This article sets out ABDO’s initial reaction to the latest consultation published by the General Optical Council (GOC) as part of its Education Strategic Review (ESR). The consultation opened on 27 July 2020 and runs until 19 October.
ABDO welcomed the launch of the ESR in 2016 and supported the aim of ensuring that student dispensing opticians (DO) and optometrists were prepared for the roles of the future. ABDO has engaged with the review throughout to help shape the GOC’s proposals for the benefit of patients, future dispensing opticians and the optical sector as a whole. Unfortunately, however, ABDO continues to have significant concerns about the GOC’s proposals.
Our first concern is that the GOC is at serious risk of failing the public by putting in place a new system that leads to lower and inconsistent standards of entry to the professions – for both DOs and optometrists. The GOC envisages a system under which there are multiple routes to registration for each profession – and for each route there would need to be a ‘single point of accountability’. This is a fundamental change to the current system, which generally involves students studying at a GOC-approved education provider and passing the GOC-approved professional examinations run by the College of Optometrists or ABDO.
The proposed change could potentially mean the removal of the rigorous, independent assessments provided by the College of Optometrists and ABDO. This change is not a problem in itself – the risk of inconsistent and lower standards arises from a combination of:
The lack of detail in the ‘outcomes for registration’ about the clinical skills and knowledge that students will need, whether dispensing opticians or optometrists; and
The lack of a common assessment framework so as to guarantee a minimum, safe entry level.
Secondly, we are concerned that the GOC is taking a ‘one-size-fits-all’ approach to its reforms. We fully understand that the GOC wishes to change the system of education for optometrists so that clinical experience is more integrated with academic study. But there has never been an explanation from the GOC as to why it wishes to impose the same root and branch changes on dispensing opticians, given that nearly all student dispensing opticians already combine academic study with working in practice.
Put shortly, the system for the education and training of dispensing opticians is neither broken nor in need of substantial repair. With appropriate, modest updates the current system can be fit for purpose for at least the next 10 to 15 years. Making substantial changes, which may have profound negative impacts, needs proper justification and must be proportionate. We have not seen any such justification.
Thirdly, we are concerned that respondents to the consultation will not be able to make an informed response because the GOC:
Has not included any estimates of the costs of the proposed new system, including the implementation costs;
Has not explained who will bear the costs, whether this is students, employers, professional bodies or GOC registrants;
Has not considered whether the expected costs would be outweighed by any potential benefits;
Has not distinguished between the impacts on the system of education for optometrists and the impacts on the system for dispensing opticians; and
Has not considered any alternative options so that the relative costs and benefits of the proposed new system can be assessed.
This information is crucial, yet it is lacking from the consultation documents. How can consultees comment appropriately on financial or economic impacts if, for example, there are no cost estimates for the proposed new system, nor any cost estimates for an updated version of the current system to enable comparison?
We set out below what the GOC is consulting on and then explain our concerns in more detail.
What is the GOC consulting on?
The GOC is consulting on three documents:
Outcomes for registration, which describe the knowledge, skills and behaviours that a dispensing optician or optometrist must have at the point when they qualify and join the GOC register, and which will replace the current GOC competencies.
Standards for approved qualifications, which describe the expected standards for the delivery and assessment of the outcomes for registration.
A quality assurance and enhancement method, which describes how the GOC proposes to gather evidence to decide whether a qualification leading to registration, as either a dispensing optician or an optometrist, meets its outcomes for registration and standards for approved qualifications.
The GOC intends to use these documents to decide whether to approve a qualification leading to registration as a dispensing optician or optometrist.
Concerns about the GOC proposals
We have three main concerns about the GOCs proposals:
The risk of lower and inconsistent standards of entry to the professions.
A one-size-fits-all approach to reform.
A lack of information about the costs of the proposed new system.
Concern 1 – The risk of lower and inconsistent standards of entry to the professions
We fear that the GOC plans would lead to lower and inconsistent standards of entry to the professions – for both dispensing opticians and optometrists. The GOC envisages a system where there are multiple routes to registration for each profession. As stated above, this is not necessarily a problem. The risk of inconsistent and lower standards stems from the lack of detail in the outcomes for registration about the clinical skills and knowledge that students will need, and the lack of a common approach to assessment which guarantees a minimum, safe entry level.
Lack of detail about clinical knowledge and skills in outcomes for registration
We agree with the GOC on the need to update the competencies which students must acquire, and which for student dispensing opticians date back to 2011, to support the development of extended scopes of practice. We support the broader focus in the new outcomes for registration on the knowledge, skills and behaviours that will be required of dispensing opticians and optometrists as healthcare professionals, with the outcomes covering areas such as ‘person-centred care’, ‘communication’, ‘lifelong learning’ and ‘leadership and management’. However, the outcomes for registration do not make clear what clinical knowledge and skills will be required of dispensing opticians and optometrists in the future. Neither do they differentiate between the two different professions.
