THE QUALIFICATION IN PRACTICE

In the second part of a special report series on the IP workforce, OT overviews projects, pilots and practice models

Independent prescribing (IP) optometrists tell us that the benefits of the qualification convey clinical, professional and personal enhancements, but the logistics of using the qualification to its fullest extent can be a challenge. In the second part of a report on IP – present and future – OT looks at the scope for IP in the community currently, what it means for practices, and some of the considerations for this growing workforce.

Collaborative working

During the COVID-19 lockdowns, Independent Prescribing Optometry Services (IPOS) drew on the skills of IP optometrists to manage complex eye conditions in primary care in areas of Wales. One such scheme was established in Cardiff and Vale, where an electronic patient record platform supported the safe transfer of patient data and images, as well as referral between practices.

Marc Drake, specialist IP optometrist and partner at Osmond Drake Opticians in Penarth, manages a rota of IP optometrists in the scheme locally.

Drake became IP-qualified in 2019, and in 2020, Sharon Beatty, the optometric adviser to the Cardiff and Vale University Health Board at the time, reached out to ask if he would consider being a part of an IP service. Within days IPOS launched and

Osmond Drake Opticians was one of four practices to start providing the service.

“The patients loved it, secondary care loved it, and it has kept going,” he said.

Now Drake dedicates two days of the week to IPOS. He said: “Day to day, we have a normal contact lens and refraction clinic running in one of my rooms and IPOS in the other.”

Drake, and his colleagues, take referrals from other practices across Cardiff and the Vale. Patients are triaged, seen and treated, and booked in for follow-up appointments. The hospital eye clinics will also refer patients to finish their treatment and monitoring in the community.

The practice does not market itself to patients attending through IPOS, and maintaining communication with the referring practice is a key part of the pathway. Drake said: “We all hate it when we get no response from secondary care, so I always write to the referring practice.”

Drake suggested that, having delivered the service through the pandemic, trust between practices, and the relationship with secondary care, has grown.

Considering the scope of IP currently, he reflected: “IPs want to be able to manage the majority of anterior segment cases up to a point, and I think it’s very important to work collaboratively with the local primary and secondary care teams so that the care is joined up and flowing in both directions.”

Change is on the horizon for optometrists in Wales, following the agreement of contract reforms in 2022. In a statement announcing the plans, Eluned Morgan, minister for health and social services in Wales, said the changes seek to enable patients to access eye care services “delivered by the right professional, in the right place across the entire eye care pathway.”

With the new contract rolling out, Drake said: “Hopefully it should open up a lot of opportunities to expand what we do, or to fine tune what we do, to make it work better for everybody.”

Piloting eye casualty care

Providing a picture of the scope for IP in Northern Ireland, Brian McKeown, vice-chair of Optometry Northern Ireland (ONI), AOP Councillor and an IP optometrist, told OT: “The scope for IP is slowly developing. IP optometrists can get their prescription pad after they pass their exams and then it’s up to them what they use it for. If you’re proactive you can use it to deliver a higher level of care.

“There certainly is a lot of good will with ophthalmologists who witnessed first-hand what IP optometrists in the community could manage during the pandemic.”

Considering the ambitions the professional body might have for the future, he said: “We feel optometry as a whole has a vital role to play in helping a congested NHS. ONI is working closely with the SPPG to ensure that optometrists always have a voice for future services.”

A pilot is just about to begin in Belfast that would see patients redirected from eye casualty to IP optometrists. At the time of writing, discussions with stakeholders are being finalised. It is hoped the pilot will be launched in the coming weeks.

McKeown explained: “Patients will be redirected from a casualty triage system to their nearest IP optometrist. The patient, suffering from iritis, foreign bodies or keratitis, will be managed in the community and a discharge letter, outlining diagnosis and treatment, will be sent to their own optometrist. The service will then be audited to establish whether it will be extended further.”

As of February 2023, there were 40 IP optometrists in Northern Ireland, with more undertaking the training. Looking ahead, what will this growing workforce mean for optometry?

“We need more IP optometrists working in the community to enable a regional IP service. Once we have that, then Northern Ireland will be extremely well-placed to offer a higher level of eye care in the community,” McKeown said.

