7
Co-management issues
Shehzad A Naroo, Baldev K Ubhi and W Neil Charman
Introduction
It is clear that the development of refractive surgery offers both a challenge and an opportunity to ophthalmic practice. Many patients, having been examined by an optometrist, express an interest in the possibilities of refractive surgery and require advice on what it involves and its likely success rate. Such patients, if they opt for surgery, represent lost short-term dispensing revenue. Thus, maybe optometrists should explore possible formal links with their local refractive surgery centres, so that not only are they better informed of the facilities these offer, but also some integration of the examination and advice offered in the practice can occur with the work of the centre. It may be sensible to make available to patients in the practice written information on the pros and cons of refractive surgery.
A second, growing and possibly more significant class of patients are those who arrive at the practice and already have had refractive surgery at some earlier date. It is important that the optometrist be alert to this possibility, since it may, for example, affect the results of tonometry and be the cause of dry eye and other problems (as detailed in Chapter 5). Even though many of these patients may consider that their surgery was successful, they may still need a spectacle or other form of correction, for example to raise their acuity to the standard required for driving, or to correct presbyopia. There is little information on the long-term enthusiasm of patients for ‘enhancement’ procedures to correct the slow drifts in refraction that occur throughout adult life in all eyes,1 but it seems unlikely that the majority of patients will wish to (or be able to) rely exclusively on their surgical correction. Many may be resentful
that having “thrown away their glasses and contact lenses”, they now need an additional optical aid. It is, then, important that the optometrist be able not only to recognize the possible symptoms of post-surgical patients, but also to respond sympathetically to any psychological difficulties that they may be experiencing. Undoubtedly, as the first generation of refractive surgery patients age, new problems may emerge, and probably the primary care optometrist is best placed to detect these and alert the general ophthalmic community.
Patients who discuss their desire to undergo refractive surgery procedures with their own optometrist often report comments from their optometrist such as “laser surgery is still experimental” or “the results are not stable”. This often leads to patients losing faith in their optometrist and possibly seeking primary eye care from another optometrist for themselves and, perhaps, for their family. Usually, the optometrists who dismiss refractive surgery with such blasé comments are those who are illinformed about current techniques. At the very least, optometrists should be aware of the type of surgery that is available in their local vicinity and should inform themselves of the results being achieved, especially now that refractive surgery has established a firm foothold as an alternative to optical aids. Those optometrists with more of an interest might want to consider a ‘sharedcare’ scheme with a local refractive surgeon or refractive surgery centre, although it would be wise first to establish with whom the responsibility for the patient ultimately lies. In this type of scheme the role of the optometrist could also involve counselling the potential patient, although ultimately the treating surgeon will decide on the patient’s suitability for surgery.
As newer techniques and instruments are developed and complication rates are minimized, refractive surgery is expected to grow further. The need for all eye-care professionals to be well equipped in their knowledge of refractive surgery is becoming increasingly important, as they are the source of professional guidance for patients who wish to undergo refractive surgery.
Optometrists and comanagement in refractive surgery
Recent market research from a Mintel report on Optical Goods & Eyecare suggests that in the UK approximately 75,000 procedures were carried out in 2001 on around 41,000 consumers and that this figure probably doubled in 2002.2,3 The question arises, what is the appropriate level of involvement that an optometrist should have with refractive surgery?
Certain optical companies are now able to provide some refractive surgery procedures and to use their existing network of practices to recruit potential patients, as well as for the preand post-operative assessment of patients. Certainly, for these latter tasks an optometrist is qualified appropriately.4
Many independent practices enter agreements with external laser eye clinics, under which the patients are seen initially at the optometric practice and are then referred to the laser eye clinic for surgery, with some of the post-operative assessment carried out at the initial optometric practice. Some of these agreements involve the laser eye clinic making a payment to the referring optometrist, in return for the optometrist making the initial assessment and providing some of the post-operative
54 ■ Refractive surgery: a guide to assessment and management
aftercare. This can be a delicate issue, as the optometrist should not feel that the payment is a ‘referral fee’. However, this fee is often more than the optometrist would charge his or her own routine patients for a regular eye examination. Of course, it could be argued that during a pre-opera- tive consultation for refractive surgery the optometrist performs additional tests (such as pachymetry, pupillometry and corneal topography). It could be further argued that a typical regular eye examination fee is actually less than the realistic fee calculated on the chair time for that appointment, and that the fee is subsidized by the sale of optical appliances, which would not be the case in a preor post-operative refractive surgery appointment.
