The GOC's ESR on education standards and learning outcomes

 

Impact on education providers

The ESR involves massive changes for education providers. Our members working in education generally told us that they are still broadly supportive of the principles behind the ESR but are not convinced that the GOC appreciates the scale of the challenge involved in its proposals. In particular, universities already offering optometry courses will need to invest a lot of time and resource to restructure their courses to meet the new approach, while also ensuring that students on pre-ESR courses receive sufficient resource and attention. We discuss the timeframe for these changes in Part C of our response (response to GOC consultation questions 11 and 12).

The GOC will need to work closely with existing and prospective education providers to give them sufficient information, and confidence in the GOC’s requirements and timescales, to deliver education programmes that meet the goals of the ESR.

Impact on students

The AOP student members we have spoken to generally welcome the move to enhanced clinical experience within education programmes, while identifying some practical issues.

In particular, students told us that the GOC, education providers and professional bodies will need to communicate the changes clearly to prospective students. This will be most important in the transition period, when students may be confused that some education providers are offering new integrated degrees which may or may not have a clearly identifiable pre-registration component, while others are running pre-ESR courses which mean graduating before the pre-registration stage. It will also be important to reassure the last cohorts of students on pre-ESR optometry programmes, who may be concerned about the implications of qualifying under an ‘old’ system. 

Most optometry programmes are currently three-year BSc courses. While there are many ways in which new programmes could be designed, the most likely seems to be a four-year degree. Although the pre-registration period is often described as a year, in practice most students take longer – up to 18 months – to complete the placement, assessments and OSCE. It may be possible to integrate all this and the current BSc into a four-year programme, but that will present logistical and financial challenges for education providers. It would also mean an additional year of student tuition fees and could reduce the scope for trainee optometrists to earn a salary in the pre-registration phase. There is a risk that these factors make new education programmes less attractive to students in the transition period.

Several of our members who are practising optometrists expressed scepticism about the concept of a ‘registrable’ degree. They raised concerns about financial impacts on students, loss of the pre-registration relationship with one supervisor and the challenges of arranging clinical experience outside of the pre-registration system.

Variety of clinical experience in education programmes

In our response to the GOC’s concepts and principles consultation we supported 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. 

However, in the context of the current consultation AOP members working in education told us they do not think the GOC has fully taken into account the way in which optometry differs from other healthcare professions that integrate clinical experience with initial training. In particular, they noted that optometry:

• Is largely performed in non-NHS settings which are also commercial businesses not geared to training, unlike medicine or nursing where supernumerary clinical placements can be arranged and funded relatively easily
• Requires extended clinical experience, including patient episodes involving multiple procedures to complete a sight test over a block of time – unlike some healthcare professions such as pharmacy, where clinical experience is generally less intensive. 

Practical implications

To offer meaningful clinical experience in the early stages of training, educational providers will need to build relationships with a diverse range of employers, and work closely with them to ensure that students are appropriately supervised, reflect on their practice and learn from their clinical experience. This will carry cost and logistical implications, including:

• Significant administrative costs to education providers in building relationships with employers and supervisors, managing placements, and ensuring students work within their clinical competence and receive meaningful learning and feedback 
• Supervisors will need to be trained, and education providers will have to put in place assurance mechanisms to be confident that supervisors are offering students the right challenge and support  
• Members working in education have told us that it will be difficult to cover the extra costs with only one additional year of student funding if programmes expand to four years   
• It will probably be challenging to find sufficient numbers of supervisors for students undertaking clinical experience in different clinical settings 
• Community optical practices provide important NHS care, but their viability is based on their retail activity – they may need compensation for the cost of providing space and supervision for students
• Many hospital eye departments do not have the space to host students on a larger scale than now, or enough staff to provide proper supervision and support for them.

Our Hospital Optometrists Committee has noted that students currently spend a few days observing in a hospital department, which gives them an overview of hospital work. This experience is not long enough to provide meaningful learning or assess competencies.  Providing all optometry students with real experience and understanding of hospital optometry would be a welcome step forward. However, current levels of education funding are not sufficient to enable this.  

