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Are you practising legally?

David Cartwright

Chair, Derby/Notts local professional network

Member, GOC hearing panel

Chair, National Eye Health Week

Non Exec Director, Nottingham Univ’ Hospital

Suffolk LOC June 2015

Objectives this evening

Understand the optical legal issues, that may affect

you.

Review the issues and risks that frequently arise.

Are there obvious learnings and actions to reduce

the risks?

Review illustrative examples.

Q&A.


GOC professional conduct competencies

“The ability to comply with the legal, ethical and

professional aspects of practice”

2.2.3 Is able to work within the law and within the codes and

guidelines set by the regulator and the profession.

- Demonstrates knowledge of the advice and guidance set by the respective

professional body and standards set by their local PCT.

- Demonstrates knowledge of the code of conduct set down by the General

Optical Council.

- Demonstrates a knowledge of the relevant law relating to their role e.g.

Opticians Act, GOS benefits, fees and charges, Medicines Act

2.2.4 Creates and keeps full, clear, accurate and

contemporaneous records


The regulation, codes & guidance

Civil action

Criminal, in our case The Opticians Act 1989 and subsequent

amendments

Codes of conduct for individual and business registrants

College & Association of British Dispensing Opticians

guidelines


Other regulation

Contract law

NHS regulations

Data protection

Freedom of information

Insurances; employers liability, public insurance

Health and safety

Disability discrimination

(Refer to “Quality in Optometry”)


Civil Action

Generally covers areas as contracts, negligence, family

matters, employment, probate and land law.

The patient has to show that we are negligent and there has

been damage as a result.

Usually taken out of our hands

Sometimes best to accept to avoid long legal process


Opticians Act

Four main functions of GOC

Setting standards for optical education and

training, performance and conduct

Approve qualifications

Maintain the register

Investigate and act where registrants fitness to

practice, train or carry on business is impaired.


Restrictions on sight tests, fitting CLs

The Act states only a registered optometrist or

medical practitioner can;

Test sight.

“duty to perform an examination of the external eye, an

intraocular examination and such additional examinations

that appear necessary”

“give a written statement re referral and the Rx”

Fit CLs

“must have a Rx from sight test less than 2 years old”

“give a signed specification, with expiry date”


Restrictions on sale of appliances

Optical appliances, (spectacles and contact lenses),

can only be sold unless by or under the supervision

of a registrant. Exemptions are;

Unregistered dispensing to anyone over 16, not registered.

The seller must have a signed dated Rx within 2 years,

verify the Rx with a focimeter and that the OCs align with

the PD.

Ready mades.

Contact lenses, under general direction of a registrant.


Titles

It is an offence under the Act for an individual

to take or use the titles of ophthalmic optician,

dispensing optician, optometrist, registered

optometrist or imply registration, when they

are not registered.


GOC individual code of conduct


As a registered optometrist, dispensing optician, or person undertaking

training as an optometrist or dispensing optician, you must:

1. Make the care of the patient your first and continuing concern;

2. Treat every patient politely and considerately;

3. Respect patients' dignity and privacy;

4. Listen to patients and respect their views;

5. Give patients information in a way they can understand and make them aware of

the options available

6. Maintain adequate patients' records;

7. Respect the rights of patients to be fully involved in decisions about their care;

8. Keep professional knowledge and skills up to date;

9. Recognise, and act within, the limits of your professional competence;

10. Be honest and trustworthy;

GOC individual code of conduct


11. Ensure that financial and commercial practices do not compromise patient safety;

12. Respect and protect confidential information;

13. Make sure that personal beliefs do not prejudice patient care;

14. Act quickly to protect patients from risk where there is good reason to believe that

you, or a colleague, may not be fit to practise, fit to undertake training, or in the case

of a business registrant fit to carry on business as an optometrist, dispensing optician

or both

15. Never abuse your professional position;

16. Work with colleagues in the ways that best serve patients' interests;

17. Register with and maintain registration with the GOC;

18. Be covered by adequate and appropriate insurance for practice in the United

Kingdom throughout the period of your registration2;

19. Ensure your conduct, whether or not connected to your professional practice,

does not damage public confidence in you or your profession.


“Not a checklist, it is up to

each clinician to exercise

their professional judgement,

however the is a common law

duty to practice to the same

standard as a reasonably

competent optometrist”.

Fitness to practice

The grounds upon which fitness to practise of a

registered optometrist or dispensing optician are

impaired may be;

Misconduct

Deficient professional performance

A conviction/caution for an criminal offence

Adverse physical or mental health or a finding by another

health/regulatory body


Fitness to practice

Process

Following receipt of an allegation it is referred to

a case worker.

