The Course Is Made up of 3 Modules

Therapeutic Prescribing for Optometrists: an initial perspective

Gunter Loffler1, Ross Henderson2, Stephen Bolland3 & Gael E. Gordon1 1 Department of Vision Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, Scotland, UK. 2 WJ Henderson Optometrist, 59 South Methven Street, Perth, PH1 5NX, Scotland, UK. 3 SevenSeventeen Projects, 16 Cuthill Towers, Milnathort, KY13 9SE, Scotland, UK

Abstract Aim: Recent legislative changes in the UK permit optometrists with additional training to be involved in the therapeutic management of eye conditions. The role of a therapeutic optometrist within the health care network is still developing and it seems timely to ascertain what impact this additional role has on those who have undertaken the relevant training. This article aims to capture a snapshot of the current status of therapeutic prescribing for optometrists in the UK.

Methods: All UK optometrists qualified as Additional Supply (AS) and Independent Prescribing (IP), as well as those undertaking training towards therapeutic prescribing, were invited to take part in an online survey. Questions concerned their perception of the training requirements, the conditions therapeutically qualified optometrists treat, the drugs they use, how often they prescribe and the general impact for their patients and their practice.

Results: Sixty optometrists completed the questionnaire. Thirty-eight respondents are qualified as independent prescribers (IP), which represents 60% of all currently registered IP optometrists in the UK at February 2011. i) All parts of the training (theoretical and clinical placement) were rated highly; the course content and duration were judged appropriate to prepare for the role of an independently prescribing optometrist. ii) Respondents manage a wide range of conditions (including blepharitis, allergic eye disease, corneal problems, uveitis and glaucoma) with an extensive range of ophthalmic drugs (including antivirals and topical steroid). iii) On average, optometrists issue 10 prescriptions per month. iv) Feedback from patients, general practitioners and ophthalmologists has been positive; the number of onwards referrals has reduced.

Conclusions: This survey provides the first insight on the impact of therapeutic qualifications on optometric practice as the participants are part of the first cohort to have

1 qualified. Therapeutic optometrists regard the training as beneficial for their practice, their clinical confidence and for patients.

Introduction

Legislation Since the first recognition via the Medicines Act in 1968 that UK-based optometrists could be generally involved in the use of medicines, legislation in this regard has changed on a number of occasions. Prior to 1999, optometrists had access to a range of diagnostic and therapeutic medicines, specified in Level 1 or 'entry level' exemptions to the Medicines Act . This allowed all registered optometrists access to a number of prescription-only medicines (POM) such as Chloramphenicol, Cyclopentolate, Pilocarpine and Atropine1 without undergoing additional training.

Dr June Crown’s Review of Prescribing, Supply and Administration of Medicines resulted in her recommendation that general prescribing should be extended to certain non-medically qualified professionals, including optometrists. In 2000, the NHS plan endorsed this recommendation on the understanding that it would provide patients with quicker and more efficient access to medicines, as well as making better use of the skills of health professionals.

This has resulted in an increased range of medicines available to optometrists through further exemptions to the Medicines Act. To permit access to a wider range of POMs and to establish prescribing partnerships with Independent Prescribers, two further levels of exemption were introduced, both of which require additional training and qualifications. Since July 2005, optometrists on the Additional Supply (AS) or Supplementary Prescribing (SP) register can supply and administer additional medicines which will allow them to manage a number of common non-sight threatening disorders (AS) or to prescribe them in partnership with a medical practitioner (SP).

In August 2006, The Medicine and Healthcare Products Regulatory Agency and the Department of Heath jointly consulted on the proposal to introduce independent prescribing (IP) for optometrists . In June 2007 the Commission for Human Medicines proposed to restrict the scope of optometrist independent prescribing by reference to the competence of the individual prescribing optometrist , rather than linking it to an approved formulary, as has been the case for entry-level and AS prescribing. The same reference to competence has been taken with regard to Nurse and Pharmacist Independent Prescribing.

1 Pilocarpine and Atropine are now available only to Optometrists with the Additional Supply Qualification.

2 The Department of Health and the General Optical Council (GOC) have since worked to achieve the necessary legislative changes . Changes to the POM Order came into effect in June 2008 and the GOC launched the IP Register on 1 November 2009.

