Therapeutic and independent prescribing

What we're calling for

To enable more optometrists to use their full range of clinical skills in NHS eye healthcare, there should be:

• A wider list of entry level medicines available to all optometrists, through general exemptions 
• More commissioning of primary eye health care extended services, including 
  • services that can be delivered by any registered optometrist - such as for minor eye conditions, monitoring eye disease and post-operative care and 
  • services delivered by optometrists with higher qualifications - such as ‘step down’ care for managing patients with diagnosed glaucoma
• Support for more optometrists to obtain higher qualifications such as the Independent Prescriber qualification, including better access to clinical placements in hospitals

Background

Optometrists are highly trained healthcare professionals, and can supply a list of prescription medicines to manage eye disease. However, the range of prescription medicines that any registered optometrist can provide is too narrow at present. It has not been reviewed since 2005 – and medicines supply and pricing have changed since then, as has optometry practice. 

Optometrists have the clinical skills to deliver a range of extended eye care services, such as for managing red eye, flashes and floaters and other minor eye conditions; repeat measures to identify disease; monitoring low risk cases of glaucoma; and post-operative cataract care. Optometrists can also deliver a wider range of patient eye care by acquiring additional clinical skills to widen their scope of clinical practice. Optometrists with the Independent Prescribing (IP) qualification can manage more complex conditions which historically had to be seen in hospital.  

NHS hospital eye services are struggling to meet rising demand for eye care from an ageing population and are under growing pressure. The NHS can commission extended eye health services in community optical practices - to relieve pressure on hospitals and provide care to patients in convenient local settings. But at the moment this isn’t happening on a wide enough scale to maximise benefits for the NHS or to avoid an unacceptable postcode lottery for patients, particularly in England. We’re calling for that to change.  

The potential of community optometry to provide more eye healthcare is being limited not only by a piecemeal approach to commissioning, but also by a lack of funding, training and placements for optometrists who want to widen their scope of practice, including through therapeutic prescribing.

What needs to change

Prescribing rights

Government needs to widen the range of entry level medicines available to all optometrists so they can make full use of their training and supply a wider range of clinically appropriate and cost effective prescription medicines to patients. This will save time, for patients and for overburdened GPs and hospitals. It will also support more accurate and responsible prescribing, because: 

• as eye care experts, optometrists are highly skilled in identifying eye disease and appropriately managing this with effective therapeutic interventions for the patient’s needs 
• the evidence shows that optometrists are efficient prescribers who supply prescription medicines for eye disease in a more targeted way than GPs or pharmacists (1,2).

This will save the NHS money as well as supporting antimicrobial stewardship. We’re pleased that the NHS and the Government have recognised the need for change to UK legislation, and we urge them to make progress with a revised set of rules to expand the list of medicines that all optometrists can safely use for patient eye care. 

Making more use of community optometry

We also need further changes to enable optometrists with higher qualifications, including those with the Independent Prescriber (IP) qualification, to make full use of their skills:

• IP optometrists providing extended services should be able to use NHS prescription pads in all parts of the UK, as they can in Scotland
• The NHS should commission more eye healthcare services making use of community optometrists with higher qualifications
• Other healthcare professionals should signpost people with eye conditions to optometrists providing extended services, in the same way as people with minor ailments are now encouraged to see their pharmacist.

Access to higher clinical skills

Education funders and providers and healthcare employers should support more optometrists to develop and maintain higher clinical skills, in order to meet the growing demand for NHS eye care. In Scotland, NHS Education Scotland has invested in the training of IP qualified optometrists and Glasgow Caledonian University has embedded elements of the current post-graduate IP training into their undergraduate optometry syllabus. Health Education North West has funded 80 places for IP training. 

Rather than each health area developing its own system, there should be national systems in each part of the UK to ensure that more optometrists can access: 

• refresher training that accredits optometrists to work, within their existing clinical competence, in particular extended services 
• the Independent Prescriber qualification  
• other higher qualifications which widen optometrists’ scope of practice, allowing them to provide services that would otherwise need to be delivered in hospital  – including the management of patients with diagnosed glaucoma and age related macular degeneration (AMD)
• higher qualifications should be tailored to enable optometrists to provide community eye care management for  specific diseases such as glaucoma, that would otherwise need to be delivered in hospitals. These should be designed to reduce unnecessary repetition of training or placements, and be accessible as a single qualification  

This would be consistent with the direction of travel of the GOC’s ongoing Education Strategic Review, which is seeking to improve the clinical content of optometric training. It should not involve any need to invent new qualifications where there are already perfectly good arrangements such as WOPEC, the refresher course that accredits optometrists to participate in MECS.

We recognise that not all the optometric workforce will need IP or other higher qualification to meet the eyecare needs of the population, but providing funding for these qualifications to meet the needs of extended primary eye care, and hospital services moved to the community, will allow more patients to be safely managed in the community rather than need to be seen in hospital.  

Clinical placements

IP optometrists are required to undertake practice-based learning during qualification under the supervision of an ophthalmologist. However, the lack of capacity in secondary care can make it difficult for optometrists to access placements. We think the NHS should give more priority to placements in hospital for optometrists training for IP and other higher qualifications. 

Offering more placement and supervision capacity for training optometrists will enable more eye care to be managed in primary care – and will therefore ultimately relieve pressure on hospitals. We recognise the practical challenges involved in providing hospital placements, and encourage our members, Local Optical Committees and employers to work together with hospital trusts in their local areas to co-ordinate efficient use of placements 

Notes

1. ‘Evaluation of a minor eye condition scheme delivered by community optometrists’ (2016), Konstantakopoulou et al, BMJ 
2. Baker H, Ratnarajan G, Harper RA, Edgar DF, Lawrenson JG.Effectiveness of UK optometric enhanced eye care services: a realist review of the literature. Ophthalmic Physiol Opt. 2016;36(5):545-57. 

November 2019

Read the rest of AOP position statements