The College submits its response to the GOC's review of the Opticians Act

Not sure.

While we would agree that these objectives are broadly appropriate, provided they are applied objectively and in cooperation with registrants and organisations across the sector, the basis for some of the changes suggested throughout the GOC document remains unclear. We believe that the GOC should conduct a further public consultation on any changes being considered before developing a case for change to the Opticians Act. It should include a review of the evidence that should be robust and compelling (as set out in paragraph 14) and an assessment of the potential impact, risks and benefits of the proposed changes on public protection and patient safety.

On Objective 7, we agree that some important and urgent reforms may not need a change in legislation, which could be a long and uncertain process to achieve. However, any decision to use alternative ways such as standards and guidance should be made in full consultation with stakeholders. We suggest rewording this objective as follows: “reform should take the simplest approach where this is appropriate and agreed in consultation with registrants and our stakeholders, i.e. considering other regulatory levers, such as standards and guidance if these would be more effective than changing legislation.”

We suggest amending Objective 8 as follows: “ensuring that any changes do not impose disproportionate administrative or financial impacts on patients and our registrants, the sector and our stakeholders.

The Act currently protects the public from unregistered persons who are not bound by the GOC standards, by protecting both title and function. We believe that the current restrictions on the activity of non-registrants should remain for the benefit of the public. This protection ensures all people receive safe and appropriate care, maintain good eye health and avoid preventable sight loss. 

A recent survey taken by members of The College of Optometrists reveals overwhelming support for the current restrictions on the activity of non-registrants to remain, including testing of sight (97% of our members who responded to the survey), fitting of contact lenses (97%), selling optical appliances to children under 16 and those registered visually impaired (93%) and selling zero powered contact lenses (90%). [Member survey conducted by The College of Optometrists in May 2022.]

The protection of title of registrants should also continue (optometrist, optometrist prescriber, dispensing optician, contact lens optician, optician and ophthalmic optician), both for individuals and body corporates. Maintaining the protection of title and functions of registrants is consistent with the GOC’s objectives in section one.

The UK has well-functioning, accessible and efficient primary eye care services and at the heart of this is the comprehensive sight test (known as the eye examination in Scotland) that all patients can access in a timely manner. Nothing should compromise access to this model of care, due to public distrust or poor patient outcomes.

We would like to see the GOC continue to ensure: 

• The function of testing of sight is restricted to optometrists and medical practitioners.
• The function of fitting of contact lenses is restricted to registrants.
• The sale and supply of optical appliances, including all contact lenses, is restricted to registrants.
• The definition of optical appliances remains unchanged.
• The definition of the testing of sight remains unchanged.

1. Testing of sight: should be restricted
2. Fitting of contact lenses: should be restricted
3. Selling optical appliances to children under 16 and those registered visually impaired: should be restricted
4. Selling zero powered contact lenses: should be restricted.

The Act has successfully protected the public, however new business models and technologies for providing restricted functions present challenges to the fundamental protection that the Act affords. The Act should protect the public by providing additional clarity in the following areas:

• The testing of sight remotely – we believe this must be restricted to UK-based registrants or medical practitioners
• The testing of sight by means of automated technology (in person or virtual) – we believe this must be restricted to UK-based registrants or medical practitioners
• The supply of optical appliances including contact lenses from non-UK jurisdictions – we believe this must be prevented, or provided under the appropriately regulated supervision of a UK-based registrant or medical practitioner.

No.

The professional bodies for optometry and dispensing optics – The College of Optometrists and The Association of British Dispensing Opticians (ABDO) – are best placed to define and accredit qualifications that enable registrants to acquire new knowledge, skills and recognised qualifications. Registrants should be supported to develop and evolve their scope of practice and training autonomously, but within the high-level oversight and governance of the GOC’s Standards of Practice.

However, the GOC should continue to publish qualifications (such as the College’s accredited Higher Qualifications and Independent Prescribing) on its register, to ensure members of the public have access to this information and to ensure the register is relevant to evolving practice. For example, having an IP qualification listed with a glaucoma higher qualification helps the public and employers understand a registrant’s scope of practice. This data will also support workforce planning, ensuring that patients and public have access to the services they need.   59% of College members who responded to our survey would like to see post-registration skills, qualifications and training recognised by the GOC and added to the register. [Member survey conducted by The College of Optometrists in May 2022]

Yes.

The basis for the extension of business regulation as outlined in the GOC’s (July 2013) Review of business regulation: consultation still applies; and we welcome the latest proposals to extend the regulation to register all businesses who provide legally restricted optical services in the UK. With the introduction of new technologies, remote consultations and optometrists increasing clinical work since 2013, there may now be additional reasons to regulate all businesses in a more consistent way. 

We believe that, in order to provide adequate protections to patients and the public and to provide public reassurance and enhanced confidence in the profession, the GOC should adopt a consistent and comprehensive system of effective business regulation. Furthermore, to supplement business regulation, we believe that the GOC should also have powers of inspection (see our response to Q13), and that businesses should be subject to an enhanced code of conduct.

Although our survey of members revealed that 66% were unsure if the basis for extension of business regulation still applied, our focus group research suggested that this uncertainty was due to a lack of awareness of business regulation, as well as limited knowledge of the GOC 2013 review of business regulation, rather than an objection to the current regulation per se.

Nevertheless, 27% of members indicated that they were in favour of business regulation, and our recent member survey suggests they are very strongly in favour, particularly in relation to the regulation of large national chains of practices. Members indicated their frustration that the GOC’s current powers are not effectively or consistently enforced. Furthermore, there is a strong view that poor business practices are impacting negatively on clinical practice, and there is a perception that some businesses are driven by profit rather than patient care.

Following our member survey, we set up a number of focus groups to understand in more detail the views of our members on specific topics. A total of 18 members, distributed according to their work setting, country of practice and qualifications took part between 6 and 8 June 2022. Quotes from the focus groups are included throughout our response to illustrate common themes arising from our members’ views and experiences.

“All optical business should follow standards, not a select few; extending regulations will ensure that this occurs and increases public protection and perception of the optical profession.” [University optometrist]

Under the current system, there were an estimated 4,000 businesses in the UK that were not currently registered with the GOC in 2013 (as indicated in paragraph 23 of the GOC’s call for evidence document). While there is little evidence to explicitly suggest that patients have suffered as a result of the current absence of universal business regulation, there are potential risks, including those arising from new business models and the use of technology and the provision of remote care. Therefore, a system of consistent, effective and proportionate regulation of all optical businesses will best protect patients and the public, maintain public confidence, and establish a fair approach.

Not sure.

As stated in our response to Q11, we believe that in order to provide adequate protections to patients and the public, and to provide public reassurance and enhanced confidence in the profession, the GOC should adopt a proportionate, uniform and comprehensive system of effective business regulation. This would also bring regulation in line with that of other healthcare businesses in the UK, such as pharmacies, and would ensure that appropriate accountability is given to all business practices. Improved regulation is also likely to enhance the standing of the profession with the public and commissioners, and help to facilitate enhanced levels of clinical work within primary eye care in future.

While we support improvement of the current system of business regulation, it is difficult to comment in detail on the advantages, disadvantages and impacts of extending it without further detail on extending the regulations. 

There is a risk that the introduction of universal business registration could place increased burden – both financial and administrative – on practices, particularly independents or small chains. This risks practices no longer being viable and could reduce public access to eye care. It is therefore important that regulation and its cost is proportionate and consistent, so that practices can continue to provide care to patients in all parts of the UK. In addition, there must not be unnecessary duplication of regulatory work with other bodies, such as the CQC (where applicable) and national health services, for those already subject to inspections for NHS contracts.

