GOC Education Strategic Review

Our response to the GOC's Education Strategic Review concepts and principles consultation (March 2018)

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The GOC is undertaking an education strategic review to make sure that, as the optical sector evolves, it continues to protect the public by ensuring that the accreditation, quality assurance and standards of education of optical professionals in the UK continues to be fit for purpose.

It has drawn up a series of concepts and principles and has consulted on these. This is our response to the consultation.

Concept 1: Standards for education providers

1. Do you agree or disagree with us further exploring the concept of new Education Standards in the way we describe above?

Agree

2. Please tell us more about your views on this concept, including any opportunities or risks you foresee.

Key points

  • Patient safety should underpin the development of standards
  • Processes should be put in place to ensure students become clinicians who can  practise safely and have the skills to continue developing throughout their careers
  • Standards should be sufficiently detailed to enable institutions to understand what is required
  • Some changes will require a significant increase in resources, for example, small group work or clinical placements. Without these in place, some changes will not be feasible.

We agree with the examples of standards. We believe the emphasis should be on patient safety – producing clinicians who can practise safely and know how to continue to develop. Unlike other health professionals, optometrists work independently from the outset in community practice, which is a risk that needs to be mitigated by the way they are trained.

The following are probably subsumed under assessment support functions but we would highlight the importance of:

  • supporting students
  • training education developers and teachers in good clinical curriculum and assessment development, teaching and assessment practice
  • universities allowing optometry courses to use standard-setting processes to set the pass mark for assessments (as opposed the university set pass mark) and a defined number of resit attempts. This would demonstrate that universities recognised that they were training students for working with the public and understood the importance of processes that related to patient safety.

We agree with taking an evidence-based approach to designing and delivering education and, by way of example, would suggest including in the standards: taking an integrated approach to teaching. This would remove the concept of having ‘done’ a module and, therefore, being able to forget it and move on, or teaching topics such as professionalism or communication as a separate module. This would be a spiral curriculum approach where students learn in a context relevant to optometric practice, and revisit topics at different stages and levels to reinforce understanding and develop skills and behaviours (also see comments in concept 2 below).

We recognise that many optometry schools are already taking the approaches set out above.

A risk might be that this would be a new way of working for many, so you may need to provide some guidance on what to do to fulfil these standards, while not being so prescriptive that you stifle innovation and difference. The GMC provides standards at an appropriate level of detail.

Another risk is that there will not be sufficient resource or funding to put these changes in place.

Concept 2: Education Standards and Professionalism

3. Do you agree or disagree with the concept of informing our education requirements by our professional standards?

Agree with caveats 

4. Please tell us more about your views on this concept, including any opportunities or risks you foresee.

Key points

  • The professional standards should strongly inform the education requirements but not dominate them
  • Professionalism should be woven into all aspects of the curriculum so students understand that professionalism is an essential part of all areas of their work as a healthcare practitioner.

We agree that the professional standards should strongly inform the education requirements, but they should not be used as individual headings from which the requirements fall, as so much knowledge and skills would end up under Conduct appropriate assessments, examinations, treatments and referrals under supervision. There would also be overlap in many of the professionalism ones, for example: Listen to patients and ensure that they are at the heart of the decisions made about their care, Communicate effectively with your patients and Show care and compassion for your patients.

It is vital to ensure that professionalism is woven into all aspects of the curriculum and not taught as a separate module, for example:

  • thinking about the ethics related to drugs when learning about the use and supply of drugs and medicines
  • communicating with patients in different ways, for example explaining what you are doing, what you have found and why, reassuring a patient about findings, establishing rapport and using appropriate listening and questioning skills to establish a history, or making decisions with a patient in different contexts.

This will ensure that students understand that professionalism is an essential element of all areas of their future practice as a healthcare practitioner.

The risk is that the format of the standards takes precedence, meaning that people try to fit different topic areas against them rather than simply ensuring that they are covered and overtly raised during teaching and the links explained. Their importance has to be recognised, however, by embedding them into all aspects of the curriculum.

