The optometrist will see you… in 48 hours

As the ageing population of the UK continues to grow, so too does the number of people who may require access to eye care remotely, either in their own home or in a care home. This can be evidenced by the increase in reported domiciliary eye tests, which has risen by more than 80,000 over the last nine years – 379,867 domiciliary eye tests were recorded in 2010–11, compared to the most recently available 2019–20 data, which recorded 462,250. Annually, when compared to all General Ophthalmic Services (GOS) sight tests performed, in 2019–20 domiciliary tests accounted for 3.5%, up from 3.18% in 2010–11.
 
Despite the UK’s ageing population, and data suggesting that domiciliary sight tests will continue to rise, up until recently it was necessary for domiciliary eye care providers across all of the UK’s four nations to provide pre-visit notification (PVN) before they were able to see a patient. These requirements meant that housebound patients could be required to wait between 48 hours and one month for their eye care. 
 
Initially introduced nearly two decades ago, optometrists practising across different nations expressed to OT they believe the requirements were introduced to tackle over-testing, during a period where patients were receiving sight tests when they were not eligible, given the timing of their last eye examination.  
 
By providing the required organisations with PVN, it is understood they can check a patient’s eligibility, as well as perform an onsite “surprise” visit on the optometrist if they wish to. 
 
Over the past two decades domiciliary optometrists have navigated slight variations in PVN requirements across the four nations as a result of different bodies governing the verification process. In some nations, tweaks have been made to better accommodate the eye care needs of the patient. However, when OT spoke to domiciliary optometrists practising across different nations, a common thread was clear: the requirements are (and were) ‘pointless,’ ‘unnecessary,’ ‘restrictive’ and ‘discriminatory.’ 
 
“I have spent much of my career fighting this,” domiciliary optometrist, AOP Councillor and co-chair of the Domiciliary Eyecare Committee (DEC), Paul Chapman-Hatchett, told OT. 
 
Nineteen years on, domiciliary optometrists in two of the UK’s four nations are still bound by these requirements. 

The whole system is completely pointless and serves no purpose, and definitely does not benefit the patient… What we are observing is our most vulnerable patients being penalised for being housebound

This is England

Despite requirements falling away formally in Wales and Scotland, in October 2023 and April this year respectively, the requirement for PVN is still in place, and most restrictive said Chapman-Hatchett, in England. 
 
Chapman-Hatchett has spent the majority of his career practising as a domiciliary optometrist in England, during which he owned his own domiciliary eye care company, Care Opticians, for 27 years. 
 
Since PVN’s introduction in England in 2005 (with amends in 2008 requiring the individual to be identified), he has been bound by the requirements, which sees contractors provide Primary Care Support England (PCSE) with a minimum of 48 hours notice (and eight weeks maximum) before performing a sight test on one or two patients at the same address, and a minimum of three weeks notice (and eight weeks maximum) before performing a sight test on more than two people at the same address. 
 
When submitting PVN, contractors in England must provide the patient’s name, address, the approximate time of the appointment, and, if they have it, the date of their last eye exam, chair of the Optical Fees Negotiating Committee (OFNC), Paul Carroll, explained to OT. 
 
They do not receive formal approval after submission; instead, “if they do not hear to the contrary, they can assume it is acceptable for them to make the visit,” Carroll shared. 
 
With a spot check visit being one of two reasons identified by optometrists as to why PVN was introduced, the OFNC informed OT that, in England, it has not been able to identify an optometric adviser who has ever conducted such a check. “Anecdotally, including feedback from optometric advisers themselves, we are not aware of any contractors who have ever experienced such a spot check across almost two decades,” Carroll said.  
 
The OFNC believes that PVN is unnecessary and has been negotiating with NHS England regarding its removal in England for a number of years now. 
 
Carroll highlighted: “In our view this is an unnecessary, bureaucratic process which is discriminatory and adds no value.” 
 
He explained: “The simple fact is that an able-bodied person could go to the High Street and have a sight test today if they have a relevant eye or vision problem. The same service has to be delayed by at least 48 hours if the person cannot leave home unaided because of illness or disability. Although it clearly contravenes the Equalities Act, even that does not appear to be sufficient reason to change the requirement for PVNs.”
 