Decision to reject or refer to FTP committee.

Civil standard, “balance of probability.”

Decide if facts are proven and whether they

amount to misconduct, deficient professional

performance or physical/mental health.


GOC sanctions

There are a number of sanctions possible

The registrants name can be erased, (except in health

cases)

The registrant can be suspended for up to twelve months

The registration is subject to conditions for up to three

years.

In addition to the directions, the FTP committee have the

power to impose a financial penalty, up to £50,000. (except

in health case).


Issues?

There are some issues that frequently come up

Supervision

Indemnity

Personal behaviours

Record card completion

Five eye exam themes


Supervision

Children will always be treated more

seriously by GOC

The supervisor is on the premises, able to

intervene if necessary.

Supervisor and supervisee are aware of their

role.

The practice should have some form of

standard operating procedure in place.


Indemnity

A requirement of registration, protecting the

patient, practitioner and practice.

Claims made and claims occurring

Remember when changing mode of employment

to make sure that you are covered


Personal behaviours

Custodial sentence

Dishonesty is viewed very dimly and will be

reported to GOC

– Cash for cash

– Theft of vouchers and money

– Fraudulent with NHS

Drugs


Records

To provide a continuity of care

– Between colleagues

– To monitor progression and trends

– Provide repeat prescriptions

To show your thought processes

– You did the appropriate tests

– You considered differential diagnosis

– You gave reasonable advice

To protect ourselves

– GOC and GOS regulations require it

– Records show you acted reasonably and is your main defence in litigation


We have a duty to keep contemporaneous and legible records

What should we record?


Not good enough today

Any other record card issues?

Business owns the records

Transfer of records to other practices

– Copy the originals & retain the original records on file

Patient has legal access

– Data protection act 1984 and 1998

– The person or someone authorised

– Written request, fee payment, 21/40 days.

– More sensible to check identity, copy and offer

explanation


What “paperwork” should be kept

Everything !

– Records, eye exams and dispensing

– Referrals

– Notes

NHS, 7 years

AOP, 10 years

Children up to 25yr of age.


Common complaint themes wrt

record cards

Review previous records

Dilation

Match tests conducted, decisions and advice

given to finding, history/symptoms

Communication of findings with patient

Speed of referral



Px. Mrs BJ Date. 0000 Optom. AS DoB. 29.3.34 (75) Last visit. 3 years

S/H. LE itchy and injected 4-5 days, yellow discharge

GH, med. Good, no med POH/FH Mother glaucoma Occ/Hob

E Eye SL, RE mild staining

LE bact conj

Lens

Vessels R+L A/V 2/3

Disc R+L CD 0.4 deep

Macula Macs healthy, R and L

Periphery Healthy R and L

Fields. Few points missed LE.

Ton Perkins R 16 L15

Vision R 6/9 L 6/9

OMB D N

Motility Pupils

Current Rx As previous card

Add

Obj

Subj R +0.75/-0.75x115 6/5 L +1.25/-0.50x65 6/5

Add +2.25

Final Rx, as found

Advice.

See GP re’ bacterial conjunctivitis.

Repeat fields in 3/12

No need to change specs.

Mrs BJ, first visit, FH glaucoma, routine exam, suspect field to be repeated

Case 4



Px. Mrs BJ Optom. YF

S/H. Reading less easy with specs

GH, med. POH/FH Occ/Hob

E Eye

Lens

Vessels

Disc

FN

Macula

Periphery

Fields. ………………….


Vision R L

OMB D N

Motility Pupils


Add

Obj

Subj R +0.75/-0.75x110 6/6 L +1.00/-0.50x70 6/9

Add +2.50

Final Rx, as found

Advice.

Varifocals

Mrs BJ, 2nd visit, 6 months later



S/H. ? Vision changed, reading difficult? After light is switched off-scattered pricks of light


E Eye

Lens

Vessels

Disc

FN

Macula

Periphery

Fields.


Vision R L

OMB D N

Motility Pupils


Add

Obj

Subj R +1.00/-0.50x105 6/6 just L +1.50/-1.00x80 6/12

Add +2.50

Final Rx, as found

Advice.

Distance and reading specs

Watch LE

Mrs BJ, 3rd visit, 18 months later



S/H. Specs seem fine


E Eye

Lens

Vessels

Disc a

FN

Macula

Periphery

Fields.


