NHS: PCA(O)(2014)1 Health and Social Care Integration Directorate Primary Care Division Dear Colleague GENERAL OPHTHALMIC SERVICES 1. THE NHS (GENERAL OPHTHALMIC SERVICES) (SCOTLAND) AMENDMENT REGULATIONS 2013 2. THE STATEMENT 3. TESTS, PROCEDURES AND EXAMINATIONS OUTWITH GENERAL OPHTHALMIC SERVICES Summary 1. This letter advises NHS Boards and Practitioner Services of: amendments to the NHS (General Ophthalmic Services) (Scotland) Regulations 2006 ( the 2006 Regulations ); and the publication of a revised Statement. which take effect from 3 February 2014. It also provides a reminder of those tests, procedures and examinations that are outwith general ophthalmic services. 21 January 2014 Addresses For action Chief Executives, NHS Boards Director, Practitioner Services For information Chief Executive, NHS National Services Scotland Enquiries to: Lynne Morrison Chief Dental Officer and Dentistry Division and Ophthalmic Policy 1st Floor East Rear St Andrew s House EDINBURGH EH1 3DG Tel: 0131-244 2529 NHSgeneralophthalmicservicesma ilbox@scotland.gsi.gov.uk Action 2. NHS Boards and Practitioner Services are asked to note the information about: 2.1 the changes to the 2006 Regulations;
2.2 the moving of the details of the tests and procedures of primary and supplementary eye examinations and the data to be kept as part of a patient s record from the 2006 Regulations to the Statement; 2.3 the introduction of separate tests and procedures for primary and supplementary eye examinations undertaken at a place where the patient normally resides, i.e. domiciliary visits, or at an approved day centre; 2.4 the revised Statement; 2.5 the tests, procedures and examinations that continue to fall outwith general ophthalmic services; contained in the Memorandum to this letter. 3. NHS Boards and Practitioner Services are also asked to note that the NHS (General Ophthalmic Services) (Scotland) Amendment Regulations 2013 can be viewed or downloaded at http://www.legislation.gov.uk/ssi/2013/355/contents/made. 4. NHS Boards are asked to urgently copy and issue the Memorandum to this letter to all optometrists and ophthalmic medical practitioners on their ophthalmic lists. Yours sincerely MARGIE TAYLOR Deputy Director
MEMORANDUM TO NHS: PCA(O)(2014)1 NATIONAL HEALTH SERVICE GENERAL OPHTHALMIC SERVICES 1. THE NHS (GENERAL OPHTHALMIC SERVICES) (SCOTLAND) AMENDMENT REGULATIONS 2013 2. THE STATEMENT 3. TESTS, PROCEDURES AND EXAMINATIONS OUTWITH GENERAL OPHTHALMIC SERVICES 1. This Memorandum advises optometrists and ophthalmic medical practitioners (OMPs) of: amendments to the NHS (General Ophthalmic Services) (Scotland) Regulations 2006 ( the 2006 Regulations ); the publication of a revised Statement; which take effect from 3 February 2014. It also provides a reminder of those tests, procedures and examinations that are outwith general ophthalmic services. The NHS (General Ophthalmic Services) (Scotland) Amendment Regulations 2013 2. The 2006 Regulations are being amended with effect from 3 February 2014 to: facilitate eye examinations undertaken at a place where the patient normally resides, referred to as domiciliary eye examinations; remove the detail of the tests and procedures of a primary and supplementary eye examination and the data to be kept as part of a patient record. These tests and procedures are being moved into the Statement, which sets down the fees and allowances which are to be paid to ophthalmic medical practitioners and optometrists; and make other minor drafting and tidying up amendments. 3. Further information about the amendments to the 2006 Regulations is provided below. Primary and Supplementary Eye Examinations 4. The mandatory tests and procedures that should be undertaken as part of a primary eye examination and additional patient specific tests and procedures that should be undertaken depending on the patient s presenting signs, symptoms or age are currently set down in Schedule 3 to the 2006 Regulations. The circumstances where a supplementary eye examination can be undertaken and the tests and
procedures which should be undertaken as part of a supplementary eye examination are currently set down in Schedule 4 to the 2006 Regulations. These mandatory and, where appropriate, additional tests and procedures require to be undertaken no matter where the eye examination takes place. 5. It is recognised that it may not be possible for all of the mandatory, and patient specific, tests and procedures of a primary or supplementary eye examination to be undertaken in a domiciliary setting. However, the 2006 Regulations as currently worded do not allow for a limited eye examination in these circumstances and so to facilitate such examinations revised tests and procedures have been agreed with Optometry Scotland for primary and supplementary eye examinations undertaken in a domiciliary setting. Similar problems arise where eye examinations are undertaken at approved day centres and so the revised tests and procedures will also apply to examinations undertaken in such centres. 6. The opportunity is also being taken to move the detail of the tests and procedures of primary and supplementary eye examinations from the 2006 Regulations to the Statement. This will help to simplify the 2006 Regulations, by removing Tables A and B of Schedule 3 and Schedule 4, provide more flexibility in making any future changes to the tests and procedures and more closely link the payment of eye examination fees to the requirement to carry out the prescribed tests and procedures. The Statement is made under regulation 17 of the 2006 Regulations. Moving the tests and procedures to the Statement does not in any way affect the requirement to undertake these tests and procedures in order to receive payment for a primary or supplementary eye examination. 7. The definitions of primary eye examination and supplementary eye examination in regulation 2(1) (interpretation) of the 2006 Regulations are being amended to: primary eye examination means a general eye health check which includes a sight test, an internal and external examination of the eye as well as other tests and procedures appropriate to the needs of the patient ; and supplementary eye examination means an eye health check which is either carried out (a) after a primary eye examination for a particular reason which has arisen during the primary eye examination; or (b) in circumstances set out in regulation 22(3C), and includes the tests and procedures appropriate to the clinical needs of the patient ; as a consequence of Tables A and B of Schedule 3 and Schedule 4 being omitted from the 2006 Regulations.