For example, let us say that a co-man- agement fee of £250 is paid to an optometrist for referring a patient to a laser eye clinic. For this fee the optometrist is expected to perform a pre-operative consultation and post-operative assessments at 1 week, 1 month, 3 months and 1 year. This fee may be hard to justify if a routine eye examination with that optometrist is charged at £20; the excessive fee may be seen as an inducement for referral. Furthermore, the optometrist should not feel any obligation or limitation to restrict himor herself to being able to advise patients to go to one particular laser eye clinic.
Currently, the General Optical Council (GOC) is examining the issue of co-man- agement fees, and recently it made a proposal to ban optometrists and opticians from receiving co-management fees or inducements.5,6 The GOC published a statement on the professional conduct of optometrists regarding photorefractive keratectomy (PRK) in 1995, although currently there are no other regulations on the more recent techniques, such as laser in situ keratomileusis (LASIK) and laser subepithelial keratectomy (LASEK). The statement advised that no optometrist should accept any fee or other inducement for referring a patient to a particular clinic. Nor should any agreement be made whereby the optometrist is restricted to referring a patient to a particular clinic. In addition, any work done prior to a referral must be paid by the patient to the optometrist and not by the clinic. However, any work carried out after treatment can be paid by a clinic on the patient’s behalf and with the patient’s consent to avoid any risk of bias or unethical behaviour.
Refractive surgery is considered a private treatment and currently is not provided under the NHS. The necessary interaction between general practitioners (GPs), optometrists and refractive surgeons and/or ophthalmologists is somewhat dif-
ferent to that which exists in the provision of general ophthalmic services (GOS). The sharing of care for a patient is often termed ‘co-management’, whereby the patient is co-managed between the ophthalmologist at the clinics and/or hospitals and the optometrist. Post-surgery, the ophthalmologist refers only non-complicated cases back to the optometrist involved, and complicated cases remain under the care of the surgeon until he or she feels that they are ready to return back into the optometrist’s care. However, although the management may be passed on to the optometrist under the co-management scheme, the ultimate duty of care remains with the surgeon.7
The Royal College of Ophthalmologists does not have specific guidelines for the involvement of optometrists in the comanagement of LASIK patients, although general guidelines on co-management schemes were issued in 1996, in conjunction with the Royal College of General Practitioners and College of Optometrists. These general guidelines advise that every scheme should be set out in a locally agreed formal protocol that should specify overall clinical responsibility at any one time. However, it has been claimed by some optometric authorities in refractive surgery that the reluctance of some clinics to have an ophthalmologist on site full time has meant that optometrists are being forced to make clinical decisions that lie outside the scope of their responsibility. An example is the ‘prescribing’ of topical ocular therapeutic agents, including topical corticosteroids, as a result of the surgeon’s absence, which is not only against the advise from the College of Ophthalmologists, but also against the Opticians Act 1989.8
Training
Many laser clinics provide training to practitioners who sign up for a co-management agreement with that clinic. The level of training varies from clinic to clinic; some offer only a few hours, which may largely consist of a visit to the laser clinic, whereas other clinics insist on regular attendance for training. There are also many other courses in the management of refractive surgery patients, some offered by the clinics themselves and others by universities or learned societies, such as the British Society for Refractive Surgery (BSRS). Much of the continued education and training (CET) available is approved by the Directorate for Optometric Continued Education and Training (DOCET). However, there is no requirement for those who elect to be
involved in co-management schemes to undergo any CET.
