GOC's Education Strategic Review

Comments:
The review is an opportunity to look at the design and delivery of optometry training in the UK and build a system that allows students to prepare to be the optometrists of the future. It is an opportunity to review the knowledge, skills and behaviours that registrants will need when beginning their careers and the tools they will need to continue to develop as optometry changes in the future. The College welcomes the opportunity to collaborate with others and be part of the solution.

The principle of working in partnership is a good one but it will be complex to implement. Below are the areas, which are cause for concern and need further thought before any new system can be put in place:

Feasibility

• The impact of working in partnership must not be underestimated. It is likely to involve multiple partners, including different employers and the College of Optometrists or the Association of British Dispensing Opticians.
• It will be resource intensive for the lead institution. Early and increasing clinical exposure and experience is desirable. It would be helpful to have more detail of what the General Optical Council (GOC) has in mind in terms of amounts, and variety, as this will help with planning. Commercial practices, unlike NHS hospitals, are not set up to take supernumerary staff, who need to be trained in different practical, clinical and communication skills in a way that is safe for both them and the practice’s patients. The optometrists within the practices are not trained as clinical teachers, even if they currently act as pre-registration trainee supervisors. This means not all commercial practices will wish to take on students in the early stages of training, which may make it difficult for optometry schools to find good placements for all their students. Any system of clinical placements will have to be sustainable for the duration of optometry undergraduate courses.
• The Hospital Eye Service is used to taking students; taking more will be difficult - it is already overwhelmed with medical students, ophthalmology trainees, orthoptist and ophthalmic nurse trainees and pre-registration optometrists. Our understanding is that individual departments do not feel able to take more, and they charge a considerable amount for taking current cohorts.
• Longer placements later in the course provide most value, as students are able to practise applying the knowledge, skills and behaviours they have learnt in a safe, supervised environment and can develop them to the point where they are capable of practising unsupervised.
• Quality assurance of placements is essential, as time in a poor practice will have a negative effect.
• Placements, and training practitioners to be teachers, will incur extra costs. Students in the early stages of training will need more than simple supervision so compelling all fully qualified registrations to have supervision responsibilities will not solve the problem.
• Making agreements with partner organisations to assess students in clinical placements, together with quality assuring those placements, will also involve extra costs.
• The costs are both direct in terms of payments for services and indirect in terms of the resources needed to co-ordinate complex arrangements. 
• There are benefits to a two-stage process, which include proven feasibility, funding and economies of scale, as well as trainees having a contract of employment and being paid. This does not preclude early and increasing clinical exposure.

Funding

• Optometry degrees are not on a clinical funding band. Universities do not put all optometry student fees back into optometry schools. To fund courses with more skills-based training (ie small group work), and with more clinical placements, will require considerably more funding than is currently available. This needs to be addressed. It would be appropriate to feed into the Augur Review, if there is still time, to ensure that optometry is not among the degrees for which fees would be cut.
• There can be no guarantee that working with partners will work until there is a clear understanding about how the money will flow between funders and institutions.

Consistency

• Maintaining consistency at the point of registration is crucial. Patients have the right to expect a consistent standard. Learning outcomes alone are not enough. The learning outcomes are high level and the detail of the teaching, together with the assessment processes, will differ. Ensuring reliability of assessment is notoriously difficult within an assessment programme, and impossible across institutions. Removing the Scheme for Registration, or any similar national  assessment, also removes the ability to standardise at the point of registration. It is important to understand that a national exam consisting of just an OSCE is not appropriate because it cannot alone be a reliable and valid assessment. Standardisation is the reason the GOC introduced the Common Final Assessment for Independent Prescribing and why the General Medical Council (GMC) is planning to introduce a national licensing examination. If individual providers are each responsible for assessing to the point of registration, there are likely to be challenges about variation in standards and this will need to be addressed.
• There is divergence in the delivery of eye care in the four nations. The GOC is UK-based and those registered with it must be able to offer a service in any of the four nations. The standard and content of programmes must allow for this.
• Flexibility is good. Different types of programmes from very academic to very practical apprenticeships allow those with different learning preferences to progress, but there is a danger that courses with different emphases in methods will increase variability and decrease consistency in professionals at the point of registration, for example by exacerbating differences in critical thinking and practical ability.

Equality impact

• An equality impact needs to be undertaken. For example, experience shows that finding placements for all students on an undergraduate programme means that some students have to travel a long way to reach their placement or live away from home. This could disproportionately affect students from disadvantaged backgrounds or those who have to be close to home for other reasons.
• If programmes are rolled out at different times, it is important to ensure that those students from institutions that begin the new system later are not disadvantaged by finding it more difficult to find employment.

Support from the GOC

• Bringing in a new system, an increase in new providers and allowing implementation times to be staggered will mean that the GOC will need, in the early years, to play a significantly greater role in supporting providers to deliver courses and assessments that will protect the public. Success will depend on strong  leadership, and open communication with those who understand the issues.

Comments:
Different sets of learning outcomes for optometrists, IP optometrists, DOs and CLOs are important. Learning outcomes must mirror the knowledge, skills and behaviours each type of practitioner needs at the point of registration and that describe a safe beginner. It also helps practitioners to see what else they need to achieve if they wish to progress.

The learning outcomes must be driven by the needs of patients, informed by the needs of employers and drawn up by educators, who understand how to write them in a way that works in terms of learning and assessment.