We know that there is real enthusiasm from many employers in community practice, including independent practices, to play more of a role in the education of students. However, the reality is that community optical practices operate in a competitive commercial environment. In the latter part of education programmes, employers will receive some benefit ‘in kind’ in return for their involvement, as students undertake clinical tasks in practice. However, for students in the early stages of education programmes the clinical experience they gain through placements in practice will generally be in the form of ‘shadowing’, clinical exposure and some closely supervised clinical work, as they will not be sufficiently competent to undertake more involved clinical tasks. 

The College of Optometrists has made the point that some students may find clinical placements away from home hard to access, because of financial pressures or other factors which make them less able to move away from home. We share that concern and think the GOC should consider how to mitigate this risk.

Types and variety of clinical experience

It is important that clinical experience is phased according to the level of experience of students in their journey towards registration. Students can gain valuable clinical learning and experience without the need for real ‘patient contact’ and this may be at times be more appropriate. Valuable experience of testing, different pathologies and clinical scenarios can be gained through the use of ‘simulated patients’, including paid or unpaid volunteers and actors – this is already used in many education programmes. These have benefits over ‘real patient contact’ by allowing students to make mistakes, be exposed to a range of pathologies (which cannot be guaranteed in real practice), by allowing the supervisor/teacher to focus on student feedback, and by offering experience of situations that it would not be practical to give students in practice early in their study^{1 2}. 

Of course, simulated clinical experience should not replace real clinical experience. However, education providers should be able to use simulated experience to meet some of the clinical experience requirements in the Education Standards. This will also be less logistically challenging to organise than placements. Another approach that education providers could take to offer clinical experience is to run their own clinics offering specific tests. We understand that some institutions have run ‘See and Treat’ screening programmes for diabetic retinopathy. 

It is also important that education providers do not rely on experience which is limited to a narrow range of clinical environments. Clinical experience should be provided in the different employer types in the community, independents and multiples, and in hospitals. There is a risk that education providers facing practical and cost challenges will use a few large employers to deliver clinical experience. The GOC should ensure that its Education Standards and quality assurance process ensure that students receive meaningful clinical experience in a genuine variety of service settings. This will better prepare students for future practice in a fast-moving profession and is in line with the concepts and principles underlying the ESR. 

Employer influence

It is right that the needs and experience of employers should inform the design of optometry education. Our Hospital Optometrists Committee has commented that in its experience, while universities provide an excellent academic grounding there is a widening skills gap between academic achievement and delivery of clinical care. Other AOP members have suggested that there is something of a disconnect between what employers expect and what education providers think is required, and that the truth is probably somewhere in between.  

Education providers under the ESR model will generally rely heavily on employers to deliver clinical experience for optometry students. This may improve communication between education providers and employers about the content or assessment of education programmes. However, there is a risk that employers – particularly those providing a large volume of students’ clinical experience – could have an undue influence on the way programmes are designed and run. At the extreme, an employer which is providing a large quantity of clinical placements for an education provider could be in a position to exert a great deal of influence on course content or assessment methods. This could affect (or be perceived to affect) the academic rigour and credibility of optometry training, unless the GOC puts robust validation and quality assurance mechanisms in place. 

Degree level apprenticeships

The risk of employers exercising undue influence may be heightened if the ESR leads to the creation of degree-level optometry apprenticeships, as seems likely. Apprenticeships could have real attractions in the context of optometry, including access to levy funding for employers, and the prospect of a salary throughout the training period for students – which could also make it easier for students from diverse backgrounds to enter the profession. However, apprenticeships would also give employers much more direct influence over the day-to-day learning experience of students. The process of developing apprenticeship content and assessment frameworks has high levels of employer involvement across the UK and is employer-led in England.