The introduction of business regulation also provides an opportunity for the GOC to further tackle the illegal supply of eye care services and optical appliances from both within the UK and abroad. In recent years, there has been an increase in online prescribing and dispensing of optical appliances. This raises issues concerning potential lack of appropriate supervision for the safe supply of contact lenses without specification verification, and spectacles supplied without ensuring the prescription is valid. This has always been a concern for the sector, and even more so since the pandemic started and people’s habits related to accessing healthcare online change. We appreciate that the GOC does not have jurisdiction to take action on overseas sales, but we would like the GOC, as a minimum, to raise the issue with the appropriate local regulator/authority and have the powers to end the illegal practice occurring in the UK. 

“With the sale of online spectacles on the rise as well as cosmetic contact lenses it is imperative that businesses are regulated fairly.” [Primary care optometrist]

Not sure.

While we would support certain powers of inspection in principle, we would welcome more details about the GOC’s intention before being able to comment. We need to understand what the purpose of these inspections would be and how they would fit with the current inspections of GOS contract holders carried out by national health services, and to assess the benefits of these inspections to patients and practice. 

Having the ability to inspect optical practices could enhance the reputation of the GOC’s role as regulator, provide additional confidence to patients and the public, and enable the GOC to fully investigate concerns where they arise – if the inspections are carried out effectively and bring about positive change. This would also bring optometry in line with other healthcare professions such as pharmacy. This may be beneficial as the majority of optical practices are not regulated by the CQC and therefore are not subject to CQC inspections. However, without further details, it is difficult to assess these benefits.

As GOS contract holders are already subject to inspection by national health services, there is a risk that there could be duplication of work, as well as increased administrative burden and costs for optical practices. 

In our survey of members, 69% said the GOC could more effectively regulate businesses if it had powers of inspection (18% were unsure and 12% disagreed). However, a further analysis of their free text responses showed that members would only support inspections in certain circumstances, particularly to investigate illegal practice or sales, to investigate fitness to practise allegations, or in situations where non-registrants were involved. Focus group participants perceived that many current regulations were not effectively or fairly enforced. There was a strong view that there is no value in the GOC having additional powers if it is not able to take effective action in pursuit of them, or if it can only enforce the rules for GOC registrants, leading to non-registrants breaking regulations without consequences. 

“Powers of inspection allows the GOC to obtain greater information about optical businesses, enhancing the process of regulation.” [University optometrist]

“Investigating allegations would be easier if you could visit a practice/premise to prove the allegations true or not. The GOC would be able to collect evidence against a person or company and take action accordingly.” [Primary care optometrist]

“The GOC will be able to ensure standards are high not only when things are going wrong.” [Primary care optometrist]

“Currently practices run and are left to continuing running, if the GOC inspected practices it would ensure better safety for patients.” [Hospital optometrist]

Furthermore, inspection powers should be used and exercised fairly and appropriately. This will enable universal business regulation rules to be better enforced, and improve both public and optometrist trust in the GOC’s role as regulator.

In order to provide a more informed view, we would like to see further details and consultation on any proposed plans.

Not sure.

We do not believe that the responsible registrant model would be appropriate or applicable to optometry in the same way that it works in pharmacy settings, as the operational nature and business model of pharmacy is different to that of optometry. For example, although pharmacy colleagues are supervised by the responsible registrant, there isn’t formal delegation of clinical roles as there is in optometry. It is also far more common for community pharmacists to operate alone, or with just one other pharmacist in the pharmacy.

In large optical practices there are often multiple optometrists, in some practices many or all of whom are locums. It is unclear on what basis an individual responsible registrant would be identified and appointed, particularly if the workforce changes daily.  It is also not clear whether responsible registrants would be subject to additional scrutiny or held to additional standards by the GOC, and whether they would require additional qualifications or training. An unintended consequence therefore could be reluctance from optometrists to take on the role. We recognise the model proposed could be an opportunity to ensure specific clinical standards are met, and to drive forward clinical ingenuity and innovation – although this would require the role of the responsible registrant to have the authority and power to do so. We therefore believe that an alternative approach to business regulation would be to strengthen the GOC’s enforcement and inspection powers (as mentioned in our responses to Q11-13); and to ensure that all registrants are responsible, accountable and confident to raise concerns. There is a need to support clinicians without an additional layer of governance; and the GOC should consider a formal mentorship programme, especially for newly qualified optometrists.

In order to provide an informed view, we would like to see further and more specific details on alternative models of business regulation, along with more evidence of their relative merits and disadvantages.

No.

The testing of sight must remain a protected function of the Act that can only be performed by an optometrist or medical practitioner who has the capability to conduct, assimilate and make a clinical decision, based on all aspects of the sight test. Our view is that refraction is a key component of the sight test and that clinical decision-making, ascertaining a person’s ocular health status and issuing a final prescription is of higher quality and improves patient safety if carried out by one individual.

The refraction, ocular health assessment, and assessment of a person’s binocular vision status are all essential components of a sight test. All three are inextricably linked, interdependent and vital to ensuring good patient outcomes. We feel that delegation of any of these components to a separate individual could harm patient outcomes.

We recognise that dispensing opticians and other health professionals may adequately conduct an objective and subjective refraction with the appropriate training, and may already do so outside the context of a sight test (for example, to check a prescription).  However, an essential aspect of conducting a sight test is the ability to assimilate the refraction with ocular health assessment and binocular vision status, in order to make a clinical decision. Testing of sight, including refraction, ocular health assessment and issuing a prescription, should remain an optometrist’s or medical practitioner’s responsibility and be conducted by that individual health professional.  Without a single optometrist conducting all components of the sight test, there is a risk of not picking up important clues to the condition of the patient.  We do not feel this proposal puts the patient first, in terms of health, logistics and safety. 

We conducted a literature review and found no high quality or compelling scientific or economic evidence that it was advantageous to the public to enable dispensing opticians to perform refraction for the purposes of the sight test. In addition, we found no evidence this would result in a more sustainable or accessible means of delivering population-led eye care in socioeconomically deprived populations. Furthermore, the ability to delegate such an integral and interdependent part of the sight test to another person serves as an incremental step change to facilitate and drive separation of refraction and ocular health assessment within the sight test.  As there has been no robust research into this model of practice, it is not possible to ascertain possible harms to patients arising from the delegation of refraction, and we would therefore strongly recommend that such studies are conducted before any amendments are made. 

85% of members we surveyed think that dispensing opticians should not be able to undertake refraction for the purposes of testing sight. No participants in our focus groups were supportive of this suggestion. The key argument driving these responses was patient safety and that the sight test is a holistic test where all elements needed to fully diagnose the patient are best performed by one individual. 

“Main reason is refraction gives you clues as to ocular health problems... Such things could go missing… like... scissor [reflex], especially in early stages. Also as practitioner doing both elements you can have strong level of confidence in work you have done” [Primary care optometrist]

“It doesn’t necessarily put the patients first either? It’s a holistic thing, a patient is an entire person and they will present with certain things and then you will find things out in their vision/health … if you don’t see the person in front of you, and are not able to check their vision, I’ll probably end up re-checking certain parts of their vision to see what effects the pathology is having on the eyes. I don’t feel as if it’s going to make the journey for the patient any better, if anything, it’s going to disrupt it and make it more disjointed ...”  [Primary care optometrist]

“It’s just too important, these are really, really key things because you’re talking about safety on the roads/and those types of situations, it's so important to be accurate for the safety of the patient and for the wider public. Certain conditions, like cataracts, borderline vision, glare, things like that, that you may not be able to explain in the refraction part… but when you look inside the eye you’ll see certain things”  [Primary care optometrist]

“We have an ever ageing population, they have more pathology; they have more cataracts, corneal problems, binocular vision problems and all these things make the refraction much more difficult” [Primary care optometrist]

The College supports the general principle of collaborative working and delegation wherever possible, and we recognise that registrants should be able to utilise technology and innovative methods in order to perform the sight test, where they are satisfied it is in the patient’s best interest. Tasks such as performing visual field tests, ocular imaging and patient support and instruction may be considered suitable for automation or completion under the oversight of an appropriate registrant optometrist or medical practitioner. 