Vision R L

OMB D N

Motility Pupils


Add

Obj

Subj R +0.75/-0.75x105 6/6 just L +1.25/-0.50x80 6/12

Add +2.25

Final Rx, as found

Advice.

Talked of varifocals

Mrs BJ, 4th visit, 2 years later


Px. Mrs BJ Optom. AS

S/H. Pain over R eye since grand daughter poked in 2/52 ago.

GH, med. Good, no med POH/FH Mother glaucoma

E Eye Slight media haze

Vessels

Disc 0.5 deep cupping.

Suspicious LE

Macula Macs healthy, R and L

Periphery Healthy R and L

Fields. Dense arcuate scotoma LE


Vision R 6/9 L 6/12

OMB D N

Motility Pupils


Add

Obj

Subj R +1.00/-0.75x115 6/6 L +1.00/-0.75x80 6/12

Final Rx,

Advice.

Refer to GP.

(NTG confirmed by hospital)

Mrs BJ, 5th visit, 3 years later

Patient, Mrs BJ

Next contact from patient is to inform the

practice that glaucoma has been diagnosed

Asks practice why it was not identified

Expert witness would suggest monitoring of

condition should have occurred

Compensation paid



Px. Mr CJ Date. 0000 DoB. 7.2.46 (70) Last visit. 4yrs Optom. FP

S/H. Patient notices near vision is worse

GH, med. Good, no med POH/FH Lazy RE` as a child Occ/Hob Retired

E Eye NAD

Lens

Vessels

Disc

NAD

Macula

Periphery

Fields.

Ton R 21 L21

Vision R 6/12 L 6/6

OMB D RSOT N

Motility Pupils


Add

Obj

Subj R +3.00 6/12 L +3.00/-0.50x65 6/6

Add +2.25 N5

Final Rx,

Advice.

1st readers

24mths

Mr CJ, first visit, “lazy RE as a child”


Px. Mr CJ Optom. FP

S/H. Routine exam


E Eye NAD

Lens

Vessels

Disc

NAD

Macula

Periphery

Fields.

Ton R 19 L20

Vision R L

OMB D N

Motility Pupils


Add

Obj

Subj R +3.00 6/24 L +3.00/-0.50x65 6/6

Add +2.25 N5

Final Rx,

Advice.

New glasses

24mths

Mr CJ, second visit, 2 years later


Px. Mr CJ Optom. FP

S/H. Reading poor


E Eye NAD

Lens

Vessels

Disc

NAD

Macula

Periphery

Fields.

Ton R 23 L23

Vision R L

OMB D N

Motility Pupils


Add

Obj

Subj R +3.25 6/36 L +3.50/-0.25x 6/6

Add +2.25 N5

Final Rx,

Advice.

Change reading

2yrs

Mr CJ, third visit, 3 years later

Patient, Mr CJ

Next contact from patient is to inform the

practice that glaucoma has been diagnosed

Asks practice why it was not identified

Expert witness suggests that the trend in

decreasing RE VA should have been noted.

Compensation paid


Learning points

Must review and compare old records

Were previous records referred to?

– No recognition of previous S/H

– VA slightly decreasing

– Was there any monitoring of a condition?


When should we take records?

Eye examination

Contact lens consultation

On the phone

At the reception

Dispensing

Contemporaneous



Detail

-Not a lot of it….however


When we next see the

record the missing areas

are complete

Learning

Don’t add afterwards!


record cards


Dilation




Speed of referral



-Patient “floaters in LE

for last 10 days”

- Myopic, -4 DS

- No dilation, no further

Qs re’ flashes,

- description of

periphery “normal”


-Patient seen 6 days later

-Increase in flashes floaters

-Definite problem

-Referred to hospital

The patient complained to

GOC

Learning points

If there is an obvious condition that the symptoms

describe, we to make sure we have completed

appropriate tests to rule out that condition.

Need to have better description of structure

Dilate, (and use indirect), high myopes or if S/H

point toward retinal problem



record cards


Dilation




Speed of referral



Px. SD Date. 0000 Age 4 Last visit. First Optom. MP

S/H. School referral-?squint. DV, seems OK

GH, med. Good, no med POH/FH no FH refractive Occ/Hob School

E Eye NAD

Lens Clear

Vessels Normal

Disc 0.2

Colour Healthy

Macula Slight foveal reflex

Periphery NAD

Fields.

Ton

Colour Ishihara OK

Vision R 6/6 L 6/7.5

OMB D ortho N ortho

Motility Full Pupils aaa

Current Rx

Obj R +0.50DS L +1.00/-0.50x70

0.5% cyclo instilled

Subj R +0.50 conc poor L +1.25DS conc poor

Final Rx,

Advice.