As and when proposals for optometry apprenticeships are developed, we think the GOC should:

• Consider carefully whether these new programmes will give students the grounding in academic knowledge and critical thinking skills that they will need, in order to practise safely in an evolving range of clinical settings with changing technology
• Ensure that the GOC’s validation and quality assurance mechanisms are robust enough to deal with the heightened risk of undue employer influence over students’ education, and the challenge of maintaining consistency in assessment between apprenticeships and other types of education programme. 

All these issues will need to be carefully assessed and mitigated by the GOC through consultation with education providers, community and NHS employers, professional bodies and others.

Validation and quality assurance

It will not be possible to assess outcomes accurately under new programmes until the first cohort of students completes their training and final assessments. There is a risk that the GOC may approve an innovative education programme, but later withdraw approval because it decides the programme is not meeting the Education Standards or enabling its students to achieve the Learning Outcomes. The likelihood of this risk may be small, but if it happens the impact will of course be significant. The GOC must mitigate this risk through a robust approach to quality assurance and approval, which can respond with agility to the development of new approaches to education. 

Sound quality assurance will be vital to delivering the ESR successfully, and will be particularly challenging given:

• The need to assess a wide variety of new education programmes, which may be of different lengths and involve different blends of academic and practical experience, varying from the current ‘three years plus one year’ model to degree apprenticeships
• The difficulty of assessing different courses consistently – which AOP members working in education perceive as already a challenge for the GOC, even under the current prescriptive and inputs-focused model of education approval.

The GOC must therefore ensure that it has the necessary resources to manage the validation and quality assurance of a much more varied set of programmes. In the short term the GOC must also ensure that the quality assurance function operates robustly through the transition period, when education programmes will be operating to both the current and new standards. 

Because the new Education Standards are more high-level than the current requirements, GOC visitor panels will need to be appropriately trained to assess new programmes effectively.  There should be a high level of educational and pedagogic knowledge on each panel, as they will need to adopt a more qualitative approach to assurance as the ESR moves the system away from quantitative assessment of eg the number of patient episodes provided by a course. 

As we noted in our response to the ESR ‘concepts and principles’ consultation, there is also scope for GOC education visits to play a supportive role in helping providers understand the GOC’s expectations, and in sharing good practice. Some AOP members working in education have told us that GOC visits can feel like they are conducted in isolation. It would be valuable for providers to learn from peer experience as they start to offer programmes under the ESR model. 

Funding 

We have described some of the financial challenges that new education programmes will face. Given the scale of the change that the ESR will bring, we think it is vital that the GOC considers the wider question of how optical education programmes are funded. Although funding is not in the GOC’s direct remit, it will play a key role in the success or failure of the ESR model and will therefore have a direct bearing on the GOC’s public protection role. We therefore suggest that:

• The GOC should urgently confirm with the UK and devolved governments and the NHS how the existing pre-registration supervision grant can be used in the future to fund clinical placements within new education programmes 
• The GOC should discuss with Health Education England, and its equivalents in the other UK nations, how further funding could be obtained to support clinical placements, recognising the need to maintain a pipeline of the optical professionals required to deliver NHS commissioned services 
• Optometry programmes are currently funded at the same level as science courses and allied health professions. Some other health professional courses, including medicine and dentistry, are classed as clinical courses and receive Government funding at a higher level. The GOC should explore, with the Office for Students and Department for Education, how a case for a higher level of funding can be made for optical professional training – to reflect the evolving roles of optical professionals and the cost of the additional clinical experience that the ESR proposes
• We understand that the NHS funds lectureships in education programmes for other health professions. The GOC should explore how such funds could be allocated to the delivery of optical education and research to reflect evolving service needs.

We recognise that these funding issues will not be easy or quick to negotiate. However, the GOC has an opportunity to take a leadership role alongside education providers and professional bodies, arguing for funders to put optical education on a footing that more accurately reflects its importance to NHS service delivery and patient care.

If the improved funding arrangements discussed above cannot be put in place, the GOC’s expectations of education providers should fully take into account the challenging financial environment facing universities, including the potential impact of the Augar review³.

