The Future of Optometric Services in Primary Care in Wales

IMPROVING HEALTH IN WALES The Future of Optometric Services in Primary Care in Wales a consultation document

THE FUTURE OF OPTOMETRIC SERVICES IN PRIMARY CARE IN WALES

The purpose of this high level document is to set out the Welsh Assembly Government s proposed strategy for optometric services in primary care in Wales and what the aims should be to strengthen and develop optometric services. We hope that you will tell us what you think about the proposals in this document. In addition please give us your view on priorities and on what needs to be done to deal with the challenges we face. We would like to publish the responses received. Please let us know if you want part or all of your response to be treated in confidence. Please send your comments by Tuesday, 31 December 2002 to: Rob Heaton-Jones Health and Well-Being Strategy and Planning Team Welsh Assembly Government Cathays Park Cardiff CF10 3NQ E-mail rob.heaton-jones@wales.gsi.gov.uk Further copies of this document can be obtained from: Health and Well-Being Strategy and Planning Team Welsh Assembly Government Cathays Park Cardiff CF10 3NQ Tel: 029 20801414 E-mail: suzanne.parfitt@wales.gsi.gov.uk

THE FUTURE OF OPTOMETRIC SERVICES IN PRIMARY CARE IN WALES Foreword I am pleased to present this high level strategy on the future of optometric services in primary care. It is released at a time when optometry is becoming seen, more and more, as a vital part of the provision of NHS Services. We recognise the importance of the service in the primary care structure. Not only do the community optometrists provide an excellent sight-testing service, but they are a vital part in detecting eye disease, undertaking an increasing role in the provision of clinical procedures through co-managed or shared care schemes. The strategy describes how the role of optometrists can be further developed within the primary care team. It also says that there are opportunities for them to become an integral part of significant improvements to the health and well being of people in Wales with visual problems and those with low or impaired vision. I acknowledge the important role that optometrists currently provide and we want to build on the excellent work that is already being developed. Already optometrists are a vital part of the National Assembly Eye Care Initiative and their contribution involving professional specialist skills will form the basis for a strategy for visually impaired people in Wales. This strategy sets out the proposed future development of the services within the primary care team which will help improve access to and co-ordination of services to meet patients needs. We aim to support the development of optometric services in Wales to provide an improved health service targeting not only individual needs but also on the prevention of eye disease. Your comments about this strategy are important in determining the future development of optometric services in Wales, please take time to consider and provide us with your views. Please distribute this document widely and encourage others to comment likewise. Jane Hutt AM Minister for Health and Social Services 1

THE FUTURE OF OPTOMETRIC SERVICES IN PRIMARY CARE IN WALES Impaired vision and failing eyesight are key issues in primary care and in the health and well being of many in society. The demand for good vision has increased as society advances technology. Technological advance brings with it problems associated with demands at the workplace and at home. Electronic communication and the ability to access individuals almost at will has created an ever increasing demand for an ability to see without impaired vision and without eyestrain. The future development of optometric services provided within the community will be structured in particular to address and meet these needs together with those of an ageing population. Good vision is one of the key factors for an individual maintaining an independent lifestyle. Optometrists work primarily in community-based practices at primary care level with some working in a hospital environment alongside ophthalmologists in the secondary care sector. Community optometrists provide a wide range of services including sight tests and eye examinations, either through the General Ophthalmic Service or privately. They fit contact lenses and dispense spectacles and undertake an increasing number of clinical procedures through co-managed or shared care schemes. Optometrists refract and detect signs of disease or abnormality of the eye the majority of referrals to the hospital eye departments are through optometric referrals. Optometrists also undertake a range of services within primary care, usually in conjunction with GPs and ophthalmologists, in order to screen for and monitor eye disease such as glaucoma and diabetic retinopathy. In some cases optometrists also provide low vision aids and specialist contact lens services. The role of the optometrist can be further developed within the primary care team. Improving access to and the co-ordination of services to patients offers real opportunities to achieve significant improvement in the health and well being of people with visual problems as well as those with low or impaired vision. Specialist Skills Optometrists can provide the following services: detection of ocular pathology and referral for treatment if appropriate monitoring of pathological conditions shared care or co-managed schemes detailed referral and grading of urgency therapeutic treatment of certain eye conditions visual assessment of the over 75 age group and specific visual field examinations to satisfy requirements for driving 2

care of children s eyes from the early stages of development through to secondary level fitting and care of the contact lens patient including specialist prescribing advice on vision and specialist eyewear for sport, occupational eye care including safety spectacles and advice and specialist prescribing for the VDU user. Co-Management This is the process by which optometrists undertake specified clinical procedures working to an agreed protocol. This relieves the burden on GPs and the Hospital Eye Service (HES) and enables the patient to be treated in the Primary Care Environment. Schemes may include: Cataract optometrists can manage the patient to the stage where surgery is necessary and assess the patient before and after surgery. Direct referral by an optometrist working to agreed protocols would further assist in the refining of these protocols and analysing inappropriate referrals. Glaucoma optometrists can provide the accuracy of referrals by undertaking further clinical investigations and monitor those patients with ocular hypertension or those with stable disease. Diabetes optometrists can deliver a highly effective monitoring service for diabetic retinopathy using slit lamp biomicroscopy, digital imaging or both. Low Vision currently the services are provided within either a hospital environment or in private practice. The skills exist to extend this service to the wider community-service based within primary care. Contact Lenses optometrists who have the relevant skills can provide medically indicated contact lenses within the community. Minor Acute Eye Problems working with GPs, optometrists can manage and treat minor eye conditions. Paediatrics the refraction of children referred from a screening service, provision of spectacles and binocular vision therapy and referral of children to the HES when necessary, are part of the optometrist s work. Current Situation Already the optometric profession has been to the forefront in driving the health agenda in Wales. Scheme already in place include Direct Referral to the HES (Bro Taf), Primary Eye Care Acute Referral (Bro Taf Caerphilly) and also the Diabetic Co-management Scheme in Gwent. Diabetic Retinopathy co-management schemes in all Local Health Group areas in Gwent as well as an optometrist led scheme in Anglesey. 3

