Managing professional identity within a changing market environment: New Zealand optometrists’ responses to the growth of corporate optometry

ABSTRACT

This research investigated the effects of changes in the market environment for optometry services and products on the professional identity of New Zealand optometrists. It explored three issues. First, ways participants’ location within either the independent or corporate sectors shaped their professional identities. Second, ways potential ethical conflicts between participants’ healthcare and retailing identities were resolved. Last, participants’ opinions concerning the future of their profession. Twelve male and fourteen female optometrists were interviewed. Nineteen participants worked within independent optometry practices. Seven worked within practices that were part of international optometry chains. Six participants were recent graduates, the rest experienced optometrists. All participants identified primarily as healthcare professionals. All recognised that practising optometry within a commercial market created the possibility of ethical conflicts between healthcare and business imperatives. There were differences in the ways participants managed this boundary, with participants working within corporate optometry seeming more comfortable with the business aspects of their profession. All participants thought the profession was changing and several suggested that the future of independent optometry was limited. The article concludes that recent changes within the market environment of optometry have heightened tensions between optometrists’ medical and entrepreneurial identities and contributed to changing work patterns within the profession.

KEYWORDS:

• Optometry
• business environment
• professional identity
• role tension

Introduction

Private optometry within New Zealand generally combines specialised healthcare with the selling of prescription eyewear. The sector is sizeable, with approximately fifty percent of New Zealanders overall wearing some kind of vision correction and over eighty percent of people over sixty-five needing corrective lenses. Over one million eye examinations are carried out each year, with around sixty percent of examinations resulting in new prescriptions for glasses or contact lenses. Legally, only registered optometrists or medically qualified ophthalmologists can carry out eye examinations, prescribe spectacles or contact lenses, or prescribe medication. The retail aspects of the industry are less regulated, with lower qualified optical technicians able to fit, and sell, frames and lenses. The large percentage of the population needing visual aids demonstrates both the medical importance of private optometry within the New Zealand healthcare system and the monetary significance of the retail aspects of optometry for practitioners.

The five year Honours degree qualification run by the University of Auckland is New Zealand’s only training programme for optometrists, although optometrists with qualifications from other countries may practise within New Zealand once they are registered. The degree programme has a strong medical focus, training optometrists to diagnosis and treat an increasing range of eye problems as well as prescribe spectacles and contact lenses (Black et al. 2019). The early professional socialisation of recent optometry graduates is therefore as highly qualified healthcare practitioners rather than as small business owners or entrepreneurs.

Optometry within New Zealand was traditionally dominated by small, independent, high street optometrists who provided an integrated service moving from eye examination to product sales to a relatively long-term customer base. The traditionally tight coupling between the health and retailing dimensions of high street optometry enabled sight-testing services to be provided at below cost rates with profits generated primarily through high margin sales of spectacles and contact lenses.

The market environment for private optometry has changed radically over the last twenty years with the entry of international chains such as Specsavers and OPSM into New Zealand and increasing competition from low-cost online optical retailers. In consequence, New Zealand optometrists face continual downward pressure on prices for both eye examinations and products. User behaviour has also changed, with younger customers being particularly likely to ‘shop around’ for the best-priced care package or to buy spectacles online (Shickle et al. 2014; Alderson et al. 2016).

Extant social science research into retail optometry falls into three main categories. First there is a limited body of economically focussed research analysing the risks which large optometry chains pose for independent optometrists and the strategies which chains use to achieve market dominance (Newby and Howarth 2012; Spaulding 2012; Olczak 2015; Patel 2016). This strand of research connects to a wider literature examining the economic relationship between small independent retailers and large retail chains. This literature generally highlights the difficulties small independent retailers face combating corporate dominance and suggests that small businesses tend to be adversely affected by the incursion of chains into their domain (e.g. Armstrong 2012).

Second, research dealing with the commercial and organisational aspects of private optometry can be linked to the growing body of organisational research examining ethical dilemmas in entrepreneurship. Much of this research explores the ways in which small business owners seek to resolve tensions between commercial imperatives and commitments to professional standards, formal governance or wider societal norms (Anderson and Smith 2007; Clarke and Holt 2010; Leitch and Harrison 2016). This research suggests that within professional sectors such as private healthcare, deeply embedded professional or occupational identities can have a strong influence on the ways in which practitioners respond to major alterations within their economic and organisational environment (Warnock 2005; Kovaleinen and Osterberg-Hogsted 2013).