Part B – the draft Education Standards and Learning Outcomes

Learning Outcomes for optometry students

We continue to support the principle of moving to high level Learning Outcomes, rather than detailed competencies. However, we think the draft Learning Outcomes for optometry students need significant amendments. Our comments below relate to the Learning Outcomes for optometry, but the same approach to revision is likely to be relevant to the other sets of Learning Outcomes included in the consultation.

Domain 1 of the Learning Outcomes (‘a knowledgeable and skilful clinician and scientist’) covers the expertise required to practise as an optometrist. As currently drafted it is hard to follow, partly because it doesn’t separate out knowledge, skills and behaviours, and partly because it employs a range of terms without defining them (eg knowledge, understands, ability, applies). 

We think Domain 1 of the optometry Learning Outcomes should be redrafted to:

• Distinguish clearly between requirements relating to knowledge, skills, and behaviours, in a similar way to the General Medical Council’s learning outcomes for graduates⁴
• State clearly what standard of attainment is required in each Learning Outcome, perhaps using a standard classification framework such as Bloom’s taxonomy or Miller’s triangle. 

In our view these changes would:

• Help students and education providers to understand what students should know, what they should be able to do, and how they should behave, by the end of their initial training
• Help education providers and the GOC consider appropriate methods of assessment for each Learning Outcome (eg written assessments for knowledge, observation and structured tests for skills, observation and assessor feedback for behaviours)
• Reduce duplication or overlap between different Learning Outcomes, such as between Learning Outcomes 1.10 (‘understands and applies the methods of selecting and fitting contact lenses’) and 1.11 (‘ability to safely and competently fit contact lenses’).

Given the need to restructure the Domain 1 Learning Outcomes, we have not provided drafting comments on them. However, we have one specific drafting query. Draft Learning Outcome 1.16 (‘as a newly qualified optometrist, has all the necessary knowledge and clinical skills for the delivery of primary eye care service contracts in the UK’) seems to require any newly qualified optometrist to be able to perform every requirement of any new primary eye care contract anywhere in the UK. In future, that could include novel requirements not included in current optometry degrees or pre-registration experience. The GOC should clarify what contracts this Learning Outcome is intended to cover. We suggest that it should specify all core competency primary eye care service contracts.  

Domains 2, 3 and 4 essentially restate the GOC’s Standards of Practice for individual registrants in a generic way, using the same wording as the draft Learning Outcomes for DO students and Contact Lens Opticians in training. It makes sense to link the Learning Outcomes for students in each discipline with the Standards of Practice they will need to meet when they qualify. However, the current drafting approach is more complex than it needs to be.

We suggest that for each discipline, the content of Domains 2, 3 and 4 could be replaced by a single Learning Outcome requiring students to demonstrate the ability to comply with the GOC Standards of Practice for individual registrants. This could mirror draft Education Standard S1.1 which links the Education Standards to the Standards of Practice for individual registrants.

This would shorten and simplify the draft Learning Outcomes, which currently include a good deal of overlapping or duplicated material, often in different domains. For instance:

• Learning Outcomes 2.4, 2.8, 2.9 and 3.2 all cover compliance with the law and/or ethical and regulatory standards, and seem to overlap substantially
• Learning Outcome 2.1 (‘understands the need to put patients’ interests first and demonstrates care and compassion for patients’) covers very similar territory to 3.8 (‘has the ability to apply skills and professional judgement doing the right thing and putting the patient first’)
• Learning Outcome 4.4 (‘understands that there will be times when they need to consult with or refer to other colleagues within or outside the optical sector and is aware of different referral mechanisms’) covers the knowledge required to apply the skill described in 1.7 (‘appropriately advises and/or refers patients where necessary to the most appropriate professional’)  

Our suggested approach would also ‘future-proof’ the Learning Outcomes to some extent, by avoiding the need to revise them whenever the Standards of Practice themselves are revised. However, a regular cycle of review will of course be needed.

