individual learning. The new set of learning outcomes, and particularly the way in which CET content will need to map to this, will be key to ensuring the right balance.

Lifelong learning and reflection 

Question 11: To what extent do you agree or disagree with the following statements? 

1. The GOC’s current CET scheme intends to promote and embed a culture of lifelong learning and encourages registrants to reflect on their practice
   
   

   The current system certainly needs reform to promote lifelong learning in a flexible way to meet the needs of individual registrants, and to give the opportunity for meaningful refection. The current wide ranging and inflexible set of CET competencies and requirements do not foster a culture of lifelong learning. Many of our members see the current CET approach as being aimed at meeting a range of basic competence and tick-box requirements. More scope for self-directed learning and improved processes for reflective and peer learning would better support the aim of lifelong learning and reflection.

2. The name of the current scheme, Continuous Education and Training (CET), helps to promote a culture of lifelong learning and reflection 
   
   

   The title of the post-registration education scheme is far less important than how it is structured. However, we can see the logic of changing the title to something that better represents a system that supports self-directed learning, reflection and professional development. This could also help signal a change in approach and learning culture to registrants – if communications are properly aligned with the implementation of changes. The title of ‘Continuous Professional Development’ for example would better fit the aims of a revised education scheme and mirrors the terminology used in other healthcare profession programmes. 

Question 12: Are these tools helpful? (in relation to the effectiveness of the different reflective elements of CET)

Reflective learning is a useful approach in health professional education, and in principle we support its inclusion in the CET scheme. However, feedback from our members indicates that the current elements of reflective learning for individuals are not always well received or effective. One reason for this is that the current elements are both too ‘tick-box’ and ‘bolt-on’ to the learning process to be meaningful. The optional elements of reflection are not perceived as providing enough value to registrants, and the required aspects can then be also seen as a burden. The current scheme therefore does not work well either for learners who are keen to engage in reflection, or for those who are more sceptical about its value.   

We recognise that designing effective systems for reflection is challenging. We discuss this further and offer proposals for improvement later in this response. 

Question 13: Are there any barriers that could make it difficult for optometrists and dispensing opticians to reflect on their practice?

• A lack of guidance or support - Yes 
• A lack of clarity around the concept of reflection and the benefits – Yes
• Fear of being open and honest – Yes 

The three points above are all inter-linked and help to explain why the current elements of reflective learning within CET do not work well. As we have said in response to question 12, the current elements of reflection do not offer enough educational value to learners and their purpose in the scheme is not well understood. Other factors are:

• Reflective learning as an approach may not be well enough understood across the optical professions currently – a culture change is needed
• The current design of the CET scheme overall could be an important barrier to reflection. As we have said, the current approach is too inflexible and does not offer enough scope for individuals to direct their own learning
• The fact that reflective statements are visible to the GOC may put off some registrants. Given recent high-profile developments in healthcare regulation, there may be fears (even if misplaced) that these could be used against registrants in the future. We recognise that the recommendations of the Williams Review may help to reduce this concern in future
• Registrants may also be nervous about declaring gaps in their knowledge or skills for similar reasons 
• The time interval between completion of CET and the opportunity to log a reflective statement could also reduce the effectiveness of reflection in the current system. 

Question 14: What more could the GOC do to support registrants in embedding a culture of reflective practice? 

There are a number of considerations that should inform an improved system for reflection. 

• Overall reforms to the CET scheme which make it more flexible and meaningful, less tick-box in nature, and give individuals more control over their learning priorities, will help promote the right learning culture 
• Adult learning theory suggests that individuals learn best when they a identify a need and learn within some structure that allows them space to reflect and embed learning more deeply
• Making reflective elements mandatory for all content is not advisable, though it will be necessary for some content such as peer review. It could lessen the impact of reflection as it would take control away from individuals 
• Individuals need to hear more about the benefits a reflective approach can have for their practice and professional development. This will help improve the understanding of reflective learning and practice in the sector overall
• One suggestion is the use of clear, relevant case studies explaining the concepts of reflection and the value this can bring to the work and practice of an optometrist or dispensing optician
• Individuals should be able to choose their own learning outcomes for CET they have accessed, as we argue in our response to question 17. This fits with a self-directed learning approach and will also better foster reflection
• There should be greater emphasis on practitioner-led peer review rather than provider-led peer discussion. Peer review allows learning to be based on real cases brought by participating individuals. This provides a better scope for reflection and individual than peer discussion where the CET provider pre-determines the case and learning outcomes. The GOC could set more flexible requirements for peer review which allowed scope for registrants’ own cases to be shared within individual peer discussion table groups – we recommend this approach in our answers to questions 18-19
• We think that a number of proposals we have in relation to self-directed learning (question 16) and peer review (question 18) will also help reflection within the CETs scheme.

We realise that designing and integrating effective and improve reflective learning into CET will be challenging. We hope the suggestions and points above will help with this process, and that the GOC will propose methods that can be discussed and reviewed with stakeholders through the CET reference group, informally and through the next phase of the formal public consultation. 