The new legislation permits IP qualified optometrists to prescribe any licensed medicine for ocular conditions affecting the eye and the tissues surrounding the eye. In practice, however, IP optometrists will only work with conditions within their area of recognised competence.

Registrants who wish to become independent prescribers are required to complete further GOC-approved training and apply for entry of their specialty in the register.

Training The additional independent prescriber training requires the completion of theory modules, a period of clinical placement, under the supervision of a designated ophthalmologist, and a final examination.

There are currently three providers which offer the theoretical part of the training; Glasgow Caledonian University, City University in London and a course run jointly by Manchester and Aston Universities . All three courses are GOC approved and cover the syllabus set out by the GOC for therapeutically prescribing specialty. Details about the delivery of the syllabus differ between institutions but all have adopted a flexible learning approach, underpinned by directed distance learning. As an example, the course offered by Glasgow Caledonian University is divided into three modules, each worth 20 post-graduate points. Each module is predominantly part-time distance learning, supplemented by two days of lectures and practical workshops at the University. The distance-learning component comprises a series of articles (e.g. basic principles of therapeutics, anti-infective and anti- inflammatory drugs for ophthalmic use, immunology and allergies, microbiology, wide range of ophthalmic conditions) and access to Internet based discussion groups and self-assessment. Lecture topics have been chosen to supplement and support the course literature and include conjunctivitis & blepharitis, superficial injury, uveitis, scleritis, keratitis, dry eye, glaucoma, and common systemic conditions and their medications. Practical workshops include gonioscopy, application and removal of punctal plugs, syringing the canaliculi, ocular first aid (including foreign body removal) and glaucoma management. Each module can be completed in 3-4 months and requires the submission of case records and passing a written exam.

Following the completion of the theoretical modules, trainees embark on a period of practice-based training. The primary purpose of this component of the training programme is to develop competency in the practice of prescribing and to facilitate the integration of prescribing theory and practice with the conditions that will be managed therapeutically. This training will typically take place in the Hospital Eye Service under the supervision of a designated ophthalmologist. For Independent Prescribing, the clinical

3 placement requires a minimum of 12 days (24 sessions of not less than 3 hours).

At the conclusion of the clinical placement, trainees sit a Common Final Assessment (CFA) administered by the College of Optometrists. The CFA for Independent Prescribing involves the submission of a logbook of Hospital experience and a computer-based exam which covers patient-based scenarios (75 multiple-choice questions in 90 minutes). The CFA is currently run twice a year. Further information about the CFA can be found on the College of Optometrist’s web page . Following completion of the CFA, the successful candidate will be awarded IP status and be allowed to register on the specialist GOC list. Once registered, optometrists are required to keep their skills up-to-date, audit their activity and comply with the additional CET requirement for specialist optometrists.

Because the legislation, training and guidance underpinning therapeutic prescribing for optometrists is very recent, the role of a prescribing optometrist in the context of the NHS is not established. Given the dynamic nature of these developments, this process will take time to evolve. The precise roles that therapeutic optometrists take on will depend on their expertise, confidence and the environment in which they work. It is clear that this role will, to some extent, depend on the individual: it is likely that hospital optometrists will take on different responsibilities from those based in community practices. It would be informative at this early stage to gain insight from IP optometrists, who have already qualified, about how they use their therapeutic qualification. Knowing what IP practitioners do at present will inform others undergoing training as well as those considering this option but it might also aid the development of a professional role description. Hence, the aim of this study was to collate information about the impact of the therapeutic qualification on every day practice from therapeutically qualified optometrists via a survey. Practitioners were asked questions which focussed on their perception of the training, the confidence gained by it, the conditions that they treat and which drugs they use, how often they prescribe and the general impact of their prescribing activity for their patients, their practice and the wider community (GPs, pharmacists, HES).

Methods

A questionnaire was developed (see appendix). The questionnaire was initially drafted by two of the authors and then reviewed by a focus group consisting of five optometrists; one IP optometrist, one who has completed the theoretical training and clinical placement and is awaiting the CFA exam, one who has completed parts of the theoretical training and two who are involved in the delivery of the theoretical training. The revised version was then

4 piloted. The questions were provided online via ‘survey monkey’ – a web- based tool which permits users to create online surveys - (www.surveymonkey.com). All practitioners who had successfully completed the CFA with the College of Optometrists were invited to complete the questionnaire. In addition, all optometrists who had completed the theoretical training at GCU were invited to participate. These included optometrists who were already AS or IP qualified as well as some that had not yet completed their clinical placement. The survey could be completed in about 5 minutes and was anonymous. Not all questions were available to all participants depending on the stage of their training.