Professional relationships and responsibilities
It is worth taking a step back and looking at the traditional relationships between optometrist, GP and ophthalmologist under the GOS system. A patient seen by an optometrist and deemed to have a pathology or abnormality that requires medical intervention or observation is referred, under the GOS terms and conditions, via the GP to the ophthalmologist to be seen under the Hospital Eye Service (HES). The urgency of the referral is suggested by the optometrist and the GP, but ultimately the ophthalmologist decides on how soon the patient is seen. The situation is slightly different if the patient’s problem is considered to be an emergency. In such a case the optometrist and/or the GP may arrange for an immediate appointment with the ophthalmologist if this is deemed to be in the patient’s best interest. When the patient is sent by the optometrist directly to be seen by an ophthalmologist, the GP is notified. Let us also consider the role of these three clinicians.
The GP’s role
A GP is described as a physician who does not have a sub-speciality, but who has a medical practice in which he or she investigates and treats illnesses. Complex problems or acute illnesses, however, are referred for secondary care at the hospital and, in terms of ophthalmological care, to the HES. The GP may also refer a patient with visual symptoms to the optometrist. GPs are independent contractors of the NHS, who are able to mix private practice with NHS contracted work. Some GPs work under the general medical services (GMS) contract and others are employed under the personal medical services (PMS) scheme, which enable the GPs to have contracts negotiated locally with commissioning health bodies, such as primary care trusts (PCTs). Patients generally are referred to secondary care under the NHS, whereby the GP refers a patient for further specialized investigation in terms of the management of a particular illness. The GP delegates the responsibility for that particular condition to the consultant at the hospital. However, if the condition is resolved and the patient discharged, the GP then continues to manage or monitor his or her patient as normal under the NHS, or privately. Thus, the responsibility for the patient in terms of that particular
condition is delegated to a consultant and team at the hospital, until discharged. At present under the NHS, the GP would normally only refer a patient to an optometrist if he or she believes the problem is refractive, although optometrists possess a range of sophisticated equipment (e.g., a slitlamp or visual field testing equipment) that is not available at most GPs and enables optometrists to detect eye disorders and diseases. However, once a patient is referred to an optometrist for visual correction, only the responsibility of undertaking a sight test is delegated to the optometrists; the responsibility for medical care, such as treating blepharitis and conjunctivitis, still lies with the GP.
The ophthalmologist’s role
The ophthalmologist is both a physician and a surgeon for conditions that occur in and around the eye and the visual pathways. Most ophthalmologists tend to work in the secondary-care environment, for example in the eye department of hospitals, and they may also hold out-patient departments at peripheral clinics. The surgical work of the general ophthalmologist may include cataract extraction, squint and glaucoma surgery, and retinal, oculoplastic and nasolacrimal surgery. Many consultant ophthalmologists also have an area of particular interest and expertise, such as glaucoma, paediatrics, retinal disorders, etc., for which they may hold special clinics. For cases in which an ophthalmologist holds a specific sub-speciality, it is not uncommon for ophthalmologist colleagues to make tertiary referrals.
Consultant ophthalmologists are responsible for all the patients in their care, and for supervising and training junior doctors. However, when a referral is sent to the ophthalmologist, the consultant or registrar decides upon the urgency of appointment, and consequently the responsibility for the patient is only taken if the ophthalmologist decides to monitor or treat the condition. It is, then, possible that the patient may be sent back to the GP, in which case the GP is responsible for monitoring the patient until secondary care is available. In contrast, the patient is not normally referred back to the optometrist for monitoring, unless the optometrist is involved in a co-management and/or a shared care scheme with the hospital.
The optometrist’s role
Optometrists are graduates who have undertaken a 3- or 4-year university-based undergraduate degree course at an accredited optometry school followed by a period of at least 1 year supervised practice before
taking professional qualification examinations. Successful completion of these examinations, set by the College of Optometrists (a public benefit body for the improvement and conservation of human vision), leads to registration with the GOC. The GOC licences optometrists to practice in the UK under the provisions of the Opticians Act 1989 and regulates the practice of optometrists in the UK who work privately or under the NHS. Once qualified, optometrists are able to perform a sight test, which includes the detection of injury, disease or abnormality in the eye, and a refraction, which enables them to dispense spectacles, prescribe and fit contact lenses and prescribe low-vision aids. Optometrists work mainly in the primary care sector and are independent contractors. They provide NHS examinations by initially registering with the PCT responsible for the location in which they intend to offer the service. This seals a contract with that PCT, under which the optometrists agrees to abide by the ‘terms of service’ for the provision of NHS services (GOS) under the 1986 regulation Statutory Instrument (SI) 1986/975. Free NHS eye examinations are available to certain groups of qualifying patients, such as minors (under 16 years of age), senior citizens (over 60 years of age), students in full time education, patients with low income, diabetic patients, glaucomatous patients and those above the age of 40 years with direct relatives who suffer from glaucoma.
