Delivering eye care in the current lockdown: your questions answered

The College, alongside representatives from ABDO, AOP, FODO and GOC, have answered your questions on delivering eyecare during the Amber phase.

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Appointments, routine, and prioritisation

Q: Our businesses are designed for routine. Therefore there will always be capacity for routine, even if we see urgent and emergency. We are seeing routine, when maybe we should not, be because our businesses are designed for routine.

A (The College): The College’s Amber Phase guidance is clear that urgent and emergency cases should be prioritised – it is not ‘business as usual’. During lockdown, all asymptomatic routine patients at higher risk of COVID-19 should be offered the choice to defer their appointment.

Q: What should I do about a patient who has symptoms of sight loss e.g. flashes and floaters or CAG, who may also have symptoms indicative of COVID-19?

A (The College): If patients have COVID-19, COVID-19 symptoms, are awaiting a COVID-19 test result, or are self-isolating and have symptoms suggestive of a serious eye condition, they should be advised to not attend the practice as part of the COVID-19 screening process. Instead, you should contact your local HES for advice.

Some areas may require you to assess the patient before referral, but this should only be done remotely.

Q: Why is routine testing not being postponed as we are encouraging people to come out of the house when not necessary? Many patients have had no or little change and just fancy a new pair of spectacles.

A (The College): The governments in all four nations have been very clear, that alongside the stay at home messaging, the public should continue to access healthcare, including routine appointments:

Access to eye care, including for routine care, forms an essential public function to preserve vision, and prevent and detect sight loss. See:

Our Amber Phase guidance is clear that patients enquiring about routine care can be seen if capacity permits, and is in the patient’s best interests.

In accordance with Amber Phase guidance, and using optometrist-led triage, optical practices should balance both the patient's risk of COVID-19 and their eye health when booking appointments. During lockdown, all asymptomatic routine patients at higher risk of COVID-19 should be offered the choice to defer their appointment.

With respect to replacement spectacles, you should use your clinical judgement to ascertain if using a patient’s existing prescription is sufficient, or if a new refraction is required. If the existing prescription is judged sufficient, you should offer to dispense remotely and deliver, rather than the patient attending the practice. The College has produced forms to document the supply spectacles and contact lenses remotely.

Q: Is it ethical or professional for the College to promote routine eye tests which is encouraging the public to break the lockdown (which is the law, and not just advisory), for no good reason if they are asymptomatic, when vaccinations are only a matter of weeks away, and emergency eye care is easily accessible if needed?

A (The College): The governments in all four nations have made exemptions in their legislation to allow members of the public to continue to attend medical appointments.

During lockdown, all asymptomatic routine patients at higher risk of COVID-19 should be offered the choice to defer their appointment.

The emerging evidence shows that the lack of access to primary eye care, across all settings, in the first lockdown, increased preventable sight loss.

Q: My practice owner is now phoning patients who missed routine appointments to fill the clinics. I don’t think this is within the guidance.

A (FODO): If you are concerned about non-compliance with COVID-19 guidance you should raise this at a local level in the first instance, if you can. For example, talk to the practice manager/owner about COVID-19 guidance and triage systems that should be in place, and explain what you feel is wrong. If that is not possible or does not work, you might find it helpful to contact your representative body who will be able to advise you, including about legal protections available to you. Alternatively you can read the GOC’s draft speaking up guidance which provides more detailed guidance on raising concerns.

Q: Should online appointments be permitted? My employer is opening up clinics for patients to book directly into the diary without triage. This results in increased risk to optometrists due to non-essential appointments being booked in. In addition, practice staff are advised to not call patients to postpone appointments to the future. Is this practice supported by the College?

A (The College): As per the Amber Phase guidance, all patients who contact the practice, either online or by phone, must be contacted and screened for COVID-19 prior to confirming an appointment; and practices are advised to prioritise those with urgent/essential needs over routine care. If patients contact the practice about routine eye care, and they are asymptomatic, then they should be offered to postpone their appointment, particularly if they are in higher risk group of contracting the virus. The College has developed dedicated guidance on patient prioritisation for all practice staff and includes the need for optometrists to be involved in this process to determine the level and urgency of care required.

Q: Where does the government say the public can access routine care if asymptomatic? That contradicts the ‘stay at home unless necessary’ message. Put simply: I don't believe government has said that.

