Optometry education in Scotland and independent prescribing

A Memorandum of Understanding was established in September 2023 between the Scottish Government, NHS Education for Scotland (NES), Glasgow Caledonian University, and the University of the Highlands and Islands regarding the reform to the optometry undergraduate degree.

This agreement will support the universities to adopt new Master’s courses, MOptom (IP), which will be delivered over five years, and will include independent prescribing (IP) in the training, enabling students to register as IP optometrists at the point of registration.

At the end of 2023, a webinar, featuring Scottish Government, Optometry Scotland, the two schools of optometry and NHS Education for Scotland (NES), outlined the proposed changes to optometry education in Scotland.

In the video, Dr Janet Pooley, chief optometric advisor to the Scottish Government, said: “Nearly one third of Scottish optometrists are independent prescribers – well ahead of any other UK nation.”

“The new training will increase community-based optometric care with all optometrists able to prescribe a full range of medication and ensure all primary care optometrists are able to support GPs and pharmacy as part of a multi-disciplinary approach,” she added.

The webinar outlined the planned delivery of the final year of the MOptom (IP) programmes, including IP placements, protected study days for clinical development and consolidation of learning.

NHS Education for Scotland: supporting evolution

Scottish Government commissioned NES to engage with stakeholders across the profession on key proposals, including the incorporation of IP into the master's degree.

“There was a good broad spectrum of opinion but overwhelmingly we saw that people were keen to have IP incorporated within the Master’s programme,” Dr Kathy Morrison, associate director optometry, NES, told OT.

“Our role will be to work in partnership to support the delivery of the MOptom (IP) programme. We will work with the universities to get their programmes approved and help with the delivery of the external clinical placements which students shall undertake as part of modules in Year 5 of the MOptom (IP) programme part of the foundation training year,” she explained.

Dr Lesley Rousselet, associate director optometry for NES, recognised how the background of IP in Scotland, and the scope for utilising the qualification, has supported new opportunities.

She told OT: “In Scotland, we have a significant history of IP, which has allowed time to achieve a number of changes that are supporting more radical evolution for the role.”

“This has enabled practices to consider how community IP can be incorporated into the business model, and a driver for practices supporting their optometrists to gain the qualification.”

Extended qualifications in Scotland – and what comes next?

Looking at the picture across optometry, Rousselet commented: “We have an outstanding level of support from our primary and secondary care colleagues. There is a clear place for optometry at the table with primary care partners in pharmacy and general practice.”

“There has been a great amount of understanding as to the value we bring to the system and how we can support what they are doing. Confidence has built as the relationships have matured over the years.” she added.

Going forward, Rousselet sees a need for a discussion around role development and clarity of the remit provided by the different extended qualifications in optometry.

The systems in place in practices, and how this supports patient safety, are also an area to focus on as the numbers of optometrists with further qualifications grow.

“Everyone in NES optometry is passionate about the teams that our optometrists work in. We rely on our receptionists, optical assistants, dispensing opticians, managers, and directors, to ensure things are safe for our patients, and the practitioners. As we delve into both IP and further extension of the remit around – say glaucoma care – then focusing on reliable systems for managing the appointment book, and returns, and things like that, all become really important.”

She added: “We see excellence around us on a daily basis, but what we probably need to work on is achieving more uniformity.”

Glasgow Caledonian University: developing a new approach

The programme proposed by Glasgow Caledonian University (GCU) has been approved to run by the university, and at the time of writing, documentation has been submitted to the GOC, with the ambition of allowing the course to progress to recruiting students.

Dr Graeme Kennedy, senior lecturer in vision sciences at GCU, who is leading the development of the new MOptom with IP, said of the newly developed course: “We think it is incredibly exciting and will be unique in the UK.”

Speaking of the inclusion of IP specifically, he suggested: “We hope that will give us a unique selling point to recruit students from all backgrounds and regions.”

The course would run over five years as a spiral curriculum focusing on three themes: the structure, function and disease of the eye and visual system, clinical and professional skills, and vision science and research.

