As the optical profession adapts to a new way of working, there are a number of themes that run through the guidance produced by the General Optical Council and professional bodies in response to the COVID-19 pandemic; professional judgement, communication and record keeping. Keeping these fundamental principles in mind should help practitioners navigate their way through these turbulent times.
Activities carried out within a primary optical care setting are well established. The legislative framework is laid down within the Opticians Act 1989, a statute that has been in place for over 30 years. The pandemic, however, turned optical practice as we know it on its head. During the ‘red’ phase of the pandemic (as defined by the College of Optometrists’ red-amber-green classification), legislative requirements were temporarily removed, entirely changing the way in which spectacles and contact lenses could be dispensed. As we moved out of that phase, the previous hustle and bustle of a busy high street practice was replaced with a greater emphasis on remote contact and limited, socially distanced face to face consultations.
NHS England’s guidance states that as far as possible, patients should be assessed and managed remotely. The College of Optometrists’ guidance on remote consultations states that practitioners should contact patients before their visit to take their history and symptoms by telephone or video. When patients do attend in person, tests should be modified to minimise close physical contact.
The challenge of adapting to such abrupt change, whilst processing the fact of the pandemic itself on a personal level, should not be underestimated. It may be helpful, however, for practitioners to take stock and to remember that the key skills and principles that are needed at this time have already been instilled in them throughout their training and already guides everything that they do.
Nine health and social care regulators, including the GOC, published a joint statement in January 2021, which states as follows:
“We encourage health and social care professionals, working in partnership with each other and people using services, to use their professional judgement to assess risk and to deliver safe care informed by any relevant guidance and the values and principles set out in their professional standards.”
NHS England also states that they trust healthcare professionals to use their clinical judgement when applying the guidance and standard operating procedures for primary care optical settings, in what NHS England appreciates is “a highly challenging, rapidly changing environment”.
Applying clinical or professional judgement is part of being a healthcare practitioner. It is perhaps that judgement that sets humans aside from artificial intelligence. Working outside of established practices, however, can be daunting and professionals might doubt their judgement or worry that their actions could be subject to regulatory scrutiny.
The provision of healthcare has, rightly, continued to be subject to regulation throughout the emergency situation of the pandemic but the GOC has been keen to reassure its registrants and the sector that the GOC will support them “when they act in good conscience and exercise professional judgement for the public benefit”.
The GOC consulted with stakeholders in respect of the guidance that it has provided throughout the pandemic and feedback from some suggested that further clarity should be provided by the GOC as professionals may find it difficult to know the right course of action to take (specifically in relation to the sale and supply of spectacles). The GOC responded to that feedback, stating that it would not be appropriate for the GOC as the regulator of the profession to provide clinical guidance but that the GOC will work with the optical representative bodies to encourage them to provide guidance where gaps are identified.
The emphasis therefore is on practitioners applying their judgement, with reference to the available clinical and professional guidance whilst acting in “good conscience” and prioritising patient care, concepts that are already at the very core of being a healthcare professional. It will also be more important than ever for colleagues to provide each other with support and to share experiences and good working practices.
In circumstances where face to face contact is limited and practitioners and patients are adapting alike, effective communication is key.
One of the ways in which communication will have changed within optical practices is in respect of remote history and symptom taking. Taking this crucial information from patients remotely, in advance of a face to face consultation is not without its risks. Practitioners and patients could find it more difficult to understand each other, there is potential for the specifics of what has been said to have been lost by the time of the actual examination and patients could feel less able to convey everything that they want to say or could forget to provide key information. Obtaining information by telephone also means losing the opportunity to observe the patient for non-verbal cues.
These potential difficulties can be overcome, however, with clear communication. It will be important to explain to patients that the initial remote contact is their opportunity to report any symptoms that they have been experiencing. It should be made clear to patients that they should not feel rushed by the process and that this forms part of their appointment. It will also be important to engage in “active listening” if communicating by telephone to compensate for the lack of non-verbal cues. The optometrist should then verify their understanding of the patient’s history and symptoms and use their judgement regarding any further questions to ask when the patient attends in person.
The guidance documents issued by regulators and professional bodies also make frequent reference to the need for clear record keeping.
The “High level principles for good practice in remote consultations and prescribing”, co-authored by a number of regulators including the GOC states that practitioners are expected to keep notes that fully explain and justify the decisions they make. This is not a new concept and, in fact, the preamble to the documents states that the principles are underpinned by existing standards and that they do not constitute new guidance.
A joint statement from the Royal College of Ophthalmologists and the College of Optometrists also states that practitioners should ensure accurate and contemporaneous records of all patient consultations, including any remote and /or telephone triage and that adjustments to sight tests or decision making should be recorded.
It will be particularly important to make an appropriate record of verbal advice given to patients in circumstances where hard copy documents (such as information leaflets) are not being given to patients to reduce the risk of transmitting the virus (although NHS England’s guidance states that written information should be given where possible and I would suggest that whilst online leaflets can be made available, it is important to remember that some patients will not have access to online information).
There will always be vulnerabilities and potential for disputes as to what should have or has occurred where practitioners are having to adapt the way that they are working. Maintaining clear and accurate records, however, can help to overcome these difficulties, meaning that anyone reviewing the record can understand the actions taken and decisions reached and the practitioner can feel confident to get on with providing patient care.
Whilst the environment in which professionals are providing care may have changed, the skills that will ground them during this time are the ones that they will have already been deploying throughout their career. I would encourage professionals to reach out to colleagues and to employers for support and if in doubt, to contact their defence organisation for advice.
BLM’s national healthcare team specialises in representing healthcare professionals including individual GOC registrants and optical businesses. Should you require assistance with any healthcare or fitness to practise matter, please contact Laura Smith (firstname.lastname@example.org), Rosie Shapiro (email@example.com) or another member of the healthcare team.