A (The College): The respective UK nations have clearly stated that legal exemptions to the stay at home message, includes attending medical appointments, and their respective health systems/NHS have advised that routine primary care should continue across all sectors due to the essential public health function they serve.

Q: Is it acceptable practice to cancel a routine appointment in order to see an urgent case if it arises?

A (The College): Clinically, yes, although you will need to discuss this with your practice manager. The College’s amber phase guidance states that urgent and emergency cases should be prioritised, ideally through good appointment book management. If sufficient time is reserved for urgent and essential appointments, and routine only booked when capacity permits, then this should minimise the risk of needing to cancel any appointment, or turn away any patient needing urgent care. 

If the patient is assessed to require emergency, i.e. hospital, treatment, you can contact your local HES for advice. If the hospital requires you to assess the patient first, then you must arrange for them to be reviewed by an optometrist, either in your own practice or another provider.

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Triaging

Q: Is triage compulsory or just advised? I’d also like to raise the point that optometrists triaging is not feasible in most high street practices with 25-30 minute clinics.

A (The College): In accordance with each nations Standard Operating Procedure, it is compulsory that patients are screened for COVID-19 when contacting the practice; and again when they arrive for an appointment, performed by an appropriately trained member of staff. 

The amber phase guidance is clear that triage should be performed to determine the level and urgency of care required for each patient, and to ensure that urgent and essential cases are prioritised over routine services, so time should be allowed for this. The College has produced a flowchart to show how this can be implemented in practice, and a risk stratification tool to help optometrists use their clinical judgement to determine patient priority, based on need and COVID-19 risk.

All appointments should allow sufficient time to perform cleaning and disinfection procedures, and to don and doff PPE between patients. This means, they must necessarily be longer than appointments pre-pandemic.

Q: Why have you done nothing to stop multiples booking tests online against your advice with no triaging?

A (The College): As the professional body for optometry, we strongly encourage any clinician who is witnessing unsafe practice to raise a concern with their practice manager, professional services team and, if necessary, escalate it to the GOC. 

We know how difficult this may feel, and be. We know many members are worried about the consequences of raising concerns about the interpretation of the amber phase guidance, and we have written to employers to make clear how the guidance should be applied, and their obligation to enable employees to raise concerns. However, there is a duty on all professionals, in all disciplines, to protect the public, as set out in the GOC Standards of Practice. 

The GOC is currently consulting on its new draft Speaking Up guidance which aims to set out the process more clearly, and proposes a new mechanism for locums to raise concerns. The College consulted with members to inform its response. 

Q: Should we be triaging/questioning every patient that rings up to book an appointment and if their reply is 'routine', should we be suggesting they wait until vaccinated if they're in a higher risk category? Who must do the triage - an optometrist or practice staff?

A (The College): We advise that an optometrist should be enabled to use their clinical judgement to help determine the level and urgency of care required.

All patients, however, must be screened for COVID-19 status, and this can be done by an appropriately trained member of practice staff. Our flowchart shows how this can be implemented in practice, and our risk stratification tool can help to determine patient priority.

If patients contact the practice about routine eye care, they are asymptomatic AND at a higher risk of being effected by COVID-19, then they should be offered to postpone their appointment.

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Contact lenses

Q: Is it possible to get clarification on contact lens supply when sight test has expired in amber phase? Patients with no symptoms are requiring sight test to validate contact lens specifications.

A (The College): Whether or not the sight test is in date is not relevant to the supply of contact lenses, only the contact lens specification must be in date. However, where the specification has expired, The GOC easements for contact lens supply during the pandemic may be applied provided you use for professional judgement to act in the patient’s best interests, there is a clinical need, and balances the risk of contracting the virus by attending against the risk of supplying with expired specification. Please refer to the College’s FAQ on contact lens supply.

The supply, however, must take into the account the patient’s needs and apply clinical judgement to determine if new refraction is necessary in all cases.

Q: What is the current guidance around contact lens new fittings and assessments? The College guidelines were originally that we needed to be in a green phase in order to resume the fitting non-medical contact lenses. What is the College’s current advice regarding new contact lens patients? 