These investigations, which contribute to the ocular health assessment, are fundamentally different to subjective refraction as they can be conducted independently, repeatedly and in isolation, with the outputs collected and assimilated by an optometrist in order to determine the ocular health status of the patient.  However refraction, due to its interdependence on binocular vision and ocular health assessment, cannot be performed effectively by another person, either independently or with oversight.

In our view, there is no definable advantage to the public of amending or removing the 2013 statement on refraction so that dispensing opticians can refract for the purposes of the sight test. 

Disadvantages to service users include:

• Some aspects of the refraction may need to be duplicated, where ocular health or binocular vision impact on the refraction – this would increase the time of the appointment and could reduce patient satisfaction and trust in their care
• Service users may need to see an additional person as part of the sight test process – increasing appointment times, with no identified benefit to patients
• It may result in a refraction where ocular health or binocular status may not have been fully accounted for or incorporated into the final prescription issued, which would result in worse patient outcomes. It may lead to the perception that the refraction and ocular health assessment components of the sight test could be reasonably separated.

We conducted a literature review and found no high quality or compelling scientific or economic evidence for the need to delegate refraction, or that it was advantageous to the public to enable dispensing opticians to perform refraction under supervision. In addition, we found no evidence it resulted in a more sustainable or accessible means of delivering population-led eye care in socioeconomically deprived populations. Members who took part in our focus groups expressed concerns that such a regulatory change has only been suggested because it could reduce business costs, rather than improve standards of care or patient outcomes. 

“Only benefits are only for the [employers], it’s more commercially viable for them. Cheaper. Not a patient centric approach” [Primary care optometrist]

“I think the push is from commercial point of view – pay less money to do part of the job”[Primary care optometrist]

“I will not be given that extra time to spend more time with my patient and do more health checks, it will literally be cut in half and then I have to see double”[Primary care optometrist] 

There is no evidence that delegation of refraction would enable optometrists to provide more enhanced or advanced clinical services and alleviate pressures on hospital eye services.  The College supports these new models of care and believes that optometrists can play a central role in delivering more services and improving patient outcomes. We are also leading work to model the eye care workforce, so we can understand current gaps or limitations and better support workforce planning in future.  However, we see the main lever to achieving new models of care relates to the appropriate funding and commissioning of services, and will not be solved by the delegation of refraction as part of the sight test.

The Act and supporting 2013 statement is for the benefit of the public and must continue to ensure all people receive safe and appropriate care, maintain good eye health and avoid preventable sight loss. 

No.

The UK has well-functioning, accessible and efficient primary eye care services and at the heart of these is the comprehensive sight test (or eye examination in Scotland), which all patients can access with no or low waiting times. This model of optometrist-led primary eye care has been recognised as one which benefits patients¹, and the current legislation is a key factor in maintaining the safety and integrity of the sight test. This protection for the benefit of the public must continue to ensure all people can see as well as possible, maintain good eye health and avoid preventable sight loss. 

75% of members we surveyed did not feel the current legislation creates unnecessary regulatory barriers.

1. IBES Diskussionsbeitrag, 2011, Comparative Analysis of Delivery of Primary Eye Care in Three European Countries.

We support maintaining the current legislation. The Act is a successful piece of patient protection legislation, evidenced by high standards, innovation in practice and technological enhancement, alongside a low incidence of harm and relatively low levels of patient complaints and fitness to practise sanctions.

There is little evidence providing comparative assessment of population level ocular health outcomes in countries with different models of eye care regulation, although a review of primary eye care systems in France, Germany and the UK indicated that there are benefits to the UK’s well-regulated, optometry-led service¹ As such it is our view that any changes could not be justified by the existing evidence base, or lack thereof. 

1. IBES Diskussionsbeitrag, 2011, Comparative Analysis of Delivery of Primary Eye Care in Three European Countries.

No. 

Optometrists currently complete over 16 million NHS-funded sight tests every year in the UK^1-4 and research indicates that only 4-6% of these sight tests result in referrals to secondary care⁵.

There have been many studies evaluating the quality of optometric referrals^5-10. Variation in the rate of referral is often confused by varying definitions of how a “false positive” is defined and do not always take account of factors that contribute to a referral decision, such as IT connectivity, local commissioning arrangements and the level of local hospital engagement (specifically whether feedback and discharge information is routinely provided to the referring optometrist). In locations where additional services are not commissioned and funded in primary care, referral following a sight test may be the only option for optometrists whose patient requires further tests or follow up. 

Local health systems, optometry practices/employers and secondary care providers hold data on ophthalmic referrals, however there is not one central repository of referral volume or quality for the UK that we can effectively analyse. NHS England and each devolved nation’s health system publish the number of referrals (GP and other (including optometry)) and the number of General Ophthalmic Service sight tests funded. 

We support more collaboration between systems and providers to collect data for the purposes of improving quality and identifying potential health inequalities. This data should be available on an open access basis and help inform robust local eye care commissioning. 

The College of Optometrists provides both professional and clinical guidance on referrals and regularly features in continued professional development material to support registrants develop and maintain good decision-making skills. The College of Optometrists’ and Royal College of Ophthalmologists’ joint vision for the delivery of safe and sustainable eye care sets out the key principles and recommendations for the development and governance of good quality, collaborative eye care¹¹.

We do not feel that the legislation is a barrier to clinical decision-making or referrals, and instead believe that communication, digital connectivity, commissioning and improved pathways are more likely to impact on referral numbers and outcomes. 

1. Health and Social Care Northern Ireland, General Ophthalmic Service Statistics in Northern Ireland 2019/21
2. NHS Digital, General Ophthalmic Services activity statistics - England, year ending 31 March 2020.
3. Public Health Scotland (2020) Ophthalmic workload statistics as at year ending 31 March 2020.
4. Welsh Government (2020) NHS ophthalmic statistics by year: 2019/20.
5. Rakhee Shah, David F. Edgar, Abeeda Khatoon, Angharad Hobby, Zahra Jessa, Robert Yammouni, Peter Campbell, Kiki Soteri, Amaad Beg, Steven Harsum, Rajesh Aggarwal, Bruce J. W. Evans, Referrals from community optometrists to the hospital eye service in Scotland and England, Eye, 10.1038/s41433-021-01728-2, (2021)
6. Parkins, DJ, Benwell, MJ, Edgar, DF & Evans, BJW. The relationship between unwarranted variation in optometric referrals and time since qualification. Ophthalmic Physiol Opt 2018; 38: 550– 561. 
7. Krystynne Harvey, David F Edgar, Rishi Agarwal, Martin J Benwell, Bruce JW Evans, Referrals from community optometrists in England and their replies: A mixed methods study, Ophthalmic and Physiological Optics, 10.1111/opo.12948, 42, 3, (454-470), (2022)
8. Alexander G. Swystun, Christopher J. Davey, Exploring the effect of optometrist practice type on NHS funded sight test outcome, Journal of Optometry, 10.1016/j.optom.2020.03.008, 14, 1, (69-77), (2021). 
9. Fadi R Ghazala, Ruth Hamilton, Mario E Giardini, Andrew Ferguson, Olivia BL Poyser, Iain AT Livingstone, Live teleophthalmology avoids escalation of referrals to secondary care during COVID-19 lockdown, Clinical and Experimental Optometry, 10.1080/08164622.2021.1916383, 104, 6, (711-716), (2021).
10. El-Abiary, M., Loffler, G., Young, D. et al. Assessing the effect of Independent Prescribing for community optometrists and referral rates to Hospital Eye Services in Scotland. Eye 35, 1496–1503 (2021). 
11. The College of Optometrists and The Royal College of Ophthalmologists, Joint statement on our vision for safe and sustainable patient eye care services (2021).

