The UK currently spends £25 billion per year on ocular disease, and there is expected to be a 40% increase in those affected by visual impairment by 2050 [1]. To manage this demand, 82% of ophthalmology units across the UK utilise non-medical healthcare professionals (HCPs), which include optometrists, orthoptists and ophthalmic nurses.
As demand continues to increase, the requirement to further train the non-medical workforce lies within current education frameworks that covers a number of essential skills and lead to the development of autonomous practitioners in both primary and secondary care [2].
Ophthalmic healthcare professionals and training requirements
Optometrists
Previously known as ophthalmic opticians, optometrists qualified eyecare professionals who specialise in eye health and vision correction. They are trained to examine eyes to detect defects in vision, signs of injury, ocular diseases or abnormality and problems with general health, such as high blood pressure or diabetes. They make an eye health assessment, offer clinical advice and treatment where appropriate, prescribe spectacles or contact lenses and, when necessary, refer patients for further management. Optometrists complete an integrated master’s degree, which must include 48 weeks of patient-facing experience to meet the General Optical Council (GOC)’s education and training requirements during the four-year course (five in Scotland). The College of Optometrists (CoO) provides 44 weeks of the required clinical placement experience for student optometrists (as part of most universities’ masters in optometry degrees) through its Clinical Learning in Practice (CLiP) programme, which are regulated by the GOC [3].
Orthoptists
Working generally with ophthalmologists in hospitals and in the community, orthoptists specialise in the assessment, diagnosis and management of visual development, binocular vision disorders, eye movement abnormalities, and related conditions. They also play a crucial role in treating conditions related to visual development and coordination, such as strabismus, amblyopia and other vision impairments. Orthoptists complete an orthoptic undergraduate degree that is a full-time three year course in England and four years in Scotland. They also undertake clinical placements at different hospitals. If students already have an undergraduate degree in a relevant science, there is an option to take an accelerated two-year MSc course at UCL or the University of Liverpool [4]. All orthoptists are regulated by the Health and Care Professions Council.
Nurses
Becoming a registered nurse takes a minimum of three years of training, through an undergraduate degree or apprenticeship, where nurses are regulated by the Nursing and Midwifery Council (NMC) [5]. After qualifying they can then specialise in eyecare. They provide care to patients with visual impairments or eye conditions and work with ophthalmologists in various settings such as hospitals and clinics. However, there is currently no NMC accredited or mandated standardised training framework for nurses wishing to specialise in ophthalmology.
Continued professional development
All HCP’s are registered with their respective UK regulator that include the GOC, NMC, and the Health and Care Professions Council. Since 2005, all regulators have required members to demonstrate their professional development to maintain registration through continued professional development (CPD). This is to ensure they keep their skills up-to-date and develop new ones in order to practise safely and protect their patients. CPD includes interactive elements, where registrants interact with peers through peer review, case discussion and / or attending physical events (conferences, lectures, courses). In addition, there is provider-led CPD organised by groups as well as self-directed CPD that includes work-based learning and academic learning, as well as reflective exercises, where each regulator has specific requirements for each HCP to meet. In addition to CPD, several educational frameworks offer ophthalmology training for HCPs that provide the opportunity for registrants to upskill and enhance the delivery of eyecare.
College of Optometrists’ higher qualifications
The CoO [6] accredits a range of higher qualifications from a postgraduate certificate through to diploma level covering contact lens practice, glaucoma, low vision, medical retina and paediatric eyecare, which encompass both academic assessments and work-based placements. Accredited courses are currently offered by a number of UK higher education institutions and are open to HCPs through standalone postgraduate courses or master-level qualifications, however CoO accreditation / affix is currently limited to orthoptists and optometrists.
Popular College qualifications that have been achieved are those in glaucoma. This is of particular relevance as the Royal College of Ophthalmologists’ (RCOphth) Way Forward paper on glaucoma [7] predicted the number of people in the UK with glaucoma to increase by 44% from 2015 to 2035. As such, there have been several optometrist-led glaucoma pathways developed in recent years in this area, where acquisition of these qualifications is a pre-requisite to working in some of these schemes that include repeat measures, shared-care and referral refinement [8].