Finally, there is a risk that high-level new Learning Outcomes could unintentionally lead to specific aspects of optical training that are vital for some types of practice being neglected. We understand the Optical Confederation Domiciliary Eyecare Committee is submitting a consultation response calling for the draft Learning Outcomes to take into account specific knowledge, skills and behaviours necessary to deliver care safely in domiciliary settings. We support this.

Education Standards

We offer specific comments and suggestions on some of the draft Education Standards below. As a general point, we think the Standards would benefit from review to ensure that language is clear, consistent and (where appropriate) defined. For example, many of the Standards refer to education and training, but Standards S1.1, S1.3 and S5.11 refer only to education. It is not clear if this meant to be narrower, or (if so) what distinction between education and training is being drawn.

S1.2: It would be better to say, ‘how programmes should be developed’ rather than ‘need to be developed’, which implies changes will only be made if absolutely necessary.

S1.3: The meaning of this Standard is unclear. What is meant by ‘embed evidence’, and what is the significance of the reference to ‘education in the UK’? It would be clearer to mirror the wording of Standard S1.4 and say, ‘ensure education and training programmes reflect good clinical, professional and educational practice’, if that is what is meant.

S1.7: It is not clear why this Standard refers to education and training ‘activity’ when other Standards refer to ‘programmes’. We do not understand what ‘unfair bias’ means – is the implication that some kinds of bias are fair? If so, this needs to be clarified. More generally, it would be helpful if the GOC could give examples of what this Standard is intended to prevent. 

S1.8: This Standard will be out of date if the GOC decides to drop the requirement for students to register. If that change goes ahead, the Education Standards will need to set out the GOC’s expectations of how providers will deal with possible fitness to practise concerns, eg by running their own fitness to practise procedures (see also our comment on S2.3 below, and our response to consultation question 16 in Part C of this response). 

S1.9: We are not sure the words ‘in practice’ add anything meaningful to this Standard.

S2.3: It could be inferred from this Standard that providers must run their own fitness to practise procedures and report the outcomes to the GOC. Is that the intention? If so, providers would need guidance from the GOC about the required standards and how procedures should be run. Some providers don’t run their own fitness to practise procedures at present.

S2.5: Some AOP members working in education have suggested that more information is needed on what ‘sufficient’ means in the context of staffing, eg would the current staffing ratio of 17:1 still be expected? This may be a suitable area for benchmarking and/or additional GOC guidance.

S3.2: If the Learning Outcomes are restructured to distinguish clearly between requirements relating to knowledge, skills, and behaviours as we have suggested above, that would support providers to deliver this Standard.

S3.3: It seems unnecessary to list the professions and specialisms in the Standard. More importantly, as discussed in Part A of this response the GOC needs to clarify its definition of a ‘safe beginner’, and so this is another Standard where additional GOC guidance could be helpful.

S3.5: This Standard could be shortened with no loss of meaning, eg ‘Ensure systems are in place to provide evidenced assurance that students have attained the GOC Learning Outcomes before registering as a qualified practitioner.’ There seems to be some overlap with S3.6.

S3.7: It is not clear what the difference is between ‘regular’ and ‘periodic’. 

S3.8: It is not clear how this differs from or goes beyond S3.5. Assessments check whether students have met Learning Outcomes, but do not ‘enable’ that. In the final line we think ‘fair’ is redundant; if results are valid and reliable, they should be fair by definition.

Introduction to Standard 4: It is important to be clear about the meaning of ‘clinical experience’ and avoid defining it too narrowly. As discussed in Part A of this response, clinical experience should not be confined to interacting with real patients in a real clinical environment. 

S4.2: Education providers will need to understand how to interpret ‘an appropriate amount and mix’ of clinical experience. This may be another area for additional guidance.

S4.4: Again, it will be important to clarify the meaning of ‘experience that is consistent with their level of study’. Should ‘study’ be replaced by ‘expertise’ or ‘understanding’?

