At a recent CET event, a member posed a question concerning a complex situation with the Hospital Eye Service (HES). At the time, I didn’t know how to advise them, it being one of those situations that requires a great deal of thought – not something you always have the luxury of in a busy practice.
However, I feel it highlights a subject that other members would find interesting and so I will give a full account of the situation. Names have been omitted and I have the permission of the member to reveal the full details.
The patient, a child aged seven, was tested in the practice by the family’s usual optometrist. Current Rx: RE: +6.50DS 6/7.5, LE: +8.00/-0.75X60 6/20 L esotropia. Retinoscopy pre cyclo: RE +6.50DS, LE +8.25/-0.75X60. Retinoscopy 40 minutes after one per cent cyclopentolate instilled: RE +7.00DS, LE +9.00/-0.75X60.
The patient was prescribed and dispensed with a new frame and minimum substance surfaced lenses, and a B voucher was claimed for. He was then referred to the HES because of the deterioration in the vision of his left eye. The parents paid for a frame and thin lenses; the voucher was submitted and a second voucher applied for on the grounds that the child would be severely handicapped if left without spectacles following a breakage or loss.
At the hospital, the patient was seen by an orthoptist who referred him on to a community optometrist, 24 miles from home. That optometrist prescribed: RE +6.25DS, LE +8.25/-0.25 x 30.
The parents returned to the original practice because they were unhappy with the HES test. The mother reported that the patient was refracted 10 minutes after cycloplegic drops were instilled. After discussion with the original optometrist, the parents decided not to have the HES prescription dispensed.
You may already thinking, “Can you do that?” Truthfully, I am not 100 per cent sure. It raises so many different issues that I thought an FAQ would make other members consider what they might do, if faced with a similar situation.
Firstly, and most importantly, do parents have a choice in deciding who tests their child’s eyes? In the present climate of ‘patient choice’ and funding I believe that, yes, it is for a parent to choose which (properly qualified and registered) practitioner their child consults.
What advice may a practitioner give to parents in such circumstances? Above all else, the welfare of the patient must be your sole concern. You cannot, of course, recommend parents only use your practice and not a competitor’s down the road for purely financial reasons. If you can truthfully say that the patient is best served by going to a certain practice then you must be able to substantiate that claim for anyone to check.
In this particular situation, was the correct advice given to the parents? Does the community optometrist have any rights in this case? He might well be feeling aggrieved, having had his prescription rejected and methods doubted. Is it right that by giving this advice, a professional person (the community optometrist) is potentially made to look incompetent?
One of the purposes of compulsory CET is to ensure a consistent standard of care, so optometrists and dispensing opticians must know the correct procedure for using cycloplegics. Optometrists must be free to rebook a child for a further consultation after instilling drops, and dispensing opticians must understand the need for flexibility of the appointment system in the practice for such patients.
When referrals are made to the HES, is the referring practice not entitled to feedback? With the print-your-own form system, there is no handy form for the clinician to send back the results or findings but rather a formal letter has to be written, copies sent to the GP and the patient but not the originator of the referral.
This question raised so many issues that you can appreciate why I was hesitant to give advice. This patient was lucky; his parents not only cared about his wellbeing but also had the courage to question a system pretty well guaranteed to discourage anyone to disagree. He was also lucky with his optical advisors; the optometrist took extra time and troubles to improve his vision and the DO was astute enough to know the system was wrong and brave enough to question which prescription should be dispensed.
It could so easily have been a different story: possibly no referral in the first place, or uncaring parents and less competent and caring professionals in the practice.