No Rx required, see 12/12

Master SD, 1st visit visit,


Px. SD Optom. DT

S/H. Mother “LE lazy”

GH, good. Med r POH/FH r Occ/Hob School

E Eye All clear

Lens

Vessels

Disc 0.2

Colour Pink

Macula

Periphery

Fields.

Ton

Colour Ishihara OK

Vision R 6/6 L 6/12-

OMB D N

Motility Full Pupils aaa

Current Rx

Obj R Plano L +0.50DS

0.5% cyclo instilled

Subj R Plano 6/6 L +0.50DS 6/12

Final Rx,

Advice.

No Rx required, 6/12

Master SD, 2nd visit, 3 years later


Px; SD, 2nd visit card

Illegible comment


Px. SD Last visit. 5 mths Optom. HP

S/H. School advised poor NV. C/o headache

GH, anaemic. Med iron POH/FH LE lazy, Occ/Hob School

E Eye All clear

Lens

Vessels

Disc 0.2

Colour Pale esp. LE

Macula

Periphery

Fields.

Ton

Colour Ishihara OK

Vision R 6/9- L HM

OMB D ortho N

Motility Pupils

Current Rx

Obj R +0.50 L +0.50DS

Subj R Plano 6/9- L Balance HM

Final Rx,

Advice.

Mother to take to surgery today.

Letter to GP requests an URGENT ophthalmology view

Master SD, 3rd visit,

Patient, Master SD

Outcome

- After referral, a catalogue of errors

- Delay in getting to hospital

- Wrong diagnosis.

- Eventual diagnosis, pituitary adenoma


Learning

- If there is reduced VA we need to have a reason

- Should we follow up referral ?


Advice and recommendations

Address the symptoms/history and anomalies. NB The most productive 1 minute you will have

Details of correction given

– When to be worn

– Adaptation

– Dispensing advice

Other action taken

– Referral/reports and what you have found *

– Advice given, e.g. if symptoms worsen to attend A&E

– Recommended re examination

– Leaflets



record cards


Dilation




Speed of referral



Px. SD Date. 0000 Age 68 Last visit. 3 yrs Optom. OJ

S/H. DV poor for last 2 months

GH, med. Slight high BP, ?medication POH/FH None Occ/Hob Drives

E Eye Normal

Lens Early l.ops R+L

Vessels

Disc 0.2

Macula

Normal R+L

Periphery

Fields. Henson R 3.4 L 3.4

Ton R 14 L15 NCT, 12.30

Vision R L

OMB D ortho N

Motility Pupils aaa

Current Rx

+1.00/-0.50x90 6/12 +1.25/-0.50x80 6/12

N6 Add +2.25 N6

Obj +1.25/-0.75x90 +1.50/-0.50x85 6/12

Subj +1.50/-0.50x90 6/9 +1.75/-0.50x90 6/9

N5/40 Add +2.25 N5/40

Final Rx, As found

Advice. New bifocals. 2 yr reminder

Miss CA

Patient; Miss CA

The next contact from the patient is to

enquire why the optometrist did not find her

cataracts

The practice explains they found, but not

tell her

Patient asks for £2k for private operation


Learning

Advice; fully inform patient.



record cards


Dilation




Speed of referral



Px; AT

-Px feels visual field

reduced

-No flashing

-Early lens changes


Fields show a marked

Right superior defect

Patient is referred


What degree of urgency?

The letter says

“ophthalmological

opinion is requested”

Expert report recommends

dilation and urgent referral

Record AT

Learning

- Consider the degree of urgency and instruct the GP

accordingly

- Optometrists have the knowledge to decide how serious

the condition is and so how urgent.


Finally….

- Code of conduct

- Have I addressed the key signs and symptoms and any

anomalous results?

- Take time at end of examination to consider what could go

wrong and have I addressed it?


Questions


What should we record; broad areas.

History and symptoms

Reason for visit, in patient own words

Visual tasks, including driving Y/N

Ocular health and history

Medical health and history

Family history

NB. show positive and negative findings

Vision and VA with current Rx

Refraction results and OMB

Ocular examination

Results of additional tests

Advice and recommendations

Referral/notification letters

Motility

Pupils

Tonometry

Fields


Current spectacles

Vision, unaided

Objective refraction

Subjective

– Visual acuity (is it acceptable?)*

– +1 blur

– Pin hole

– OMB

Prescription advised

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