"As demand continues to increase, the requirement to further train the non-medical workforce lies within current education frameworks"
The highest glaucoma level qualification the College offers is the diploma in glaucoma, which supports a range of independent clinical decision-making [9]. The concept of the National Institute for Clinical Excellence (NICE)-defined extended roles for non-medical HCPs was expanded in the NICE-approved joint RCOphth and Clinical Council for Eye Health Commissioning (CCEHC) Commissioning Guide: Glaucoma [10]. The related training and accreditation requirements for glaucoma monitoring were assimilated into the Commissioning Guide. The Guide used the CoO glaucoma higher qualifications as an example of accreditation required for each role, with levels I, III and IV being equivalent to optometric core competence, CoO Glaucoma Higher Professional Certificate and Professional Diploma, respectively [8].
Independent prescribing
Legislation sets out the specific regulated HCPs who can independently prescribe (IP) – that includes optometrists, pharmacists and nurses. Not all regulated professions can currently access these mechanisms, such as orthoptists, but this may change in the future. To enable HCPs to prescribe, they currently have to complete the relevant postgraduate academic and work-based learning and assessments through an accredited provider.
Nurses gained the ability to IP in 2006, providing it’s within their scope of practice, any licensed medication for any disorder. In 2009, further legislation was passed to allow nurses to prescribe unlicensed medication and amended in 2012 to allow nurses to prescribe any controlled drug from Schedules 2–5 (The Misuse of Drugs (Amendment No.2) Regulations 2012 No 973, 2012). However, there are restrictions when treating patients with addiction (Joint Formulary Committee, 2022) [11].
Soon after nurses gained IP rights, optometrists gained the ability to train for IP in 2007. Once qualified, they can prescribe any licensed medicine (except for controlled drugs or medicines for parenteral (injected) administration) for conditions affecting the eye, and the tissues surrounding the eye, within their recognised area of expertise and competence. For both optometrists and nurses, after successful completion, they are registered with their respective regulator and have to continue CPD related to their prescribing. As of 2024, there were 18,127 optometrists registered with the GOC, that would infer that among these 10.8% of all optometrists now have IP qualification [12].
Prescribing is beneficial to both service users and practitioners, spanning primary and secondary care. Studies evaluating clinical decisions of IP optometrists in primary care found most cases could be managed to resolution without the need for further referral [13,14], thus supporting the hypothesis that IP qualification promotes effective independent clinical decision-making. In addition, studies have found good agreement of IP optometrists to ophthalmologists within the hospital eye service, which supports their ability to manage high-risk cases as well as the significant acquisition of advanced skills [15,16]. It’s important to note that the ability to prescribe does not define advanced-level practice [17], which is discussed later. This pathway could be sought after the acquisition of Advanced Clinical Practice (ACP) status in ophthalmology, where for ophthalmic nurses this may be preferred, considering the absence of a mandated training framework for those desiring to work in ophthalmology post nursing registration.
Independent prescribing supports professional development and further enhances care delivery in both primary and secondary care. For optometrists, depending on their scope of practice and setting, the CoO’s Clinical Management Guidelines [18] offer information on the diagnosis and management of a range of conditions that present with varying frequency in primary and first-contact care. For example, an entry-level IP optometrist can independently manage minor ocular emergencies such as a corneal abrasion. However for independent glaucoma management, both IP status and the CoO’s Diploma of Glaucoma or a qualification of similar equivalence would be required.
RCOphth: Ophthalmic practitioner training framework
The RCOphth’s Ophthalmic Practitioner Training (OPT) framework (formerly known as OCCCF, first published in 2016) was developed in collaboration with a number of UK stakeholders to provide a universal standard of training for HCPs providing ophthalmic care [19]. This is delivered at three levels and covers approximately 130 learning outcomes (competencies) across 13 domains. The standard required to pass each competency is described for three levels, where Level 1 demonstrates performance to assist medical decision-making to independent decision-making (Level 3) [20].