Results

Demographics & Qualification

Sixty optometrists participated in the survey. All participants had completed their theoretical, University-based training. Sixty-two percent of participants are working in Scotland, 35% in England and 3% in Wales.

Forty-seven of the participants had completed the clinical placement; 39 had passed the CFA and were registered with the GOC as therapeutic prescribing specialists. All but one of the 39 who had passed the CFA (n=38) were qualified as IP optometrists (Fig. 1 A). As of February 2011 there are 62 IP optometrists (43 in England, 1 in Wales, 17 in Scotland, 0 in Northern Ireland and 1 overseas) and 33 AS optometrists (29, 1, 0, 1, 2) in the UK [12]. The survey therefore sampled 61% of all currently registered IPs. Of those qualified as IP, the majority (19 out of 38) are practicing in England, 17 in Scotland and 2 in Wales.

Thirty-two (53%) of the optometrists work exclusively within the community, 20% in hospitals and 27% work in both. The distribution of the year optometrists first registered with the GOC is essentially uniform (Fig. 1 B). The likelihood of optometrists to undertake therapeutic training appears to be largely independent of the year in which they first qualified.

5 Fig 1: Demographics and Qualification. A: The majority of participants are qualified as IP (63%), one is qualified as AS; 35% are not yet registered as therapeutic prescribing specialists but have completed the University based training. Those qualified as IP represent 61% of all currently registered IPs in the UK. B: The relationship between the year of qualification and the numbers undertaking therapeutic training.

University training The majority of survey respondents underwent their training at Glasgow Caledonian University (78%), the remainder in London. Three quarters rated the theoretical training 8, 9 or 10 on a scale from 1 (not helpful) to 10 (essential to prepare for IP prescribing), with a mean of 8.4 and a median of 9 (Fig. 2 A).

6 Fig 2: Perception of various components of the therapeutic training. All parts of the training are rated high. A: Theoretical, University-based training. Three quarters rated the theoretical training 8, 9 or 10 on a scale from 1 (not helpful) to 10 (essential to prepare for IP prescribing), with a mean of 8.4 and a median of 9. B: Clinical placement. The majority rated the clinical placement as ‘essential to prepare for IP prescribing” (1 = not helpful and/or relevant; 10 = essential to prepare for IP prescribing). C: College exam (CFA). The

7 distribution of responses peaks between 6 and 7 (1=not assessing relevant skills; 10=best way to assess skills and knowledge required from an AS/IP optometrists) with an average of 6.9. D: General impact of IP training on practice. Seventy-five percent see the training as very helpful for their practice, rating it at 8 and above on a scale from 1 ‘not helpful, work in practice has not changed as a result of training’ to 10 ‘very helpful, skills and knowledge gained have a significant impact on everyday practice’.

Clinical Placement

Forty-seven optometrists had completed their clinical placement, 10 were currently undertaking it and 3 had not yet started, this latter group indicating that difficulty finding a hospital placement had prevented them from commencing the placement.

During their clinical placements, optometrists attended clinics that are relevant for their intended area of prescribing. The most popular clinics to attend for training were glaucoma, A & E and General and Primary Care Ophthalmology (Fig. 3 A). A significant number attended retinal and macula clinics, even though IP optometrists are not permitted at present to administer injections for wet macula degeneration or diabetic macula oedema.

8 Fig 3: Clinical placement. A: Clinics attended. The most popular clinics to attend for training were Glaucoma, A & E and General and Primary Care Ophthalmology. B: Time taken to complete training. Most optometrists completed the 12 required days for IP within 3 months. Nearly all completed it in 6 months or less. C: Length of placement. More than two-thirds consider the required 12 days for IP as adequate. D: Number of patient episodes. The range and number of conditions seen during the placement was judged sufficient (1 = insufficient; 10 = sufficient range and number of conditions). E: Interactions with supervising ophthalmologist. Opportunity to discuss management with the ophthalmologist was judged sufficient to extensive (1 = insufficient; 10 = extensive).