The draft standards and learning outcomes address most of the key themes of the Concepts and Principles of ESR. Some providers have suggested that they do not have the resources to be accountable for the whole process. Having only one set of learning outcomes does not take into account the comments made in relation to this in concepts 6 and 7 in the previous consultation. Independently of the College, some also stated that they thought the Scheme for Registration was the way to get solid clinical experience and to mitigate the differences between degree institutions.

Comments:

Standards

Language and structure
These are clear. The General Dental Council (GDC) provides examples of the types of evidence that it would look for by each standard. This would be a useful addition.

Completeness
There is a standard relating to supporting students but we think this would benefit from being expanded. Similarly, we think it would be helpful to include a standard about supporting all educators (academics as well as visiting teachers from practice), supervisors, assessors and examiners in relation to training and resources.

Learning outcomes
Learning outcomes need to be measurable if they are to be assessed properly, so their meaning needs to be very clear. These are not.

Language used
The phrases understands and or is able to are redundant. Many of the other words that follow these phrases work well on their own as they are action words and, therefore, easier to assess – for example: demonstrate, recognise, explain, describe, apply, assess, evaluate, interpret, appraise, record, diagnose, record, illustrate etc. The GDC has a useful table in its learning outcomes (page 14), setting some of these out.

Jargon type phrases, such as do the right thing (3.8) should be avoided.

‘Understands’ is not appropriate for learning outcomes for assessing knowledge and skills for being put on the register, so for example 4.5 might read: explains and 4.6 applies

Many of the learning outcomes are very wordy and combine several elements. For clarity, the different elements should be separated – for example 1.7 combines diagnosis, management, advising the patient and referral. 1.16, 3.1 and 3.8 are also very broad and would be difficult to assess in their current format.

In some cases, they are repetitive - referral appears twice (1.7 and 4.4), understanding evidence (although that word is not used) is in 1.15 and 3.1, and complying with the law appears in 2.8 and 4.2

Structure and flow

Domains
The domains are those previously used by the GMC and are too overlapping for clarity. They do not effectively define or reflect the content of the four categories; for example, why does learning outcome 3.1 not belong in domain number one? Is the title of domain number four is appropriate? Is it realistic to expect a student to finish their studies as a “collaborative and effective” manager? 4.1 seems excessive – it is important that students are aware of different ways of practising within the UK but this changes continuously and it seems inappropriate for students to be assessed in this.

The GMC has changed its domains, eliminating the overlap and grouping those that are similar. Those of the GDC, as well as the draft General Pharmaceutical Council (GPhC) standards and learning outcomes for initial education and training for pharmacists, also provide more clarity.

Completeness
In the interests of consistency in terms of what patients can expect of those entering the register there should be a minimum list of practical procedures that a newly qualified optometrist is capable of undertaking. This will change over time as technology moves on, but it would ensure that everyone was capable of undertaking and interpreting a core set of techniques.

Although we recognise that interpreting test results and communicating them appropriately to patients will feature in the learning outcomes, we want to emphasise here that being able to undertake practical procedures alone is not enough; however, we believe it is important for consistency that a list of practical procedures be set out.

Disagree

Comments:
The standards are appropriate, with some caveats. There is still considerable work to be done to present the learning outcomes in a clear, meaningful and
measurable way.

No.

Comments:
Each provider will have its own deadlines and restrictions and these will become more complex if it is working in partnership with other organisations. This means
that the 2024 deadline may not be achievable for everyone. Early clarity about the system will be necessary to help our planning in relation to working in partnership with others.

No.

Comments:
They might be helpful for optometrists to use as a basis for defining their scope of practice, particularly in the early years but it should not be compulsory.

It is important that the way CET is managed should not be restrictive. Using learning outcomes would be helpful to DOs who wanted to do more and eventually train to become optometrists.

Comments:
Linking CET to the learning outcomes only will be restrictive for optometrists, who could progress into more clinical roles or other wider business or teaching roles.

It would be better if optometrists had to define their scope of practice and demonstrate how they were keeping up-to-date and practising safely within that defined scope, as in the future they are likely to have more diverse areas of practice at different levels. One example might be that supervisors should obtain CET for demonstrating that they are keeping up-to-date with their supervisory skills.

We appreciate that this is more difficult and potentially resource intensive to administer.

Comments:
Without student registration, it will be essential to ensure that all providers have their own fitness to practise processes in place to manage inappropriate behaviour or performance and/or risks to the public that may occur during student training. Institutions who do not have fitness to practise processes in place for other health students would have to agree to put them in place, and this would mean they would incur significant costs, because it is likely to involve fitness to practise cases and legal challenges. Keeping student registration will address these issues. Providers can then concentrate on instilling a culture of professionalism to prevent issues from happening.

Additional comments:
This is a welcome opportunity to set out our thoughts on making the review a success and the College is supportive of working with others to find a workable
solution. The following are the areas where we believe attention needs to be focused

• Feasibility – is it realistic for providers to achieve what is wanted, given the way that optometry practice is structured? It is very different from the NHS.
• Funding and the flow of funding to partner organisations – where will the money come from to implement these plans?
• Consistency of standards at the point of registration, and therefore patient safety.
• The impact on students from backgrounds that preclude them from travel.
• Success will depend on strong leadership and support from the GOC.

Submitted: 20 February 2019