Optometric Prescribing
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Independent Prescribing by Optometrists
The History of Optometric
Prescribing
Optometrists have been able to supply and administer a range of ophthalmic medications in the course of their practice for many years by means of specific exemptions from the Medicines Act 1968. Drugs are supplied by means of a "written order" (effectively a private prescription) signed by a registered optometrist.
The Crown Report (1998) recommended that the ability to prescribe medicines should be extended to optometrists and the recommendations of the report were largely accepted by the Government.
In 2005, secondary legislation was enacted which introduced two categories of prescribing for optometrists, known as Additional Supply (AS) and Supplementary Prescribing (SP). To attain the AS or SP qualifications, optometrists must undergo a period of additional training which includes didactic instruction, a clinical placement and a final assessment. The intention was that this should be a step towards Independent Prescribing (IP) for optometrists.
The list of ophthalmic medications which were covered by exemptions from the Medicines Act 1968 had become considerably out of date. This was updated, and a number of additional medications were added to the list which may be prescribed by optometrists with the AS qualification, though still on a written order. The AS list broadly includes mydriatics, miotics, local anaesthetics, some topical antibiotics, lubricants, mast cell stabilisers and one non-steroidal anti-inflammatory.
Optometrists who attain the SP qualification may prescribe any ophthalmic medication, but only where the management plan has been agreed with the patient and with a principal prescriber who must be medically or dentally qualified.
The numbers of optometrists taking the AS and SP qualifications to date has been small.
Progress towards independent prescribing (IP) for optometrists
In 2006, proposals to allow optometrists to prescribe independently were put out to public consultation. The Royal College of Ophthalmologists, the British Medical Association, the optometric professional bodies and many other organisations were invited to comment.
Five options were put forward for discussion:
Option 1: No change
Option 2: Prescribing from a
limited list for a limited range of eye conditions
Option 3: Prescribing from a
limited list for any eye condition
Option 4: Prescribing any
ophthalmic medication for a limited range of conditions
Option 5: Prescribing any
ophthalmic medication for any eye condition
Both this College and the BMA recommended Option 2. The RCOphth submission specifically recommended that glaucoma medications, topical steroids and antivirals should be excluded from the list of medications prescribed by optometrists, pointing out that the few optometrists likely to achieve and maintain competence in managing conditions where these drugs would be prescribed were likely to be covered by the provisions of Supplementary Prescribing or Patient Group Directives.
After collation of responses to the consultation by the Department of Health, the responsibility of making a recommendation to Ministers from the available options was given to the Commission on Human Medicines (CHM).
One of the members of the CHM, Professor Martin Kendall, Professor of Clinical Pharmacology at Birmingham University, met with key stakeholders including the RCOphth to clarify the points put forward in the submissions to the public consultation. He then summarised his conclusions at a full session of the CHM in June 2007 at which the RCOphth was represented.
The CHM's recommendations to Ministers were made public on 28 August 2007. Briefly, the CHM rejected options 2,3 and 4 on the grounds that any list of medications or eye conditions rapidly becomes out of date and, in this case additional legislation would be required every time an update was required, which was judged to be impractical. Instead, the CHM recommended a modified version of Option 5, which stipulated that optometrists must only prescribe within their sphere of competence. It was further recommended that the scope of independent prescribing by optometrists should be informed by management guidelines supervised by the College of Optometrists.
The College of Optometrists has, over a number of years commissioned and maintained about 60 condition-specific guidance documents which describe the condition, outline the principles of management and recommend a plan of action for the optometrist ranging from "manage to resolution" through to "refer immediately to an ophthalmologist". A number of ophthalmologists have contributed to these guidance documents in an advisory capacity but the copyright and responsibility for content remain with the College of Optometrists.
What are the next steps?
If ministers accept the recommendations of the CHM, secondary legislation to enable IP for optometrists is likely to come before Parliament in Spring 2008. Previous proposals to extend prescribing responsibilities to professional groups other than doctors or dentists have generally had cross party support and it is likely that this will be the case here.
Responsibility for accrediting training courses for IP for optometrists will rest with the General Optical Council (GOC). Optometrists who pass the final assessment will receive an endorsement on their GOC registration to denote the additional qualification.