Yes.

We strongly refute the case for separating the refraction from the eye health check. 

To protect the public from avoidable sight loss it is vital that the testing of sight continues to mandate an ocular health assessment along with every refraction. There is a strong case for maintaining the current position. The UK has well established and developed optometric provision, with a good level of accessibility¹. Waiting times are relatively short and there is a good geographic coverage of local optometric provision, both NHS funded and private care.

We conducted a literature review and found no high quality or compelling scientific or economic evidence that it was advantageous to the public to separate refraction from the ocular health assessment.

In fact, evidence shows that separating refraction from the ocular health assessment carries increased risk of eye conditions and vision loss.

• Marlee et al (2021)² and Irving et al (2016)³ showed that gaps in the public’s knowledge of vision-threatening conditions and misinformation could lead to fewer eye exams and increased risk of vision loss.
• Michaud and al (2014)⁴ reviewed data from a large eye care centre in Canada and retrospectively reviewed records selecting those presenting only with refractive symptoms and then examined whether on further investigation during the eye examination any ocular diagnoses were revealed. The authors reported that asymptomatic eye conditions were found in 26% of patients.
• Robinson et al (2010)⁵ showed that periodic eye exams prevent vision loss and blindness.
• Offord et al (2010)⁶ found that removing protection via regulation may lead to other professions offering services that they are less qualified to provide.
• The Italian optometric system is predominantly based around refraction with no obligation to detect ocular pathology. A study by Cheloni et al (2021)⁷ reported that there were several conditions that would likely remain undetected in this type of eye care model. The authors indicated that around 20% of patients may have ocular pathology that required treatment or monitoring and that would be undetected without the requirement for concurrent refraction and eye health examination.
• Parfitt et al (2019)⁸ showed that some people with symptoms of wet AMD do not recognise the importance of eye health checks and think they just need new spectacle lenses.
• Hayden, C (2012)⁹ indicated that there is a limited public awareness or understanding of eye health, which is understood almost exclusively in relation to having good or poor sight. This has been identified as a key barrier that is preventing access to primary care services.

We believe it is essential that the sight test should continue to be a single episode of care delivered on the same day, at the same location and carried out by one registrant optometrist or medical practitioner.

There is strong consensus across the optometric profession that the sight test should remain as it is and should not be divided into a refraction and separate eye health examination. Combined with a general lack of public awareness on the importance of the eye health examination, to do so would present a risk to patient health, as it is likely patients would prioritise having a refraction over an eye health examination.

Our members who participated in our focus groups unanimously expressed strong concern at the prospect of separating refraction from the ocular health check. This was due to the impact on patient safety and potential for there to be an increase in late diagnoses and preventable sight loss. There was a concern that people would not present for eye health checks for themselves or their children, as they do not understand the importance of eye health. There was also concern that this would increase health inequalities disproportionately in some communities. 

“it’s massively worrying, I’m really, really shocked to see this being discussed… I’m so proud of what Optometry has achieved and this system has shown how well it’s held together and how well the profession’s stood up to these challenges… I’m just surprised that they’d want to mess with it really and want to make it unstable in any way, because we have managed to keep things running for the country’s eye health” [Primary care optometrist]

“The Opticians Act is like the heart, it protects a profession that already knows how to advance itself, if you start to mess with it at the very heart of it, the whole thing breaks down. As it is, the eye test, refraction, health check, advanced technology are working together really well and anything that looks to degrade that I’d be very wary of because it’s a system that works really well” [Primary care optometrist]

“The eyes are very unique, there’s not another organ of the body that you can look into and actually see the micro-vasculature… and know what is wrong with somebody. So from the point of view of picking up high blood pressure, cholesterol, diabetes, all kinds of different systemic conditions can be picked up from an eye test. So if all those people are not having their eye health checked and developing blood pressure, maybe having strokes and the comorbidities with that, and the pressure that that would put on the NHS and their families. It’s really easy for us to sound like we’re protecting our career but it’s important that you understand that…, it’s much, much bigger than that in terms of the health of the population and the system” [Primary care optometrist]

“I feel very, very strongly: keep them together.  Over the years, the number of patients that come in because they just want new glasses and I’ve found something very, very wrong with their eyes, that could even have been life threatening if they hadn’t come for an eye test” [Primary care optometrist]

We recognise that there is more to do, in order to improve awareness of and access to eye care, in particular in rural, costal and inner cities areas and communities who are less likely to access health care¹⁰. However, we do not believe that legislative reform would benefit patients. 

We look to the GOC to continue to maintain the vital connection between mandatory ocular health assessments and refraction, for the benefit of the public and patient outcomes.

1. IBES Diskussionsbeitrag, 2011, Comparative Analysis of Delivery of Primary Eye Care in Three European Countries.
2. Marlee M Spafford, Deborah A. Jones, Lisa W Christian, Tammy Labreche, Nadine M Furtado, Sarah MacIver & Elizabeth L Irving (2021) What the Canadian public (mis)understands about eyes and eye care, Clinical and Experimental Optometry, DOI: 10.1080/08164622.2021.2008793.
3. Irving, Elizabeth L.*; Harris, Joel D.†; Machan, Carolyn M.‡; Robinson, Barbara E.*; Hrynchak, Patricia K.‡; Leat, Susan J.*; Lillakas, Linda§ Value of Routine Eye Examinations in Asymptomatic Patients, Optometry and Vision Science: July 2016 - Volume 93 - Issue 7 - p 660-666, doi: 10.1097/OPX.0000000000000863
4. Michaud L, Forcier P. Prevalence of asymptomatic ocular conditions in subjects with refractive-based symptoms. J Optom. 2014 Jul-Sep;7(3):153-60. doi: 10.1016/j.optom.2013.08.003. Epub 2013 Sep 20. PMID: 25000871; PMCID: PMC4087174
5. Robinson BE, Mairs K, Glenny C, Stolee P (2012) An Evidence-Based Guideline for the Frequency of Optometric Eye Examinations. Primary Health Care 2:121. doi:10.4172/2167-1079.1000121 
6. Offord, L. (2010). Feature - Eye Care: Focusing on the Patient. AJP: The Australian Journal of Pharmacy, 91(1085), 62–65. 
7. Cheloni, R., Swystun, A. G. ., Frisani, M. ., & Davey, C. J. . (2021). Referral in a routine Italian optometric examination: towards an evidence-based model. Scandinavian Journal of Optometry and Visual Science, 14(1), 1–11. 
8. Parfitt A, Boxell E, Amoaku WM, et al Patient-reported reasons for delay in diagnosis of age-related macular degeneration: a national survey BMJ Open Ophthalmology 2019;4:e000276. doi: 10
9. Hayden, C (2012) The barriers and enablers that affect access to primary and secondary eye care services across England, Wales, Scotland and Northern Ireland. RNIB report: RNIB/CEP/IR/01, 2012. 
10. D. Shickle, T.M. Farragher, Geographical inequalities in uptake of NHS-funded eye examinations: small area analysis of Leeds, UK, Journal of Public Health, Volume 37, Issue 2, June 2015, Pages 337–345.

No.

There is a good consensus amongst our members that it is important to maintain the current legislation, as it is in the best interests of patients. For example, to reduce the risks associated with contact lenses that have not been correctly fitted, or supplied without advice on safe handling and wearing schedules.  84% of members of The College of Optometrists think the fitting of contacts lenses legislation does not create any unnecessary regulatory barriers. 

