Avoidance of Doubt letter – Examining Clinically Challenging Patients in England

As Members will be aware, NHS England issued a letter on 25 February 2019 about providing services to clinically challenging patients specifically

  • very young children
  • people with dementia
  • people with learning disabilities

when a full sight test cannot be completed.

The letter was modelled on a type of communications – an ‘avoidance of doubt’ letter – which is routinely sent to front-line dentists to clarify contractual issues.

The Optical Confederation had input to a first draft but did not see the final version about which Members have raised concerns. These have been passed on to NHS England.  However the letter does contain extremely useful advice particularly the following paragraphs:

What needs to be recorded?

That a sight test was conducted/attempted. If it could not be completed, then a record should be made of the parts of the sight test that were completed, along with notes of the parts that could not, and the reason(s) why.

If an external examination can be conducted, but a full internal examination cannot, then a record should be made of what can be seen. This may be as simple as ‘red reflex’ on retinoscopy, indicating that there is no sign of cataract.

If internal examination can be partially completed, but detailed examination is not possible, a note should be made on the record to indicate this e.g. ‘red reflex seen, glimpses of optic disc and macula, appears normal as seen’

Can I claim a GOS sight test?

As long as a reasonable attempt has been made to examine the patient, appropriate records of this are kept and any legal obligations are met, then a GOS sight test fee can be claimed. This includes cases where the examination is very limited, but significant concerns in case history have indicated the need for onward referral for examination in secondary care.

The Opticians Act requires you to perform an internal and external examination when conducting a sight test. NHS England considers that in exceptional circumstances (and only if nothing else is possible), this would require an assessment of the pupil “red reflex” and an attempt to assess any prescription, sometimes with retinoscopy alone. Records should reflect what was attempted and why it was not possible to carry out a full examination.

It would be helpful if Members could ensure this advice reaches optometrists and, where appropriate, is incorporated in SOPs.

Recall Intervals

The final paragraph about recalls is slightly misleading.  The advice that recalls should be “in line with normal clinical practice” is correct.  However, in the case of clinically challenging patients, particularly in cases where vision and pathologies can change rapidly, the clinician should always recall the patient at the interval they judge is clinically appropriate – just as for any other patient.  This might not “normally be two years”.   The intention is to make this clearer in the next version of Making Accurate Claims in England.


If you have any queries about this guidance, please contact us on [email protected].