5 April 2022

Guidance to support optometrists' expanding scope of practice: Have your say

The College is seeking your input on the development of key principles for the safe expansion of scope of practice when providing new eye care related clinical procedures, activities or services.

We fully support optometrists to develop professionally as they are increasingly involved in managing patients with more complex needs and in delivering a wider range of eye care.  We believe this enhances and broadens the eye care available in primary and secondary settings to help improve patient outcomes and access to treatment. Some treatment options or investigations may involve clinical procedures or interventions that require further training or qualifications (beyond core competencies) and governance.  

We have therefore developed guidance that sets out the key principles we believe are necessary to consider when deciding if a new procedure or activity requires additional training or support to provide them safely and effectively. 

We welcome feedback from members, non-members and stakeholders, which we will consider before publishing the final version.  

Please review the proposed guidance and complete the form below and tell us your views by Monday 18 April 2022 (this consultation is now closed)

Expanding scope of practice principles for optometrists

Introduction

There is a growing need for health care professionals to work beyond the competencies gained from their entry level professional registration. Optometrists are increasingly involved in managing patients with more complex needs which would previously be managed exclusively by other health care professionals, particularly in hospital eye care services. The expansion and development of health professional roles will continue as populations and need change over time, with new care pathways evolving that deliver safe and effective care to improve patient outcomes and best utilise the available workforce. The College of Optometrists supports further opportunities for optometrists to develop professionally by delivering a wide range of eye care pathways, which will enable your scope of practice to evolve depending on the services you provide. 

Your “scope of practice” is the limit of your knowledge, skills and experience in which you can practice safely, effectively and lawfully. The General Optical Council’s (GOC) Standards for Optometrists and Dispensing Opticians set clear expectations of registrants when they start practising, supported by our Guidance for Professional Practice. However, your scope of practice will change as your knowledge, skills, and experience develop. Local population needs and the local eye care services provided will also shape or influence your scope of practice.  

The College encourages optometrists to safely expand their scope of practice.  This will both enhance and broaden eye care available within primary and secondary care settings and ultimately improve patient outcomes. 

Some treatment options or investigations for eye conditions may involve clinical procedures or interventions that require further training or qualifications (beyond core competencies) and governance. This document sets out the principles that will support you when deciding whether a particular procedure or therapeutic activity falls within your scope of practice, or when moving into a new area of practice, to ensure patient safety.  

Within this guidance we have used the administration of intravitreal injections as an example to show how these principles should be applied.  However, the principles in this guidance are applicable to all relevant clinical activities and procedures that are above those expected of an optometrist at entry level registration.

You must have the appropriate training and/or qualifications to demonstrate that you have the necessary skills, knowledge and experience to competently perform the procedure or activity safely, effectively and, where relevant, to a recognised standard. You should also be able to maintain competence through a sufficient level of clinical activity and relevant CPD to keep up to date with the latest scientific evidence and guidance relevant to the procedures or activity and wider management of the condition being treated.  

For example, the UK Ophthalmology Alliance (UKOA) has published recommendations for training and maintaining competence for safe delivery of intravitreal injection for macular disease by non-medical health professionals. 

You should seek opportunities to participate in collaborative reflective learning or mentorship should be sought to gain experience and ensure you are supported where appropriate to consistently improve patient outcomes. 

You must act lawfully and remain within any legal restrictions associated with the procedure or activity, such as prescribing or protected functions. Your job role may also specify or limit the areas of activity you are expected to perform.  

For example, while optometrists can administer intravitreal injections, the Human Medicines Regulations (2012) states that an optometrist (prescriber or otherwise) can only do so if they are acting in accordance with the directions of an appropriate practitioner (i.e. doctor), as they cannot prescribe medicines for parenteral administration. 

You must ensure you have appropriate professional indemnity insurance that covers the procedure or activity. You should check whether this is already provided by your employer and, if necessary, contact your existing provider to notify them or obtain a new policy before commencing training in the procedure or activity. 