In contrast to deregulation many members felt the current contact lens supply rules were outdated and too lax, with increasing numbers of the public purchasing from unregulated contact lens suppliers outside UK jurisdiction. 

“The Opticians Act needs to come into the present in some parts, it’s a bit behind the times – some of the supply of contact lenses, in particular, is too lax” [Primary care optometrist]

“There are grey areas. Contact lenses sold online, not from UK don’t fall in line with Opticians Act. Needs to be tightened up. Cosmetic contacts also” [Primary care optometrist]

Maintaining the current legislation ensures a good level of protection for contact lens wearers and minimises the risk of unintended consequences of change. The most significant risk for contact lens wearers is likely to result from unsafe use of lenses, leading to infection and sight loss. Regular review via fitting and aftercare appointments provide the opportunities by which unsafe wear may be detected and wearers educated to change their behaviour, if they are posing a risk to their ocular health¹. We are supportive of the requirement that contact lenses can only be fitted by an optometrist or a dispensing optician with a contact lens specialty.

Stapleton et al (2008)² showed that online contact lenses sales lead to increased complications and Mingo-Botin et al (2020)³ demonstrated that contact lenses bought online lead to less frequency of eye health checks and less proper fitting.

In the US, Fogel et al (2008)⁴  showed that individuals who purchase contact lenses via the internet or store do not follow a number of FDA contact lenses recommendations, therefore putting their eyes at risk.

We also support the conditions setting out that contact lens fitting must begin before the re-examination date specified in a valid sight test prescription (dated less than two years before). The Act therefore maintains a link between the sight test and the contact lens fitting. This ensures a vital connection between mandatory ocular health assessments, refraction and contact lens supply, for the benefit of the public.   

Evidence based recommendations:

• Contact lens-related complications are common, affecting around one third of wearers, although most are mild and easily managed. However, management requires expert knowledge and only a registrant is able to apply to safely manage any complications.^5,6
• Regulatory authorities charged with the responsibility of stipulating the validity of a contact lens prescription should continue to allow optometrists to set an expiry date relevant to the circumstances of individual lens wearers.^7,8

1. Morgan PB, Efron N. Influence of practice setting on contact lens prescribing in the United Kingdom. Cont Lens Anterior Eye. 2015 Feb;38(1):70-2. doi: 10.1016/j.clae.2014.07.014. Epub 2014 Aug 20. 
2. Stapleton F, Keay L, Edwards K, Naduvilath T, Dart JK, Brian G, Holden BA. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology. 2008 Oct;115(10):1655-62. doi: 10.1016/j.ophtha.2008.04.002. Epub 2008 Jun 5. PMID: 18538404
3. Mingo-Botín D, Zamora J, Arnalich-Montiel F, Muñoz-Negrete FJ. Characteristics, Behaviors, and Awareness of Contact Lens Wearers Purchasing Lenses Over the Internet. Eye Contact Lens. 2020 Jul;46(4):208-213. doi: 10.1097/ICL.0000000000000702. PMID: 32443017
4. Fogel, J. and Zidile, C. (2008) Contact lenses purchased over the internet place individuals potentially at risk for harmful eye care practices. Optometry 79 (1): 23-35. 
5. Stapleton F, Bakkar M, Carnt N, Chalmers R, Vijay AK, Marasini S, Ng A, Tan J, Wagner H, Woods C, Wolffsohn JS. CLEAR - Contact lens complications. Cont Lens Anterior Eye. 2021 Apr;44(2):330-367. doi: 10.1016/j.clae.2021.02.010]
6. Zaki M, Pardo J, Carracedo G. A review of international medical device regulations: Contact lenses and lens care solutions. Cont Lens Anterior Eye. 2019 Apr;42(2):136-146. doi: 10.1016/j.clae.2018.11.001
7. Efron N, Morgan PB. Rethinking contact lens aftercare. Clin Exp Optom. 2017 Sep;100(5):411-431. doi: 10.1111/cxo.12588. Epub 2017 Sep 4. PMID: 28871604.]
8. Bridget E Claydon, Nathan Efron, Craig Woods, Non-compliance in optometric practice, Ophthalmic and Physiological Optics, Volume 18, Issue 2,1998,Pages 187-190,ISSN 0275-5408.

No.

We recognise that the sale and supply of optical appliances to certain groups of vulnerable patients should be appropriately managed, particularly as sight problems are more common among certain vulnerable groups:

• Patients with learning disabilities – Adults with learning disabilities are 10 times more likely and children with learning disabilities 28 times more likely to have a serious sight problem compared to the general population and less likely to be self-reporting an issue¹
• Patients with dementia – Research shows that the prevalence of visual impairment is disproportionately higher in people with dementia living in care homes. Almost 50% of presenting visual impairment is correctable with spectacles, and more with cataract surgery².

However, there is a range of factors to consider before legally restricting the sale and supply of optical appliances to additional groups of patients. These include whether such restrictions would improve patients’ outcomes, whether it is always possible to identify a member of a vulnerable group – as optical practices currently have no access to patients’ shared medical care records, and whether changes would further restrict patients’ access to eye care (particularly in groups with low baseline access).  This risks registrants and practices inadvertently breaking the law if they cannot identify an individual from one of the above vulnerable groups or if an individual does not want to disclose information that identifies their vulnerable status.

56% of our members who responded to our survey think that the sale and supply of optical appliances be further restricted to certain groups of vulnerable patients, but a further analysis of their responses showed that they wanted to ensure that these vulnerable groups were looked after, suggesting that service provision models and funding were likely to be more of an issue than the primary legislation. 

Instead of legal restrictions, we would recommend that better training is available to all members of staff within an optical practice, so that they can recognise when patients may have additional needs, provide appropriate information and support with using new appliances.  These should not require additional qualifications.

1. Emerson E, Robertson J (2011) The estimated prevalence of Visual Impairment among people with learning disabilities in the UK, RNIB and SeeAbility Learning Disabilities Observatory (2011)
2. Bowen M, Edgar DF, Hancock B, Haque S, Shah R, Buchanan S, et al. The Prevalence of Visual Impairment in People with Dementia (the PrOVIDe study): a cross sectional study of 60-89 year old people with dementia and qualitative exploration of individual, carer and professional perspectives. Health Serv Deliv Res 2016;4(21)

There are as many advantages and disadvantages of further restricting the sale and supply to certain vulnerable groups.

Advantages:

• These vulnerable groups are already at greater risk of eye disease and would benefit from the requirement to see a registered professional to obtain optical appliances.
• This would help ensuring that patients' appliances are prescribed and fitted optimally, and their use described clearly, helping keep their vision is at its best to keep their quality of life high.
• Optometrists and dispensing opticians have the necessary clinical and communication skills to effectively manage, understand and treat these patients.

Disadvantages:

• This may further limit patients' access to care and add more barriers to a group who already face greater difficulties accessing healthcare equitably.
• With a growing number of the population affected by (for example) learning disabilities or dementia, some patients from vulnerable groups  may have further limitations on when their appliances can be dispensed  and this could cause more barriers to care and increase distress for these patients.

No.

It is important to maintain this restriction in the best interests of patients, and to reduce the risks associated with contact lenses that have not been correctly fitted, or supplied without advice on safe handling and wearing schedules^{1, 2}.

As long as the patient is not under 16 or registered visually impaired, they may be supplied under the general direction of an optometrist or dispensing optician, who does not need to be on the premises at the time. This is not an unnecessary barrier and should be maintained.  83% of our members who responded to our survey felt that the legislation related to the sale and supply of contact lenses did not create any unnecessary barriers.