Chapman-Hatchett agreed, asserting: “The whole system is completely pointless and serves no purpose, and definitely does not benefit the patient.”
 
He added: “What we are observing is our most vulnerable patients being penalised for being housebound. It is discriminatory to the patient and, as an optometrist wanting to provide eye care, it is devastating.” 
 
“It should be removed altogether,” optometrist and Specsavers domiciliary clinical director, Dawn Roberts, told OT, highlighting the administrative burden it also places on providers and the NHS. 
 
An important barrier of concern for PVN in England is that it does not allow contractors to see someone urgently, shared Carroll. 
 
From a patient perspective, “a delay of 48 hours, or if you happen to live in a care home and there are two other individuals who also need to be seen quickly, a delay of three weeks, can result in a sight threatening condition going undetected and untreated,” Carroll highlighted.  
 
Roberts find this particularly frustrating. “Domiciliary optometrists play a key part in local health systems with the expertise and experience to support the NHS. However, it is frustrating because it is not possible to see patients who need care urgently,” she said. 
 
Chapman-Hatchett pointed out that while optometrists must provide PVN before seeing a patient with, for example, sudden change in vision in a care home, there is no such requirement for GPs. 
 
“The message it sends to care home managers is that if you can present on the High Street you can get your sight tested immediately because that is a very trustworthy person, but if you need an optometrist to test the vulnerable person that you are caring for, you have to give 48 hours notice as we are not as trustworthy,” he said. 
 
It is also confusing for the patient. “Patients doesn’t understand why they have to wait. I would explain that it is legislation, but when questioned as to why, I have never been able to explain it,” Chapman-Hatchett said. “As an optometrist, it is devastating when it is not in the patient’s best interest,” he added. 

Anecdotally, including feedback from optometric advisers themselves, we are not aware of any contractors who have ever experienced such spot check across almost two decades

It is not only the patient being penalised by PVN, explained the OFNC. From the practitioner’s perspective, “they are prevented from maintaining efficiency,” Carroll stated. He explained that if appointments are cancelled, practitioners cannot readily allocate their time to another patient, which would support financial business viability, as well as waiting lists. 
 
Chapman-Hatchett also questions the cost that has been and continues to be incurred in providing the monitoring service, noting that he has never been subject to a spot check visit for NHS England during his career.
 
When it was first established, the optometrist recalls writing and faxing patient records for between 40 to 50 patients a day, which he explained would be manually cross-checked at the end of the month against his PVNs. “The cost to NHS England must have been huge,” he said.  

Although it clearly contravenes the Equalities Act, even that does not appear to be sufficient reason to change the requirement for PVNs

With restrictions still in place in England, the OFNC continues to express to NHS England its position that “the requirement for PVNs should be removed.” 
 
Carroll revealed that “a few years back” the OFNC believed it was finally being heard, only for NHS England to change direction without explanation.
 
“The OFNC got close a few years back to agreeing with NHS England and the Department of Health and Social Care that the requirement should be abolished in England, and we had been promised draft regulations to this effect,” Carroll told OT, explaining “then suddenly that changed without proper explanation – although there was mention of NHS England wishing to reconsider whether there would be any risks in making these changes on safeguarding grounds.” 
 
Unfortunately, progress has subsequently halted. Carroll said: “NHS England tells us that it is keen to ensure that processes meet operational governance requirements but do not add unnecessary burden to the system, yet no further action has taken place.” 
 
Carroll stressed that the issue remains a priority on OFNC’s active list of issues needing urgent attention “and is not going away.” 
 
“Patient care and equality of treatment are far too important for that, especially with an ageing and less mobile population with increasingly complex healthcare needs,” he added. 
 
Reflecting on progress made to contracts in nations such as Wales and Scotland, where PVN has been dropped, Carroll said they have “sensibly abandoned the requirement without, as far as we can tell, any adverse consequences for patients or the health service. On the contrary there are benefits for both.” 

Scotland without constraints

On 1 April this year, PVN requirements were formally dropped in Scotland. They had been suspended since the pandemic and were never re-introduced. 
 