Most optometrists completed the 12 required days (24 sessions) in the hospital within a 3-month period (Fig. 3 B). All but 5 completed their placement in 6 months or less, but 4 required more than a year. More than two-thirds consider the current placement requirement of 12 days adequate (Fig. 3C). Most optometrists felt that they saw a sufficient number of conditions during their placement (Fig. 3 D) and had sufficient time to discuss management with the supervising ophthalmologist (Fig. 3 E). Overall, the

9 majority of respondents judged the clinical placement to be essential in preparing for IP (Fig. 2 B).

College IP exam

The Common Final Assessment (CFA) for Specialist Qualifications in Therapeutics received an average rating of 6.9 (1=not assessing relevant skills; 10=best way to assess skills and knowledge required from an AS/IP optometrists; Fig. 2 C).

Outcomes of Therapeutic training

The great majority of IP optometrists practice (or plan to) in the fields of primary eye care or glaucoma. Just over half have are specialised in both and only a few manage conditions in additional areas (Fig. 4 A).

75% reported that they have received feedback with regards to their therapeutic management from patients, GPs, pharmacists and ophthalmologists following qualification in specialist therapeutic prescribing. The majority of reported feedback (83%) has been positive or very positive (Fig. 4 B and C).

10 Fig 4: Impact of prescribing. A: Areas of specialty. The vast majority of IP optometrists practice (or plan to) in the fields of primary eye care or glaucoma. Just over half have are specialised in both. Other areas are comparatively uncommon (see inset for a list). B & C: Feedback. 75% of optometrists have received feedback with regards to their therapeutic management from patients, GPs, pharmacists and ophthalmologists and the majority of this feedback was positive or very positive.

Managed conditions

In an attempt to ascertain any potential benefit of the training independent of the possibility to prescribe drugs, practitioners were asked if they now treat or manage conditions after the training, which do not require AS/IP drugs but which they did not manage before. Forty percent reported that this was the case.

Table 1 summarises the most frequent conditions that optometrists stated they manage after the training that they could have managed before.

Conditions (not requiring AS/IP) managed after training Dry eye (including severe cases) Epiphora Lash removal Tear duct syringe Blepharitis Meibomian gland dysfunction Chalazion Bacterial and viral conjunctivitis SAC/PAC, allergic eye disease GPC Episcleritis Foreign body removal Corneal abrasion (including recurrent), trauma, epithelial defects Marginal ulcers

Table 1: The most frequent conditions that optometrists stated they manage after the training that they could have managed before.

Regarding therapeutic management that requires medications only available to AS and IP optometrists, all but one of the 39 therapeutically qualified optometrists (97%) indicated that they treat/manage conditions with AS/IP medications. When asked to indicate which conditions they treat and what drugs they use, the combined response showed a wide range of conditions including blepharitis, allergic eye disease, a variety of corneal problems (including herpes simplex keratitis), uveitis and glaucoma and using an extensive range of ophthalmic drugs. A number of responses indicated the

11 use of topical steroids. Systemic medications are generally absent from the list, with the exception of treatment for severe blepharitis. Table 2 lists the conditions and medications that therapeutically qualified optometrists currently use. The data suggest that in some cases ocular disease management is falling outside the recommendations within College of Optometrists Clinical Management Guidelines . Whilst this is possible (and indeed likely) within designated local protocols or within the HES it should be mentioned that it might not be appropriate for optometrists practising outside of these situations

Conditions managed with AS/IP qualification

Category Condition Medication Dry Eye

Lids+Lashes: Blepharitis & Chronic Fusidic acid Severe Blepharitis

Conjunctiva Allergic eye disease Mast cell stabilisers & anti histamine; Nedocromil Sodium (Rapitil); Olopatadine (Opatanol) Ketorolac trometamol (Acular) SAC, PAC, AKC, VKC Viral conjuctivitis Adult inclusion Conjunctivitis Angular conjuctivitis

Cornea FB removal Filamentary keratitis Marginal keratitis Marginal ulcers: Chloramphenicol, steroids Corneal ulcers/contact Ofloxacin (Exocin) lens- related corneal ulcer Antibiotics for infection mainly Ofloxacin bacterial keratitis (small, off axis) Herpes Simplex anti viral, Aciclovir (Zovirax eye Keratitis ointment) Abrasions Corneal graft Steroids: Dexamethosone 0.1% and Neomycin (Maxitrol)