If during a routine eye examination an optometrist detects an injury or disease, he or she is obliged to manage the patient under certain referral criteria set by the NHS. The GOS Amendment (No. 2) Regulations 1989 SI 1989/1175 requires that a patient who is diagnosed with diabetes or glaucoma be referred to the patient’s GP. This must also be done if a satisfactory standard of vision is unlikely to be achieved with corrective lenses. In England and Wales this procedure is carried out via the GOS 18 Referral Form, which is the standard form for an NHS referral.
Under the Opticians Act 1989, the GOC is given the power under sections 31(5) and 5(A) to make rules on referral that apply to all practising optometrists, be it under the NHS or private. Thus, the ‘Rules relating to Injury or Disease of the Eye, 1999’ are the present regulation, and are set by the GOC. Therefore, under these regulations a patient who presents to an optometrist with an injury or disease must be referred to the patient’s GP, unless that patient is acting on the advice or instructions of his or her GP or if the patient is suffering from a condition
Co-management issues ■ 55
that requires immediate attention, in which case the optometrist should refer the patient directly to the local HES, although the GP would be informed. If the professional judgement of the optometrist deems that no referral to the GP is necessary, he or she may (at his or her own discretion) decide to monitor the patient and not refer on that occasion. It is considered that, under SI 1999/3267, the optometrist transfers the authority for dealing with the patient to the GP upon referral. This includes the dispensing of optical appliances until the patient is released back to the care of the optometrist or the optometrist receives instruction from the GP or ophthalmologist to dispense the optical aid.
General optometry comanagement schemes
Recognition of the basic skills and training received by optometrists has led to the establishment of various co-man- agement schemes. These schemes deal with pathological abnormalities of the eye, such as cataract, diabetes, glaucoma and low-vision aids. These are managed differently to refractive surgery co-management, as they are set up to improve the quality of referrals to secondary care. They are undertaken in accordance with a protocol agreed with hospital ophthalmologists and GPs, in accordance with the 1996 general guidelines on co-management schemes from the College of Ophthalmologists. This agreed protocol usually involves a number of hours per year training for the optometrist with the ophthalmologist in a lecture and clinical training format. Failure to comply with this required training can lead to the removal of the optometrist from the scheme. Furthermore, the optometrist undertakes responsibility for the part of the service that is provided by him or her. Additionally, the co-management schemes provide for patients for whom a confirmatory diagnosis has been made in the secondary care sector, and the schemes are outside the GOS. Payments to practitioners are made from hospital and community health services funds, although where refraction is required as part of the agreed protocol, a NHS sight test fee is claimed by eligible patients. This is very different to the situation that exists in the co-management of refractive surgery patients.
As mentioned above, the co-manage- ment schemes that exist in refractive surgery do not have guidelines in terms of training required, payment methods or apportioning of responsibility. Optometrists involved in these schemes see the responsibility for the patients as remaining with
56 ■ Refractive surgery: a guide to assessment and management
the treating surgeon, which is what the clinics advocate. This may lead to certain problems if the co-managing optometrist is appointed by the clinic and does not have any dealings with the treating surgeon. If a problem arises, the treating surgeon may argue that they did not approve the optometrist involved in the scheme. Thus, surgeons will need to feel comfortable with the recruitment process that the clinic uses to recruit co-management partners.
Insurance and legal issues of responsibility
Surgeons involved in refractive surgery will have their own medical defence indemnity insurance cover. Some defence organizations are reviewing whom they offer cover to because of the proliferation of litigation cases among refractive surgery patients. The Royal College of Ophthalmologists recently updated its advice to patients on refractive surgery, and is currently also considering its guidelines to surgeons. It is felt that the Royal College of Ophthalmologists will suggest that only surgeons who have been providing refractive surgery for a certain number of years or those who are accredited ophthalmologists should provide refractive surgery.