S4.6: This could be a wide-ranging new demand on education providers. It should be made clear that it is not an open-ended requirement, and only applies to the extent necessary to support delivery of the programme each provider is offering. 

Introduction to Standard 5: We do not think that requiring ‘good value for students’ is within the GOC’s remit; that is a role for the Office for Students and the market. In any case, it is not clear what ‘good value’ means in this context.

S5.2: The final sentence of the Standard will be out of date if the GOC decides to drop the requirement for students to register.

S5.4: If the GOC decides that students should continue to be registered, it will be important to set out clearly the respective obligations of the learning provider and the GOC for dealing with student declarations, for instance about physical and mental health issues. Again, this may be an issue for additional guidance.

S5.6: While there is value in education providers supporting professional mobility, this is not a public protection issue and we do not think it is an appropriate topic for a GOC Standard. 

S5.7: it is not feasible to ‘continuously improve’ these aspects of education and training programmes. It would be more realistic to require education providers to keep these issues under continuous review.

 S5.11: See comment on S5.7.

Part C – answers to the consultation questions

Section 1: Views on draft Education Standards and Learning Outcomes

Question 7: What opportunities and impacts (including equality, diversity and inclusion) may arise from the content of the draft Education Standards and Learning Outcomes, and how could they be mitigated? 

We are pleased that the GOC has now published a draft Impact Assessment (IA) for the ESR. It’s important that the GOC identifies and seeks to mitigate the risks associated with the ESR and consults on the impact of its policies in line with the principles of good regulation.  

We set out our views on some of the key impacts of the ESR in Part A of this response, summarised below, and we invite the GOC to consider those views when revising the IA:

• Moving to a single set of Learning Outcomes for the whole journey to registration as an optometrist:
  • carries risks – which can be mitigated by clearly defining the knowledge, skills and behaviours required by a ‘safe beginner’ optometrist, and ensuring robust and consistent assessment
  • will entail significant time and resource costs for education providers
  • will need to be clearly explained to prospective students
• Integrating more clinical experience into education programmes:
• will have cost and logistical implications for education providers, community optical practices and hospital eye departments 
• raises questions around the type and variety of clinical experience required, and the risk of undue employer influence 
• The ESR changes will put more demands on the GOC’s own validation and quality assurance processes, which need to be resourced accordingly
• The changes also raise questions about the way in which optometry education programmes should be funded.

There are other risks and impacts relating to the ESR which are not covered in the current IA, and which we think the GOC should consider both in the IA and in its ESR planning:

Some AOP members working in education thought the case for GOC registration of students might become stronger if the ESR leads to more patient contact earlier in the training journey. However, GOC student registration offers no real additional patient protection because responsibility for patient safety will always lie with the registered practitioner supervising the student. If the ESR leads to more patient contact for students, it will be vital for the GOC to make the patient safety responsibilities of supervisors clear to education providers, employers, and supervisors themselves. 

Members working in education also noted that without GOC student registration, a past conduct issue which could prevent an optometrist practising might not be identified as a problem until the student has completed training. If the student registration requirement is dropped, the GOC will need to find a way of managing this risk. Some universities already require new optometry students to undergo a DBS check which will flag the existence of issues that might affect the student’s ability to register. It may be appropriate for the GOC to provide guidance to education providers on what steps they should take to check for such issues at the start of the training process, and how they should work with the GOC to assess any issues that arise.

The GOC will also need to help education providers understand how to deal with potential Fitness to Practise (FTP) issues that arise during the course. The universities that currently offer optometry programmes have varying approaches to FTP processes, and our members told us the GOC’s current expectations in this area are unclear. Since the ESR will lead to more and earlier patient contact for students, education providers will need to have robust and consistent approaches to ensuring patient safety, whether or not the GOC registration requirement is dropped. This is another area where change could create additional risks (eg of legal challenge) and costs for education providers.

The Association of Optometrists
February 2019