Uveitis/Scleritis Episcleritis

12 Anterior uveitis: Cyclopentolate; pred forte Uveitis Steroids: mainly Dexamethosone 0.1%(Maxidex)/ Betamethasone (Betnesol)

Refraction Atropine

Glaucoma Drugs used include: prostaglandin analogues, CAIs (carbonic anhydrase inhibitors), beta-blockers, pilocarpine, alpha agonists. Timoptol, Xalatan Azopt Trusopt, Alphagan, Lumigan, Saflutan, Diamox and combination drugs such as Xalacom, Duo Trav, Ganfort, Combigan, Cosopt, Cosopt Preservative free & Azarga

Post-operatively Cataract Maxitrol, Betnesol –N, Betnesol, Maxidex/ Prednisolone 0.5% 0.5% minims, Dexamethasone 0.1% minims, Predforte, Acular

Table 2: Conditions that therapeutically qualified optometrists manage. Abbreviations: seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), atopic keratoconjunctivitis (AKC), vernal keratoconjunctivitis (VKC), foreign body (FB).

Prescribing

Most therapeutically qualified optometrists (87%) prescribe on a daily or weekly basis (Fig. 5 B). Half of the 36 respondents have access to a prescription pad (10 of those use it exclusively), the remainder rely on GPs, ophthalmologists or patients to buy their medications (Fig. 5 C). The average number of prescriptions issued is 18 per month with a median of 10. According to this estimate, optometrists issue a prescription approximately once every two days.

13 Fig 5: Prescribing activities and referrals. A: Impact of prescribing on referrals. Onward referral rates have decreased for more than half of the 39 therapeutically qualified optometrists. B & D: Frequency and number of prescriptions. Most therapeutically qualified optometrists prescribe on a daily or weekly basis. The median number of prescriptions issued per months is 10. C: Way of prescribing. Half of the 36 respondents have access to a prescription pad (10 of those use it exclusively), the remainder rely on GPs, ophthalmologists or patients to buy their medications.

Wider impact Ninety-two percent of optometrists feel more confident with diagnosis and management as a result of the therapeutic training. Seventy-five percent regard the training as very helpful for their practice (rating of 8 and above on a scale from 1 ‘not helpful, work in practice has not changed as a result of training’ to 10 ‘very helpful, skills and knowledge gained have a significant impact on everyday practice’; Fig. 2D) and the overwhelming majority (93%) would recommend IP training to a colleague.

Onward referral rates are reported to have decreased for more than half of the 39 therapeutically qualified optometrists. Referrals have remained the same for 41% but a minority of 8% refer more often (Fig. 5 A).

14 Discussion

This survey shows a very positive perception of the training and practice for prescribing optometrists. Both aspects of the training, the theoretical component as well as the practical placement, are rated highly. Optometrists are satisfied that the training provides improved theoretical and practical knowledge for therapeutic management of a wide range of eye conditions.

The survey was deliberately restricted to those who have at least completed the University training and the majority of the participants are qualified as therapeutic prescribers. This allows a view on various aspects of the training and the resultant practical implications. Many more optometrists will become AS and IP in the next few years. In Scotland alone, more than 250 optometrists have started GCU’s course since 2009 and almost 100 have completed it. This corresponds to approximately 20% of all optometrists in Scotland.

Prescription pads are an essential feature of prescribing. Not only do they allow patients easy and often cheaper access to medications, they allow Health Boards in Scotland and Northern Ireland and Primary Care Trusts in England and Wales to audit the prescribing activities including, for example, whether the prescriber is prescribing to the local formulary. Prescribing via the GP may be an acceptable route for local hospital eye departments but it could be a problem if GPs do not accept the requests of an optometrist for a prescription. According to our survey, at the moment 70% were reliant on others (GPs, ophthalmologists) for at least some of their prescriptions.

An essential aspect of IP delivered by optometrists is the impact on health care. This is difficult to determine not least because different aspects (e.g. patient satisfaction and cost savings) would have to be weighted against each other. It can be seen from our data that in total there are fewer onward referrals after training than before. The number of prescriptions issued might provide an indirect estimate of impact of IP. On the assumption that most of these patients were treated successfully and did not require subsequent referral, prescription numbers should correlate with ease of access for patients and reduced costs for the NHS: non-prescribing optometrists would have referred these patients for diagnosis and management, a process which would have incurred additional costs. Nevertheless, without a careful audit, this indirect assessment of the impact of IP on health care remains speculative and there is a clear need for future studies to quantify the impact of IP optometry on NHS costs and care.