8. Paragraph 14(1A) (eye examinations) of Schedule 1 to the 2006 Regulations is also being amended, as follows, as a consequence of Tables A and B of Schedule 3 and Schedule 4 being omitted from the Regulations: (1A) An eye examination carried out by an ophthalmic medical practitioner or optician in accordance with these Regulations shall consist of every test or procedure appropriate to the needs of the patient for the purpose of that examination unless (a) the ophthalmic medical practitioner or optician considers that the patient has a physical or mental condition which would make the carrying out of any such test or procedure clinically inappropriate; or (b) the patient has refused to undertake any such test or procedure. 9. The definition of required equipment in regulation 2(1) (interpretation) of, and paragraphs 4(f) of Part A and B (information, certificates, disclosure requests, disclosure records and undertakings to be included in an application for inclusion in the first or second part of the ophthalmic list) and 2(b) of Part C (declarations to be provided in terms of regulation 26(6)) of Schedule 2 to the 2006 Regulations are omitted. Practices will still require to have in place the items of equipment required in order to be able to undertake primary and supplementary eye examinations. Records 10. The data that should be kept as part of a patient s record is set down in Schedule 5 to the 2006 Regulations. To further simplify the 2006 Regulations the detail of this data is also being moved to the Statement. The definition of records in paragraph 2(1) (interpretation) of the 2006 Regulations is revised as a consequence. Other Amendments 11. The definition of mobile practice is being amended to make it clear that such practices can provide domiciliary eye examinations at any place where a patient normally resides and not just at day or residential centres. 12. Regulation 14 of the 2006 Regulations allows for the disclosure of information about a contractor or assistant by a Health Board to certain specified persons or bodies. Regulation 14(2) and (7) of the 2006 Regulations are being amended to include NHS Education for Scotland in the list of persons or bodies which a Health Board can disclose information to. This will allow NHS Education for Scotland to obtain the information it needs in order to meet its responsibility for providing continuing education and training for those who provide or assist with the provision of general ophthalmic services (GOS). 13. Paragraph 6(2) (premises and equipment) of Schedule 1 to the 2006 Regulations is being amended to make it clear that all contractors who provide GOS at day centres, residential centres or at places where patients normally reside
require to have proper, sufficient and appropriate equipment and procedures for the provision of those services. 14. Paragraph 13(6) (payments) of Schedule 1 to the 2006 Regulations currently allows contractors to demand and recover from a patient a sum in respect of loss of remunerative time resulting from a broken appointment. This sub-paragraph is being removed as there are currently no primary legislative powers which allow for charges for broken appointments to be levied. 15. A number of minor drafting amendments are also being made. 16. A copy of the NHS (General Ophthalmic Services) (Scotland) Amendment Regulations 2013, which bring the above amendments into effect, can be viewed or downloaded at http://www.legislation.gov.uk/ssi/2013/355/contents/made. The Statement 17. As advised in paragraph 6 above the detail of the tests and procedures of primary and supplementary eye examinations are being moved from the 2006 Regulations to the Statement with effect from 3 February 2014. The revised Statement sets out in separate Appendices the conditions for payment of fees, i.e. the tests and procedures which must be undertaken in order to receive payment, for: 17.1 primary eye examinations undertaken at practice premises (Appendix B); 17.2 primary eye examinations undertaken at a place where the patient normally resides or at a day centre (Appendix C); 17.3 supplementary eye examinations undertaken at practice premises (Appendix D); and 17.4 supplementary eye examinations undertaken at a place where the patient normally resides or at a day centre (Appendix E). 18. The tests and procedures for primary and supplementary eye examinations undertaken at practice premises have not changed, although they have been worded to focus more on the tests and procedures to be undertaken rather than the equipment to be used. 19. The tests and procedures for primary and supplementary eye examinations undertaken at a place where the patient normally resides, i.e. domiciliary visits, or at a day centre are based on those for examinations undertaken at practice premises but revised to take account of the particular challenges which arise from providing GOS in these settings. An additional requirement of a primary eye examination undertaken at a domiciliary visit or at a day centre is that a clinical report should be issued, where appropriate, and where it would be useful for the patient s carer, medical professional, and family. This report has to include:
(i) (ii) (iii) (iv) type of spectacles required and when they should be worn; quality of vision achieved; any existing eye conditions; any other comments. This report can be issued as part of the GOS(S)2 patient s optical prescription or statement. 20. Clinically appropriate equipment must be used for each test or procedure and examples of equipment are given in the Tables in Appendices B to E. Optometrists/OMPs are asked to note that where: a) the patient has refused to consent to the use of a particular piece of equipment; or b) the patient has a physical or mental condition which would make the use of a particular piece of equipment clinically inappropriate; alternative equipment may be used which, despite not being a direct equivalent to the suggested examples for that particular test or procedure in terms of clinical thoroughness, will enable the required test or procedure to be carried out. 21. An Amendment to the Statement in accordance with regulation 17 of the 2006 Regulations is attached at Annex A to this Memorandum. Optometrists/OMPs should familiarise themselves with the revised Statement. Tests, Procedures and Examinations outwith General Ophthalmic Services 22. There continues to be certain tests, procedures and examinations that fall ouwith GOS and these are set out at Annex B. Enquiries 23. Any enquiries arising from this Memorandum should be taken up with your NHS Board. Scottish Government Health and Social Care Integration Directorate 21 January 2014