Ophthalmic Practitioner Training is delivered in the workplace under the supervision of local trainers. It’s a competency-based programme in which the curriculum sets standards that are assessed in the workplace by the collection of evidence in a portfolio. Competence is acquired through self-directed learning, teaching in the workplace, clinical experience, supervision and formative assessment that covers four subject areas: medical retina, glaucoma, cataract and emergency (acute eyecare). The learner is responsible for driving their own learning, supported by their Trusts and their supervisors [21].
NHS England: Advanced clinical practice
The definition of advanced practice is that it’s delivered by registered HCPs that demonstate a level of practice characterised by a high degree of autonomy and responsibility for complex decision-making. Since the first framework was published in 2017 and advanced practitioners have played a key role in managing complex patient needs, championing innovation, quality and compassionate care in a rapidly changing healthcare landscape. This framework is underpinned by a post-registration master’s level award or equivalent, which is undertaken by an experienced practitioner that encompasses all four pillars of advanced practice that are: clinical practice, leadership and management, education, and research [17]. For ophthalmology, the highest level of OPT (Level 3) forms a major part of the clinical pillar within the master’s degree in ACP [22], which is accredited by NHS England’s Centre of Advancing Practice.
The master’s degree offers a structured programme in ACP to develop clinical practice and to contribute to the advancement of eyecare delivery in primary, secondary, or tertiary care. This covers the four pillars that encompass the four busiest ophthalmic specialties in the UK and worldwide: glaucoma, medical retina, ophthalmic emergencies, and cataract.
The first accredited master-level ACP programme for adult ophthalmology by NHS England’s Centre of Advancing Practice was awarded to the University College London (UCL) MSc ACP programme in 2025, which also encompasses all four OPT subjects and the CoO frameworks in glaucoma and medical retina. Furthermore, it’s the only UK ACP programme that is accreditedup to the diploma level in glaucoma by the CoO.
This degree enables graduates to expand their scope of practice in ophthalmic care by obtaining specialist clinical skills as well as acquiring the knowledge,and behaviours to take on roles in leadership, research and education in the healthcare setting by simultaneously building a work-based portfolio. Candidates need to undertake work-based learning and assessments that are arranged with their employer, which require a designated education supervisor to organise the appropriate clinical supervision.
A recent paper demonstrated the current relevance of the ACP ocular emergencies curriculum, if students decide to specialise in this area, where this aligned with 15 of the 22 advanced optometric clinical skills that were desired for optometrists working in Europe’s largest tertiary dedicated ophthalmic hospital’s (Moorfields Eye Hospital) accident and emergency clinic [15]; a number of these skills were also common in external disease and urgent care services, where these skills could also be adopted and may enhance current urgent primary eyecare services [13,14,23].
The UCL ACP in Optometry and Ophthalmology is open to UK apprentice and non-apprentice students [25]. If graduates are non-UK registered HCPs or are based in the UK and are unable to secure a work-based placement, UCL offers an academic-only MSc programme in optometry and ophthalmology, where no work-based placements are required yet all the academic learning is mapped to all the above curriculum stated in the ACP MSc [26]. All programmes can be completed full-time or part-time, ranging one - five years, bar the apprenticeship route that requires completion within three years . The scope of ACPs in ophthalmology is expanding, where there are a growing number of accredited higher education institiutions that offer similar ACP programmes in adult ophthalmology or ACP paediatric ophthalmology.
Future and long-term NHS Workforce Plan
It has been noted that by 2035 there will be fewer staff than projected in the 2023 Long-Term Workforce Plan [24]. Utilisation of current HCPs to access further training and increase their scope of practice is essential in order to meet the increasing demand in ophthalmology. Completion of these education frameworks aligns with the NHS long-term workforce transformation plan [27] that will expand on HCP’s delivery of care. Healthcare professionals will be able to develop themselves and work in senior roles within the NHS as ACPs that feed into the four pillars in both primary and secondary care, or as independent contractors by co-managing NHS patients or providing independent care to meet continued eyecare demand.