Of the seven areas covered by the outcomes for registration, six are generic and could apply to any healthcare professional. The remaining area – outcome six – is ‘clinical practice’ and this is very high-level, with the same three outcomes applying equally to dispensing opticians and optometrists. These outcomes are:
“O6.1 Undertakes safe and appropriate ocular examination using appropriate techniques and procedures to inform clinical decision-making including management of medicines within individual scope of practice.
O6.2 Engages with developments in research, including through the critical appraisal of relevant and up-to-date evidence, to inform personal clinical decision-making and to improve quality of care.
O6.3 Analyses visual function from a range of diagnostic sources and uses data to put together a management plan in areas of professional practice such as:
Dispensing of Optical Appliances
Low Vision/Visual Impairment
Anterior eye and Contact Lenses
Ocular and systemic Disease
Patients with Learning Disabilities and complex needs
This lack of detail creates the risk that what students learn will varying considerably depending on where they study and that patients, employers, commissioners and the GOC will have no guarantee that students are meeting a common standard on entry to their chosen profession.
To help to address these concerns, we will be working with education institutes and the GOC to review the FBDO Level 6 Diploma in Ophthalmic Dispensing so that this is aligned with the proposed new outcomes for registration and provides the required detail about the clinical knowledge and skills that students will need to acquire. We will also contribute to the indicative document that the GOC intends to commission in order “to support providers as they develop new qualifications or adapt existing approved qualifications”. However, the standards for approved qualifications do not require education providers to comply with this indicative document, which means there will be no guarantee of consistent, high standards across the board.
Absence of a common approach to assessment
The risk of lower and inconsistent standards is increased by the fact that the GOC has not developed a common assessment framework, which was one of the key steers given by its Council in July 2019. This was described by the GOC as a standardised framework that:
“gives an assurance that people will reach the same level, but gives room for flexibility to decide which elements to assess, when and how to ensure that the individual reaches the baseline for a ‘safe beginner’”.
This led us to believe that the common assessment framework would help to offset the risk of inconsistent and lower standards in the event that there are different routes to registration. The GOC now say that the idea of a common assessment framework has been incorporated in the standards for approved qualifications, but requiring each provider of a qualification to meet particular standards in relation to assessment will not provide assurance that all students will reach the same baseline on entry to the profession. For example, Standard 3.7 in the standards for approved qualifications states that:
“Assessment (including lowest pass) criteria must be explicit and set at the right standard, using an appropriate and tested standard-setting process.”
It is left entirely unclear who decides what this “right standard” is. If it is left to the discretion of the provider of the approved qualification, it seems inevitable that there will be significant variations between different approved qualifications. This is not in the interests of students, patients or the public more generally.
Furthermore, Standard 3.6 states:
“Assessment (including lowest pass) criteria, choice and design of assessment items (diagnostic, formative and summative) leading to the award of an approved qualification must ensure safe and effective practice and be appropriate for a qualification leading to registration as an optometrist or dispensing optician.”
Again, this will not ensure a consistent baseline for entry to the professions because the lack of detail in the proposed outcomes for registration about clinical practice means that what is considered to be “safe and effective practice” and “appropriate for a qualification leading to registration as an optometrist or dispensing optician” is likely to vary between approved qualifications.
Concern 2 – A ‘one-size-fits-all’ approach to reform
Under the proposed new model, there could be multiple routes to registration with the GOC for each profession – dispensing opticians and optometrists – and for each route there would need to be a single point of accountability (SPA). This is a fundamental change to the current system, which for student dispensing opticians generally involves studying at a GOC-approved education institute and passing the professional examinations run by ABDO to gain the GOC-approved FBDO qualification. This protects the public by ensuring that all dispensing opticians who gain the FBDO-qualification meet the same high standards, regardless of which education institute they have attended.
Under the proposed new system, the GOC would only approve the qualification awarded by the SPA. The SPA would be able to work in partnership with other organisations, such as professional bodies, education institutes and employers, but would be responsible for the quality of the education received by students. If ABDO were to become a SPA, working in partnership with education institutes that provide dispensing programmes, it would need to invest significant extra resources in order to, for example, comply with Standard 4.1. This sets out the wide responsibilities of the SPA. It states:
“The SPA is responsible for the award of the approved qualification, the assessment (measurement) of students’ achievement of the outcomes leading to award of the approved qualification, and the approved qualification’s development, delivery, management quality control and evaluation.”
This would require ABDO to exert far more control over the education institutes who deliver the syllabus by, for example, auditing the quality of teaching, notwithstanding the fact that they already have well-established management systems in place.
The GOC’s rationale for moving to the SPA model is to ensure that clinical experience is integrated with academic study. While there might be a need for optometry students to gain earlier clinical experience, nearly all students DOs combine studying with working in practice from day one. They also have a choice of programmes, including weekly day release and distance learning combined with block release to develop clinical skills. Furthermore, the GOC’s own research found that more than 70 per cent of newly qualified dispensing opticians said they had received the right level of clinical experience during their education, compared with less than forty per cent of newly qualified optometrists.