ANNEX A NATIONAL HEALTH SERVICE (SCOTLAND) GENERAL OPHTHALMIC SERVICES THE STATEMENT The Scottish Ministers, in exercise of powers conferred on them by sections 28A and 28B of the National Health Service (Scotland) Act 1978 and regulation 17 of the National Health Services (General Ophthalmic Services) (Scotland) Regulations 2006, after consultation with such organisations as appear to them to be representative of contractors providing general ophthalmic services, make the following determination (referred to as The Statement )- Interpretation Part I 1. In this Statement the 2006 Regulations means the National Health Service (General Ophthalmic Services) (Scotland) Regulations 2006 (SSI 2006/135). 2. In this Statement Optometrist includes an optician as defined in the 2006 Regulations. 3. Any terms defined in regulation 2 ( Interpretation ) of the 2006 Regulations are to be given the same meaning in this Statement. Fees Payable Part II 4. The fees payable to an ophthalmic medical practitioner or optometrist for undertaking eye examinations are set out in Appendix A and are payable in accordance with the conditions set out in: a) Appendix B for the purpose of a primary eye examination undertaken at practice premises; b) Appendix C for the purpose of a primary eye examination undertaken at a place where the patient normally resides or at a day centre; c) Appendix D for the purpose of a supplementary eye examination undertaken at practice premises; d) Appendix E for the purpose of a supplementary eye examination undertaken at a place where the patient normally resides or at a day centre.
Appendix F sets out the additional domiciliary visiting fee which is payable when an ophthalmic medical practitioner or optometrist undertakes a visit to a place where the patient normally resides for the purpose of carrying out one or more eye examinations. 5. Appendix G sets out the allowance payable to an ophthalmic medical practitioner or optometrist for continuing education and training. 6. Appendix H sets out the records that must be kept in accordance with paragraph 8 of Schedule 1 to the 2006 Regulations as a condition of the fees payable under appendices A to F. Scottish Government Health and Social Care Integration Directorate January 2014
APPENDIX A FEES PAYABLE TO OPHTHALMIC MEDICAL PRACTITIONERS AND OPTOMETRISTS FOR EYE EXAMINATIONS 1. Fees payable for each primary eye examination carried out in accordance with Appendix B or C by an ophthalmic medical practitioner or optometrist for those aged under 60 years: on or after 1 April 2010 37.00 2. Fees payable for each primary eye examination carried out in accordance with Appendix B or C by an ophthalmic medical practitioner or optometrist for those aged 60 years and over: on or after 1 April 2008 (no digital photograph taken) 40.00 on or after 1 April 2010 (digital photograph taken) 45.00 3. Fees payable for each supplementary eye examination carried out in accordance with Appendix D or E by an ophthalmic medical practitioner or optometrist: on or after 1 April 2010 21.50 4. A payment made under paragraph 1, 2 or 3 above to an ophthalmic medical practitioner who is participating in the National Health Service Superannuation Scheme, is subject to adjustment in respect of superannuation by deduction of the appropriate contribution.
PRIMARY EYE EXAMINATION UNDERTAKEN AT PRACTICE PREMISES APPENDIX B 1. Table A of this Appendix lists the mandatory tests and procedures of a primary eye examination undertaken at practice premises. 2. Table B of this Appendix lists the additional tests and procedures of a primary eye examination undertaken at practice premises which must be carried out in respect of certain categories of patients. 3. Each of the tests and procedures listed in table A of this Appendix must be carried out, as appropriate, when a primary eye examination is provided to a patient unless- a) the patient has a physical or mental condition which would make the carrying out of a specific test or procedure clinically inappropriate; or b) the patient has refused to undertake a specific test or procedure. 4. Where a patient meets one or more of the descriptions in column 1 of table B of this appendix, each test and procedure in the corresponding entry in column 2 of table B must be carried out, as appropriate, unless- a) the patient has a physical or mental condition which would make the carrying out of a specific test or procedure clinically inappropriate; or b) the patient has refused to undertake a specific test or procedure. 5. Clinically appropriate equipment must be used for each test or procedure carried out under this appendix. Examples of equipment given in the tables are indicative of the equipment that is clinically appropriate. 6. Where a) the patient has refused to consent to the use of a particular piece of equipment; or b) the patient has a physical or mental condition which would make the use of a particular piece of equipment clinically inappropriate; alternative equipment may be used which, despite not being a direct equivalent to the suggested example for that particular test or procedure in terms of clinical thoroughness, will enable the required test or procedure to be carried out.