Professional Vision The profession needs to develop to become Primary Eyecare Practitioners. To achieve this goal the following priorities will need to be addressed: Implementation of the Crown Report (Review of Prescribing, Supplying & Administration of Medicines: Final Report March 1999) granting independent prescribing rights to accredited optometrists. Development of competencies in Therapeutics. Adequate IT resource and training on par with other health professionals. Funding issues relating to technological advance in instrumentation and equipment. Continuing Education and Training (CET) and Continuing Professional Development (CPD) opportunities mirroring those of other contractor professions. Development of an improved integrated multi-disciplinary workforce and environment. The establishment of the Welsh Post Graduate Optometric Centre. Without the current General Ophthalmic Service (GOS) sight test there should be a needs driven examination for all ocular medical conditions, which will have different entry points: GP referral Referral from secondary care GOS referral Self referral Referral from social services and other partner agencies. Access In common with other health professionals, there are areas across Wales which do not have access to optometric services within the Community. These are areas in which it is not economically viable to set up practice and the problems will need to be addressed along with other professions, by way of a means of underwriting this service. The profession is committed to the equality of access and opportunity. The establishment of Primary Care Resource Centres involving an integrated professional environment might address this issue. 4

Work Force Planning Whilst there is no national shortage of optometrists there is a difficulty in attracting optometrists to work in certain parts of Wales especially the deprived areas. Consideration will need to be given to options presented to overcome this problem. IM & T It is essential that the profession of optometry is fully integrated into the mainstream of the NHS to facilitate communications across the network. This is an issue for the development of: Telemedicine - electronic direct referral schemes - co-management schemes e.g. diabetes and glaucoma - communication feedback from other professional involved in the patient care pathway Web Based - CET and CPD Premises The profession provides a good clinical environment provided for patients and funded by the profession. Where there is perceived to be a variance from this standard then practice inspection will address the problem. The profession would expect parity with other professions around such issues as improvement grants. Continuing Education (CE) & Continuing Professional Development (CPD) The increasing demands of meeting the needs of patients to provide the highest standards of optometric service require a significant commitment on behalf of the individual to CE and CPD. The establishment of a Postgraduate Centre for Optometry in Wales at the Department of Optometry at Cardiff University is considered to be an essential part in the delivery of the necessary development of the optometrist. It will also provide for further post graduate studies and would be breaking new ground within the UK. The profession is proud of the achievement of that department of the award of a five * in the recent RAE results as well as achieving an "excellent grade" in teaching quality. Professional Development The development of the profession will have short, medium and long term objectives. In the short term the establishment of the All Wales Eye Health Examination, launched by the Minister of Health and Social Services, serves to bring to certain "at risk" groups the benefits of a detailed eye examination by accredited optometrists working within the community. A further expansion of the Primary Eye Care Acute Referral Scheme across the Principality will further provide urgent patient access to the optometrist to assess the acute ocular needs of the patient and appropriately prescribe or refer. The granting of prescribing 5

rights to optometrists to increase the range of medication will further refine this scheme. The rolling out across Wales of a Direct Referral scheme will again benefit the patient through reduction in waiting times. Direct referral to agreed local protocols established with Ophthalmologists will result in a reduction in the number of inappropriate referrals to secondary care. Where this scheme is established the initial audit indicates a 20% reduction in such inappropriate referrals. Later this year will see a further initiative from the Assembly of the establishment of an All Wales Low Vision Services Scheme which will develop the provision of low vision services within the community from accredited optometrists with an expertise in low vision. In the medium and long term the profession will increasingly seek to develop skills in the areas of minor surgery and possibly laser intervention for the treatment of ametropia. Benefits of Professional Development The involvement of optometrists in co-management of conditions such as stable glaucoma, the monitoring of ocular hypertensives, refining cataract referrals and diabetic co-management will enable patients to be examined within the community with benefits of local access, shorter waiting times, more convenient appointments, and reduction of lengthy trips to hospitals. The development of an All Wales Diabetic Retinopathy Screening Service this year affords the opportunity for optometric involvement. This provides for specialist examination using a slit lamp biomicroscope under dilation of the eye as well as the opportunity for those optometrists with retinal cameras to link into a digital recording criteria of the retinopathy scheme. In summary the opportunity for professional optometric development and the expansion of the optometrist s skills in other areas will result in: shorter waiting times shorter waiting lists greater patient convenience more efficient use of secondary care resources increased co-operation between healthcare professionals. Development of optometric services will result in an improved health service targeting the needs of the individual based not just upon treatment and appropriate referrals but also in the prevention of eye disease. This will have a direct impact upon and offer financial benefits to the NHS within Wales. 6