We understand that there is a need to update the GOC’s current education handbooks, but that does not explain why the GOC is taking a one-size-fits-all approach to reform and seeking to impose the SPA model on dispensing opticians. The GOC has not consulted publicly on this idea before and yet the proposed standards for approved qualifications assume this is the right way forward.
There is a question regarding the SPA model in the current consultation, with the GOC asking:
“The ‘Standards for Approved Qualifications’ include a proposal to integrate what is currently known as pre-registration training within the approved qualification…What do you think the impact of this proposal will be on the expected knowledge, skill and behaviour of future optometrists and dispensing opticians?”
This question further highlights the GOC’s one-size-fits-all approach and shows a failure to take account of the fact that the system of education for dispensing opticians is significantly different to the system for optometrists. Student optometrists generally gain their university degree before starting work in practice to carry out their pre-registration training. For nearly all student dispensing opticians, there is no separate period of pre-registration training – clinical experience is integrated with academic study. These different approaches are reflected in the fact that there is one set of GOC competencies for student dispensing opticians, whereas for student optometrists there are two sets of competencies, one relating to the period of academic study and the other relating to the period of pre-registration training. As a result of these significant differences, the above consultation question will not generate meaningful findings.
We believe the GOC should have asked separate questions about the impact on future optometrists and the impact on future dispensing opticians.
Concern 3 – Lack of information about the costs of the proposed new system
We are concerned that the outline impact assessment which the GOC has published is flawed in a number of ways. For example:
It does not include any estimates of the costs of the proposed new system, including the implementation costs.
It does not explain who will bear the costs, whether this is students, employers, professional bodies or GOC registrants.
It does not consider whether the expected costs would be outweighed by any potential benefits.
It does not distinguish between the impacts, including costs and benefits, relating to the system of education for optometrists as opposed to the system for dispensing opticians, even though the two systems are different and therefore the impacts will be different.
It does not consider any alternative options so that the relative costs and benefits of the proposed new system can be assessed.
This approach is contrary to the Government’s Code of Practice on Consultation, which the GOC says it will follow in its Consultation Framework. It is also contrary to the approach which the GOC has taken when consulting on other major changes to the regulatory system, such as the reform of business regulation.
The GOC says in the outline impact assessment that:
“Current providers of GOC-approved qualifications within the UK…are…better-placed than the GOC to assess whether the proposal to integrate professional and clinical experience within the approved qualification will have a positive or negative financial impact.”
It is hard to see how providers of approved optometry qualifications will deliver earlier, more varied and more extensive clinical experience without this having a negative financial impact and it is not credible for the GOC to suggest that there will be no additional costs involved in training and supporting the requisite number of supervisors. In any case, we would have expected the GOC to gather information about the expected costs and benefits in advance of publishing the consultation rather than simply speculating about the likely impacts. As it stands, the absence of any estimates of the expected costs and benefits means that respondents to the consultation will not be able to provide an informed response.
There is an implicit acceptance that extra funding will be required in that the outline impact assessment refers to a GOC report which:
“…described the funding landscape for undergraduate optometry and dispensing optician programmes and GOC approved qualifications and began to map potential sources of additional, increased or reallocated funding to support SPA’s implementation of the new, integrated qualifications.”
This report does not provide any guarantee, however, that additional funding will be available.
The absence of any information about costs and the absence of any guarantee that additional funding will be available is particularly significant given that the costs of implementing and running the new system will need to be spread by providers across a relatively small number of students. For example, around 250 dispensing opticians gain the FBDO qualification and join the GOC register each year. A much higher number of students enter other healthcare professions. For example, 20,000 UK nurses joined the NMC’s register for the first time in the last year.
In summary, it is our view that the GOC proposals create a significant risk of inconsistent and lower standards of education. This is because the high-level education outcomes do not make clear what clinical knowledge and skills students will need in order to join the GOC register. Without a common assessment framework, there will be no guarantee that students reach a safe baseline for entry to the profession. The risk of inconsistent, lower standards is magnified by the fact that there is the potential for multiple routes to registration for both optometrists and dispensing opticians.
The GOC has also failed to explain why it is proposing to introduce the SPA model for dispensing opticians given that nearly all students combine academic study with working in practice already.
ABDO is also concerned that respondents to consultation will be unable to make an informed response because the GOC has not published any estimates of the costs associated with the proposed new system; has not explained who will bear these costs; has not shown that the costs will be outweighed by any potential benefits; has not distinguished between the impacts on the system of education for optometrists and the impacts on the system for dispensing opticians; and has not considered any alternative options so that the relative costs and benefits of the proposed new system can be assessed.
Notwithstanding these concerns, we remain committed to protecting the public by ensuring that student dispensing opticians are equipped for future roles and will continue to work with the GOC in an effort to develop a new system that delivers consistently high standards of education and supports extended scopes of practice.