One of the concerns expressed before the IP legislation was that optometrists would not get enough experience . Our study found that 42% of prescribers write 1-10 prescriptions a month with a median of 10. Most of our sample prescribes on a daily or weekly basis. It remains to be seen if this is sufficient to maintain competence.

All IP optometrists must state the number of prescribing events in their annual registration with the General Optical Council. The purpose of this is to provide

15 a safety net and prevent the public being exposed to an optometrist who is prescribing only very infrequently. It is of some concern that 32% did not report auditing their prescribing, as this is a GOC requirement. Audit enables the optometrist to measure and reflect on their IP practice. It is an essential part of NHS practice [4] and is recommended in the College’s ‘Advice and Guidelines for Optometrist Prescribers’ . Recent experience shows that evidence from audit can be used both to implement local protocols (e.g. Glasgow Integrated Eyecare Service) and lobby for governmental changes to regulations .

Positive feedback, especially from patients, is critical to the future success of IP and it was encouraging to see that the majority of feedback received was positive or very positive and that this feedback was coming from GPs and ophthalmologists as well as patients. This may be an area for future research, especially with respect to examining the awareness within the general public of the existence of this service.

The average time taken to complete the practical placement was 4 months. Adding the time to complete the theoretical part (a minimum of 10 months in the case of GCU) and about 2 months to apply and prepare for the College CFA exam, gives a total of 16 months. Hence, optometrists can acquire IP registration in about a year and a half.

The speciality is still very much in its infancy. The first IP optometrists qualified only 18 months prior to our survey, in November 2009 and less than 1% of the profession are on the specialist therapeutic prescribing register at the time of writing. Although the opinions expressed in this survey represent more than 60% of all currently registered IP optometrists, this nevertheless means that the actual number of participants is small. The purpose of this survey was not to ascertain the view of the profession as a whole towards therapeutic prescribing (see for the viewpoint of a wider sample of optometrists). Instead, the aim was to learn what those optometrists, who have completed the theoretical training, think about the training and what impact it has had on their practice. This article is therefore restricted to providing an initial perspective. A subsequent review in a few years time will be indicated to provide a description of how prescribing for optometrists has established itself. We hope that a description of the initial stages has the potential to help shape that establishment by informing the wider profession and those already registered as IP optometrists about the experience of the early prescribers. This should be of interest to those who are already qualified (to draw comparisons with their peers), to those who are considering undertaking therapeutic training but also to the broader optometric community. The development, scope and practical implementations of IP Optometry may also interest members of other health care professions.

Notwithstanding the new development, the practitioners sampled in this survey are using their newly gained prescribing rights to manage a wide range of conditions with an extensive range of medications.

16 References

Acknowledgements We would like to thank Dr Mhairi Day for her help in designing the questionnaire and providing invaluable feedback on this document.

17 Appendix A – Training Questionnaire

About You

1. In which country do you practice? (Tick one) Scotland / England / Wales / Northern Ireland / Other (please specify)

2. In which year did you first register with the GOC?

3. Where do you work? (Tick all that apply) In the community / In a hospital / Other (please specify)

AS/IP Training - University Based (Theoretical)

1. At which University did you take your AS/IP training? (Tick one) Glasgow / London / Manchester / Other (please specify)

2. How would you rate the University training? (Scale: 1 = not helpful and/or relevant; 10 = essential to prepare for IP prescribing)

AS/IP Training - Clinical Placement

1. At what stage is your Clinical Placement? (Tick one) Not Started / In-Progress / Complete

AS/IP Training - Clinical Placement (Not started)

1. What is preventing the start of your clinical placement? No time / Not possible to get placement / Other (please specify)

AS/IP Training - Clinical Placement (In progress)

1. Where (e.g. which hospital) are you doing your clinical placement?

2. Do you feel you will examine a sufficient number of patients with relevant clinical conditions? (Scale: 1 = insufficient; 10 = sufficient range and number of conditions)