However, the requirement that a contact lens specification must be in date is a barrier to registrants acting in the patients’ best interests in exceptional circumstances. During the pandemic, while practices were following the College's and GOC's amber phase guidance and policies, easements enabled registrants to act in their patients’ best interests to support an ongoing supply in exceptional circumstances. This discretion helped members of the public safely maintain an ongoing contact lens supply, and for appropriate care to be scheduled as soon as reasonably possible. Continuing this policy of discretion would be of benefit as a permanent change and may reduce the number of people driven to unregulated contact lens supply in exceptional circumstances (for example when they run out of lenses and are waiting for their next appointment).  The regulations must be supportive of clinicians using their professional judgment, to ensure members of the public can maintain a safe supply of contact lenses and good vision.

1. Stapleton F, Bakkar M, Carnt N, Chalmers R, Vijay AK, Marasini S, Ng A, Tan J, Wagner H, Woods C, Wolffsohn JS. CLEAR - Contact lens complications. Cont Lens Anterior Eye. 2021 Apr;44(2):330-367. doi: 10.1016/j.clae.2021.02.010
2.    Zaki M, Pardo J, Carracedo G. A review of international medical device regulations: Contact lenses and lens care solutions. Cont Lens Anterior Eye. 2019 Apr;42(2):136-146. doi: 10.1016/j.clae.2018.11.001

Yes.

As long as the patient is not under 16 or registered visually impaired, they may be supplied under the general direction of an optometrist or dispensing optician, who does not need to be on the premises at the time. There is no evidence that this is an unnecessary barrier to safe supply.

However, we would like to see the same regulation effectively and consistently applied to online sellers of contact lenses, including those who are based outside of the UK but supply to UK customers.

No.

Verification is only required if – as well as being conducted under general direction – the seller does not have the original specification.  We believe this continues to be an important patient safety measure as it reduces the risk of patients being supplied with incorrect lenses, as well as to ensure that lenses are not supplied beyond the expiry date of the specification. 

Verification is an important step in ensuring the correct contact lenses are supplied to a patient. While it means there is an administrative responsibility for both the supplier and the original issuer of the specification, removing verification could result in consumers being supplied contact lenses to an incorrect specification or inappropriate contact lens substitution.  However, we believe the current system could be improved by enabling the use of electronic copies of the contact lens specification and removing the need to verify it unless the specification (or duplicate of it) is unclear, contains an obvious error or the registrant believes it has been altered or tampered with. 

Verification is not necessary: 

• By or under the supervision of the patient’s contact lens fitter 
• Under the general direction of the patient’s contact lens fitter (who will have their specification) 
• By or under the supervision of an appropriate practitioner 
• Under the general direction of an appropriate practitioner who has the patient’s original specification  

As verification was introduced for the protection of the public, and lenses can be supplied remotely under the circumstances above, we see no reason to relax the verification requirements at this time.

“I can go on Facebook and there’ll be adverts, ‘You can buy your contact lenses here’ and it’ll ask you for a prescription but it may not ask you for an eye test date….Some patients haven’t been into the practice for 6/7 years and they’re still buying contact lenses, which will slowly wear away the cornea, from ill fitting lenses, or risking infection.  Some sites will ask for the prescription and will ask if you’ve had an eye test and patients can lie, ‘I had an eye test a few weeks ago/that’s my prescription’, there’s no enforcement of that” [Primary care optometrist]

Removing the requirement to verify a copy of the contact lens specification could result in consumers being supplied contact lenses to an incorrect specification, in circumstances where the appropriate practitioner does not have the patient’s original specification.

A recently published review¹ considered the implications of inappropriately substituting soft contact lens types and concluded: “Contact lens are medical devices which are prescribed and fitted; they should never be substituted for another lens type in the absence of a new prescription further to a full finalised fitting, for the simple reason that all soft contact lenses are not created equal. A substituted lens may have properties that results in undesirable consequences in respect of vision, ocular health, comfort and cosmetic appearance, and may be incompatible with the lifestyle of the patient.”

1.  Efron N, Morgan PB, Nichols JJ, Walsh K, Willcox MD, Wolffsohn JS, Jones LW. All soft contact lenses are not created equal. Cont Lens Anterior Eye. 2022 Apr;45(2):101515. doi: 10.1016/j.clae.2021.101515. Epub 2021 Sep 25. PMID: 34583895.

No.

Guidance covering aftercare and contact lens check-ups is already available.

Sections A399-A401 and A403-A411 of The College of Optometrists Guidance for Professional Practice provides the necessary guidance for clinicians.  There is no evidence that further legal definition is required.

No.

Zero powered contact lenses carry the same risks for eye health complications as contact lenses with a prescription and therefore should only be dispensed and fitted by qualified practitioners.

Snyder et al (1991)¹ reported five cases of severe microbial keratitis associated with the use of these lenses. This subpopulation of patients who possess no refractive error are at risk of developing severe complications from contact lens wear. They have identified several issues which can be addressed by regular contact with eye care professionals and better regulation.

In the US, Fogel et al (2008)²  showed that individuals who purchase contact lenses via the internet or store do not follow a number of FDA contact lenses recommendations, therefore putting their eyes at risk.

Appropriate handling, cleaning and disinfection techniques are essential and it is important to comply with the recommended wearing times and frequency of lens replacement.

Individuals who wear contact lenses that have not been correctly fitted by a qualified practitioner may be putting the health of their eyes at risk. For this reason, we believe that the legislation should continue to stipulate that cosmetic lenses should only be supplied under the supervision of a registered optometrist, dispensing optician or medical practitioner.  The supervisor must be able to exercise their professional skill and judgement as a clinician. Sellers will need to prove they meet the necessary requirements for supervision.  90% of our members surveyed think that selling zero powered lenses should be restricted to GOC registrants.

We also recommend the GOC to run more regular public campaigns to better inform the public about the risk associated with contact lenses. A contact lens is a medical device and its handling, regardless of power, should continue to be managed by a qualified professional.

We know, from members’ feedback, that many practitioners are aware of the illegal sale of zero powered cosmetic and novelty contact lenses in their local area and would like to notify vendors that they are breaking the law. However, they feel they do not have the means to do so.

1.   Snyder, R.W., Brenner, M.B., Wiley, L. et al (1991) Microbial keratitis associated with plano tinted contact lenses. CLAO J. 17; 4: 252-5. 
2.    Fogel, J. and Zidile, C. (2008) Contact lenses purchased over the internet place individuals potentially at risk for harmful eye care practices. Optometry 79 (1): 23-35. 

Yes.

Research conducted by the College showed that almost 60% of people dressing up at Halloween considered wearing cosmetic contacts lenses. The same research shows that only 22% of people would buy novelty lenses from an optometrist. [Research undertaken by Opinium on behalf of the College of Optometrists in September 2021. 2000 people were surveyed]

There is evidence that contact lens users who buy their lenses through alternative supply routes may be more susceptible to poor hygiene procedures and to an increased risk of infection¹.

A US study found that consumers who bought contact lenses from sources other than their eye care practitioner were less likely to comply with good eye care health practices and have reported cases of serious corneal ulcers and infections associated with wear of zero powered contact lenses². Corneal ulcers can progress rapidly, leading to internal ocular infection if left untreated. Uncontrolled infection can lead to corneal scarring and vision impairment.  In extreme cases, this condition can result in blindness and eye loss.

Another more recent study found that those who purchase contact lenses via the internet or store do not follow a number of US Food and Drug Administration contact lens recommendations³.

Research from Australia shows a higher risk of developing microbial keratitis when lenses are bought online. The risk associated with internet/mail order purchase of lenses was 4.76 times higher than when lenses were bought from an optometrist⁴. 

Other risks associated with the use of zero powered lenses include conjunctivitis (an infection of the eye), corneal swelling, allergic reactions, corneal abrasion from poor lens fit and a reduction in vision, resulting in interference with activities such as driving.