The first four years of the programme will be largely campus-based with an increasing volume of clinical teaching, while the fifth year will involve an extended salaried external clinical placement. This will make up the majority of the clinical experience required by the GOC.

It is this final year that is anticipated to integrate IP-specific placement and training opportunities. Kennedy explained that stakeholder engagement is ongoing to discuss what the fifth year of the programme would look like in terms of activity in practice, assessments, and the involvement of employers.

Recalibration

Professor Gunter Loffler, head of department of Vision Sciences at GCU, explained that the whole course has been overhauled, telling OT: “We decided that in order for students to have the required understanding and skills in order to become IP, we needed to tailor it so there is a clear and straightforward progression from getting exposed to anatomy and physiology, to applying it clinically, and to being exposed to patient groups and taking on management decisions.”

“Our intention is to have IP [as part of the course] but we will need to change wholesale in order to make this possible,” he added. “To roll that out for all undergraduates, rather than those who select to take that on after graduation as is currently the case, requires a recalibration of the general understanding of what the role of an optometrist is.”

This is supported by extending the course to five years, a requirement of Master’s level programmes in Scotland.

Kennedy commented: “I think what we hope to do is foster the sense that one of the primary functions of optometry is to manage eye disease and to do that in a way that is accessible and convenient for patients, so rather than having to be referred to a hospital eye clinic and potentially wait for a long time for those appointments in inconvenient locations, optometry will be – as it has for a number of years now – promoted as the first port of call for any eye condition.”

“We hope to foster that sense in our students during their educational journey and hopefully that will inspire the profession across the UK to think in that way and look at ways of making that uniformly the case across the UK,” he continued.

Concerns: levels of experience versus complexity of conditions

The academics recognised the concerns that some may have around the level of experience that newly-qualified optometrists with IP qualifications would be leaving university with.

Loffler explained: “These graduates will not be expected to independently manage complex and complicated conditions on day one. They are expected to manage independently conditions for which they feel confident at that point, and other conditions they will take on as their experience builds.”

He noted that recent graduates of medical degrees would not be expected to immediately prescribe in specialities that they had no background in, adding: “They are ready to prescribe but they wouldn’t go outside of their zone of experience and understanding.”

Scottish Government, through NES, has also committed to a postgraduate support system as graduates enter their careers.

“The prescribing understanding is built in, but the way in which graduates build a portfolio of conditions for which to prescribe is individual and needs to be supported by a robust post-graduate support framework,” Loffler shared.

This change requires a shift in ethos, he suggested, explaining that an understanding of personal limits of competence and experience needs to be embedded in the learning.

“We need to be absolutely clear that those graduates have that understanding, and with the support we have available, we are confident that can be built in,” Loffler said. He added: “but it is clearly important to get this right.”

Concerns: the cost of training

One of the challenges the academics have identified is that of fees. As optometry courses are redeveloped into Master’s degrees, entry into the profession could become more expensive for budding optometrists.

Loffler said: “If the new education is more expensive for the student than it used to be – and we don’t know exactly what that will be, as a profession we need to be very careful that the new education programmes don’t have a detrimental effect on people from disadvantaged backgrounds choosing a career in optometry.”

Fees for Scottish domiciled students are paid by the Scottish Funding Council.

Loffler added: “We are hopeful we can maintain the positive trajectory we have been on to support widening access.”

Training the future optometrists

Kennedy expressed his hope of seeing more practitioners engaged in the training of future optometrists.

Comparing optometry to other NHS medical and allied health professions, where it is common to have a student on placement, he said: “What we hope to do is to get people thinking more about the education of the next generation as fundamentally part of the role of optometrists who are working in practice. Particularly if they are delivering NHS services. That this will become part of the core role of optometrists to have trainees, and use their knowledge and skills to educate the next generation.”

“I expect there will be some challenges along the way, but we are excited about the work we’ll need to do,” he said.

All being well, the university hopes to roll out the programme from September 2024.

Kennedy shared: “Then it will be a case of continuing to work with stakeholders to keep people informed about what it is we are doing. Although the programme is planned to begin in September of this year, the long placement period won’t take place for another four years – students will not be going into that placement until 2028.”