Concept 3: Learning Outcomes

5. What are your views on the concept of system-wide learning outcomes for optometry and dispensing optician education and training, instead of an educational competency-based approach?

Key points

  • The learning outcomes should reflect the knowledge, skills and behaviours that an optometrist needs at the point of graduation or registration – what they need to know, be able to do, and how they should behave, and to give them the skills they need to continue to learn and develop throughout their careers.
  • Learning outcomes should be sufficiently detailed to enable institutions to understand what is required, but not so prescriptive that they have no room to innovate.

We agree with a learning outcomes approach. The current competency framework is far too detailed. The learning outcomes should reflect the knowledge, skills and behaviours that an optometrist needs at the point of graduation or registration – that is what they need to know, be able to do and how they should behave. They need to be sufficiently detailed to enable institutions to reassure the public that all students have the knowledge, skills and behaviours they need to practise, but be flexible enough to allow institutions to take different approaches. Importantly, they should remove any possibility of students taking a tick box approach.

There is a risk in making them so high level that they apply to all programmes of learning for registration, as they will be meaningless. While they might cover the same overarching areas, learning outcomes must relate to what is expected of the different professions at the point of graduation or registration. They need to be sufficiently detailed to guide institutions about what is expected. While innovation and varied approaches are to be welcomed, all students need to emerge with the same core knowledge, skills and behaviours and at the same standard, so that the public and employers understand what they can expect. The GMC provides learning outcomes at an appropriate level of detail, as well as supplementary advice, which gives institutions clarity about what is expected.

Concept 4: Links to Continuing Education and Training

6. What do you see as the merits to removing the current link between CET and our education requirements, if any?

Key points

  • The current system is not fit for purpose in a world where optometry practice is changing rapidly
  • A system geared to what the optometrist actually does and that helps them improve in that area is needed
  • Optometrists will need guidance on how to manage their own learning and processes that will help them do this effectively.

The current points-based system appears good because it forces people to do at least six points a year and 36 points over a three-year period covering the whole competency framework. However, it encourages a race to the bottom for CET providers – for example not wanting to write challenging MCQs because others write easier ones and registrants will choose those. In addition, points from journals are easily obtained by those who are not optometrists because they are comprehension tests. Interactive points are also easily gained by sitting through a lecture and listening to questions, and those not trained as optometrists could probably contribute enough to a peer discussion to get through. There is also a danger that the current system sets 36 points as a goal rather than the minimum practitioners should aim for and potentially discourages some from undertaking further development once they have reached this level.

A system should have the flexibility to support those who want to develop further, particularly as we do not know what future practice will look like. A system geared to what the optometrist actually does and that helps them improve in that area would be considerably more meaningful. However, it would also be more challenging for optometrists. It would involve them in planning their learning, and reflecting on what they had learned and how to apply it to their practice, and building a portfolio to evidence their development.

This is crucial as optometrists already on the register will have to be able to adapt to fast changing practice for the rest of their careers and they will need guidance on how to manage their own learning and processes that will help them do this effectively.

7. Do you envisage any disadvantages or risks in this approach, and if so what are they?

It will require a change of culture.

It is possible that some will take a risk and avoid doing much CET on the basis that, if a portfolio system were introduced, for example, it would be impossible to check everyone’s portfolios.

Concept 5: Educational Content

8. What do you see as the key changes needed to the current content of optometry programmes and dispensing optician programmes to ensure our future requirements are fit for purpose?

Key points

  • The safety of patients is paramount and the education system should include core skills, knowledge and behaviours to support this.
  • It is essential that students learn to direct their own learning from the beginning of their undergraduate course and begin to develop professional skills that will help them grow throughout their careers
  • Institutions will need the resources and funding to implement these changes.