Appendix B TABLE A THE TESTS AND PROCEDURES REQUIRED FOR THE PURPOSE OF A PRIMARY EYE EXAMINATION UNDERTAKEN AT PRACTICE PREMISES The taking of a relevant detailed history and symptoms, which includes relevant medical, family, and ocular history The recording of unaided vision, visual acuity or pinhole vision as appropriate Sight test appropriate to the presenting signs, symptoms, and aided/unaided acuity unless this is not possible/advisable due to eye infection, disease or injury A pupillary assessment including testing for relative size, shape, direct, consensual and near responses An examination appropriate to the reason for referral from a medical practitioner or other carer, if applicable An eye health assessment appropriate to the patient s needs and any presenting signs or symptoms An internal examination of the eyes by direct or indirect observation as appropriate, for example using direct ophthalmoscope, slit lamp with condensing lens or head mounted biomicroscopy An external examination of the eyes using illumination and adjustable magnification, for example using slit lamp biomicroscopy, and using any appropriate diagnostic agents A relevant assessment of extra ocular motor function; oculo-motor balance and ocular motility A visual field assessment The communication of the clinical findings, including preparation of a referral letter and clinical report (where appropriate), results and diagnosis to the patient, his or her carer (where appropriate), and other appropriate health professionals as agreed by the patient and/or his or her carer
Appendix B TABLE B THE ADDITIONAL TESTS AND PROCEDURES SPECIFIED FOR THE PURPOSE OF A PRIMARY EYE EXAMINATION UNDERTAKEN AT PRACTICE PREMISES Column 1 Column 2 Children aged under 16 years (where the ophthalmic medical practitioner or On first appointment, stereopsis and, where clinically appropriate, colour vision optometrist carrying out the eye examination does not have access to or means to access the patient s records) Children aged under 16 years (where the ophthalmic medical practitioner or optometrist carrying out the eye examination does have access to or means to access the patient s records) Adults aged 40 and over Adults aged 40 years and over who have a family history of Glaucoma Adults aged 60 years and over (i) where the ophthalmic medical practitioner or optometrist carrying out the eye examination does not have access to or means to access the patient s records or (ii) where the ophthalmic medical practitioner or optometrist does have access or means to access the patient s records and it is the patient s first examination after having reached his or her 60 th birthday Colour vision and stereopsis where clinically appropriate Intra ocular pressure measurement Intra ocular pressure measurement, automated suprathreshold visual field tests, and assessment of the optic nerve head (i) Assessment of visual field using automated equipment to give a defined measurement with accurate repeatability, for example automated supra-threshold fields (ii) The performance of a binocular internal examination of the eyes by indirect observation as appropriate with mydriasis, for example using a slit lamp with condensing lens or head mounted biomicroscope (iii) Digital fundus imaging or scanning of the internal central area of the fundus for example using a digital fundus camera, retinal scanner etc. (To obtain at minimum a digital image of the central fundus) unless this is not possible where there is no access to a digital camera, as the practice does not have the room to accommodate a camera
Subject to the provisions of the row above, adults aged 61 years and over (where the ophthalmic medical practitioner or optometrist carrying out the eye examination does have access to or means to access the patient s records) Patients discharged from an ophthalmic hospital following a cataract operation Patients presenting with suspect vitreo retinal disorder aged 60 years and over Patients with suspect glaucoma or ocular hypertensives Patients with suspect macular disorders aged 60 years and over Patients with cataract aged 60 years and over (i) Assessment of peripheral vision function using automated equipment to give a defined measurement with accurate repeatability, for example automated supra-threshold fields as clinically indicated (ii) The performance of a binocular internal examination of the eyes by indirect observation as appropriate with mydriasis, for example using a slit lamp or head mounted biomicroscope (iii) Digital fundus imaging or scanning of the internal central area of the fundus for example using a digital fundus camera or retinal scanner etc Postoperative cataract examination and sight test A binocular vitreous examination and fundus assessment with mydriasis. including assessment of the peripheral fundus using appropriate equipment for example dilated slit lamp biomicroscopy (with condensing lens), indirect headset or gonio fundus lens Intra ocular pressure measurement by non-contact or applanation tonometry as appropriate, automated supra-threshold visual field assessments, and assessment of the optic nerve head (i) A binocular examination of the macula by direct or indirect observation with mydriasis and using adjustable magnification and illumination, for example using slit lamp biomicroscopy (ii) Test to investigate sudden onset of visual distortion in one or both eyes A binocular internal eye examination (with mydriasis), for example using a slit lamp biomicroscope with condensing lens or a head mounted biomicroscope
Other presenting signs and symptoms Any of the following as clinically appropriate to the presenting signs and symptoms : (a) Standard tests such as binocular function and stereopsis, amplitude of accommodation, colour vision, confrontation fields and/or any other appropriate tests excluding the following tests and procedures when undertaken as part of a supplementary eye examination on the same day: cycloplegic refraction; internal eye examination with mydriasis, for example using head mounted binocular indirect ophthalmoscope or slit lamp and condensing lens for patients aged under 60 with small pupils measuring 2mm or under, or where an adequate view of the fundus cannot be obtained without dilation; dilated internal examination as appropriate for example using a slit lamp biomicroscope with condensing lens, for patients aged under 60 with suspect: o cataract; o macular disorders; o diabetic retinopathy; o vitreo retinal disorders; o glaucoma; o neurological symptoms; or o tumour risk (b) Issue advice and instruction to patients prior to referral into a care pathway, shared care scheme or a level 2 optometric pathway (c) Direct referral, where clinically appropriate, to an ophthalmic hospital, to the patient s General Practitioner, or to another ophthalmic medical practitioner or optometrist
