The Moorfields/UCL laser course for ophthalmic healthcare professionals was designed following a continuously evolving field in the management of glaucoma, with calls for expansion of the professional categories treating and managing glaucoma [16,17,18,19].

Primary SLT for OAG and OHT is beneficial to patients, who can remain largely drop-free for up to 6 years after treatment [8]. Patients initially treated with SLT demonstrate a reduced need for cataract and glaucoma surgery which is a cost-effective secondary outcome for the NHS. The introduction of new SLT lists in glaucoma units in the UK is, therefore, imperative for delivering effective treatments and efficient services, but this could be at the detriment of delivering other glaucoma clinical services die to the limited supply of trained clinicians in the face of increasing demand. Reports on the glaucoma service nationally have revealed a shortage of senior ophthalmologists [17, 35], but the number of glaucoma patients is expected to grow by a fifth over the next decade and backlogs are expected to increase [17, 36]. With complex cases requiring higher level decision-making and surgical input forming approximately 20% of senior ophthalmologists’ time in the NHS [17], the need to allocate non-complex cases and procedures to other members of staff is imperative.

This training programme described was developed using educational principles with the aim of providing structured training to non-medical ophthalmic practitioners.

Clinical competence was ranked using Miller’s pyramid [37] (Fig. 3), which distinguishes between acquisition of knowledge and action in the workplace. In this training programme clinicians were assessed at different stages of learning leading up to the setting in which the procedure needed to be delivered. As the understanding of the clinician learners increased, they interpreted and applied knowledge taught subsequently demonstrating and performing the procedure in the workplace, ultimately reflecting the knowledge, skills and behaviours acquired. The programme was designed in three stages, to reflect a gradual build-up of knowledge, skills and confidence: Stage 1 - Knowledge acquisition and demonstration of procedure; Stage 2 - Work-based learning and assessment; Stage 3 - Reflective practice.

The levels of learning are demonstrated on the Moorfields Laser Course, depicting the development of clinical expertise through each stage of the course.

Clinicians were also trained on and encouraged to conduct self-audit, an important aspect of professional practice, self-evaluation and improvement, linked to self-regulated learning and self-awareness [38]. Audit improves care, safety, quality, and outcomes and can be used as an educational tool, helping to identify learning and training needs; it is recognised by the Care Quality Commission (CQC) as a professionally led exercise, which is an essential component in clinical governance and the delivery of high-quality care. The course concluded with reflective practice, described in the literature as “a generic term for intellectual and affective activities which individuals engage to explore their experiences in order to lead to new understanding and appreciation” [39]. In contrast to audit, reflection consolidates deep learning by reflecting on the experience, re-evaluating both negative and positive feelings of an entire learning journey and contributes to the holistic practice within a healthcare setting. At the end of this stage, learners had formed a community of practice where these experiences could be shared.

A principal glaucoma-specialist optometrist regularly performing SLT, after being trained in an apprenticeship format commented on the benefits of the structured training and the exposure to model eyes commented: “It can be quite daunting for clinicians in the early stages of training to perform a laser procedure, despite being highly trained to perform tests and make complex clinical decisions. Having a structured training process enables the clinician to grasp and embrace this new skill safely and effectively; practising on model eyes gives a feel for what happens during the procedure and what to look out for”.

Previous qualitative data indicated that medical training could also utilise a formal, structured training framework, possibly the same as the one developed for optometrists [27]. Current ophthalmology training encompasses a laser induction course, but this is not followed by structured in vivo training. The apparent differences in the laser-training requirements between optometrists and trainee ophthalmologists may warrant further investigation and careful consideration by professional bodies. Adoption of a structured programme by ophthalmology speciality trainees and/or medical professionals trained outside the UK could be of benefit to clinicians, patients and Trusts.

The audit performed at Moorfields Eye Hospital for 6 glaucoma-specialist optometrists having undertaken the structured course described here indicates that optometrists deliver safe treatments, whilst adhering to local protocols. IOP spikes, defined as an IOP > 30 mmHg, occurred in 3.7% of performed procedures. This is higher than 1% reported for the LiGHT trial, where an IOP spike was defined as a post-laser increase in IOP larger than 5 mmHg [8]. Differences in definitions and pre-treatment IOP are likely related to the IOP spike incidence differences between the two populations. The safety of non-medical delivery of SLT has been previously described in the UK [33] and is comparable to that reported for ophthalmologists [8, 40, 41]. However, it is worth noting that the procedure has been delivered by optometrists in the US for some years [25, 42].

The lack of a formal training scheme has caused concerns around the governance of non-medically delivered ophthalmic laser procedures [27]. The main indemnity insurance provider for optometrists currently covers delivery of such procedures in the HES, assuming adequate training, accreditation and adherence to local protocols. Optometrists wishing to offer these services outside the HES have other indemnity insurance options.

Our previous work identified the lack of standardised training as a challenge in developing a healthcare system supportive of ophthalmic practitioners competent in delivering ophthalmic laser treatments. The training programme described here was developed to address this concern and was the first UK hospital/university based structured laser training available to ophthalmic practitioners. Recently one more UK university has developed a similar programme for eye-care practitioners [43], indicating a need for a national approach to the training of non-medical ophthalmic practitioners in laser procedures. The current availability of two UK ophthalmic laser-training courses and the significant increase in the number of optometrists delivering SLT in the HES [20] calls for the need to develop national standardised training and treatment protocols.