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June 17 2010
Optometrist Peter Frampton (pictured) shares his views on independent prescribing.
As a community-based independent prescribing optometrist I feel compelled to argue the case for more optometrists to pursue advanced training.
Previously I suggested that Independent Prescribing is potentially our profession’s greatest opportunity since we were allowed to use diagnostic drugs (Frampton 2009). Further, I proposed that if we do not capitalise on this opportunity we will be failing future optometrists.
Shared care schemes all require quality assurance; since the need for interested practitioners to be accredited is explicit, why do I feel part of a seriously beleaguered minority who seem to be at odds with mainstream optometry?
A well-accepted argument against pursuing prescriber status is purely financial. A common lament is why put ourselves through a tough, time-consuming and expensive process that will not be rewarded. At first consideration this is a strong argument; but I hope in most cases, it is actually grossly incorrect. Simply because some PCTs do not, as yet, remunerate us for these services, does not mean there are no other active funding avenues. It would beggar belief if, years after deregulation, any serious contact lens practitioner is not charging private professional fees. These fees would include, one assumes, dealing efficiently with acute presentations. Access to Additional Supply drugs, and now a wider range of medications, means that paying patients can be dealt with more promptly and efficiently. I have increased my fees accordingly.
For other acute presentations, and for non-professional fee paying contact lens wearers, I simply charge privately. Not everyone chooses to pay the fees, and they are welcome to proceed to eye casualty, however when a patient is seen in the practice they do pay for the service.
For contact lens practitioners I would suggest there is also an ethical reason for pursuing prescribing status that transcends any financial considerations. As contact lens practitioners we prescribe medical devices known to be a primary cause of infective and inflammatory processes (Murillo-Lopez 2006, Onfrey et al 1995) and yet, until recently we were not allowed the tools to resolve those rare but inevitable episodes. As little as five years ago this argument would not have registered with any of us, but, regardless of how contact lens practice evolved, think how counter-intuitive this could appear to outside observers; imagine a refractive surgeon ablating an eye but not able to prescribe a steroid if post-operative inflammation occurred. Many optometrists in other countries still can’t dilate or cycloplege, that is normal for them, but if we did not use those skills we would be considered negligent. Future optometrists may be considered equally negligent if they do not possess prescriber rights.
There also appears to be a genuine fear of prescribing drugs. This is totally understandable; we have evolved from pure screeners, reporting abnormalities without any diagnostic interpretation. Further, optometrists often work in complete isolation and the increased responsibility of committing to a management plan unsupported is certainly a daunting one.
My argument is this; as a profession we must not fear prescribing. The barrier our profession faces, unfortunately, comes much earlier in the management process and is at the point of diagnosis. If a clinician is confident of the diagnosis, prescribing a drug should not cause any concern; this is virtually a recipe book procedure. However, if we do not become confident diagnosticians then our potential value to any shared care scheme must be compromised. GPs want to be told what to do, PCTs need to save money and still supply patients an equal or better service; to be of real value we must be able to advise them appropriately and this requires a diagnosis to be made. Many optometrists, regardless of IP status, have been prescribing a wide range of systemic and topical medications via their GPs for years; AS and IP qualifications allow us to expedite the treatment process.
The critical inter-relationship between diagnosis and treatment should be self-evident, but this does not appear to be universally accepted. Even the Clinical Management Guidelines (CMG) prepared for independent prescribing optometrists, but extremely useful for all optometrists (College of Optometrists 2009), do not assume diagnostic competency. For a new presentation of simplex keratitis, for instance, the CMG recommends no treatment should be instigated by the optometrist ‘because this could make confirmation of the diagnosis by the ophthalmologist more difficult’. As a community optometrist, how have I aided the patient, GP or PCT, if I can only prescribe an anti-viral after I have sent the patient to the hospital for diagnosis?
The challenge for community optometrists, who must work in isolation, is to build into their daily routines clinical and audit procedures that improve and hone diagnostic confidence.
Within my practice a diagnosis and clinical management plan is quickly prepared for every acute presentation. Especially when referring to the HES, I ensure the patient is fully aware of the most likely management; the patient is left in no doubt that, were it not for legal constraints, the problem could be dealt with at the community level. It is essential that the practice also has an outcome audit system where every patient is followed up, not referred and forgotten, allowing us to learn from every misdiagnosis and to re-enforce our confidence when proved correct. We are not paid for this, I know, but the educational gains far exceed those in any CET workshop.
Addie, Darroch and Henderson (2009), discussing the Scottish system, identify several challenges facing clinical optometry. Optometrists, the authors suggest, are not generally considered access points for primary eye care; there needs to be more encouragement for patients with acute ocular conditions to consider this option. A serious caveat is that optometrists must have sufficient experience of eye disease to be able to deliver treatment confidently; currently there is a tendency for false-positive referrals to the HES.
These are significant observations, since in Scotland the financial infra-structure to manage many acute and chronic ocular conditions is in place. However, data collected from the GOS forms suggests that the uptake is low. The authors propose that many patients may simply be unaware that optometrists can manage these conditions, and GPs refer to optometrists approximately 50% less than other care professionals. These are educational issues and while the commencement of shared care schemes will enhance our clinical profiles we must not wait for these to be organized before incorporating acute eye management into our routines.
Of course, to practise our skills we need patients; another barrier is often as simple as not having enough acute presentations. It takes time to build reputations that will ensure our profession is considered the access point for acute eye management. A good source, initially, is our own contact lens patients. So we have come full circle, by ensuring we deal professionally, promptly and efficiently with our contact lens patients, without recourse to secondary care, the process will start. Educating patients, sending competent reports to GPs, and ensuring no patient is turned away, will quickly increase the flow of acute presentations through your practice.
I urge people to consider pursuing any prescriber status; we need a critical mass for this to truly impact on the future of optometry. Ignore the negativity of conventional wisdoms: we are not paid enough, there isn’t enough time, we don’t see the patients, there is no need, prescribing is frightening. When Galbraith coined the term ‘conventional wisdom’ he was not being complimentary. He believed ‘conventional wisdom’ flourishes because – ‘We associate truth with convenience and with what most closely accords with self-interest and personal well-being or promises best to avoid awkward effort or unwelcome dislocation of life’ (Levitt and Dubner 2006). Let’s not do that.
About the Author
Peter Frampton studied optometry in Brisbane before moving to Britain in 1986. He attained a Masters Degree in Ocular Therapeutics from Bradford University and has Additional Supply, Supplementary Prescribing and Independent Prescribing qualifications.