APPENDIX C PRIMARY EYE EXAMINATION UNDERTAKEN AT A PLACE WHERE THE PATIENT NORMALLY RESIDES OR AT A DAY CENTRE 1. Table A of this Appendix lists the mandatory tests and procedures of a primary eye examination undertaken at a place where the patient normally resides or at a day centre. 2. Table B of this Appendix lists the additional tests and procedures of a primary eye examination undertaken at a place where the patient normally resides or at a day centre which must be carried out in respect of certain categories of patients. 3. Each of the tests and procedures listed in table A of this appendix must be carried out, as appropriate, when a primary eye examination is provided to a patient unless - a) the patient has a physical or mental condition which would make the carrying out of a specific test or procedure clinically inappropriate; or b) the patient has refused to undertake a specific test or procedure. 4. Where a patient meets one or more of the descriptions in column 1 of table B, each test and procedure in the corresponding entry in column 2 of table B must be carried out, as appropriate, unless - a) the patient has a physical or mental condition which would make the carrying out of a specific test or procedure clinically inappropriate; or b) the patient has refused to undertake a specific test or procedure. 5. Clinically appropriate equipment must be used for each test or procedure carried out under this appendix. Examples of equipment given in the tables are indicative of the equipment that is clinically appropriate. 6. Where a) the patient has refused to consent to the use of a particular piece of equipment; or b) the patient has a physical or mental condition which would make the use of a particular piece of equipment clinically inappropriate; alternative equipment may be used which, despite not being a direct equivalent to the suggested example for that particular test or procedure in terms of clinical thoroughness, will enable the required test or procedure to be carried out.
Appendix C TABLE A THE TESTS AND PROCEDURES REQUIRED FOR THE PURPOSE OF A PRIMARY EYE EXAMINATION WHERE UNDERTAKEN AT A PLACE WHERE THE PATIENT NORMALLY RESIDES OR AT A DAY CENTRE The taking of a relevant detailed history and symptoms, which includes relevant medical, family, and/or ocular history The recording of unaided vision, visual acuity or pinhole vision as appropriate Sight test appropriate to the presenting signs, symptoms, and aided/unaided acuity unless this is not possible/advisable due to eye infection, disease or injury A pupillary assessment including testing for relative size, shape, direct, consensual and near responses An examination appropriate to the reason for referral from a medical practitioner or other carer, if applicable An eye health assessment appropriate to the patient s needs and presenting signs and symptoms An internal examination of the eyes by direct or indirect observation as appropriate, for example using direct ophthalmoscope, head mounted binocular indirect ophthalmoscope or slit lamp with condensing lens An external examination of the eyes using illumination and magnification, for example using slit lamp biomicroscope or a handheld magnifying loupe (with appropriate illumination), together with appropriate diagnostic agents where indicated A relevant assessment of extra ocular motor function; oculo-motor balance and ocular motility A visual field assessment minimum by confrontation A clinical report to be issued, where appropriate, where this information would be useful for the patient s carer, medical professional, and family, to include: (i) type of spectacles required and when they should be worn (ii) quality of vision achieved (iii) any existing eye conditions (iv) any other comments This report can be issued as part of the GOS(S)2 form
Appendix C TABLE B THE ADDITIONAL TESTS AND PROCEDURES SPECIFIED FOR THE PURPOSE OF A PRIMARY EYE EXAMINATION UNDERTAKEN AT A PLACE WHERE THE PATIENT NORMALLY RESIDES OR AT A DAY CENTRE Column 1 Column 2 Children aged under 16 years (where the ophthalmic medical practitioner or On first appointment stereopsis and, where clinically appropriate, colour vision optometrist carrying out the eye examination does not have access to or means to access the patient s records) Children aged under 16 years (where the ophthalmic medical practitioner or optometrist carrying out the eye examination does have access to or means to access the patient s records) Adults aged 40 and over Adults aged 60 years and over Patients discharged from an ophthalmic hospital following a cataract operation Patients with suspect glaucoma or ocular hypertensives Patients with suspect macular disorders aged 60 years and over Colour vision and stereopsis where clinically appropriate Intra ocular pressure measurement An internal binocular examination of the eyes with mydriasis, for example using a head mounted binocular indirect ophthalmoscope or a slit lamp biomicroscope and condensing lens Postoperative cataract examination and sight test Intra ocular pressure measurement by non-contact or applanation tonometry as appropriate, field of vision assessment, and assessment of the optic nerve head (i) Internal examination of the macula by direct or indirect observation as appropriate for example using head mounted binocular indirect ophthalmoscope with mydriasis, slit lamp biomicroscope and condensing lens with mydriasis or direct ophthalmoscopy (ii) Test to investigate sudden onset of visual distortion in one or both eyes
Other presenting signs and symptoms Any of the following as clinically appropriate to the presenting signs and symptoms : (a) Standard tests such as binocular function and stereopsis, amplitude of accommodation, colour vision, confrontation fields and/or any other appropriate tests excluding the following tests and procedures when undertaken as part of a supplementary eye examination on the same day: cycloplegic refraction; internal eye examination with mydriasis, for example using head mounted binocular indirect ophthalmoscope or slit lamp and condensing lens for patients aged under 60 with small pupils measuring 2mm or under, or where an adequate view of the fundus cannot be obtained without dilation internal eye examination with mydrasis, for example using head mounted binocular indirect ophthalmoscope or slit and condensing lens, for patients aged under 60 with suspect: o cataract; o macular disorders; o diabetic retinopathy; o vitreo retinal disorders; o glaucoma; o neurological symptoms; or o tumour risk (b) Issue advice and instruction to patients prior to referral into a care pathway, shared care scheme or a level 2 optometric pathway (c) Direct referral, where clinically appropriate, to an ophthalmic hospital, to the patient s General Practitioner, or to another ophthalmic medical practitioner or optometrist