A (The College): After reviewing the evidence and listening to feedback, the College updated their guidance around contact lens fittings last August. Optometrists should use their professional judgement and act in the patient's best interests. There may be legitimate reasons why it is in the patient's best interests to have a contact lens fitting, such as if they are a key worker.

Fittings should only be offered when there is capacity, having prioritised urgent and essential patients, and when it is safe to do so.

Q: Whilst I understand that eye exams can pick up asymptomatic patients with pathology, shouldn’t we be actively encouraging our routine asymptomatic contact lens aftercares to convert to a telephone triage system first of all, so that most people can access the service without having to come into the practice?
 
A (The College): The answer is yes. This is entirely consistent with the Amber Phase guidance and the stay-at-home message, but in all cases of patient contact, the optometrist or contact lens optician should use their professional judgement and act in the patients’ best interests. Regarding aftercares for example, where they’re asymptomatic or if there are no concerns about contact lenses, this can be achieved through remote consultation but were any ocular symptoms a cause for concern, they may be offered a face-to-face examination when necessary to address them and provide a treatment when required. Regarding fittings, there may be legitimate reasons why it’s in the patient’s best interests for this to happen such as if they’re a key worker. And contact lenses are a form of correctional spectacles - they are a registered medical device and would fall within the legal current exemption for a medical appointment and importantly, fittings should only be offered when there is capacity, having prioritised urgent and essential patients and when it’s safe to do so. 

Q: How can I perform a contact lens teach safely?

A (The College): There is a section on this in our COVID-19 guidance. Section 4.18 -4.21.

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Definition of red phase

Q: Why did the College change the wording of red phase and not send an email to say they had?

A (The College): The wording was updated in November 2020 to provide additional clarity and ensure it was aligned with each nations approach to local and national lockdown. This change was communicated to all members in the subsequent enewsletter on 2 December 2020.

All four nations are clear that health services should remain open whenever possible:

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Employment

Q: If I whistleblow I’ll be sacked. What employment protections do I have?

A (AOP): If AOP members have concerns over whistleblowing they should speak to the employment team via employment@aop.org.uk who will be able to help guide you through the required steps to ensure that you are offered all available protections.

Q: Can I refuse to see a patient if I live with someone in the extremely vulnerable category?

A (AOP): If there are other practitioners who have a lower risk and who are happy to see these patients then it would be sensible to redirect the patient to that clinician. You should discuss this with your employer, to ensure patients are booked appropriately, in advance of their appointment.

Q: Optometrists in most workplaces do not have any control over which patients they can/can't see. Retail managers dictate who is seen and who isn't. What would the panel suggest in this scenario?

A (The College): The College’s Amber Phase guidance states that all patient’s contacting the practice must undergo screening for COVID-19, which can be performed by suitability trained practice staff – however, when a patient reports visual/ocular symptoms, optometrists should be alerted to determine the level of urgency of their symptoms and use their professional judgement as to whether they can be managed remotely in the first instance, or require face-to-face assessment.

The College has produced a prioritisation flowchart to help practice staff understand when an optometrist should be alerted, and a risk stratification tool to help optometrists determine which patients should be given priority.

Q: If a member of staff refuses to wear a mask (not legally exempt), is it sufficient for them to wear a visor?

A (The College): The Amber Phase guidance states that all practice team staff should wear a fluid resistant face mask (surgical Type IIR) as recommended by PHE, at all times when providing care to patients at a distance of less than 2m, unless this is behind a screen.

Optometry practices are health care settings. If a member of staff has a medical exemption, they should contact their occupational health department or practice owner to consider whether they can be redeployed based upon an individual risk assessment – please see section A3. 11: The College of Optometrists Primary eye care COVID-19 pandemic guidance.

Q: Does acting against College guidance invalidate AOP indemnity insurance? Thinking of both individual and practice insurance.

A (AOP): Not following College guidance will not invalidate your AOP indemnity, however, it may make it more difficult to defend a civil negligence claim, or to defend a complaint to the GOC.

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Funding and business

Q: As a practice owner [in England], if we are paying optometrists to sit doing phone triages with little face to face work, how do we get remuneration for the time spent doing this work as a sight test is not actually being performed? Our local CCG has not signed up to CUES.

A (FODO):  We are acutely aware of this issue, and OFNC colleagues are in discussions with NHSE-I about how best to support practices over the next few months. Read the latest OFNC statement.