“The big consideration is geographic coverage for any regional scheme. Also, are all the IP optometrists interested in working in a new service? When there is a willing workforce then appropriate remuneration needs to be discussed. The fee needs to cover the optometrists’ time and the enhanced skill level, as well as creating good value to the commissioner,” McKeown said. The fee for the new pilot is £90, he explained.

Practice referrals

With optometrists the first port of call for patients presenting with eye concerns in Scotland, Eilidh Thomson,

Access To Fp10 Pads

A survey carried out by LOCSU in April 2021 showed that only 27% of Clinical Commissioning Groups who had commissioned either Minor Eye Condition Services or COVID-19 Urgent Eye care Services had also enabled access to FP10 pads for the local IP optometrists within the service.

Reflecting on the audit, Zoe Richmond told OT that progress has been made in the past two years, explaining: “Our purpose in performing the audit was to raise awareness and encourage local systems to consider solutions, working with their LOCs and primary eyecare companies.” vice chair of Optometry Scotland and an optometrist for Black & Lizars, reflected that the balance is starting to shift towards more provision in primary care optometry practices.

Between 30–40% of the optometry profession in Scotland is made up of IP optometrists. Having the IP workforce as part of community optometry allows that provision to remain in primary care, Thomson suggested.

This means that patients can be treated closer to home, while secondary care can focus on cases that cannot be managed in the community. Thomson said: “I think that it makes it all more streamlined for the patient. That’s the main thing we are trying to do – make the patient journey better,”

This spring sees a pilot of the Community Glaucoma Service launch in Glasgow, through which IP optometrists who have completed the NHS Education Scotland Glaucoma Award Training (NESGAT) will support the safe discharge of glaucoma patients from the hospital to community optometry practice.

Once the pilot has been delivered, the next step would be to review the learnings and consider what is needed to roll it out across the country.

Meanwhile, plans are in development for a new scheme in Scotland that would outline a list of conditions that could be managed in the community, and would support referral between practices with and without an IP optometrist.

Thomson shared: “It is hoped that the new scheme will adequately remunerate IP optometrists to encourage business owners to support the service.”

Frank Munro, a founding member and clinical adviser for Optometry Scotland, has been involved in designing the new specialist supplementary

General Ophthalmic Services (GOS) examination – building on work carried out in Glasgow to design treatment ladders for anterior eye conditions.

The model, funded through GOS will focus on specific, complex areas of care, with 10 specialty supplementary GOS scenarios defined at present.

Munro, of Munro Optometrists, explained: “There will be a list of IP optometrists in that area who are willing to see those patients on behalf of non-IP colleagues. The IP colleague would see the patient, treat them, and feedback the results to the non-IP optometrists.”

With the plans for an intra-referral pathway in the works, Munro suggested this would be “another big step change in service development in Scotland, and establishing optometry as the main player for dealing with eye problems in the community.”

A variable outlook

In interviews with OT, optometrists seemed to agree that the opportunity in England to utilise the IP qualification to its fullest extent is variable.

Providing context, Dr Peter Hampson, AOP clinical and professional director, explained that the opportunity to use the full scope of IP “really depends on where you are prescribing.”

“There are a handful of practitioners who have built really quite developed business models around quite a wide range of conditions,” he said, but pointed out that there are those who have the qualification, but feel they are not using it widely.

Funding and availability of FP10 pads is also an issue, he noted.

“Budget for the FP10 pad has to come from somewhere. Normally this comes from one of the local prescribing budgets; the GP prescribing budget, for example,” Hampson said, adding that this requires a balancing of budgets and a level of assurance – something that takes time to develop.

Zoe Richmond, clinical director of the Local Optical Committee Support Unit (LOCSU), told OT: “Within LOCSU we are well aware there is an interest from primary care practitioners to deliver a wider scope of clinical care, to better meet their patient needs, upskilling and taking on higher qualifications where needed.”

“At the same time, we hear significant frustration from practitioners with higher qualifications that they do not always have the opportunity to fully utilise these skills when working solely within primary care,” Richmond continued. “Even where there are appropriate local commissioning arrangements, empowering primary care clinicians to work in an enhanced clinical role, we often hear that this does not always extend to FP10 pads for IP optometrists.”

