Policy responses and statements
- Name of organisation:
- Medicines and Healthcare Products Regulatory Agency (MHRA)
- Name of policy document:
- MLX 334: Proposals to introduce independent prescribing by optometrists
- Deadline for response:
- 27 October 2006
Background: MLX 334 sought views on proposals to enable optometrists to become independent prescribers. This would be achieved primarily by amendments to the Prescription Only Medicines (Human Use) Order 1997 and consequential amendments to NHS regulations, and Rules made by the General Optical Council.
This consultation has been produced by the MHRA and the Department of Health. The proposed changes to medicines legislation would apply throughout the UK both in the NHS and in the independent and voluntary sectors. However, the focus and pace of development of optometrist independent prescribing and the arrangements for training within and for national health organisations, are matters for each of the separate administrations.
Optometrists (previously known as ophthalmic opticians) are health specialists who are trained to examine eyes, test sight, give advice on visual problems, and prescribe and dispense spectacles or contact lenses. They also recommend other treatments or visual aids where appropriate. Optometrists are trained to recognise eye diseases, referring such cases as necessary for further advice and/or treatment. They can already supply and administer various ophthalmic medicines in certain circumstances as part of their professional practice.
This consultation will help determine:
- whether optometrists should become independent prescribers;
- whether any restrictions should be placed on prescribing by optometrists in terms of the ocular conditions they may treat and/or the range of medicines they may prescribe.
COMMENTS ON
MEDICINES AND HEALTHCARE PRODUCTS
REGULATORY AGENCY
MLX 334: PROPOSALS TO INTRODUCE INDEPENDENT PRESCRIBING BY OPTOMETRISTS
The Royal College of Physicians of Edinburgh is pleased to respond to the MHRA on consultation MLX 334: Proposals to introduce independent prescribing by optometrists.
In general terms, the proposal appears to have merit. Concerns have been raised previously about proposals to introduce independent prescribing by pharmacists and nursing staff, because such individuals are not trained in diagnostic medicine. By contrast, optometrists are trained to recognise and diagnose ocular disorders and the ocular manifestations of systemic disorders. Therefore, it can be argued that suitably trained individuals would be well placed to function as independent prescribers. However, there are specific caveats to this role. Optometrists are not trained in the pharmacokinetics and the pharmacodynamics of drugs, nor in their interactions. Reservations about the proposals are expressed in the answers to specific questions.
Support can be offered only for the adoption of Option 2 ie that optometrists should prescribe for certain ocular conditions from a limited formulary. In particular, the formulary should be restricted to drugs which have little or no systemic absorption. Furthermore, it should be mandatory that general practitioners are kept informed of drugs prescribed for their patients by an optometrist.
General comments on content of document
P4 B8. It is the impression of ophthalmologists that the current training of optometrists enables them to recognise abnormalities affecting vision and the eyes. This is not the same as identifying disease states.
P4 B9. It is the opinion of many medical specialists in ophthalmology that the current training of optometrists is deficient in practical experience. Pre-registration trainee optometrists, attached to ophthalmology departments, usually do not have competence in the ability to examine the fundus with the slit lamp, nor are they able to identify or manage eye disease.
P4 B10. The last statement is one of concern, as this implies that optometrists act as gatekeepers despite, in the opinion of ophthalmology, having appropriate training
P5 B13. The seven proposed pathways in Scotland are specifically instructed by SEHD as being outwith the remit of the current new GOS contract.
P5 B15. The point raised about B10 is also relevant here.
Replying to questions
1. Benefits to be gained by introducing independent prescribing by optometrists.
Benefits will occur only if optometry and ophthalmology are more closely aligned. Traditionally, referrals from optometry to ophthalmology have not been of a particularly high standard, leading to a belief held by many ophthalmologists that optometrists lack appropriate clinical skills. Entry requirements for optometry, however, are not dissimilar to those for medicine. Cohesion between ophthalmology and optometry could be addressed (at least in Scotland) at an early stage of optometry training through restructuring the four-year degree course offered by Glasgow Caledonian University. In particular in Scotland, optometry students could be attached in an integral way throughout their four-year training to all of the ophthalmology departments, in the same way that medical students are attached to all hospitals for training. At present, they perhaps attend twice during their entire four years. They could receive the same (non-surgical) basic specialist training that ophthalmologists currently obtain. This would facilitate the dismantling of professional barriers to optometry prescribing, as an essential component of any effective primary care optometry NHS service. Working together would break down professional barriers, through the fostering of mutual respect.
2. Is it feasible and beneficial to make no change?
From a clinical governance point of view, the question should be phrased the other way round. What is being proposed is revolution, rather than evolution.
3. Should optometrists prescribe for certain conditions from a limited formulary?
This would be the safest option for patient care, and the one which could most readily be supported.
4. Suitability of proposed formulary and list of ocular conditions for prescribing
Many of the medications listed in Annex A are archaic and are not part of modern ophthalmic medical management. The effectiveness for many of the indications listed is extremely dubious. Some are oral medications with significant potential side effects and some are expensive intravenous infusions (verteporfin) that are used only by sub-specialists within ophthalmology as part of a United Kingdom audit. This list therefore needs to be extensively redrafted.
5. Should optometrists prescribe for any ocular condition from a limited formulary (Option 3)?
No. See reply to question 1.
6. Suitability of proposed formulary for optometrist independent prescribing?
See reply to questions 1 and 4.
7. Should optometrists prescribe any licensed medicine for a specific set of conditions?
No. See reply to question 1.
8. Suitability of proposed list of ocular conditions for optometrist independent prescribing?
See reply to question 1.
9/10. Classes of medicines that would be considered inappropriate for prescribing?
A medical practitioner should prescribe any form of systemic therapy. An optometrist should not prescribe drugs which have significant systemic absorption.
11. Which option would you favour overall and why?
Option 2. The use of a limited formulary could be advocated, within the setting of additional training for optometrists.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[26 October 2006] |
