The Royal College of Ophthalmologists and The College of Optometrists have collaborated on the Ophthalmic Services guidance: Designing Glaucoma Care Pathways using GLAUC-STRAT-FAST. This is in response to the NICE National Institute for Health and Care Excellence. NG81 Glaucoma: diagnosis and management, updated 26 January 2022.
Ongoing glaucoma care is delivered in a wide range of environments, by several professional groups and with differing levels of training, accreditation, experience, and supervision provided by consultant ophthalmologists. Multiple models of care have evolved across the NHS and it is crucial that the whole multidisciplinary ophthalmic team in primary and secondary care safely contribute to glaucoma care, to increase capacity and reduce the backlogs which put patients at risk of permanent and avoidable sight loss and improve the patient experience.
The ranges of patient care can be met by a variety of services from consultant-led face to face outpatient clinics in hospital utilising a multidisciplinary team to ‘virtual clinics’ with decision making remotely based on diagnostic data to ‘shared-care’ or ‘co-management’ with primary care optometrists.
However, the service is configured to meet patient demand, it must be developed using robust risk stratification. The UKEGS/RCOphth GLAUC-STRAT-FAST tool provides new guidance on how patients with glaucoma-related conditions can be risk stratified based on their lifetime risk of developing visual loss.
This new document guidance provides levels of qualification and supervision that are required for patients with glaucoma in different risk categories described in the UKEGS/RCOphth GLAUC-STRAT-FAST and greater clarity on individual clinical risk and supports integrated service design proportionate to that risk. As such, the guidance provides more context for utilising The Royal College of Ophthalmologists’ Ophthalmic Practitioner Training (OPT) and The College of Optometrists’ Glaucoma qualified practitioners to see the right patient at the right time. It also includes Healthcare Professionals (HCP) qualifications required in virtual and face-to-face service settings.
The principle is that the higher the risk, the more senior the level of clinical professional involvement or supervision should be. Contributing factors should be considered a potential indicator for care at a higher level and specific red flags or the transition of an individual patient to a higher risk level identifies the need for consultant /senior decision maker involvement.
The College of Optometrists offers a series of higher qualifications for optometrists and other HCPs to advance their skills set above those of core competency, with courses and assessments delivered by academic partners prior to the awarding of the qualification by the College of Optometrists. The Higher Certificate and Diploma require the optometrist to undergo extensive further clinical training in a secondary care setting with a specified number of glaucoma patients seen and involve skills development through clinical placements. There are an ascending three-level order of skills development:
- The Professional Certificate in Glaucoma
- The Professional Higher Certificate in Glaucoma
- The Professional Diploma in Glaucoma
The Independent Prescribing (IP) qualification: NICE guidelines NG81 clearly indicate that an IP qualification alone is insufficient for glaucoma practice. However, when combined with the Higher Certificate or Diploma in Glaucoma, the IP qualification enables the autonomous therapeutic management of cases according to the appropriate risk stratification, under the local governance arrangements for NHS funded care.
The Royal College of Ophthalmologists’ Ophthalmic Practitioner Training (OPT) has been designed as training for the non-medical workforce within a secondary care setting in a structured, standardised and transferrable way. The curriculum covers the highest volume areas in ophthalmology: Cataract, Glaucoma, Medical Retina and Emergency Ophthalmology. It is based on the existing framework for ophthalmology trainees and introduces a medical model of training to HCPs working in secondary care. The OPT competency-based curriculum defines a minimum standard of competence, knowledge and skill and the practitioner is assessed on their performance in the workplace through Workplace Based Assessments (WBAs) and other evidence collected and presented in a portfolio. Each subspecialty area above is separated into 3 levels:
- Level 1 – Ophthalmic Clinical Practitioner
- Level 2 – Ophthalmic Specialist Practitioner
- Level 3 – Ophthalmic Advanced Practitioner
The guidance outlines qualifications for independent or autonomous HCP practice in virtual clinics and consultant-led face-to-face clinics.
Patients within GLAUC-STRAT-FAST categories G1 to G3 and A1 to A3 are potentially suitable to be monitored using attendances in which clinical data is captured and later reviewed virtually by a clinical decision-maker. The clinical decision-maker may be an optometrist or ophthalmologist in primary or secondary care, with appropriate qualification. A HCP can work autonomously, making the decisions on all aspects of care, but qualifications must be assessed against the risk of the patients.
Qualifications for HCP in Consultant-led Face to Face Clinics Patients in GLAUC-STRAT-FAST categories R1 to R3 and those showing a red flag should be seen in consultant-led face-to-face clinics where the consultant is present and directly overseeing care. These clinics may be delivered by a range of professionals but their complexity and risk level is such that the physical availability of a consultant to monitor their condition and discuss treatment options is necessary.
The authors would like to thank the members of the UK and Eire Glaucoma Society for their help and input in the drafting of this document.