Optometrists in routine practice usually have indemnity insurance to protect them against any potential litigation from patients. It is a requirement of the College of Optometrists that its practising members or fellows have indemnity cover to at least a pre-set level. Many optometrists in the UK are members of the Association of Optometrists (AOP), which provides its members with some advice when entering co-management schemes, published in their fortnightly journal Optometry Today.9 The AOP’s advice to its members says that they should obtain a written contract that sets out the terms of engagement. The AOP professional indemnity insurance will cover them for
References
1Saunders H (1981). Age-dependence of human refractive errors. Ophthalmic Physiol Opt. 1, 159–174.
2Ewbank A (2001). The current status of
laser refractive surgery in the UK.
Optician 222, 24–27.
3Ewbank A (2002). Trends in laser refractive surgery in the UK. Optician 224, 20–24.
work that they may normally undertake as optometrists, but not for work that they do not normally perform (such as prescribing medication or performing surgical techniques). The AOP advises good record keeping and suggests that members do not advise patients on surgery, but rather inform them of what the surgery can offer, highlighting any pros and cons. Importantly, the AOP also suggests that if a member is involved in a comanagement scheme then the patient must be given details of the agreement that exists with a refractive surgery clinic. The AOP suggests that taking this course of action will mean that professional indemnity for the patient remains with the treating surgeon and that, if required, the clinic will be able to produce satisfactory documentation to demonstrate this professional indemnity to the optometrist.
Sources of further information
There are various sources for information on refractive surgery to which clinicians may wish to refer. Many of the professional bodies have their statements on their websites. Below is a list of some useful organizations and their respective web links.
Governing bodies
•General Medical Council (GMC) – all practising medical practitioners in the UK must be registered with the GMC. www.gmc-uk.org
•General Optical Council (GOC) – all practising optometrists in the UK must be registered with the GOC. www.optical.org
Professional bodies
•Royal College of Ophthalmologists – produces the refereed journal British Journal of Ophthalmology. www.rcophth.ac.uk
4Hanratty M (2003). Optometric comanagement of Lasik: Part 1 – Preoperative assessment. Optician 225, 26–29.
5Hunter I (2003). Frictionless fees. Optom Today 43, 3.
6Optometry Today (2003). GOC seeks ban on referral fees. Optom Today 43, 4.
7Doshi S (2001). Co-management schemes. Optician 222, 34–35.
•College of Optometrists – produces the refereed journal Ophthalmic and Physiological Optics. www.college-optometrists.org
Professional societies
•United Kingdom and Ireland Society of Cataract and Refractive Surgery (UKISCRS)
www.ukiscrs.org.uk
•British Society for Refractive Surgery (BSRS)
www.bsrs.co.uk
•European Society of Cataract and Refractive Surgeons (ESCRS) – jointly produce the refereed Journal of Cataract and Refractive Surgery
www.escrs.org
•American Society of Cataract and Refractive Surgery (ASCRS) – jointly produce the refereed Journal of Cataract and Refractive Surgery
www.ascrs.org
•International Society of Refractive Surgery (ISRS) – produce the refereed
Journal of Refractive Surgery and have just become part of the American Academy of Ophthalmology (AAO), who produce the refereed journal
Ophthalmology www.isrs.org
Other publications
•Cataract and Refractive Surgery Today www.crstoday.com
•Refractive Eye News – the supplement of Eye News ren@pinpoint-scotland.com
•Ocular Surgery News www.osnsupersite.com
•Eurotimes www.escrs.org/eurotimes
•EyeWorld www.eyeworld.org
•Optometry Today – journal of the AOP www.optometry.co.uk
•Optician www.optometryonline.net
8Doshi S (2002). Co-management in refractive surgery: a honey trap? Optician 224, 28–29.
9Association of Optometrists (2001). Optometric services in refractive surgery: Advice for AOP members. Optom Today 41, 19.