Section 2: Views on the proposed changes to the CET scheme

Question 15: To what extent do you agree or disagree with our proposed approach giving optometrists and dispensing opticians more control over their learning and development?

Strongly agree

Question 16: What are the benefits and challenges of moving to this approach?

We strongly welcome the principle of giving individuals more control over their learning and development. As we have said above, this is necessary to allow individuals to take responsibility to identify the right learning priorities, better supports reflective learning, and should make CET more agile and relevant to today’s varied clinical practice. A key benefit of self-directed learning is that it will allow individuals to prioritise CET that meets the needs of their own mode of practice. 

However, to ensure that this change brings these benefits it will be important for the GOC and the wider sector to explain these changes to registrants, who will need to feel encouraged, supported and informed about how CET can meet their individual learning and professional development needs. This work will need to address the following points:

• The GOC has not yet set out detailed thinking about how this approach will work in practice, so we cannot tell how effectively it will work, or how easy it will be to persuade registrants of its benefits. As with the potential changes to peer review and reflective learning we look forward to further stakeholder review and consultation
• An important aspect of how individual registrants experience and engage with self-directed learning is the process they need go through to record their CET and have it approved. The system for this needs to provide some assurance that the system is robust, whilst not being onerous or inflexible for registrants 
• To support self-directed learning, we think the GOC should allow individual registrants to decide on their own learning outcomes after they have accessed CET content from providers – giving personal responsibility for demonstrating learning and better supporting reflection
• We recognise that this would require some kind of assurance. A system where a proportion of individual CET portfolios were audited by random sampling could be a way of providing this. However, it would be important to explain the benefits of this to registrants and reassure them that it will not have an undue impact on them, either in terms of administrative burdens or the risk of regulatory action
• An assurance system based on sampling will also carry costs for the GOC, but these could be offset by removing the current complicated system for approval of CET
• We understand the logic of linking the new CET learning outcomes to the GOC Standards of Practice for individuals. The CET scheme should support registrants to work within the standards. However, it also needs to work in a way that allows scope for individuals to develop professionally and enhance their clinical skills 
• Some of our members have cited a potential risk that self-directed learning may lead to a minority of registrants becoming deskilled in areas of practice/learning they find difficult and do not prioritise. As we have said earlier in our response, deskilling itself is not a problem as long as practitioners reskill to meet the requirements of their mode of practice (question 9). We also think this can be managed and mitigated by adequate assurance within the system, and effective communication and support for registrants that explains how to choose content that meets their skills needs. It is counter-intuitive for an effective learning system to ‘force’ registrants to meet minimum standards. Ultimately it is always down to individual practitioners to ensure they work safely within their competence and comply with the Standards of Practice. This culture of individual responsibility needs to be central in changes to the CET scheme.

Aligning CET requirements for optometrists and dispensing optician

Question 17: If you are responding as an optometrist or dispensing optician, what is your experience of peer review and any benefits it has had on your practice? 

We consider peer review to be a potentially very valuable part of the CET scheme. It allows individuals to learn with colleagues, can encourage reflection, and mitigates isolated practice. The majority of our Council members were strongly in favour of peer review as a component of the scheme. However, some of our Councillors and other members also raised concerns about its use, particularly in the current scheme. Points our members have made include:

• The scope for networking created by peer review is valuable, and can particularly benefit those practising in a setting that is isolated from other practitioners 
• However, the current process for setting up peer review is too cumbersome, and this can make it difficult for those living in remote areas to access. Some members have said that they find it difficult to access interactive CET locally, which can be a particular challenge to those with family/caring commitments 
• Members have commented that they get the most benefits from peer review when discussion develops around cases and flows organically into other areas of practice - allowing participants to share experiences and learning from each other. This is a good framework for supporting reflective learning
• However, the structured nature of peer discussion where cases are pre-selected by the provider does not support this type of learning
• The need for practitioner led peer review to receive pre-approval for learning objectives also mitigates against this. By definition it is difficult or impossible to specify in advance what the learning outcomes of an open-ended peer review conversation will be
• Peer review puts the onus on registrants to advise the GOC of their CET, and the rejection rate by GOC is high. For some of our members, frustration associated with setting up a peer review has led them to become sceptical of the entire process and the learning it provides
• Most members who expressed negative views about peer review found problems with accessibility and inflexibility in the process. Some also questioned the efficacy of peer review, and thought it was not necessarily valuable for all practitioners. 

We have suggested a number of solutions to the barriers to accessing meaningful peer review, in our answer to question 18. 

Question 18: To what extent do you agree or disagree that peer review should play a more central role in a scheme which aims to embed a concept of lifelong learning and reflection? 