The safety of patients is paramount and the education system should include the core skills, knowledge and behaviours to support this. This includes professional skills as well as clinical skills. These should be skills that the optometrist has a realistic chance of practising regularly in the early years of practice so that they have an opportunity to consolidate them, preferably under supervision or with the help of a mentor, if that were feasible. For example, while we agree that some training in therapeutics, which includes the law, systemic health and general prescribing, would be useful for all optometrists, we do not believe that they should enter the register qualified as independent prescribers. This is because they will not have had enough opportunity to consolidate clinical decision-making skills, or their knowledge and skills in relation to diagnosing and treating diseases such as anterior eye disease, and because there would not be enough prescribing work for all optometrists to keep their prescribing skills up-to-date and remain safe to practise in this area.

Students should be well supported so that they emerge as competent, critical and reflective practitioners, confident in their abilities. This might mean more small group work, involving problem-based learning (see comment about resources under Concept 1).

We believe that, as practice is likely to change rapidly, it is essential that students learn to direct their own learning from the beginning of their undergraduate course.

If the profession wants to grow, students also need to begin to develop leadership, mentoring and evaluative skills.

Knowing that much of this is already in place in many optometry schools, we nevertheless suggest the following core skills, knowledge and behaviours should be included:

Basic and clinical science

Basic and clinical sciences to underpin their clinical decision making skills and help in dealing with patients with different needs. This needs to be integrated so students understand why this is important for their clinical practice from testing to prescribing drugs to advising patients.

Clinical and practical skills

  • History taking
  • Clinical assessment skills such as ocular examination, visual function, analysis of digital data, refraction (which will still be needed for some time and will always be needed for some groups, for example those with learning difficulties or dementia)
  • Critical thinking and problem solving to underpin clinical decision making skills, including which tests to undertake, interpreting results, diagnosis, management, prescribing drugs appropriately
  • Reflection skills
  • An ability to write clearly and concisely and with the information the recipient needs – no more and no less. This is particularly important for referrals
  • Communication skills: listening, explaining, and reassurance, involving patients in decision making
  • Prescribing drugs appropriately but only in areas where they have the management expertise at registration. We believe it is very important that prescribing matches capability in terms of diagnosis and management and any higher level prescribing qualifications should be taken at the appropriate time after registration when the optometrist has the requisite experience and capability to diagnose and treat particular diseases. This is because skills must be practised regularly to minimise patient safety issues
  • Practical procedures that they need at the time of registration and continuing experience of doing them. 

Professional skills

  • Information management from keeping accurate records, to writing clear and concise referrals, and finding and verifying information
  • Working in a multi-disciplinary team
  • Understanding how to give and accept feedback, including negative feedback
  • Working with patients
  • Ethical principles and the law
  • Equality and diversity
  • Self-directed learning and reflection
  • Clinical governance, including clinical audit to improve care
  • Understanding evidence and how to read a research paper critically
  • Patient safety issues such as infection control and safeguarding.
  • Healthy living
  • Epidemiology and evidence based practice
  • Leadership skills and the ability to teach others.

Institutions will need the resources and funding needed for small group work, if this is to be feasible.  

Concept 6: Enhanced clinical experience for students

9. Do you agree or disagree with the concept of embedding clinical elements of education and training progressively from the outset of programmes?

Agree that there should be enhanced clinical experience for students

Disagree that the pre-registration period should be abolished and that all clinical experience should be embedded in undergraduate programmes

10. Tell us more about your views on this concept.

Key points

  • We support the concept of students spending structured time in a clinical setting with exposure to different types of patients to help them relate what they are learning in a classroom, clinic or laboratory setting to a real life environment
  • We believe an independently assessed pre-registration period, including a mixture of assessments, is necessary
  • The Scheme for Registration has already been adapted for new optometry schools and can be adapted further. The important point is that it is underpinned by sound assessment principles.

