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CAMHS won't see you now

Local optician has his eye on my job

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One of the biggest threats to UK general practice is the high street optician. (Hear me out).

Rarely do I sift through my daily paperwork without stumbling upon a letter from the local SpecSavers asking for an onward referral. The dilemma then comes: do I refer immediately (easy, job done), or do I take more time and effort (difficult, the paperwork is mounting), contact the patient, discuss whether they actually want to be referred and, with cataracts, do they actually qualify?

Like many localities, we have to complete a prior approval pro-forma for cataracts. It’s an irksome little document.

‘Question 1: Is the acuity equal to or better than 6/12 in the affected eye?’

Then, a tricky collection of qualifying questions follows. 

The process feels like skiing a slalom: miss one gate and your patient’s stuffed; their eyesight consigned to 6/11 at best (in the affected eye) for the next 12 months.

So, by the time you’ve tracked down the patient, discussed their optic oddity, gained their consent to refer, negotiated a prior approval request that will suffice and dictated a referral, that’s a good six minutes of invaluable GP time down the tube. Would it not make more sense for the optometrist (clinician who measures vision) or optician (technician who fits spectacles) to go through this fraught process themselves?

This issue’s been a GP bugbear for aeons, but I’m still new(ish) to this game and I’ve seen some worrying developments in the offing. 

Last week, a local optometrist wrote the following in their report: ‘Patient appears lost to ophthalmology follow-up, suggest you investigate and rectify. Patient will contact you next week and expects an update’ without so much as a ‘please’. 

I wrote back: ‘Suggest patient could be encouraged to investigate this for themselves, or perhaps optometrist could chase? Will update patient suggesting this if contacted.’

And just yesterday, one I contemplated framing for the coffee room: ‘Vision normal, routine review 12 months. Of note, she has a lesion on the right cheek. Please refer to dermatology as I think this may be a BCC.’ Much more polite this time, and even features a please, but shouldn’t I probably have a quick look at the ‘BCC’ first?  

It looks like we’ve become superfluous, glorified referral machines with needless clinical acumen.  Next time I get my eyes tested, I intend to discuss an ingrowing toenail, a mild seborrhoeic dermatitis and the pros and cons of vasectomy.

Dr Tom Gillham is a GP in Hertfordshire and specialty doctor in A&E. You can follow him @tjgillham.

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Readers' comments (3)

  • Let common sense prevail

    Ask your local commissioners to investigate the development of a PEARS scheme in your locality. This will shift the responsibilities for managing a wide range of eye conditions to participating optometrists, will resource them appropriately for providing that service, and will deal with issues of quality control etc. There are further advantages of reducing GP workload and reducing secondary care (and A/E) spend on ophthalmology.
    There are plenty of good examples running in various locations around the country.

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  • Tom, although some of the comments you have made may be slightly tongue in cheek, you raise some important points. Instead of thinking of optometrists as being after the jobs of GP colleagues, I would suggest that they are a profession in primary care ready, willing and able to support GP colleagues to provide more (eye) care for patients in the community.
    In answer to your first question, I agree wholeheartedly that it would make more sense for optometrists to be more involved in the cataract pathway you have described, as they have skills and equipment to do so, as well as an understanding of the patient's needs. However, as David has pointed out, the CCG needs to commission them to do so if they are currently only commissioned to provide NHS sight tests in your area. In addition to the PEARS scheme David has mentioned, the LOC Central Support Unit (LOCSU) has developed a national pathway template that allows pre and post operative cataract assessments to be done by community optometrists, integrated with secondary care.
    To put your second point into some context we should consider that under the General Ophthalmic Services contract (NHS sight testing contract), optometrists are essentially required to refer if any signs of abnormality are detected. Therefore optometrists do have a duty to let you know of anything that they observe that they feel warrants further investigation. It seems any acknowledgement from the refer that you may wish to do some initial assessment yourself was missing in the case in question; improved communication and regular dialogue between primary care professionals so that they can better understand each other’s roles is the way forward in my view.
    I should declare a conflict of interest as Managing Director of LOCSU and a qualified optometrist.

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  • Unfortunately because of the Honey Rose case many Optometrists will be refusing to manage ambiguous cases especially children. Have a look at Guilty thread to get a feeling of the professions reactions to this. Where previously a patient might be brought back in 3/12 to review their symptoms, and monitored to avoid unnecessary referral they now will be referred straight away. The value of an eye examination? Priceless surely? No £21.31p is what's paid. Perhaps choosing to write about Optometrists is a tad insensitive just now..
    Yes I am an Optometrist

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