References
1. www.fightforsight.org.uk/media/
3302/time-to-focus-report.pdf
2. Greenwood V, Stanford P, Beddow C, et al. Changing practice for the non-medical ophthalmic hospital workforce in the UK—a snapshot survey. Eye (Lond) 2021;35(7):1886–94.
3. www.college-optometrists.org/qualifying/
a-career-in-optometry#orthoptists-76448d18
4. www.orthoptics.org.uk/become
-an-orthoptist/study-orthoptics
5. www.nmc.org.uk/education/becoming-a-nurse
-midwife-nursing-associate/becoming-a-nurse
6. www.college-optometrists.org/professional
-development/further-qualifications/higher-qualifications
7. www.rcophth.ac.uk/wp-content/uploads/2015/10/
RCOphth-The-Way-Forward-Glaucoma-300117.pdf
8. Harper RA, Gunn PJG, Spry PGD, et al. Care pathways for glaucoma detection and monitoring in the UK. Eye (Lond) 2020;34(1):89–102.
9. https://glaucoma.uk/wp-content/uploads/2020/
09/Glaucoma-Risk-Stratification-Tool-1.pdf
10. www.rcophth.ac.uk/wp-content/uploads/
2020/08/Glaucoma-Commissioning
-Guide-Long-June-2016-Final.pdf
11. Dunn J, Pryor C. Non-medical prescribing in nursing: the history and evolution of independent and supplementary prescribing. Br J Nurs 2023;32(20):1004–8.
12. Public register search (2024). https://str.optical.org
13. Cottrell P, North R, Sheen N, Ryan B. Optometry independent prescribing during COVID lockdown in Wales. Ophthalmic Physiol Opt 2022;42(6):1289–303.
14. Ansari E, Patel M, Harle D. Acute community ophthalmology services provided by independent prescribing optometrists supporting hospital eye services during the COVID-19 outbreak. J Optom 2022;15(2):175–8.
15. Jindal A, Abdulrasid S, Mulholland PJ, et al. An evaluation of optometric advanced skills within a UK tertiary based setting. Eye (Lond) 2024;38(7):1276–82.
16. Todd D, Bartlett H, Thampy R, et al. Agreement in clinical decision-making between independent prescribing optometrists and consultant ophthalmologists in an emergency eye department. Eye (Lond) 2020;34(12):2284–94.
17. https://advanced-practice.hee.nhs
.uk/mpf2025/introduction
18. www.college-optometrists.org/clinical-guidance/
clinical-management-guidelines
19. www.hee.nhs.uk/our-work/advanced-clinical
-practice/ophthalmology-common-clinical
-competency-framework-curriculum
20. www.rcophth.ac.uk/training/
ophthalmic-practioner-training
21. www.rcophth.ac.uk/wp-content/uploads/
2021/08/OCCCF-Portfolio-Guidance.pdf
22. www.hee.nhs.uk/our-work/advanced-clinical
-practice/ophthalmology-common-clinical
-competency-framework-curriculum
23. Konstantakopoulou E, Edgar DF, Harper RA, et al. Evaluation of a minor eye conditions scheme delivered by community optometrists. BMJ Open 2016;6(8):e011832.
24. https://assets.publishing.service.gov.uk/
media/6888a0996478525675738f3a/fit-for-the
-future-10-year-health-plan-for-england-executive-summary.pdf
25. www.ucl.ac.uk/prospective-students/
graduate/taught-degrees/optometry-and
-ophthalmology-advanced-clinical-practice-msc
26. www.ucl.ac.uk/prospective-students/graduate/
taught-degrees/optometry-and-ophthalmology-msc
27. www.hee.nhs.uk/our-work/workforce-transformation
[All links last accessed September 2025]
Declaration of competing interests: Anish Jindal is employed by Moorfields Eye Hospital and holds a position at UCL as Deputy Programme Director for the MSc Optometry and Ophthalmology (ACP) programme.