We support the concept of students spending time in a clinical setting with exposure to different types of patients. We believe this helps students to relate what they are learning in a classroom, clinic or laboratory setting to working with patients and to develop the full range of clinical and professional skills they need at the point of registration. To ensure good quality, placements must be structured so students have clear objectives that match their level of attainment, and it must be an integral part of the curriculum. For example, students need to see patients that match the level of their skills – so in the early years, this will be low level, allowing them to get used to speaking to and dealing with patients and colleagues in a practice setting, rather than examining and treating patients. They should keep a reflective portfolio and discuss cases with their tutors.

We do not believe that the concept of early and increasing student placements at undergraduate level precludes a pre-registration period run by an independent organisation. We would argue strongly that the current Scheme for Registration (suitably revised), which is a national registration assessment programme involving work-based assessment, should be retained. It is crucial for demonstrating consistency of standards at the point of registration and for giving trainees a structure for a lengthy period in practice, which enables them to make the transition from the support of a university setting to full registration, where they may be the only optometrist in the practice.  

Through the Scheme for Registration, the profession already has an assessment process which:

  • Is delivered by a body independent of providers of undergraduate education and employers (but answerable to the GOC)
  • Assesses students in their workplace on real patients
  • Includes long assessments on simulated patients to cover important processes
  • Uses a final assessment, in the form of an OSCE to sample across the skills needed for practice
  • Prevents trainees who do not meet the standard set from entering the register and allows feedback to all institutions and employers about student performance in the workplace and the final assessment
  • Has a large enough assessor and examiner body in place to deliver assessments and examinations across the UK throughout the year
  • Has the added value of an infrastructure, including staff to develop and run the assessments, supported by IT, finance and communications teams
  • Delivers a combination of assessments that are underpinned by clear information for trainees and clear guidance and training for supervisors, assessors and examiners
  • Incorporates many quality assurance measures to make the workplace assessment as reliable as possible, and it sits towards the top of Miller’s triangle in the shows how and does categories.

We believe this is an opportunity to adapt and develop the Scheme for Registration further to ensure it can continue to provide an independent assessment. The principles of good assessment that we apply could easily be adapted to a learning outcomes approach.

The Scheme is currently run:

  • At the end of a three year BSc programme (four years in Scotland)
  • Alongside MOptom programmes at the Universities of Aston, City and Ulster.

In addition, we have adapted the Scheme to fit the new methods of delivery at the Universities of Hertfordshire and Portsmouth and could continue to adapt it to fit with new methods of training, including a more flexible work-based assessment, which could be run either in conjunction with the undergraduate programme or at the end of it. 

11. What do you foresee as being any positive or negative impacts on students, education providers, employers, patients and carers from taking a hybrid approach?

This is a complex issue for optometry. Most optometry is delivered in High Street practices, which can be very small and have a limited number of patients. These practices are also primarily businesses. This can make it difficult to find enough practices locally willing to take on students and to be sure that they can see and obtain the appropriate learning experiences during the placements.

Experience of the major disease groups is mainly available in the Hospital Eye Service and we know that the Hospital Eye Departments are already inundated with medical students, ophthalmology trainees, nursing and orthoptic students and pre-registration optometry trainees. Funding is already an issue and this will increase significantly. However, we believe that this experience is important, not just in relation to experience of eye disease, but because it gives students a valuable insight into the issues of working in secondary care and of working as a part of a team with other professionals.

Clinical placements are essential. It is important to ensure that students have appropriate support and guidance during the placement as well as follow up by way of formative
assessment. A negative impact would be if it did not work well and some did not actually get training during a placement or could not find a placement.

From the employer point of view, there is no doubt it would be an added burden on resources, so they would want funding. Supervision would have to be very close, at least initially. Supervisors would also need to understand what to expect from trainees at each placement and how to manage them, for example, a first year undergraduate on a placement would require more support and guidance than a third year undergraduate. It would also be wrong to assume that the same practice would take the same trainee back for placements over the full course of the degree. As undergraduate numbers continue to increase, any multiple placement programme needs to be able to expand to meet demand. As students paying fees, as opposed to trainees receiving a salary, the relationship between student and employer would change, with the student being in a position to demand more.