Agree

We broadly welcome a greater focus on peer review within the CET scheme. However, the process for setting up peer review should be reformed to ensure that it is accessible for individuals and flexible enough to provide a good learning experience. We make a number of suggestions for improvement: 

• A central problem with the current peer review process is the need for content or learning objectives to be pre-approved by the GOC. In any given session individual learners will share different perspectives and gain different insights, leading to varied learning outcomes – it would be better for these to be logged by individuals after the session. However, this should be done in a way that minimises administrative burdens on registrants or requests for further information 
• There is great scope to improve the way that provider-led peer discussions work for individuals. The requirement for individuals to discuss provider-chosen cases within pre-determined outcomes can restrict the learning experience. We think providers should instead be allowed to act as facilitators for different groups of peer reviews taking place within the session – practitioners at each table could then bring their own cases for discussion during the session. This would fit better with the concepts of self-directed and reflective learning - with individuals taking responsibility for logging the learning outcomes they achieved, alongside submission of their reflective statement 
• It should not be necessary for a practitioner led peer review group to have its learning objectives approved in advance either. This is cumbersome and means that cases need to be found that match the pre-set criteria. This is particularly important for improving access for those who find it difficult to access peer review due to their location or circumstances 
• The GOC should review its approval process for peer review which can be cumbersome and time consuming. We understand the need for assurance but there is room for this to be improved, for instance by sampling as we have suggested above
• Access to peer review could also be improved by enabling remote engagement through webinar type platforms. This is something that has already worked well for interactive CET content, and we understand the GOC may be able to introduce this in 2019
• Another barrier to access is the requirement for peer review sessions to have at least four participants. We think this could be reduced to a requirement of two participants. The number of participants isn’t a factor in the quality of discussion or learning experience
• Peer review facilitators should receive CET points for their role in the session.

Question 19: To what extent do you agree or disagree with the principle that the GOC should have the same CET requirements for all fully qualified optometrists and dispensing opticians, by introducing peer review for dispensing opticians?

Strongly agree

Question 20: What impact and barriers, if any, would this policy have on dispensing opticians? 

We welcome the introduction of peer-review for dispensing opticians. Many DOs already choose to benefit from the learning experience provided by peer review. Making this a requirement would help provide this valuable learning experience for all DOs.  

We think that DOs and optometrists should also be able to participate in the same peer review sessions. Whilst this might not be appropriate for all sessions there is a great deal of peer learning that can take place amongst professional groups that work so closely together in clinical practice. This would fit well with the GOC move to align learning outcomes for both professions. To facilitate this, the GOC should align the requirements for optometrists and DOs so that a single approval process can cover CET for both professions.

One challenge will be the recruitment of DO facilitators - but this should be manageable and be mitigated if the GOC allows flexibility for inter-professional peer review. Otherwise, we think the same barriers for access to peer review apply as we have set out in our answers to questions 17-18. 

Section 3: Views on the proposed timeframe for introducing changes? 

Question 21: What impact, if any, will there be as a result of proposals for a one-year transition period where registrants will still be expected to complete CET as outlined above? 
Question 22: How could the GOC best support stakeholders during the transition year and into a new scheme starting in January 2020? 

The implementation of a transition year in 2019 carries risks in terms of registrants being confused about CET requirements or becoming less engaged. We think these risks can be managed acceptably if the transition only lasts for one year, and the next full 3-year cycle begins in January 2020. To manage risks the GOC should be clear and timely in its communications to registrants about the transition period, the expectations on them and the further changes planned for 2020. We agree with the GOC setting an expectation for registrants to achieve 12 points during the transition year, including at least 6 interactive points. 

However, the review of CET is aligned with the GOC’s wider strategic review of education, and these are both involved and challenging work programmes. The timetable for both projects has already been re-phased more than once. We therefore think there is a significant possibility that the timetable could slip further – and indeed, this may be necessary to ensure that the final reforms are fit for purpose. 

If timetable slippage were to lead to a two-year transition period, we think the associated risks of confusion and loss of engagement would become unacceptably high. For this reason, we think that:  

• The GOC should urgently make a candid assessment of to the likelihood that it will deliver the full range of necessary reforms to the CET scheme, in a way that is fully fit for purpose, by January 2020 
• If the GOC concludes there is a material risk that the January 2020 target can’t be met, it should instead begin a further three-year cycle under the current CET framework in January 2019 and implement the full set of reforms in January 2022

We recognise that if another three-year cycle is implemented the GOC will need to revise its communications to registrants and confirm plans to providers. However, we think the risks arising from a two-year transition would clearly outweigh the risk of the overall reforms being delayed by an additional year. Those risks include:

• Sending the wrong message to registrants about the importance of robust CET requirements, including the need for peer review, interactive learning and content for IP optometrists 
• Undermining the messages the GOC wants to give registrants about reflective learning and self-directed learning  
• A higher risk that registrants don’t meet the 12-point expectation, and that their practice is affected as a result
• As a lesser but still material consideration, an extended transition period would create instability for CET providers

Whilst some of these risks also exist in a one-year transition period, we think they would become significantly higher with a two-year transition. 

AOP, September 2018