It is disappointing and frustrating that about 25% of CCGs in England have not yet commissioned a MECS or CUES service. This is a great disservice to patients, GPs and hospitals who would all benefit from this increased capacity. LOCSU is leading the effort to support LOCs and PECs and is working with NHSE to engage with these CCGs with a view to then commissioning a CUES. If you have any specific feedback that might help, please do contact LOCSU with this intelligence.

Q: If NHS England want us to stay open - why are they not supporting us with loss of earnings/lack of sight test fees? There has been no offer this lockdown of average sight test fee payments. If we rely on symptoms led over routine we are not financially viable. What are the funding arrangements?

A (AOP): The AOP, via OFNC, continue to make the case to NHS England regarding ongoing funding. OFNC have explained the difficulties that many practices are facing.

Q: The vast majority of opticians are reliant on retail sales, i.e. sale of appliance to remain economically viable. This is the retail side of the business which is distinctly separate to the emergency and urgent cases which the panel are discussing. Logically, there is no reason why this part of our businesses should be treated differently to other retail outlets which are currently subject to full lockdown in view of soaring infection rates higher than those in the initial lockdown to protect staff, patients and the NHS i.e. why not go to red phase emergency and essential only, and not rely on whistle blowers?

A (The College): The reason practices remain open is, first and foremost, as healthcare settings, to provide primary eye care services to the public. Optometrists are clinicians providing the essential public health function of preventing and detecting sight loss, and maintaining vision. Optometrists are clinicians providing the essential public health function of preventing and detecting sight loss, and maintaining vision. The College’s Amber Phase guidance is aligned with all other primary care services, maintaining services on the basis that practices are health care settings.

Q: Without having as full an appointment book as we can, how are we supposed to survive (small independent practice), and if patients are now not phoning in to book routine appointments how do we operate?

A (AOP): The AOP, via OFNC, continue to make the case to NHS England regarding ongoing funding. OFNC have explained the difficulties that many practices are facing. Practices should also look to make use of furlough arrangements if necessary to reduce overheads.

A (FODO): We would advise you to contact your representative body to make your situation known and for bespoke advice suited to your circumstances.

In terms of general advice, you can still review patient records for those who are due, assess which patients might find it helpful to be contacted and offered an appointment – to triage and all IPC precautions of course.

You can also use this tool on gov.uk to look up whether there is any government support you might be able to access based on where your practice is based in the UK.

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Lateral Flow Testing

Q: In areas where one in three people are asymptomatic, should we be screening our patients using Lateral Flow Tests before attending the practice if available?

A (The College): The standard operating procedures for optical practices in each UK nation during the pandemic don’t require lateral flow tests to be performed on patients, and given the low sensitivity/specificity of lateral flow tests and the risk of many false negatives, they are not advised as a screening method. At present, they are only available to practices with NHS primary care contracts in England and just for staff use.

Despite the low sensitivity/specificity, PHE have reasoned that even if a third of asymptomatic cases are detected by LFT, then that is significant enough to help drive down transmission amongst practice staff.

Q: Are the weekly lateral flow tests a legal requirement? I work for a large chain and my employer has told me that we are not doing it at all as they are not accurate.

A (The College): All contractors have been asked by NHSE to encourage their staff to participate in the Lateral Flow Test (LFT) programme to help keep practices safe by detecting asymptomatic COVID-19 cases that would otherwise be missed.

At present, LFTs are only available to practices with NHS primary care contracts in England. We are hopeful they could be made available in all nations in the coming weeks.

Despite the low sensitivity/specificity, PHE have reasoned that even if a third of asymptomatic cases are detected by LFT, then that is significant enough to help drive down transmission.

Weekly testing is not a legal requirement. Any member of staff can opt out, but where available we recommend that their use is encouraged to help drive down transmission.

If your employer is not participating, NHSE should be informed.

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National guidance

Q: Is there a difference in advice in Wales and England on whether to see an asymptomatic shielded if there is capacity for routines or not? Do we postpone a shielder in Wales or not?

A (The College): The Welsh government and Optometry Wales, have advised that higher risk patients should contact their medical teams, NHS 111, rather than optometrists in the first instance to help them make an informed decision to seek eye care by balancing the risk of contracting COVID-19 against the risk of visual/ocular concerns.