Talking to OT about the removal of PVN, domiciliary care representative for Optometry Scotland and optometrist director of Specsavers Fife Home Visits, Mark Gillooly, emphasised that it has put eye care accessibility for care home and day centre residents “on the same level as everyone else.”
 
“Patients can be seen promptly which, as clinicians, we know can be critical to maintaining ocular health and quality of life for our patients,” he explained, adding: “It removes any distractions from our clinicians so every decision being made is purely in the best interests of the patient.”
 
Welcoming the end of advance notices in Scotland, lead optometrist at Visioncare at Home in Scotland, Gavin Sommerville, is also pleased that domiciliary patients now experience fewer barriers to accessing domiciliary eye care, while the administrative burden on domiciliary optometrists is reduced too. 
 
“This might seem like a small technical change, but it really does free up resource and allow us to be adaptable,” he said. 
 
Prior to its removal, PVN in Scotland required domiciliary optometrists to provide their health board with one month’s notice when seeing three or more patients at the same address. 
 
“Each health board had its own procedure for submitting notifications. Some used the NHS standard form, others had their own versions,” shared Sommerville, explaining the barriers that advance notification used to cause practitioners. “The system was admin heavy and a significant burden,” he added. 

It was often met with confusion and created a sense of uneasiness because there were barriers being imposed which were entirely different to regular practice

Gillooly recalls times when due to PVN he had to explain to patients and family members that they had to wait one month to access eye care. “It was often met with confusion and created a sense of uneasiness because there were barriers being imposed which were entirely different to regular practice,” he said. 
 
Discussing the introduction of the requirements in 2006, Sommerville said he believed it was “so the health board knew where we were in case they ever wanted to visit us for a practice inspection.”
 
However, “this never occurred in any health board,” he said. 
 
Reflecting on the removal of PVN, Sommerville emphasised: “This change means domiciliary patients experience fewer barriers to accessing domiciliary eye care.”

[In Wales] we can’t stress enough how positive this change has been for both our patients and our practices

A Wales first

The first nation to formally remove PVN was Wales, with the introduction of new Wales optometry contract reform on 20 October 2023. 
 
Prior to reform, domiciliary providers in Wales were required to provide notice at least 48 hours before a domiciliary visit to one or two patients at a single dwelling, and three weeks’ notice to see three or more patients, optometrist and clinical adviser for Optometry Wales, Sharon Beatty told OT.

While they could visit sooner in “exceptional circumstances,” in these instances practitioners were required to phone NHS Wales Shared Services Partnership to request authorisation.
 
When consulting with the Welsh Government on the removal of the restrictions as part of reforms, Beatty highlighted that the importance of this change was noted in its consultation response, which highlighted the need to “ensure an equitable level of access and treatment for citizens of Wales who are unable to access services in fixed optometric premises.”
 
Today, more simply, in order to provide eye care as a mobile service, practitioners are required to have a mobile service agreement with the Health Board aligned to the location/s in which they wish to deliver the service.
 
Discussing the restrictions that previous requirements created, Beatty told OT that they “did not allow the patient or the practitioner the freedom to arrange an appointment at their mutual convenience.” 
 
This, she explained, could cause delays in patients receiving the care they had requested. “It also placed an unnecessary administrative burden on the practitioner providing domiciliary eye care, which was not required if the patient was to attend High Street practice,” she added. 
 
For Beatty, the removal of PVN and the introduction of new rules with Welsh optometry contract reform ensures that “the domiciliary patient enjoys the same flexibility as the person visiting the High Street as to when they can access an eye examination or urgent care.” 
 
This care, Beatty pointed out, extends to accessing urgent eye care, the Low Vision Service Wales, and treatment by an independent prescribing optometrist in the home environment, “which can reduce the need for a patient to access hospital services,” she emphasised. 
 
When OT spoke to Beatty, it was almost six months since the removal of PVN in Wales and she reflected that it had been “a positive step forward for both patients and practitioners, supporting equality in access for people who depend on care at home.” 
 
Asked to share her advice for nations seeking change in PVN requirements, Beatty said: “[In Wales] we can’t stress enough how positive this change has been for both our patients and our practices. If there is that desire to enact change, we completely support that. We are very grateful to the Welsh Government, all Health Boards and stakeholders who have worked hard to enable this change in Wales.”