From an education provider point of view, providers would need significantly more resources to find placements, arrange contracts, ensure vetting and barring procedures were in place, as well as insurance, whistleblowing policies and safeguarding procedures. This would be in addition to planning the content, training the supervisors, providing assessments, putting feedback mechanisms in place for practices and students, and quality assuring the practices. This involves a layer of complexity that does not currently exist for the majority of providers. There will be a huge reputational risk for the providers if this element of the programme is sub-standard.

From a student perspective, our data shows that trainees like to study and practise close to their home and university. Assuming this trend continues, there will be considerable pressure on practices close to the universities to provide placements. Students who are unable to secure a placement near to home or their university will face higher costs in terms of accommodation, travel and cost of living each time they have to undertake a placement.

Patients and carers would have to give permission so would not have to have a student with them if they did not wish it.

Designing, arranging and assessing clinical placements requires significant resources and funding, and planning this will not be feasible without knowing whether these will be forthcoming.

Concept 7: National registration examination

12. Do you agree or disagree with the concept of a national registration examination?

Agree with caveats

13. What are the merits and risks of this concept?

Key points

  • This will ensure a common standard for those entering the register (currently achieved through the Scheme for Registration)
  • It would be essential that the assessment was fair to candidates and demonstrated that they were prepared for practice in a way that was both valid and reliable, as well feasible in terms of costs and resources needed
  • Assessment drives learning so this could stifle innovation
  • Who will pay for the national licensing assessment?

There is no doubt that with an increasing number of schools being encouraged to provide innovative courses, an assessment that stands above them all will ensure a common standard for those entering the register.

It would be essential that the assessment was fair to candidates and demonstrated that they were prepared for practice in a way that was both valid and reliable, as well as feasible in terms of costs and resources needed. The exam must test the knowledge, skills and behaviours needed in practice to be valid. Being reliable means that students would pass or fail whenever or wherever they took it.

There is also the question of cost to consider. Who would pay for it?

As you point out, there is a danger that it would affect what was taught and what was learned at optometry school, thus impeding the very innovation that is hoped for in this review. It is well known that assessment drives learning. As a very high stakes assessment, it would affect how students approached their learning, and universities would not want the national assessment to show that their training was not as good as that of others.

We do not disagree with this concept, and we know that there are national licensing examinations in both optometry and medicine in other jurisdictions. We know, for example, that the US national licensing examination for medicine is very well put together and based on evidence about the best assessment methods. However, it is very resource intensive and costly.

We are also aware that the GMC has just agreed to put in place a medical licensing assessment but has been able to agree only on an applied knowledge test, which puts it on the knows how level of Miller’s triangle. It seems a pity to go from a national assessment at the shows how and does levels, like the Scheme for Registration, to one at the knows how level.

Ensuring that those entering the register have reached an appropriate standard is, however, crucial for patient safety, so in the absence of a comprehensive work-based assessment run by an independent body, we would support this concept.

Concept 8: Multi-disciplinary education

14. How feasible would it be to develop inter-professional and multi-disciplinary elements of study within optometry and dispensing optician education programmes?

Key points

  • It is important that different professionals working together trust and respect each other. Multi-disciplinary education is a way of helping this
  • The purpose has to be very clear and the learning has to reflect the purpose in a demonstrable way.

Professionals have to work together and increasingly lines are becoming blurred between professions. It is important that different professionals, working together, trust and respect each other. Multi-disciplinary education is a way of helping this.

If multi-disciplinary learning is to be put in place, the purpose has to be very clear and the learning has to reflect this in a demonstrable way. Sometimes this can be difficult to achieve at undergraduate level because the institutions do not train the groups of professionals that will be working together in the future - optometrists and doctors and dispensing opticians, for example.