If a high risk patient contacts the practice to seek eye care, optometrists should use their professional judgement to determine the level of care and urgency they require.

If asymptomatic, with no known existing or risk of an eye condition, such patients should be offered the choice to postpone their appointment until restrictions have eased.

Q: The College mentions that one of the reasons for being able to keep primary care in amber is that we now have CUES. What difference does it make in parts of England, i.e. Northumberland, where the local CCG has not commissioned CUES, or any other MECS type service?

A (The College): Prior to the pandemic, pathways existed for practices to handle urgent and emergency cases – the pandemic has, however, changed the mechanism by which this is delivered, namely remote consolations and prescribing.

CUES is one of mechanisms that has enabled this to happen and we are frustrated that CUES has not been commissioned in every part of England. However, even where it has not been commissioned, optometrists perform an essential public health role through routine eye examinations and completing accurate referrals when indicated.

Q: The Scottish government are, quite rightly, asking the public to stay at home. Why then are Scottish optometrists being asked to meet minimum sight test targets in order to receive their support payment for January?

A (Answered by FODO): The Scottish government guidance to the general population is to stay at home. But for the health sector, and those needing healthcare, it is different - for these specific reasons, you can leave home, such as attending medical appointments – thus, there is no conflict then in the government advising people to stay at home but continue to seek healthcare in accordance with Covid-19 guidance. 
 
On the specifics about the GOS grant in Scotland, the latest PCA for optometry in Scotland explains that provided practices meet 20% of their historical GOS activity they will receive a GOS grant. This threshold is set by the NHS, and minimum thresholds are also a condition of grant support in other parts of the health service across the UK. So it is not unique to optometry. Policymakers have a complex balancing act to ensure there is sufficient capacity to meet needs without placing pressure on GPs and hospitals, whilst ensuring optical practices can continue to operate. If they demanded very high threshold that might drive too much face to face care, and if they had no threshold more practices might close altogether and result in pressure on other parts of the system. Whatever decision policymakers make here about the grant they will have considered the impacts as part of their own decision making process. 
 
Those with specific questions about the support package in Scotland might also want to contact Optometry Scotland for more information.

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OCT

Q: Any advice on a practice adding OCT scans, appointments for routine patients when we are trying to keep examinations as short and essential as possible?

A (The College): The need for an OCT should be assessed by an optometrist, applying their clinical judgment, and based on patient need. The College has produced specific guidance on imaging with respect to ensuring their use is appropriate and clinically justified: Patient records. OCTs and fundus imaging may help streamline the consultation, and reduce the time needed to perform ophthalmoscopy/ indirect slit lamp biomicroscopy.

However, it is important to take a needs-led approach, so clinicians should not be performing all tests on every patient.

The use of any instrument to determine eye health status should be on an ‘as needed’ basis to minimise contact with the patient. Again, in accordance with the amber phase guidance, routine screening should be minimised to reduce time spent in pre-screening areas which are typically confined spaces.

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PPE

Q: The BMA is lobbying for the FFP3 mask. Isn’t the surgical Type IIR mask the College currently advises us to wear inadequate? Why has the College not been at the forefront of this?

A (The College): We are in regular contact with PHE, whom lead the review/consensus, and base our position on the evidence available. The recent evidence and expert consensus review of the transmissibility of new COVID-19 variant, and adequacy of current PPE and IPC, have shown that surgical masks (fluid resistant) are sufficient when non-aerosol generating procedures (AGPs) are performed. This includes optometric practices advice not to carry out AGPs, such as using Alger brush for foreign bodies or micro-exfoliation for blepharitis.

Q: Why does wearing PPE and carrying out IPC not completely prevent transmission?

A (The College): PPE and IPC minimises the risk of transmission, but nothing can completely eliminate 100% of the risk. It is important to remember the most likely place for transmission in your practice is not the consulting room - it’s the back office staff areas and travelling to and from work. Almost a year on, it is critical to avoid complacency, and to not allow colleagues to take short cuts. The scrupulous following of IPC is as important now as it has ever been.

Reference: Coronavirus (COVID-19): personal protective equipment (PPE) hub

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Safety and risk

Q: I am considered higher risk of contracting COVID-19 due to pregnancy – what can I do to keep safe?