If the legislative timetable proceeds as anticipated, it is likely that the first cohort of optometrists with the IP qualification will appear in 2009.
What will be the likely impact of independent prescribing by optometrists, and is there any cause for concern for ophthalmologists?
At this stage, it is difficult to estimate the number of optometrists who will obtain the IP qualification. The training will be expensive (both in terms of course fees and lost income) and in most cases will probably have to be self-funded. A recent survey has suggested that worries about litigation or complaints over prescribing decisions may be a deterrent for many optometrists. It is likely therefore that IP will attract only a minority of optometrists.
A number of ophthalmologists have expressed concerns that the introduction of IP for optometrists will lead to an upsurge in irresponsible or unsafe prescribing. Although this College's recommendation that steroids, glaucoma medications and antivirals should be excluded from the scope of IP for optometrists was not accepted, the College believes that the proposed legislation contains two important safeguards which reduce the likelihood of unsafe prescribing.
Firstly, there is an overriding principle that optometrists must not prescribe outside their areas of competence. Competence implies appropriate training in diagnosis and treatment and regular, evidence based practice in the area in question. Secondly, there is an overriding principle that prescribers must take personal responsibility for their prescribing decisions. In essence, the same standard of care will apply to an optometrist who diagnoses and treats an eye condition as a doctor who diagnoses and treats the same condition in similar circumstances.
There are already a number of shared care and referral-refinement schemes in the UK involving optometrists and ophthalmologists. Many optometrists employed in hospital eye departments take on a range of clinical responsibilities beyond their traditional roles. Many optometrists in these situations are already acquiring and maintaining the clinical skills necessary to prescribe a range of ophthalmic medications safely. There may be considerable benefit in optometrists who practise in remote rural areas acquiring prescribing responsibilities where there is a strong working relationship with the nearest hospital eye department.
Ophthalmologists have also expressed concerns that IP for optometrists could lead to an increase in wasteful or ineffective prescribing. However, the prescribing habits of optometrists who issue NHS prescriptions will be recorded as part of Prescribing Analyses and Cost (PACT) data which is available to PCTs and Health Authorities. The Royal College of Ophthalmologists has already discussed with the optometric professional bodies some potential situations where prescribing decisions by community optometrists might be unhelpful. For instance, the College believes it would be unhelpful for an optometrist to start patients with suspected glaucoma on a prostaglandin analogue as a preamble to referral to an ophthalmologist unless there was a clear and immediate threat to vision. However, the College believes that issues of this type can be resolved by the development of practice guidelines.
Clinical placements for optometrists taking an Independent Prescribing Qualification
As part of courses of study towards a qualification in IP, optometrists will be required to undertake a clinical placement. This will be similar to clinical placements which already form part of courses for the Supplementary Prescribing and Additional Supply qualifications. The College has already issued advice to ophthalmologists who may receive requests for clinical placements http://www.rcophth.ac.uk/standards/supplementary-prescribing.
It is important to emphasise that ophthalmologists who supervise such placements are not expected to sign off optometrists as competent to prescribe. The question of whether or not the optometrist receives the qualification will be determined by a final assessment which is administered by the institution running the course and quality-assured by the General Optical Council.
Richard Smith
October 2007
Supplementary Prescribing by Optometrists
Clinical Placements for Optometrists undertaking
training to become Supplementary Prescribers or Additional Supply Optometrists
Optometrists have been permitted to
prescribe a limited range of ophthalmic therapeutic agents for many years
through exemptions from the Medicines Act 1968.
The Crown Review of 1999 recommended that the ability of optometrists to
prescribe should be extended, and this recommendation was accepted by the
government. Two new frameworks for prescribing known as "Additional Supply" and
"Supplementary Prescribing" entered the statute book in Summer 2005 and these
terms are defined in the appendix.
The General Optical Council (GOC) is
entrusted with responsibilities for accrediting courses of training and
maintaining registers of optometrists who have completed training for
Supplementary Prescribing and Additional Supply prescribing. A number of academic institutions are
providing courses of study for optometrists who wish to undertake post-registration
training to join either register.
Courses must conform to the GOC's Competency Framework for Therapeutic
Prescribing.
