Evidence submitted by the Royal College
of Ophthalmologists (WP 33)
EXECUTIVE SUMMARY
1. The Royal College of Ophthalmologists
(the College) thanks the Health Committee for this opportunity
to contribute to the Inquiry into workforce needs and planning
for the health service. The College has been very active in anticipating
the workforce required to deliver quality eyecare for patients
equitably throughout the UK. We have published a chapter on "Medical
Workforce in the Hospital Eye Service" as part of our Ophthalmic
Service Guidance and this is available in the public section of
our website http://www.rcophth.ac.uk/docs/profstands/ophthalmic-services/WorkforcePlanningOct2005.pdf
The College also has a tradition of collaborating
with other professional groups (orthoptists, optometrists etc)
to ensure ready patient access and the best use of NHS resources.
2. In summary, the College's concerns centre
on:
(i) The challenges presented by an ageing
population as so many eye conditions are age-related.
(ii) The disruption of the balance between
the number of specialists completing training and the number of
opportunities for their employment.
(iii) The local recruitment of doctors specifically
to deliver targets to the detriment of services for patients with
complex or chronic debilitating conditions.
(iv) The trend towards short, fixed term
and locum contracts for career doctors.
(v) The employment of less well qualified
doctors to take inappropriate levels of responsibility.
(vi) The knock-on effect on the provision
and quality of training for the next generation of specialists.
(vii) The need to improve the status and
training of Staff and Associate Specialist (SAS) grade doctors
who deliver much of the hospital eye service.
(viii) The trend away from salaried contracts
to fee-for-service for professionals.
(ix) The impact of the European Working Time
Directive (EWTD) which from 2009 is likely to significantly reduce
the availability of a 24 hour on-call service.
(x) The number of uncertainties that make
workforce planning difficult and these include:
(a) Whether the changes in the gender balance
of medical graduates will result in changes in the recruitment
and retention of ophthalmologists.
(b) Whether the introduction of Independent Sector
Treatment Centres (IS-TCs) will affect hospital eye units that
offer a total service to all local patients.
(c) The extent to which retirement of medical
staff before the age of 65 can be predicted
3. The College's response now follows based
on the issues raised by the committee:
EFFECTIVE WORKFORCE
PLANNING
4. The College collaborates with the Central
workforce team and for many years planning was very effective,
achieving a balance between specialist vacancies and the provision
of qualified specialists. However, since recruitment was devolved
to a local level, and particularly in the last two years, consultant
opportunities have fallen by 50% as preference has been given
to (cheaper) less well qualified doctors. The emphasis on delivering
volume to meet targets has benefited certain patients but has
been to the detriment of those patients with more complex or chronic
blinding conditions (eg diabetic retinopathy, glaucoma) who require
more comprehensive holistic care. Newly qualified specialists,
expensively trained through years of postgraduate education are
unemployed, taking locum positions or being lost overseas.
WORKFORCE NEEDS
5. The Modernising Medical Careers (MMC)
initiative has developed a robust training scheme for specialists
and the Postgraduate Medical Education and Training Board (PMETB)
has recently approved the College's curriculum. This is intended
to produce a specialist who can provide comprehensive quality
care for patients and manage ophthalmic provision for local communities
in collaboration with other professional groups (orthoptists,
optometrists, nurses, medical photographers). The Association
of Health Professions in Ophthalmology (AHPO), worked with the
College to develop training programmes to extend the expertise
and versatility of staff across professional boundaries. This
has led to a Foundation Degree for Ophthalmic Science and Technology
offered at New College, Nottingham and is an example of good practice
that will result in more comprehensive services for patients.
6. Connecting for Health and the electronic
patient record will facilitate ophthalmic assessments on different
sites by a variety of professionals as the results are recorded
in digital format. However diverse the delegation, the process
needs to be medically led to ensure high standards of diagnosis
and clinical decision making and ensure quality through robust
audit. The College discourages isolated practice, preferring professionals
to work in group premises for the protection of the patients and
the mutual support of the professionals.
FUTURE PLANNING
7. The ophthalmic workforce should be planned
centrally, taking demographic and epidemiological data into consideration,
to ensure the most accurate projections. Implementation should
be undertaken more locally but in areas of sufficient size to
facilitate cooperation (rather than competition) between the primary
community services—eg health centres, optometric practices,
community hospitals—working in harmony with the treatment
centres and more comprehensive hospital services. Quality care
for the management of patients with ophthalmic disorders, including
accidents and emergencies, should be available for all patients
within their locality, with experienced senior specialists managing
teams of ophthalmologists and other professionals to ensure the
best outcome. Travel to centres of excellence should be reserved
for those with rare conditions which require super-specialist
treatment modalities. Fragmentation of services into separate
groups with separate contractual arrangements leads to dysfunctional
delivery of care. Planning of initiatives in separate areas of
the Department of Health requires close communication and cooperation
to ensure no duplication of effort or conflicting solutions. Planning
at a more devolved level inevitably leads to duplication of effort
in each locality. Flexibility can be ensured by training the workforce
in extended roles such as through the AHPO scheme. A pyramidal
structure led by senior clinicians, with planning in partnership
with managers both for the community services, treatment centres
and hospitals, leads to a seamless services for patients. Local
or short term contracts for services lead to disrupted care for
patients and an uncommitted and disillusioned workforce. They
make multidisciplinary team working much more difficult to establish
and weaken continuity of care for patients.
TRAINING THE
WORKFORCE
8. Training should be part of the way of
life for all healthcare professionals. It should be undertaken
in an environment providing holistic care where the patient's
needs are central and there is an ethos of cooperation and integration.
Professionals in fixed term or locum posts are unsuitable for
training the professionals of the future. Similarly overseas professionals
on short term working holidays are not subject to the rigorous
UK appointment systems, on-going appraisal or other clinical governance
procedures.
9. The numbers training for each profession
should be regulated centrally and be in balance with the anticipated
need assessed on a countrywide scale. For example, orthoptists
belong to a specific paramedical profession and are crucial to
the management of children with ophthalmic problems and to the
screening in schools for children with visual impairment. Orthoptists
are a versatile profession and with appropriate training, readily
take on other tasks when necessary. However there is a severe
shortage nationally as training opportunities have been reduced
and children's screening services have been curtailed in some
areas.
10. Optometrists also represent a valuable
resource in the delivery of eye services and are trained in considerable
numbers. With appropriate additional training and working in medically
led teams, they may deliver ophthalmic screening and primary care
in the community. However, the Department of Health will need
to consider the economic rationale of such a system.
11. Mechanisms for continuing education
and professional development should be in place for all professional
groups delivering healthcare and robust appraisal and revalidation
procedures should be rolled out to safeguard the patients.
15 March 2006
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