However, it should be stressed that complications from zero powered contact lenses are generally associated with poor compliance and hygiene, and with unregulated lens sales. As with all contact lenses, provided they are handled and cared for properly and only used according to the prescribing practitioner's recommendations, the risk of eye infection is very low.

1. Steinman, T.L., Fletcher, M., Bonny, A.E. et al (2005) Over-the-counter decorative contact lenses: cosmetic or medical devices? A case series. Eye & Contact Lens 31; 5: 194-200. 
2. Snyder, R.W., Brenner, M.B., Wiley, L. et al (1991) Microbial keratitis associated with plano tinted contact lenses. CLAO J. 17; 4: 252-5. 
3. Fogel, J. and Zidile, C. (2008) Contact lenses purchased over the internet place individuals potentially at risk for harmful eye care practices. Optometry 79 (1): 23-35. 
4. Stapleton, F., Keay, L., Edwards, K. et al (2008) The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology 115: 1655–1662.

Yes, but legislation alone will not be sufficient.

See our response to Q31.

The online illegal supply of eye care services and optical appliances has always been a concern for our members. 89% of members who responded to our survey felt that legislation related to the sale of optical appliances was required to protect consumers.

“… the Opticians Act does need updating because I don’t think it necessarily reflects the threat to the profession and patient health that comes with that. So it doesn’t really tackle well the fact that we see patients every day who are buying contact lenses from internet suppliers... offering very, very cheap lenses, very poor quality, to people who haven’t got fully valid prescriptions and so on.... But those companies aren’t being held to account over that at all.” [Primary care optometrist]

In recent years, there has been an increase in online prescribing and dispensing of optical appliances. This raises concerns about the potential lack of appropriate supervision for safe supply of optical appliances and zero powered contact lenses. Increased shifts to online consumer behaviour exposes more patients to online suppliers of spectacles and contact lenses, and increases risk of harm occurring.

Anderson et al (2016)¹ compared spectacles bought online with spectacles from optometry practices and showed that a greater number of online spectacles were deemed unsafe or unacceptable because of poor spectacle frame fit, poor cosmetic appearance, and inaccurate optical centration. This seems particularly pertinent to PAL lenses, which are known to increase falls risk. 

We would like the GOC do more to prevent online illegal sales of optical appliances and to stop illegal activity occurring in the UK, by adopting a more proactive approach in tackling illegal practice from overseas suppliers that do not comply with UK legal requirements. E believe the GOC should have more powers to take action against these illegal activities. 

In addition, there is a growing need to educate the public about the risks of buying contact lenses and spectacles online, particularly from sellers based abroad who may be operating outside UK regulation. The GOC needs to make the public aware that when they buy optical products from overseas, these may not be subject to the regulatory assurance that is provided in UK law to keep them safe. We recommend the GOC leads regular public awareness campaigns on the risks of sourcing optical appliances from these overseas online suppliers, to help protect patients and the public.

The GOC should be supported in taking agile action against illegal practice to meet its responsibility for public protection. This should include an evolved regulatory remit to enable the GOC to meet the increasing challenges of healthcare in the forms of products and services being marketed online, facilitated by improvements in technology and artificial intelligence. The two main future risk areas of harm to patients and the public will be:

• The growing online sales of optical products
• The emergence of unregulated online refraction and optical services 

It is therefore vital that the GOC’s powers as set out in legislation allow it to tackle these threats to public protection. The current Department of Health and Social Care plans to reform healthcare regulation and its engagement with individual regulators about their underlying powers provides a useful opportunity to achieve this.

1. Alderson AJ, Green A, Whitaker D, Scally AJ, Elliott DB. A Comparison of Spectacles Purchased Online and in UK Optometry Practice. Optom Vis Sci. 2016 Oct;93(10):1196-202. doi: 10.1097/OPX.0000000000000955. PMID: 27536974; PMCID: PMC5049952.

We believe the advantages of the legislation remaining unchanged are that optometrists can advise and inform patients before assessing and fitting contact lenses. This includes those contact lens customers who do not wear lenses for vision correction and who may not recognise the importance of regular sight tests to check their eye health. This will ensure the safe supply and use of contact lenses continues, and encourage more people to have regular eye health checks.

However, there are disadvantages. People may continue to buy contact lenses online from unregistered professionals or suppliers based on lower costs. This could lead to an increased risk of harm occurring to the consumer. Strengthening the GOC's power (as set out in our response to Q32) would help mitigate this.

No.

The UK has well-functioning, accessible and efficient model of primary eye care services.  The current model has not unduly restricted the innovation of care or that the supply of optical appliances. It ensures the appropriate level of registrant oversight when supplying optical appliances and ensures any such devices are effective (evidenced based), safely used and appropriate for a person’s needs. 

N/A

Yes.

The current legislation is vital to protect the public, both through safeguards to the supply of appliances and because of the impact of article 3 of The Sale of Optical Appliances Order 1984, which effectively ensures members of the public using optical appliances are encouraged to have regular sight tests. The definition of optical appliance as defined within the Act should not be changed. 89% of our members who responded to our survey think that legislation regarding the sale of optical appliances is necessary to protect consumers.

There continues to be a competitive market for both sight tests and optical appliances in the UK, with over 7,000 optical practices¹ providing a wide range of services. Many people can access an NHS funded sight test, and for those who are not eligible sight tests are available across a range of price points, with minimal waiting times for appointments. In short, a sight test is relatively convenient and accessible and does not pose a significant barrier for many people wishing to purchase an optical appliance. 

We recognise that people in certain areas (especially rural, coastal or deprived areas) may not have easy access to a local optical practice, or may be put off accessing eye care due to perceptions of cost². 

While these groups will be disadvantaged by the current legislation – as it means they cannot easily access optical appliances – we do not believe that the law needs to change to improve this situation.  Effective commissioning of services and improved public awareness of the importance of regular sight tests (and the availability of NHS-funded tests and vouchers for eligible groups) should be prioritised, as the legal requirements are important to maintaining public safety. 

1. IBES Diskussionsbeitrag, 2011, Comparative Analysis of Delivery of Primary Eye Care in Three European Countries.
2. D. Shickle, T.M. Farragher, Geographical inequalities in uptake of NHS-funded eye examinations: small area analysis of Leeds, UK, Journal of Public Health, Volume 37, Issue 2, June 2015, Pages 337–345, 

No.

85% of respondents to our member survey disagree that the two-year prescription restriction on the purchase of spectacles from non-registrants is an unnecessary barrier. For more detail, see our response to Q36.

The disadvantage and impact of removing the two year requirement, would be to effectively separate supply of ocular appliances from ensuring a regular ocular health assessment. People may be supplied non-optimal visual correction, which may not give them an adequate level of vision and could result in greater risks related to falls, driving accidents etc. Patients would also not be encouraged to have, and therefore benefit from, regular ocular health checks. This would result in higher rates of preventable sight loss and conditions such as glaucoma not being detected in the early asymptomatic stages. 

Removing the two-year requirement may lead to an increase in health inequality, where people from lower socioeconomic backgrounds may choose to delay or not have their sight test in order to save money. They could replace optical appliances to old prescriptions and risk both their eye health and vision. 

This protection for the benefit of the public must continue to ensure all people can see as well as possible, maintain good eye health and avoid preventable sight loss.

We support maintaining the current legislative framework. Please see our response to Q38 for more detail.

No.

See our responses to Q6, Q7 and Q8. Optical appliances need to be supplied with appropriate advice from suitably trained, qualified and regulated health professionals. 

Selling optical appliances, including sportswear optical appliances, to children under 16 should continue to be restricted to GOC registrants.

Although these types of sportswear are usually only worn for short periods, it is generally important to wear the appropriate protective glasses, for example against increase ultraviolet (UV) exposure, when taking part in winter sports. People with light coloured eyes are most at risk from sun damage, and children are even more vulnerable to UV because they have larger pupils and clearer lenses in their eyes¹.