A (The College): All workplaces must perform risk assessment for their staff to determine their suitability to carry out their role. The College, along with the AOP, FODO and ABDO, has produced a risk assessment for new and expectant mothers to help conduct this, and the RCOG has produced specific guidance for pregnant and new mothers and COVID-19 infection.

Q: Am I safe to use a mask with Pulseair or is it an aerosol generating procedure? Is using Pulseair an aerosol generating procedure? Is it safe to use, as long as you are wearing a mask?

A (The College): There was a lack of evidence at the beginning of the pandemic about the status of non-contact tonometry (NCT) as an aerosol generating procedure, and the guidance on PHE wasn’t specific on every detail – which is why our initial guidance advised not to use any of these procedures.

However, over the summer, new evidence was published that showed low prevalence of viral particles in the tear film and ocular surface, even those with active COVID-19 or conjunctivitis.

Now we know that NCT is unlikely to pose a significant risk without active COVID-19 or conjunctivitis, and can continue to be used after undertaking a risk assessment and following IPC guidance. Our guidance recommends that the instrument head is wiped with an appropriate disinfectant and that the optometrist performs three puffs between each patient to clear the tip.

With respect to wearing a mask when using Pulseair, we recommend all practice staff wear Type IIR fluid resistance surgical mask when providing care.

Q: Are optometrists – in unventilated rooms for up to 45 minutes at a time - more vulnerable to the virus than say GPs and dentists (whose patient facing time is 10mins)?

A (The College): There is no data or evidence to show that optometrists are at any higher risk of contracting the virus than GPs and dentists; although, as for all healthcare roles, contact with members of the public are higher risk compared to non-healthcare workers.

Optometrists are considered as working in a medium risk pathway because patients are screened for COVID-19, optometrists are not performing AGPs, and IPC procedures and PPE are in place.

Q: Is it more of a risk to see a routine patient for an asymptomatic eye condition than catching COVID-19 and getting seriously unwell?

A (The College): While no calculation has been done to weigh the risk vs the benefit of seeing routine patients, the Royal College of Ophthalmologists, UK Ophthalmology Alliance and studies by University College London have reported that suspension of routine primary care during the first lockdown had a significant impact on peoples eye health, with over 10,000 people missing out on eye care to maintain their sight, and a 25% reduction in patients with known wet AMD attending appointments.

This underlines the crucial public health function of eye care. The decision to offer patients face-to-face care is one when an optometrist must use their professional judgement to balance the risk of adverse visual/ocular outcomes against contracting COVID-19 on a patient by patient basis.

Some staff may be considered at higher risk of contracting COVID-19, so your employer should conduct an individual risk assessment for their staff to assess the most appropriate working environment for them. People at particular risk, or those who live with people who are ‘extremely clinically vulnerable’ may go to work as long as the workplace is COVID-secure, but should work from home, or away from others, where possible.  The College, FODO, AOP and ABDO have produced interim guidance on a workforce risk assessment in primary care. This includes a risk assessment form for new and expectant mothers.

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Staff

Q: Where do we find guidance on what to do when staff test positive? How does this affect businesses /practices?

A (The College): First refer to your local Track and Trace/public health teams for advice. If contact has been made with a staff member who tests positive for COVID-19 in clinical area, and PPE was worn, then you and other members of staff do not have to self-isolate as they will not be considered a close contact for the purposes of contact tracing and isolation. If the contact with the staff member was in a non-clinical area where IPC procedures are not likely to have been thoroughly implemented, i.e. canteen/staff room, then all those who made contact with that staff member in that area must also self-isolate and be tested for COVID-19, even if everyone accessing that area was wearing PPE.

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Vaccine

Q: What if I don't want a vaccine?

A (AOP): The AOP have provided advice for members on this issue, and as you would expect it depends on a number of individual circumstances. AOP members can seek advice from the employment team via employment@aop.org.uk.

Q: Are all practice staff, including student optometrists, in line to receive the vaccine?

A (The College): Yes. As frontline health care workers, all practice staff, including locums, pre-reg trainees and optometry students who have clinics, should have access to the vaccination along with all other front line health workers as part of the Joint Committee for Vaccinations and Immunisations (JCVI) prioritisation group recommendations.

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