SUPPLEMENTARY EYE EXAMINATION UNDERTAKEN AT PRACTICE PREMISES APPENDIX D 1. The table in this Appendix lists the tests and procedures of a supplementary eye examination undertaken at practice premises. 2. Where the reason for the supplementary examination is listed in column 1 of the table in this appendix, each test and procedure in the corresponding entry in column 2 of the table must be carried out, as appropriate, unless - a) the patient has a physical or mental condition which would make the carrying out of a specific test or procedure clinically inappropriate; or b) the patient has refused to undertake a specific test or procedure. 3. When a supplementary eye examination is carried out at practice premises, the patient s relevant medical, family or ocular history must be updated and the reason for and date of the supplementary eye exam must be recorded. 4. Following a supplementary eye examination, if it is appropriate to the patient s clinical needs, they should be referred directly to an ophthalmic hospital, to the patient s General Practitioner, or to another ophthalmic medical practitioner or optometrist. 5. Clinically appropriate equipment must be used for each test or procedure carried out under this appendix. Examples of equipment given in the tables are indicative of the equipment that is clinically appropriate. 6. Where a) the patient has refused to consent to the use of a particular piece of equipment; or b) the patient has a physical or mental condition which would make the use of a particular piece of equipment clinically inappropriate; alternative equipment may be used which, despite not being a direct equivalent to the suggested example for that particular test or procedure in terms of clinical thoroughness, will enable the required test or procedure to be carried out.
TABLE Appendix D THE TESTS AND PROCEDURES SPECIFIED FOR THE PURPOSE OF A SUPPLEMENTARY EYE EXAMINATION UNDERTAKEN AT PRACTICE PREMISES Column 1 Column 2 Following routine sight test Cycloplegic sight test Paediatric follow up within A sight test; twelve months of the previous examination Oculo motor balance; and Referral refinement/repeat or follow-up procedures that are not detailed in the sections below Stereopsis To include, as required: A sight test where this could not be undertaken as part of the primary eye examination due to eye infection, disease or injury Repeat of automated visual field assessment by full threshold visual fields Repeat tonometry by contact applanation Repeat internal or external examination as appropriate which may include mydriasis, for example using slit lamp biomicroscopy (with condensing lens where needed); and/or appropriate diagnostic agents Repeat digital retinal imaging, photography or scanning Suspect glaucoma, unusual optic disc appearance, or where other retinal or choroidal abnormalities have been detected during the primary eye examination Also to include where referring: general referral advice and counselling specific to the referral reason To include, as required: Repeat of automated visual field assessment by full threshold visual fields
Column 1 Column 2 Repeat tonometry by contact applanation Patient aged under 60 with suspect cataract, suspect macular disorder, suspect diabetic retinopathy, suspect vitreo retinal disorders, suspect glaucoma, suspect neurological symptoms, suspect tumour risk, small pupils measuring 2mm or under Suspect or diagnosed anterior segment disorder, damage or infections, as detailed in the patient s record, including corneal abrasion, foreign body, dry eye, conjunctivitis, red eye, scleritis, episcleritis, iritis, or uveitis Children aged under 16 years Patients discharged from an ophthalmic hospital following a cataract operation Patients presenting with reduced visual acuity, sudden vision loss, sudden onset flashes and floaters, or neurological symptoms Repeat internal examination of the eyes appropriate to the relevant detected or suspected eye abnormality, for example using slit lamp biomicroscopy with condensing lens, repeat digital imaging or scanning which may include mydriasis To include as required: Dilated internal examination of the eyes, for example by direct ophthalmoscopy and/or slit lamp biomicroscopy with condensing lens, and any other tests and procedures appropriate to the patient s symptoms Repeat digital imaging/scanning External eye assessment as appropriate to the patient s symptoms using for example slit lamp biomicroscopy with relevant diagnostic agents Cycloplegic sight test Postoperative cataract examination and sight test To include as required: Sight test Macular assessment test Internal examination of the eye which may include mydriasis, for example using slit lamp biomicroscopy with condensing lens And any other tests and procedures appropriate to the patient s signs and symptoms
APPENDIX E SUPPLEMENTARY EYE EXAMINATION UNDERTAKEN AT A PLACE WHERE THE PATIENT NORMALLY RESIDES OR AT A DAY CENTRE 1. The table in this Appendix lists the tests and procedures of a supplementary eye examination undertaken at a place where the patient normally resides or at a day centre. 2. Where the reason for the supplementary examination is listed in column 1 of the table in this Appendix, each test and procedure in the corresponding entry in column 2 of the table must be carried out, as appropriate, unless - a) the patient has a physical or mental condition which would make the carrying out of any specific test or procedure clinically inappropriate; or b) the patient has refused to undertake any specific test or procedure. 3. When a supplementary eye examination is carried out at a practice premises, the patient s relevant medical, family or ocular history must be updated and the reason for and date of the supplementary eye exam must be recorded. 4. Where appropriate to the patient s clinical needs, following a supplementary eye examination, a patient should be referred directly to an ophthalmic hospital, to the patient s General Practitioner, or to another optometrist or ophthalmic medical practitioner. 5. Clinically appropriate equipment must be used for each test or procedure carried out under this appendix. Examples of equipment given in the table are indicative of the equipment that is clinically appropriate. 6. Where - a) the patient has refused to consent to the use of a particular piece of equipment; or b) the patient has a physical or mental condition which would make the use of a particular piece of equipment clinically inappropriate; alternative equipment may be used which, despite not being a direct equivalent to the suggested example for that particular test or procedure in terms of clinical thoroughness, will enable the required test or procedure to be carried out.