You must have appropriate accommodations (for example, a dedicated treatment room or clean area) and equipment of adequate specification to perform the procedure or activity. Facilities should be available and processes in place to securely store and service equipment and instruments according to relevant health and safety requirements and standards.  

Most clinical procedures or activities will not be performed as part of an initial consultation. It would be more appropriate to schedule another appointment, ideally as part of a dedicated session for that procedure or activity. This means the room and equipment can be set up in advance and aid in clinician preparation.  

For example, a dedicated treatment room, equipment and instruments for delivery of intravitreal injections can be set-up in advance to aid preparation and patient listing on specified clinic dates. 

You must have sufficient infection prevention and control measures in place in line with national guidelines, including access to relevant personal protective equipment (PPE), and follow necessary clinical waste disposal regulations. This includes sterility procedures that reflect national guidelines for reusable instruments, although disposable instruments are recommended where available. 

For example, if administering intravitreal injections, you should follow NICE guidance on sharps containers and must follow guidance for their safe disposal.  

You must ensure your work setting has appropriate clinical governance structures in place to deliver the procedure or activity. This includes ensuring appropriate health and safety personnel have been identified, relevant staff are appropriately trained, and all are aware of their responsibilities. It is essential to deliver the procedure or activity to an agreed standard at all times so patients receive safe, effective, consistent and high-quality care, including appropriate arrangements for aftercare. 

For example, if providing intravitreal injections as part of a commissioned service, you should ensure your practice meets any applicable clinical governance requirements, such as those set out by the Care Quality Commission (CQC), the Regulation and Quality Improvement Authority (RQIA), Healthcare Improvement Scotland (HIS) and Healthcare Inspectorate Wales (HIW). 

There should be clear lines of accountability and safeguards in place for the overall quality of care and patient safety. Regular clinical audit should be conducted to measure the quality of care and identify how it can be improved.  

Risk identification, assessment, and management protocols must be in place to manage potential emergency complications before, during and after the procedure or activity. 

For example, to offer an intravitreal injection service, you would need to ensure that you have protocols in place for managing complications and an agreement for rapidly accessing local emergency medical care, such as for anaphylaxis, cardiac arrest or serious ocular adverse events. 

Patient Safety

Whenever you recommend or provide a particular procedure or activity, you must make patient safety your priority. The patient’s welfare should be at the centre of all decision making. You must also ensure you obtain valid informed consent, by having an open, honest and sensitive discussion with patients about their options for treatment, including no treatment, and allow time for questions. Whenever possible, you should provide written information to enable the patient to have sufficient time to reflect and confirm their decision to proceed. On the day of the procedure, check with the patient if anything has changed since the consent discussion.   Information on consent for invasive procedures has been published by the Royal College of Surgeons

Given the potential safety risks of advanced clinical procedures or activities, however small, you must be aware of these risks and be clear about your responsibilities in protecting patients. Likewise, patients can expect to have effective safeguards in place to protect them when they receive any treatment. This is necessary for both continued care and one-off interactions with your patient.  

Practitioner Safety

You should ensure that you have completed a full occupational health risk assessment before commencing the particular procedure or activity. Certain procedures or activities may require or recommend completion of specific immunisation programmes for your own health protection. 

For example, when providing an intravitreal injection service, you should ensure that you are fully aware of what to do in the event you experience a needle-stick injury in the workplace

Summary 

Determining your scope of practice is for you to decide, using your professional judgement. While you should consider whether a new procedure or activity falls within your existing general scope of practice, you must ensure you have the relevant knowledge, skills and experience to perform this safely, effectively and legally; with appropriate professional indemnity insurance cover in place. Expanding your scope of practice not only increases the range of care and treatments you are able to provide to your patients, but contributes toward enhancing your professional development throughout your career. The above principles will help guide your decision making and identify any gaps that need addressing through additional training and/or support when considering expanding your scope of practice. 

Further information