Local commissioning can lead to fragmentation and variation, but Richmond shared that consistency in the delivery of locally commissioned services has been increasing in recent years, pointing to the work of Local Optical Committees (LOCs) with LOCSU and the sector bodies to develop and publish national pathways and pathway guidelines, used by LOCs across England.

“My ideal would be a national extended eye care service delivered from networks of practices making optimal use of our collective clinical expertise –including those with high qualifications – and equipment and providing timely accessible care in local communities,” Richmond said, adding that LOCSU and sector bodies have “long called” for a national solution for England.

In 2022, CCGs ceased to exist and Integrated Care Systems (ICS) became legal entities in England. There are 42 ICSs in England, made up of Integrated Care Boards (ICBs), and Integrated Care Partnerships (ICPs).

With the new structure in place, Richmond suggested: “The move from local commissioning to large ICB commissioning footprints should help to reduce current unwarranted variation.”

Positive momentum

Specsavers has seen prescribing as a norm in Australia and New Zealand for some time already. In England, however, Paul Morris, director of professional advancement for Specsavers, identified a “patchwork quilt” effect: “There isn’t one strategy for it. Optometrists have got to plough their own furrow, by offering private services, or I know some who have moved locations so they can more freely practise with the skills they’ve obtained.”

Michael Bradbury, clinical operations communications manager for Specsavers and an IP optometrist, also noted the variation across the country, but added: “I do think there’s been a positive move forward over the last couple of years, with the big uptake of CUES that came as a response to the pandemic. Hopefully there will be a positive legacy of that, a momentum to get more widespread access to those sorts of minor eye care services.”

Despite the variable approaches, IP will be a part of the future, as Morris suggested: “Whatever happens with the health economy in England, IP is absolutely enshrined in the psyche of optometrists and how they wish to develop.”

In targeted areas where IP forms part of the fabric of the health economy, the company is sponsoring IP courses.

Morris reflected: “Whenever I speak to people who have gone through the IP learnings, they all tell me that they’ve become more confident as clinicians, and that should not surprise us.”

How IP is incorporated into practice depends on services in the local areas, but colleagues are encouraged to use designated slots. Morris said: “Setting up and maintaining an appropriate diary over multiple consulting rooms can be complex. Our local directors and clinicians are best placed to understand their own health economy, having some sort of provision to meet the need, by using the data you have of previous clinics that have run, to predict what you'll need in the future and set yourself up accordingly.“

Forging a path

Leightons Opticians & Hearing Care is considering what its patient journeys might look like as optometrists seek out higher qualifications such as IP.

Kiki Soteri, head of clinical services for Leightons Opticians & Hearing Care, explained: “A lot of people think of IP as being related to providing NHS services, and our strength is in our private eye care provision.

“What we’re doing at the moment is looking at how we can deliver IP at a scale, and not waiting for the NHS to provide it. NHS England hasn’t got to the same place as NHS Wales, NHS Scotland, or in Northern Ireland. Therefore, we kind of have to lead the way for private eye care, and IP, and how that fits in.”

Diary management and funding are key considerations to be balanced. Andrew Bridges, director of professional services at Leightons Opticians & Hearing Care, emphasised that without NHS funding, the fees have to be appropriate to sustain the practice, while Soteri added: “Emergency presentations or consultations may need follow up and review in a short timeframe, and that’s a very different way of working to routine eye examinations with long recall intervals. That would be one of the practicalities – thinking about how practice infrastructure and fee structure can support that.”

Supporting the learning of optometrists is key, Bridges shared, noting that more than 30% of optometrists in the company either have, or are studying for, a higher qualification. This is not limited to IP, of course, and the group is looking into how optometrists can be enabled to support local enhanced services, particularly in glaucoma.

A natural part of practice

Describing how he sees the scope for IP, Ian Cameron, managing director of Cameron Optometry, a Hakim Group practice in Edinburgh, said: “Patchy. If you’re in some practices or settings, there is significant scope to use your IP – even close to its fullest extent. I would say that is the case in our practice.”

Prescribing has always had some presence in his practice through the