2. Which clinics do you attend? (Tick all that apply) None / A+E / Glaucoma / Retina / General Ophthalmology / Macula / Vitreoretinal / Uveitis / Other (please specify)

3. When do you expect to complete your placement? (Tick one) Within next month / Within next 3 months / Within next 6 months / Within 1 year / Other (please specify)

4. What do you feel about the duration of the clinical placement? (Tick one)

18 Too short / Just right / Too long

6. How would you rate the Clinical placement? (Scale: 1 = not helpful and/or relevant; 10 = essential to prepare for IP prescribing)

AS/IP Training - Clinical Placement (Complete)

1. In which hospital was your clinical placement?

2. Did you feel you examined a sufficient number of patients with relevant clinical conditions? (Scale: 1 = insufficient; 10 = sufficient range and number of conditions)

2. Which clinics did you attend? (Tick all that apply) None / A+E / Glaucoma / Retina / General Ophthalmology / Macula / Vitreoretinal / Uveitis / Other (please specify)

3. To what level did you discuss management of patients with the supervising ophthalmologist? (Scale: 1 = insufficient; 10 = extensive)

4. How long did it take to complete your placement? (Tick one) 1 month / 3 months / 6 months / 1 year / Other (please specify)

5. What did you feel about the duration of the clinical placement? (Tick one) Too short / Just right / Too long

7. How would you rate the Clinical placement? (Scale: 1 = not helpful and/or relevant; 10 = essential to prepare for IP prescribing)

AS/IP Training - Qualifications

1. Are you qualified as ... (Tick all that apply) AS / SP / IP / Not yet qualified

AS/IP Training - College Exam

1. How would you rate the College exam? (Scale: 1 = not assessing relevant skills; 10 = best way to assess skills and knowledge required from an AS/SP/IP optom)

Feedback

1. Have you received any feedback from ... (Tick all that apply) Patients / GPs / Pharmacists / Ophthalmologists / No feedback received / Other (please specify)

2. Has feedback been: Very positive / Positive / Ambivalent/mixed / Additional Comments

19 Patient Management / Prescribing (Qualified)

1. As a result of the therapeutic training, do you feel more confident with respect to diagnosis/management of your patients? More confident / Less confident / About the same

2. Do you treat or manage conditions now that do not require AS/IP drugs but which you did not manage before? (Tick one) Yes* / No (* LIST CONDITIONS)

3. Do you refer patients more or less often than before? More / Less / Same

4. In which conditions do you specialise or plan to specialise? (Tick all that apply) Primary Eye Care / Glaucoma / Other (please specify)

5. Do you treat/manage conditions that require AS and/or IP? (Tick one) Yes* / No (* LIST CONDITIONS AND THE DRUGS YOU USE)

Prescribing

1. How often do you prescribe? (Tick one) Never / Daily / Weekly / Monthly / Less than monthly

2. How many prescriptions do you issue per month on average?

3. How do you prescribe? (Tick all that apply) Prescription pad / Written order / via GP / via Ophthalmologist / Other (please specify)

4. Do you audit your prescribing activities? (Tick one) Yes / No (If 'Yes', please give details)

Patient Management / Prescribing (Not yet qualified)

1. Do you feel more confident with respect to diagnosis/management of your patients? More confident / Less confident / About the same

3. Do you treat or manage conditions now that do not require AS/IP drugs but which you did not manage before? (Tick one) Yes* / No (* LIST OF CONDITIONS)

4. Do you refer patients more or less often than before? More / Less / Same

5. In which conditions do you specialise or plan to specialise? (Tick all that apply) Primary Eye Care / Glaucoma / Other (please specify)

AS/IP Training -It's Impact

20 1. How helpful was the AS/IP training for your practice? (Scale: 1 = not helpful, work in practice has not changed as a result of training; 10 = very helpful, skills and knowledge gained have a significant impact on everyday practice)

2. Would you recommend IP training to a colleague? (Tick one) Yes / No / Maybe

3. What aspects of the IP training would you improve?

AS/IP -The Future

1. Do you expect to manage more conditions in the future? (Tick one) Yes / No (If 'Yes', please list conditions and drugs)

2. What changes would you like to see in the future?

3. Where do you see the future of prescribing for therapeutically qualified optometrists?

4. Please enter any additional comments you would like to make