Containing escalating referrals by bringing optometrists into the NHSBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3044 (Published 08 May 2014) Cite this as: BMJ 2014;348:g3044
- Vishal Shah, medical student1,
- Laurence Leaver, general practitioner2,
- Muir Gray, consultant in public health3
- 1Green Templeton College, Oxford, UK
- 2Jericho Health Centre, Oxford. OX2 6NW, UK
- 3Better Value Healthcare, Oxford, UK
We agree with Clarke that current screening for intraocular pressure (IOP) would fail the Wilson criteria owing to high false positive rates for pneumatic tonometry as much as cost effectiveness.1 In Oxfordshire (2013), 141/182 patients (77%) with raised IOP on pneumatic testing were normal when re-checked by applanation tonometry, and similar data are available from elsewhere.2 3 Before the 2009 National Institute for Health and Care Excellence guidelines,4 only 20% false positives were found in one hospital outpatient department.5 Perhaps optometrists exercised more professional judgment then, whereas now their professional bodies mandate adherence to NICE guidelines,6 accepting that many patients will be normal but ignoring the opportunity costs. There is also inequity—opportunistic screening tends to omit those with physical disability or lower socioeconomic standing.
We should not blame optometrists. The government expects skilled professionals in high cost premises to provide expert examinations, yet the fee (£20.90; €25.50; $35.13) is derisory and requires profits from sales to subsidise these examinations. The prescribing and dispensing of drugs are financially separated for good reasons, but the same logic is not applied to lenses. If the government wants to contain escalating referrals, it should bring optometrists into the NHS culturally (with shared clinical protocols) and financially (with budgetary responsibility), divorcing the sale of spectacles from the aim of optimising eye health with finite resources.
We risk unintended consequences from a simple linear response to a complex challenge, and so must develop a system in which all professionals play their part. Despite little or no recompense, many clinicians have created admirable schemes where optometrists are key players in integrated services. However, while large chains of opticians can lobby parliament, it will take political bravery to change this national contract; but we ask that politicians join in. Is anyone for evidence based government?
Cite this as: BMJ 2014;348:g3044
Competing interests: None declared.
Full response at: www.bmj.com/content/348/bmj.g2084/rr/692573.
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