Appendix E TABLE THE TESTS AND PROCEDURES SPECIFIED FOR THE PURPOSE OF A SUPPLEMENTARY EYE EXAMINATION UNDERTAKEN AT A PLACE WHERE THE PATIENT NORMALLY RESIDES OR AT A DAY CENTRE Column 1 Column 2 Following routine sight test Cycloplegic sight test Paediatric follow up within twelve Sight test; months of the previous examination Oculo-motor balance; and Referral refinement/repeat or follow-up procedures that are not detailed in the sections below Stereopsis To include, as required: A sight test where this could not be undertaken as part of the primary eye examination due to eye infection, disease or injury Repeat tonometry by contact applanation Repeat internal examination of the eyes which may include mydriasis, for example using direct ophthalmoscopy, head mounted binocular indirect ophthalmoscope or slit lamp with condensing lens; and/or appropriate diagnostic agents Suspect glaucoma, unusual optic disc appearance, or where other retinal or choroidal abnormalities have been detected during the primary eye examination Also to include where referring, general referral advice and counselling specific to the referral reason To include, as required: Repeat tonometry by contact applanation Repeat internal examination of the eyes by direct or indirect examination as appropriate to the suspected abnormality, and with mydriasis if required, for example using direct ophthalmoscopy, head mounted binocular indirect ophthalmoscope or slit lamp and condensing lens
Patient aged under 60 with suspect cataract, suspect macular disorder, suspect diabetic retinopathy, suspect vitreo retinal disorders, suspect glaucoma, suspect neurological symptoms, suspect tumour risk, small pupils measuring 2mm or under Suspect or diagnosed anterior segment disorder, damage or infections, as detailed in the patient s record, including corneal abrasion, foreign body, dry eye, conjunctivitis, red eye, scleritis, episcleritis, iritis, or uveitis Children aged under 16 years Patients discharged from an ophthalmic hospital following a cataract operation Patients presenting with reduced visual acuity, sudden vision loss, sudden onset flashes and floaters, or neurological symptoms Internal examination of the eyes, for example using dilated direct ophthalmoscopy, head mounted binocular indirect ophthalmoscope or slit lamp with condensing lens, together where possible with any other tests and procedures appropriate to the patient s symptoms External eye assessment with magnification for example using slit lamp or loupe (with illumination) and, as appropriate, relevant diagnostic agents Cycloplegic sight test Post-operative cataract examination and sight test To include as required Sight test Macular assessment test Internal examination of the eyes for example using direct ophthalmoscopy, head mounted binocular indirect ophthalmoscope, or slit lamp and condensing lens which may include mydriasis And any other tests and procedures appropriate to the patient s signs and symptoms
APPENDIX F DOMICILIARY VISITING FEE The additional fees payable to an ophthalmic medical practitioner or optometrist for visits to a place where the patient normally resides for the purpose of carrying out NHS eye examinations under General Ophthalmic Services on or after 1 April 2013 are: for a visit to one establishment to undertake an NHS eye examination of one but no more than two patients. For a visit to one establishment to undertake an NHS eye examination of more than two patients. - 36.82-9.22
APPENDIX G CONTINUING EDUCATION AND TRAINING ALLOWANCE 1. In this appendix: assistant means a person who has undertaken to assist in the provision of general ophthalmic services and whose name is included in the second part of the Ophthalmic List; CET means continuing education and training; CET allowance means the sum of 516; contractor means a person, other than a body corporate carrying on the business of optometrists, who has undertaken to provide general ophthalmic services and whose name is included in the first part of the Ophthalmic List; professional registration means for optometrists registration with the General Optical Council and for ophthalmic medical practitioners registration with the General Medical Council; and relevant year means the year commencing 1 January 2012. 2. Subject to sub-paragraph 5, a CET allowance shall be payable to an optometrist other than a body corporate if a. that optometrist s name was included in the first part of the Ophthalmic List of a Health Board for a period of at least six months during the relevant year; b. the optometrist has maintained their professional registration; c. the optometrist has undertaken appropriate continuing education and training during the relevant year; and d. the optometrist complies with sub-paragraphs 7 and 8. 3. Subject to sub-paragraph 5, a CET allowance shall be payable to an ophthalmic medical practitioner if a. during the relevant year that practitioner s only remunerated medical or optical activity was the conduct of General Ophthalmic Services; b. the practitioner s name was included in the first part of the Ophthalmic List of a Health Board for a period of at least six months during the relevant year; c. the practitioner has maintained their professional registration; St Andrew s House, Regent Road, Edinburgh EH1 3DGwww.scotland.gov.uk