In addition to attending the theoretical part of the course and passing a viva assessment conducted by a panel which includes an ophthalmologist and an optometrist, aspiring prescribers must also undertake a clinical placement of 10 half days (Additional Supply) or 24 half days (Supplementary Prescribing) before the additional qualification can be registered with the General Optical Council.
Consultant ophthalmologists may be asked, either by individual optometrists or by the organiser of the course in which they are enrolled, to supervise a clinical placement, and may be offered a fee for so doing.
Registered optometrists have a personal responsibility under the Opticians Act 1989 (amended 2005) to make sure that they are adequately and appropriately covered by insurance throughout the period during which they are training and when they are on the specialist register.
When coming to a decision to accept or decline a request for such a clinical placement, a consultant and his / her employing trust will need to take into account a number of considerations:
- His / her existing training commitments. Most consultant ophthalmologists have responsibility for one or more trainee ophthalmologists. Many also have training commitments to medical students, pre-registration optometrists and others. It is important that their training is not compromised.
- The impact on the clinical service. Even a passive observer has an impact on the throughput of a clinic because of the need of the supervisor to explain what he / she is doing and demonstrate clinical signs. If the training is taking place during regular clinical sessions, the consultant's employer may expect to be reimbursed for the "lost" service commitment.
- The relevance of the case-mix of his / her outpatient clinics to the circumstances under which the aspiring prescribing optometrist may be practising in the future.
- The improved communication and co-operation especially with regard to referral criteria.
- The potential future gains from having appropriately trained optometrists either accessible in the community or as a resource within the specific trust in the future.
If requests for clinical placements are likely to occur on a regular basis, eye departments may consider creating a dedicated training clinic where one ophthalmologist supervises more than one optometrist simultaneously and recruits suitable patients. Such an arrangement may be formalised by establishing a training contract (Service Level Agreement) between the trust and the educational establishment offering the training course, so that the costs of training are made explicit. Moorfields Eye Hospital is an example of a unit which has followed this path.
The ophthalmic "casualty" queue or urgent referral clinic or ophthalmic primary care clinic are likely to be fruitful sources of suitable patients who will often be more than happy to be diverted into a consultant-led teaching clinic. Supplementary prescribing is likely to find particular application in glaucoma co-management schemes and it will therefore be desirable for aspiring supplementary prescribers to attend some glaucoma clinics. If it is possible to create dedicated training clinics for this purpose, it may also be possible to arrange for patients to return to the same clinic for review so that the optometrist may be able to see at first hand the outcome of therapeutic decisions. It is not anticipated that much if any of the training will be in the use of clinical techniques for ocular examination.
Within the time constraints of the clinical placement, the optometrist will necessarily see a limited range of eye conditions, so the primary focus of the clinical placement should be for the optometrist to gain an understanding of the principles of clinical decision making which underpin decisions to prescribe (or not to prescribe) ocular therapeutic agents. The optometrist is required to maintain a training portfolio which includes a log of all patients seen. The supervising ophthalmologist will be required to verify that the optometrist has participated in the clinical placement satisfactorily, but does not carry the responsibility of determining whether the optometrist meets the standard required by the GOC.
Appendix:
Additional supply optometrists (originally called Level 2 Exemption)
All optometrists are
able to use diagnostic
drugs such as mydriatics and local anaesthetics, or issue written orders for
pharmacists to supply certain ocular medicines to patients. Additional supply optometrists are able to
use and supply (in certain circumstances) an additional range of drugs, and to
write written orders for some additional drugs to be supplied to the patient by
a pharmacist To be an additional supply
optometrist, the optometrist must have demonstrated their competency. A list of additional supply optometrists will
be maintained by the GOC.
Supplementary Prescribing
Optometrists
who wish to be supplementary prescribers must also reach the appropriate level
of competency as laid down by the GOC, who will maintain a specialist list of
supplementary prescribers.
Further Information
The GOC's Competency Framework for
Therapeutic Prescribing is available at:
www.optical.org/index_files/education/therapeutics.doc).
Guidance for doctors who train or
mentor non-medical prescribers is available from the National Prescribing
Centre's website:
(www.npc.co.uk/pdf/designated_medical_practitioners_guide.pdf)
here