The third relevant strand of research comes from medical sociology. This research generally investigates health related issues such as optometrist/patient communication, the status of medical expertise and professional ethics. Two British studies of patients’ perceptions have revealed that both younger and older adults appraise optometrists differently to other healthcare professionals, downplaying their medical expertise and suggesting that they are primarily concerned with selling products rather than providing eye care. Large optometry chains were considered particularly sales focussed, although they were also seen as providing better value for money (Shickle et al. 2014; Shickle and Griffin 2014). The few sociological studies looking directly at the organisational and economic aspects of private optometry can be linked to a far larger body of sociological research exploring the interaction between privatised medicine, ethical issues and the market economy for healthcare (e.g. Adams 2013). This research generally highlights the ways in which market forces alter the relationship between the client and healthcare professional, creating an association that is closer to a commercial transaction than to the traditional relationship between healthcare professional and patient.

Until now, there has been no research examining either the ways in which New Zealand optometrists in private practice manage the tensions between their dual roles as healthcare professionals and specialist retailers, or the ways in which independent optometrists are responding to the rapid growth of large optometry chains within a small and highly competitive market. Bourdieu argues that research into professional identity often under-estimates the level of diversity within professional groups (Bourdieu and Wacquant 1992). He suggests that different segments of a profession may work within diverse organisational fields and may develop divergent professional identities. To give an example, recent research into the professional identity of chiropractors within the U.K., Australia and America, (Villanueva-Russell 2011; Brosnan 2017) highlighted the ways in which different groups within the profession are struggling to shape the occupational boundaries and identity of the profession in ways which best benefit their own market position, while presenting an ostensibly unified professional identity to outsiders. The relatively recent, and highly significant, changes within the market economy for retail optometry within New Zealand have created the opportunity to examine discrepancies between optometrists’ dual roles as private healthcare professionals and specialist retailers, and to explore differences between optometrists within the independent and corporate sectors.

Research design

This research was an exploratory study investigating the ways in which New Zealand optometrists interpret their professional identity, and the ways in which they perceive and have responded to the entry of large optometry chains into New Zealand.

All 85 registered optometrists working in the lower North Island between Palmerston North and Wellington were sent letters inviting them to participate in the research. 26 optometrists expressed interest in participating at a time that was mutually convenient for participants and researchers. Individual, semi-structured interviews were carried out with these optometrists. Three sets of participants were interviewed: owners and employees of small, independent high street optometrists; franchise holders/partners and employees of corporate optometry chains such as Specsavers and OPSM, and recent optometry graduates. This strategy enabled the views of optometrists working within small independent practices to be compared with those of optometrists working within corporate practices and the views of experienced optometrists to be compared with those of recent graduates.

Twelve men and fourteen women were interviewed. Fifteen participants owned or part owned their own businesses, with eleven owning independent practices and four owning corporate practices. The eleven other participants were employees, seven of whom worked within independent practices and four within corporate optometry chains. All recent graduates were employees, with the two men working within corporate practices and the four women working for independents. The preponderance of participants from independents is indicative of the greater freedom within independent optometry practices, as many optometrists working within corporate optometry practices indicated that they were unable to take part in the research without first gaining head office approval.

The interviews explored similar topics with each participant group, with questions tailored to each participant’s individual circumstances. Topics included participants’ personal histories as optometrists, reasons for choosing to buy or work within an independent practice or corporate optometry chain, the perceived advantages and disadvantages of the different types of workplace, ethical dilemmas between providing eye care and selling products, changing relationships with customers, and the future of the profession.

All interviews were carried out, recorded and transcribed by the authors. A three step analytic process was followed. Each transcript was initially analysed individually to identify key themes for that participant. The transcripts within each participant group were then compared to identify commonalities and differences within groups. Finally, the key issues raised by different groups were compared and contrasted to see whether there were differences between optometrists working inindependent and corporate practices, owners and employees, and experienced and newly qualified optometrists.

Findings

The findings are organised in relation to three key themes. First, ways in which the expression of professional identity was shaped by participants’ location within either the independent, or corporate, sectors. Second, ways in which potential ethical conflicts between participants’ healthcare and retailing roles were resolved. Lastly, participants’ opinions concerning the future of their profession.

Professional identity and market sector

All participants identified primarily as healthcare professionals, with many participants commenting on their extensive clinical training and the high professional requirements of registration. Strong allegiance to their identity as health professionals was communicated by participants working within both independent and corporate practices. Participants working within the independent practices were, however, more likely to highlight the putative superiority of their practises compared to those of corporate optometry. In contrast, optometrists working within the corporate sector emphasised the ways in which clear divisions of labour and well-designed reporting systems enabled them to continue providing quality optometric care with shorter consultation times. To give an example, the owner of a small independent optometry practice emphasised the high level of academic training and the rigorous professional standards all optometrists are held to, thereby emphasising the skilled nature and integrity of the profession as a whole, before calling attention to the ways in which the standard of care provided within her practice exceeded the care provided by corporate optometry.