One approach could be shadowing other professionals to find out what life is like from the point of view of the other profession and/or discussions with other professionals that help to demonstrate the effect each profession can have on the other through their actions. This can aid mutual understanding.

15. Tell us about any examples you know of already in other disciplines from within or outside the UK?

Griffith University in Australia has implemented a framework for inter-professional learning in the health professions.

The Universities of Birmingham and Nottingham in the UK are carrying out a project, which looks at incorporating inter-professional education within pre-registration training of health professions.

Concept 9: Duration of education and training programmes

16. What do you see as the strengths and weaknesses of retaining the current minimum duration as described above?

Key points

  • Optometry schools are in a better position to answer this question
  • It would mean an extra year’s tuition fees for students
  • A period of supervised practice is important in relation to patient safety.

Optometry schools are better placed to say whether they would be able to deliver a modernised education system, including significant placements within four years. However, this would mean an extra year’s tuition fees.

Our data shows that the majority of trainees will successfully complete the Scheme for Registration in 18 months, without the added pressure of the academic content of the final year at university. If the programmes are fixed at four years and students must be fit for registration by that time, the element of flexibility for those who need a little longer, which currently exists within the Scheme for Registration, will be lost.

17. What could be done differently in order to ensure students become competent, confident and safe beginners?

We believe that a period of practice under supervision is very important for public safety, particularly if the work becomes more clinical. This is particularly true in optometry as many optometrists work in High Street practices, where they are the only optometrist. Additionally, newly qualified professionals need someone to discuss their work with or to ask for help when they come across something about which they are unsure. A buddy or mentor system would provide this support. However, this would require resources and there may be implications for insurance.

Concept 10: UK educational routes to registration

18. What do you see as the opportunities for more flexibility between the education of different regulated and non-regulated optical professions?

Key points

  • Those with the right aptitude, attitude and interests should be able to move into and between optical roles
  • A good selection system should be put in place, as it should also be for post A level or equivalent entry.

We agree that no unnecessary constraints should be put in the way of this concept. Those with the right aptitude, attitude and interests should be able to move into and between optical roles.

19. What are the constraints and risks to this?

A good selection system should be put in place, as it should also be for post A level or equivalent entry.

There is a risk that students taking this route could have missed important background education that others had in a previous stage of education and training and processes should be in place to mitigate this.

Concept 11: Proportionate quality assurance

20. Are there any other principles and concepts we should consider at this stage in exploring future approaches to our quality assurance processes?

Key points

  • A risk-based approach to quality assurance would seem sensible, together with using evidence about the most appropriate methods of clinical training and assessment as a benchmark
  • As providers will be taking a new approach to course design and delivery, it might be sensible to work with them during the first years of delivery.

A risk-based approach to quality assurance would seem sensible, together with using evidence about the most appropriate methods of clinical training and assessment as a benchmark. However, there are risks inherent in the work of optometrists in the High Street, in that they work independently from the point of registration.

As providers will be taking a new approach to course design and delivery, it might be sensible to work with them during the first years of delivery – visiting to hold supportive discussions rather than inspecting. The GMC took this approach in 1993 when it introduced Tomorrow’s Doctors, which involved new methods of course design and delivery for medical schools.

Equality and Diversity

We must ensure that we recognise the impact of any future proposals from the Education Strategic Review on all our stakeholders.

21. Please tell us about any direct or indirect impact you can foresee from the concepts and principles we have set out in this public consultation on anyone with protected characteristics?

Key points

  • Students may have to pay an extra year’s fees at university, which may be prohibitive for some
  • Students are also likely to incur additional costs if they are required to undertake multiple placements away from their home or university accommodation.

The main risk is that students may have to pay an extra year’s fees at university, which may be prohibitive for some.

Students are also likely to incur additional costs if they are required to undertake multiple placements away from their home or university accommodation.

 

 

 

 

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