SPOKE: Sector Partnership for Optical Knowledge and Education

Barriers to Advanced Practice

Challenges can be viewed as barriers if the mindset is not open to opportunities. Advanced Practice should augment our core business model, strengthening patient loyalty and respect for optometrists as clinicians. However, there persists the notion of Advanced Clinical Practice as a ‘Replacement’ income stream rather than an ‘Auxiliary’ one, creating a barrier to uptake.

Financial and ethical argument 

Before considering more esoteric arguments for Advanced Optometry, I believe contact lens practice is an immediate and incontestable financial and ethical argument for prescribing qualifications. Your contact lens patients constitute a ready-made income stream, and potential recipients of your IP skills. Fee-based contact lens models must offer services patients value. Immediate access to medical grade optometrists, able to resolve problems promptly in the community, is that value. Patients appreciating such services also tend to be loyal to the practice.   

The role of optometrists 

The skill to resolve contact lens problems without recourse to secondary care should be self-evident. No matter how meticulous the clinician, or how good modern contact lenses may be, these optical appliances represent the number one risk factor for infective keratitis and are significant triggers for a range of inflammatory processes. While designated ‘medical devices’ in 1976, optometrists were not allowed the tools to resolve these rare, but inevitable, problems until 2009. I have argued prescribing optometrists are the sole professional group bridging the gap between contact lenses as ‘optical appliances’ and contact lenses as ‘medical devices’. 

Less quantifiable aspects of advanced practice

‘Advanced practice’ reinvigorates enthusiasm for a profession of which we should be proud. Attracting undergraduates to optometry as a first option and retaining them for an entire career will be secured, in my opinion, when optometry is recognised as a stimulating vocation rather than a job. 

Never assume higher qualifications simply involve treating, with prescription drugs, a variety of pathological conditions. This is important, rewarding and cost effective for the NHS but is only part of what makes advanced qualifications worthwhile. We have more to offer than a prescriptive approach to acute eye management. 

The role of community-based prescribers

With the difficulty of seeing a GP and the workload of hospital clinics, an important role for community-based prescribers is advising patients on what they have not been told! The confidence to answer their many concerns involving ocular and general health, as well as confusion over drug litanies to ensure compliance, is fulfilling and drives patient trust. 

Respect from patients, leading to patient loyalty, is not measured by the number of machines we possess. It is earned by how we engage with individuals. Patients rarely remember the tests you do, they remember you. While positive clinical reputations are not spontaneously generated on qualification, they evolve rapidly when patients are informed collaborators in the management processes. 

A reputation then brings referrals from patients, pharmacists, GPs and other optometrists, increasing the purely clinical aspect of the business. In these situations, the value is in the clinical care, not the corrective outcome. But how is this altruistic approach to patient care funded? 

Introducing alternative funding streams

Verifiable and evidenced ‘advanced qualifications’ give demonstrable support for the introduction of alternate funding streams, of which there are numerous permutations. We have introduced a two-tiered system, largely a reflection of my social conscious. Our non-IP optometrists work to a GOS model, upgrading when necessary, occasionally with intra-practice referrals. For ‘medical’ level optometrists an automatic upgrade is levied above the GOS fee. This covers the medical optometrist of choice, advanced qualifications and additional time, not machinery.

But there remains the conundrum of how to repudiate the great ‘replacement theory’. 

Funded schemes, for a variety of ocular morbidities, are becoming commonplace. The budgets are set, but the fees never correlate with the perceived business priority of selling optical appliances. This inconvenient truth is logical, as a contractor does not budget for the huge floor space and associated staffing costs associated with retail optometry. Regardless, the replacement argument simplistically accepts substituting a routine sight test with an emergency appointment does not make financial sense. Indiscriminate amassing of all income streams into a simple EBITDA formula to estimate profitability and financial performance will accentuate these misgivings.

I wish to suggest the need to adopt a more realistic approach to practice economics, although for some this will require courage.

The best analogy is our attitude to hearing care services. We have a spare room, we install the hearing care group, they sell things, and we get paid, which immediately bolsters pre-tax profit. However, if a spare room were not available, offering a hearing service would necessarily replace a more profitable one. 

A similar business approach for enhanced services needs to be accepted. Consider your business as two, running parallel, within the same building. Your core, traditional business income stream, requiring for instance three full time optometrists and associated support colleagues, continues unaffected. However, since there is a spare room, standing idle and therefore contributing to the overall costs of the business in floorspace rent, why not use it to generate an alternate, clinically heavy income stream. The challenge comes with the need to have an extra clinician in attendance. 

In my practice we have three IP optometrists and two non-IP, with enough scope to leave gaps for emergencies. Auditing the number of emergency appointments per week gives a clear picture distinguishing core business work from auxiliary clinical work. The emergency income stream isn’t as profitable as our core business, but it represents augmented profit not replacement profit. I would also suggest access to services, availability of clinicians and continuity of care feeds practice growth. 

There is no recipe. Every practice is different. Imagine a fully booked, one room, practice. If incorporating an acute scheme is an imperative, with an estimated uptake of one emergency per day, extending opening times by half an hour per day would achieve the auxiliary income goal.

As I scream toward retirement, frankly ready or not, community based shared care is evolving rapidly. Great news for optometry and young enthusiastic optometrists. The sea change is now inevitable, best to rethink how to gauge economic and clinical success sooner rather than later.