Children under 16 need to be fitted by suitably trained and qualified professionals, in particular children with squints and binocular problems. Where children are undergoing treatment for squint or lazy eye, it is important to ensure they wear sportswear with their accurate prescription incorporated, to continue the beneficial effect of their treatment. 

We know from experience that it can be difficult for children to realise or tell a practitioner if there is something wrong with their vision or glasses. Correct fitting of optical appliances, including sportwear, is therefore imperative for optimum vision. A failure to do so can lead to lifelong impacts on children's vision and risks harm in the short and long term.  93% of our survey respondents believe that selling optical appliances to children under 16 and those registered visually impaired should be restricted to GOC registrants.

1. Sun HP, Lin Y, Pan CW. Iris color and associated pathological ocular complications: a review of epidemiologic studies. Int J Ophthalmol. 2014 Oct 18;7(5):872-8. doi: 10.3980/j.issn.2222-3959.2014.05.25. PMID: 25349810; PMCID: PMC4206898.

While removing the restrictions may mean children have increased access to sportswear optical appliances and eye protection, potentially at a lower cost, we do not believe the advantages outweigh the risks. Children, who have developing visual systems, need to be under the supervision of a professional with an understanding of their prescription and who can safeguard accuracy.

Buying sportswear optical appliances under the supervision of a registrant / registered medical practitioner ensures that the prescription is appropriately incorporated and that the appliance is correctly fitted to a growing child.  Increased contact with a registrant also encourages the child to have regular sight tests, with associated benefits of detecting changes to vision or eye problems early and ensuring that they have good long-term ocular health and vision.  It also reduces the risk of poor vision having a negative impact on their development and achievement at school.^1,2

1. Simmers, A. J., and P. Dulley. "Amblyopia and the relevance of uncorrected refractive error in childhood." Optom Pract 15 (2014): 169-176.
2. Mocanu V, Horhat R. Prevalence and Risk Factors of Amblyopia among Refractive Errors in an Eastern European Population. Medicina (Kaunas). 2018 Mar 20;54(1):6. doi: 10.3390/medicina54010006. PMID: 30344237; PMCID: PMC6037249. 

See our response to Q41.

No.

See our responses to Q41.

Yes.

Developments in technology and innovations in optics are increasingly influencing the delivery of eye care. 

Recent years have seen advances such as automated refractors, deep level analytics of the OCT, iPhone ophthalmoscopes, clear-lens extraction, free-form lenses, online purchasing of corrective eyewear and online refraction¹. The use of OCT has become commonplace, artificial Intelligence and machine learning are being used to analyse retinal images in some care settings, and remote delivery of optical care has accelerated through the pandemic². Many of these developments bring benefits, but they also create new risks for patients and practitioners. For example, AI algorithms can contain unconscious bias, improper use of remote care can lead to poor outcome and barriers in care, and decisions devolved to technology can bring into question who is accountable.

The central principle for optical regulation and practice should be that registered, competent optical professionals must remain in control of clinical decision-making as new technologies and innovations are deployed. The Opticians Act should not unduly restrict innovation, but should also maintain its current fundamental principles to ensure the public benefits from safe care and regular and complete sight tests. 

1. The College of Optometrists, Optical Confederation, Foresight: A discussion of the potential impact of technology on the UK optical sector to 2030 (2016).
2. Nikolaidou A, Tsaousis KT. Teleophthalmology and Artificial Intelligence As Game Changers in Ophthalmic Care After the COVID-19 Pandemic. Cureus. 2021 Jul 14;13(7):e16392. doi: 10.7759/cureus.16392. PMID: 34408945; PMCID: PMC8363234.
3. Panch T, Mattie H, Atun R. Artificial intelligence and algorithmic bias: implications for health systems. J Glob Health. 2019 Dec;9(2):010318. doi: 10.7189/jogh.09.020318. PMID: 31788229; PMCID: PMC6875681.

Not sure.

Technology and remote care are two different topics that should be addressed separately. The GOC should not combine the two when considering the outcomes of this Call for Evidence. 

As discussed in our response to Q45, there have been many advances in eye care-related technology, which create both opportunities and risks.  There needs to be robust analyses of these impacts on patient and public health. There is not yet a robust evidence base  on the overall impact of the increased use of technology or remote care on future patient safety or care, although individual studies are being published and adding to our growing knowledge. 

However, it should be acknowledged that remote healthcare has generally been beneficial throughout the pandemic, allowing patients to maintain access to professional advice, and face-to-face appointments if needed while reducing the risk of COVID-19 transmission. We expect the demand for remote eye care to increase, both due to the direct impact of the pandemic and also changing consumer/patient habits¹. However, remote care carries an increased risk of missed pathology and its rapid evolution and adoption has outpaced changes to regulations and legal requirements for standards of remote care².

50% of our members who responded to our survey felt that increased use of technology or remote care may have a mainly negative impact on patient safety or care in the future, but a further analysis of their written responses showed that members were focussing on the negative impact of remote consultations. There was significant ambivalence and concern expressed, though some members were more positive in the experiences that they reported.

1. GOC, Public Perceptions Research 2022.
2. Gillam M, Hawrami D, Dutton C, Price L, Hardman-Lea S, Manzouri B, (2022); Ensuring high-quality telemedicine consultations; Optometry in Practice, vol.23, Issue 2, London,  

No.

Although most technological developments that are currently and commonly used in practice did not exist or envisaged when the Opticians Act came into effect or was amended in 1989, the Act does not restrict the type of equipment, products or technology that can be used by registrants.

See also our responses to Q9, Q31-Q32 and Q45-Q46.

Yes.

58% of our members who responded to our survey were unsure as there was little discussion of whether or how the current legislation or policy addresses the use of new technologies such as OCT, or how it impacts on either remote care within the UK operated by GOC registrants, or remote care from outside of the UK by non-registrants.

“There’s remote refraction, so companies who are operating from abroad, saying, ‘If you look into this machine, we’ll tell you what your prescription is’ and that’s just an attempt to chip away at the Opticians Act, which is bad for the patient, bad for the profession, bad for all the network of businesses that support the healthcare. I think it does need to be considered in better detail” [Primary care optometrist]

Remote care should be appropriately and proportionately regulated to provide patients and the public with the sufficient level of protection and trust they expect.  Registrants who provide remote care should ensure they are applying the same standards of care as they would to face-to-face appointments.

We recommend that:

• Patients and the public should have the choice between remote care and face-to-face examination if needed or recommended by the practitioner.
• Standards of care provided remotely should be developed and be equivalent to those that apply to face-to-face care.
• Remote care should remain under the direction of a registrant and it should be their decision and responsibility as to how they provide and manage it.
• Registrants providing remote care should ensure they have the appropriate training, skills and experience.

However, it should be clear that we do not support the principle of remote refraction for the purposes of the sight test, for the same reasons as those set out in our response to Q20. With the current technologies available, this would be equivalent to splitting refraction from the eye health check, and may also be provided by companies who operate outside the UK and are therefore not sufficiently regulated.  Both of these factors would negatively impact public health and patient outcomes.

Similarly, the central principle for the regulation of new eye care technologies should be that registered, competent optical professionals must remain in control of clinical decision-making as new technologies and innovations are deployed, and that any technology or treatment should only be provided if it is in the patient's best interests.

See also our responses to Q9, Q31-Q32 and Q45-Q46.

See our responses to Q9, Q31-Q32 and Q45-Q46.

Yes.

See our responses to Q9, Q31-Q32 and Q45-Q46.

See our responses to Q9, Q31-Q32 and Q45-Q46.

No.

No.

No.

No.