“We have made a lot of decisions about what that final year might look like, but it is almost five years away. The landscape may change in that period of time, and we need to have flexibility to be able to deliver what is required by the sector at that point,” he added.

Optometry Scotland: supporting the voice of practices

Eilidh Thomson, optometrist and vice chair of Optometry Scotland, explained that the Scottish Government saw the GOC’s mandate to change undergraduate programmes: “As a way to start from scratch and look at what we would want if we had a blank slate to start again.”

“Incorporating IP into the MOptom degrees is such an ambitious step. It still requires a lot of work to make it a reality,” Thomson said. “Optometry Scotland is committed to supporting and ensuring that members are engaged and prepared for the changes. Our biggest role in the process is to make sure that our members know what is coming and that they are happy with their place in the new scheme.”

Reflecting on the move to incorporate IP into the degree, Thomson shared that this has been an ambition that has been in the pipeline for many years, but the updated education and training requirements provided an opportunity to consider how it could be achieved.

At present, stakeholders are engaging in “regular, open and honest dialogue amongst the whole sector,” Thomson said.

Thomson also emphasised the level of enthusiasm she has seen amongst student and newly-qualified optometrists, eager to undertake further qualifications.

She told OT: “In my role in practice, I am frequently engaging with younger optometrists. If you ask about their future aspirations, you would be hard-pressed to find someone who doesn’t mention IP: if they are not already undertaking the training for it, they are talking about it being on their agenda. I do think within the younger generation of optometrists, there is a huge demand for IP.”

Listening to concerns

Acknowledging there may be apprehension around some of the potential changes, Thomson said: “We fully understand, and we want to be the go-between, listening to our members’ concerns and reporting them back, then working together to find solutions.

“We are keen that, in doing so, Scotland is going to be able to provide a unique student experience and prepare graduates for their onward career in optometry in a different way than we have been able to do before,” she added.

Thomson echoed reassurance OT heard from Loffler around the level of experience graduates with IP will be expected to have.

“I don’t think there is any expectation that a brand-new IP optometrist, whether through the new MOptom or the traditional IP qualification, would be prescribing for a complex condition on day one,” she said. Thomson added: “You must work within your level of competence and that does increase with time, exposure, and experience, and that will remain the case once IP optometry graduates enter the workforce.”

Easing referral processes

With the potential for more IP optometrists to enter the workforce in future years, will this bring about a shift in referral processes or patient pathways?

Thomson highlighted potential changes already in the wings for referrals, sharing: “The biggest thing we’re hopeful to be able to do as soon as possible, is launch the long-awaited specialist supplementary scheme. That is going to allow intra-referral from a non-IP optometrist to an IP optometrist within the community.”

“That’s likely to be the single biggest change in how IP skills are currently being used, and it’s going to make the process so much more efficient for patients,” Thomson added.

Work on this has been ongoing in the background, but funding is a hurdle still to be overcome before the service will gain a launch date.

“We’re ever-hopeful, and always in regular discussion with the Scottish Government about when this is going to be feasible,” she said.

Having a seat at the table

Discussing the future role of IP in optometry and wider primary care, Thomson shared: “As IP uptake in the community is going to increase, there is going to be a natural shift in that balance of care more than there is already from secondary care to primary care.”

“As that continues to happen, optometry needs to have a seat at the table discussing where we can support our counterpoints in other sectors. But also, we must ensure that we have adequate funding and resources so that our workforce is able to deliver that service,” Thomson said. “That is Optometry Scotland’s biggest area of concern and is the thing we are always engaging with Scottish Government and ministers about.”

Optometrists in Scotland have been the first port of call for eye problems for some time and public awareness is growing.

Thomson said: “Having IP optometrists in the community will only help with that because it’s going to streamline the process for patients when they attend the optometrist. There will be a higher percentage likelihood that the person there is going to be IP and able to deal with the problem there. That can only be a good thing for the public.”

OT approached the University of Highlands and Islands for comment.

Look back on OT’s special report series on the IP workforce here.

OT was sad to learn of the death of Dr Graeme Kennedy after the publication of this story.