d. the practitioner has undertaken appropriate continuing education and training during the relevant year; and e. the practitioner complies with sub-paragraphs 7 and 8. 4. Subject to sub-paragraph 5 and 6, a CET allowance shall be payable to a contractor in respect of each assistant who assists that contractor if that assistant a. is either (i) an optometrist (other than a body corporate), or (ii) an ophthalmic medical practitioner whose only remunerated medical or optical activity during the relevant year was the conduct of General Ophthalmic Services; b. is included in the second part of the Ophthalmic List of the Health Board in respect of which the contractor makes a claim for a CET allowance; c. has assisted in the provision of general ophthalmic services for a period of at least six months during the relevant year; d. has maintained their professional registration; and e. has undertaken appropriate continuing education and training during the relevant year, and the contractor complies with sub-paragraphs 7 and 8. 5. Only one CET allowance may be paid in respect of any one person. 6. Where an assistant assists two or more contractors, the CET allowance shall be paid to the contractor who the assistant nominates for the purposes of payment of the CET allowance under this determination. 7. A claim for a CET allowance shall be made in writing on the form provided for this purpose by the Health Board. 8. A separate claim form shall be completed for each CET allowance claimed. 9. A claim for a CET allowance must be made by 29 November 2013. St Andrew s House, Regent Road, Edinburgh EH1 3DGwww.scotland.gov.uk
APPENDIX H RECORDS An ophthalmic medical practitioner or optometrist must keep appropriate records as relevant to the eye examination conducted (this data is a record of the relevant patient details, symptoms, tests performed and results thereof): For primary eye examinations: Personal Patient Data Name, title, address, telephone number, Date of Birth, General Practitioner s details, Community Health Index number (where available), occupation, driver Yes/No, relevant interests, date of examination Symptoms & History Presenting signs & symptoms and reason for visit, past ocular history, past medical history, family ocular and patient s own medical history, medication, reason for referral to or from the ophthalmic medical practitioner or optometrist, smoker Yes/No (if relevant), if family history, or symptoms of age related macular degeneration For supplementary eye examinations: Person Patient Data Date of examination and update of name, title, address, telephone number, General Practitioner s details, occupation Symptoms & History Presenting signs & symptoms, reason for visit or referral update of ocular and medical history, details of any further referrals and the reasons for this For all eye examinations: Diagnosis/Findings Record of all findings and any diagnosis or outcomes. Record of reason why any specified/expected procedures or test was not carried out Where digital fundus photographs or scans have been taken, the photographs/scans should be retained either in electronic form or in hard copy and backed up either in electronic form or hard copy Where a drug has been issued to a patient, a record of the batch number of that drug, the expiry date and the date when that drug was administered to the patient should be kept, either in the patient record or in a register held at the practice for the specific purpose of recording the drugs which have been administered Communication Note any advice, statements, reports or referrals issued to the patient or made on behalf of the patient Data to be recorded where appropriate for tests and procedures specified in the Tables A and B in Appendix B and C and the Table in Appendix D and E: External Examination A record of all relevant findings, technique and equipment used St Andrew s House, Regent Road, Edinburgh EH1 3DGwww.scotland.gov.uk
Internal Examination Neurological Assessment Oculo-Motor Function Visual Fields Intra Ocular Pressure Sight test Colour Vision Imaging A record of whether this was with or without mydriasis, the technique, equipment and diagnostic agents used and a full description of the ocular media, fundus, blood vessels, optic disc and macula All relative tests undertaken, which may include pupil assessment relative size, shape, direct, consensual and near responses All relevant tests undertaken which may include cover test, convergence, muscle balance, motility, stereopsis, amplitude of accommodation Record findings, technique and equipment used Intra ocular pressure measurement, type of tonometer and time of measurement Objective/subjective findings, unaided vision, pinhole acuity, visual acuity, back vertex distance (over 5D), prescription issued, dispensing details Record findings and test procedure Record reference to any electronic images taken. Where any electronic images have been taken the image should be retained either in electronic form or in hard copy and backed up either in electronic form or hard copy St Andrew s House, Regent Road, Edinburgh EH1 3DGwww.scotland.gov.uk
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ANNEX B TESTS, PROCEDURES AND EXAMINATIONS THAT CONTINUE TO FALL OUTWITH THE NHS EYE EXAMINATION Diabetic Retinal Screening Programme LVA examination Care Pathway examinations Delegated Care Schemes/Shared Care/Co-Managed Schemes Contact Lens specific tests Children s pre-school screening programmes Colorimetry, coloured overlay and rate of reading tests for those with reading difficulty Occupational tests or reports for admission to the Armed Forces, Police, Fire Brigade, Ambulance Service, Railway, etc Occupational tests specifically for the provision of VDU spectacles Occupational tests specifically for the provision of safety spectacles DVLA acuity and visual field checks Behavioural Optometry St Andrew s House, Regent Road, Edinburgh EH1 3DGwww.scotland.gov.uk