We are all trained in the same way … so because everybody is a registered optometrist you would hope that the healthcare itself is not questionable. I think the big problem (with corporates) is the lack of time with the registered professional because it can take time to get to the bottom of something and it could be that something isn’t addressed, especially for those people who come in and don’t know that they have something wrong. And it’s not just about that duty of care. It’s about getting the right prescription for that person’s lifestyle. So that’s the difference I think. We can give better service. We spend more time so I can use my skills to give the patient the best outcome for them. (Participant No 17, female, 30 plus years experience, sole owner independent practice).

Similarly, the owner of a corporate optometry practice explained his decision to buy into a franchise by emphasising the high clinical standards within corporate optometry and his ability to provide healthcare of a standard equivalent to independent optometry practices:

To begin with I thought that (corporate) is not for me. The main thing for me was that my professional integrity was respected and I was well supported in what I did. My big concern was that I was used to having 45 minute appointments. I wasn’t willing to cut corners. Then I went and looked at a busy (corporate) practice and sat in with them for a day and decided that with the pre-testing I wasn’t going to be under much more pressure than I usually was. I have not done a twenty minute book though –at times we did and it wasn’t effective for us. It was better to take 25 minutes and allow people to feel more cared for. (Participant No 13, male, 30 plus years’ experience, part-owner corporate practice)

The focus on clinical identity was particularly strong for newly qualified graduates, all of whom highlighted the strong emphasis on clinical skills within their university training and declared that their current focus was entirely on improving clinical skills. Despite this, there were subtle differences in perspective between the four participants who had chosen to work in independent practices and the two participants working in large optometry chains, suggesting that differences in the expression of professional identity start forming relatively early in optometrists careers.

The four female graduates who were working as employees in the independent sector all contrasted the pressured environment of corporate optometry with the slower pace of the independent sector, arguing that the longer consultation times enabled them to refine their clinical skills, focus on more complex eye problems and build a better rapport with their clients. A newly qualified participant who had worked in both sectors as a student explained:

Corporate is really rushed. They try to squeeze every single person in … sometimes to the point where care is slightly compromised. Especially where the patient is more complicated than usual … they try to refer them on because they don’t make money out of it. … I don’t want to be that sort of optometrist. … At university what I liked was to try and do anything within my scope. So if I think I can solve something given a bit more time – then I would definitely spend the time. (Participant No 1, female, new graduate, employee at independent)

In contrast, one of the two male participants working within corporate optometry contrasted the wider variety of clients seen within optometry chains with the more limited and affluent client base of independents; suggesting that the more diverse clientele enabled him to gain a more comprehensive clinical experience and offer a socially valuable service to low income customers who could not afford the prices charged by independent optometrists. The other participant argued that corporate optometry represented the future of the profession and it was therefore essential to learn how to practice competently within that framework.

In conclusion, all participants emphasised that they had completed a rigorous academic and professional training programme concentrating on the healthcare side of optometry. In consequence, all participants shared an interest in preserving and enhancing the healthcare credentials of their profession. Although there were commonalities between participants, their identities as healthcare professionals were influenced by the market sector within which they worked. All participants emphasised the superior efficacy and value of work organisation within the market segment in which they currently worked, while carefully avoiding criticising the professional expertise of colleagues in competing sectors of the optometric market.

Healthcare versus retailing

Every participant recognised that practising within the private healthcare sector created the possibility of ethical conflicts between clinical and business imperatives. Participants working within the independent sector seemed less comfortable acknowledging and balancing the two aspects of their profession, perhaps because the tension between the healthcare and retailing aspects of optometry has become increasingly salient with the emergence of corporate optometry chains offering low cost eye tests and spectacles.

All participants acknowledged that the retail side of optometry subsidises the provision of eye tests, which are generally provided free, or billed at uneconomic rates. Over half of the participants working within independent optometric practices identified the uneconomic charging rate for eye tests as an increasing problem undermining both the healthcare credentials of the profession and the economic viability of their businesses. An optometrist with over thirty years of experience in the independent sector explained:

For me it [the growth of free eye examinations] is just appalling really. You spend five years at university and you come out as a therapeutically endorsed primary eye care practitioner and your time is worth nothing in those places [corporate optometry practices]. The public just see you as providing a pair of glasses. It definitely undermines the way your clinical skills are valued. You do have to run a business but it’s a question of how you go about doing it while maintaining an ethical standard. I would have to say that over the last five years it has been harder to do that. I think of them as a patient when they sit in the chair and a client when they are out the front, which I suppose is a coping mechanism. (Participant No 19, male, 30 plusyears experience, joint owner independent practice)

While all participants from independent practices acknowledged the link between the healthcare and retail aspects of private optometry, many were distinctly uncomfortable with the idea that their practices should have overt conversion targets linking eye examinations with retail sales. The owner of a provincial independent observed:

We don’t have a conversion rate here at all. The corporates do. So the pressure is there to sell another pair of glasses. Ethically, I don’t think there should be [conversion rates]. If people don’t need them [new spectacles] they don’t need them. That’s my opinion … It does get difficult though when things are financially tough and you have staff who are financially dependent on you. (Participant No 20, male, 30 plus years experience, joint owner independent practice)

Participants working within corporate environments were more at ease with conversion targets, although all argued that they are a business management tool separate from the clinical aspects of optometry. The part owner of a corporate franchise explained:

The healthcare side obviously comes first but without the business side you wouldn’t be able to offer the healthcare side so both need to be working well. … Once I became a partner I started to see how optometrists had different conversion rates and I started to think why. Experienced optometrists have naturally higher conversion rates than new graduates and I realised that it’s about the trust patients have in you. It wasn’t about selling people glasses that they didn’t need. It was about explaining the options in a way that they trust your recommendations. At [name of corporate] the optometrist isn’t involved in the whole process so it’s also about the retail staff as well. They help the patient choose the frames and do the actual selling. (Participant No 24, male, approximately 10 years’ experience, part-owner corporate practice)

Recent graduates were both less interested in the retail side of the profession than business owners were and more open about the retail pressures within the industry. This may reflect the fact that recent graduates had qualified at a time when the therapeutic and healthcare aspirations of the profession were increasing and the retail aspects of optometry had become more overt. A male graduate working within a corporate practice commented that:

As an optometrist I’m just a salaried worker, I don’t get a bonus or commission. What I need to do is make an efficient judgement and make recommendations. It depends on the people out front what kind of pressure they put on them. They are not optometry related they are just managerial and financial and that is all they have an interest in. It’s not the most pleasant aspect. (Participant No 14, male, 1 years’ experience, employee corporate practice)

In summary, all participants were aware of the potential conflict between the healthcare and business aspects of retail optometry and used a variety of strategies to balance these constraints ethically. All participants claimed they adopted an ‘educational and informative’ strategy as their principal method of maintaining integrity. Essentially, this involved informing clients of the advantages and drawbacks of different options and then trying not to influence their decisions. Participants working in corporate practices generally handed clients to other staff to choose frames, sidestepping potential ethical conflicts by remaining disengaged from the actual sales process. In contrast, several participants working in independent practices saw continued involvement as a way of enhancing their clients’ experience and as a continuation of their professional role.

The entry of corporate optometry chains into New Zealand

All participants acknowledged that the entry of corporate optometry chains such as Specsavers and OPSM had created radical changes in the business environment of New Zealand optometry, with several current or former owners of independents describing years of serious, and sometimes unsuccessful, struggle to maintain the viability of their businesses in the face of corporate competition. Most participants felt that the market was now reaching a new equilibrium, with corporate optometry dominating the lower end, relatively uncommitted, mass market and independents retaining and consolidating their appeal to older, higher value, clients. Despite this, there was considerable bitterness in several participants’ descriptions of the ways in which international optometry chains had undermined their businesses. The former owner of a small independent who had lost her business because of the corporate influx and 2008 economic recession explained:-

When I started everyone was either a small business owner or employed by one. When the corporates came in it all changed. Their philosophy was different, “we have to do what is right by our shareholders and we need to sell things”. Traditionally everyone was part of the community and was a healthcare professional and your patient came first. If it’s your own business you can cut people some slack. But now it’s changed and you have to run a business first and if you don’t then you will be like me and you won’t have a business anymore. (Participant No 3, female, 30 plus years’ experience, employee corporate practice)

Owners and employees of independent and corporate practices described markedly different sets of advantages and disadvantages. Several owners of independents drew attention to their freedom, highlighting their ability to choose their own opening times, product ranges and working practises. Against this, several people described working long hours, considerable administrative and financial burdens and concerns about the long-term viability of their businesses. The owner of an independent practice in a small provincial town explained:

My market was certainly eroded by all that has happened. I no longer employ other optometrists. I have thought about converting to [corporate] but you have to obey all their rules. Conversion rates, their selection of frames, their opening hours, their appointment times. There is very little say at the bottom as to what really happens. I’ve been my own boss for so long I really couldn’t operate in an environment where someone else sets all the rules. … We can’t match [corporates] on price though. We have to concentrate on delivering excellent personal service. It’s exhausting! (Participant No 17, female, 30 plus years’ experience, sole owner independent practice).

In contrast, owners or franchise holders within corporate practices emphasised the high level of administrative support provided by the corporate structure, which simplified managing their business. They also talked favourably about the buying power of large chains, with several people drawing attention to the ways in which corporate funding had enabled them to buy into their practices and access state-of-the-art equipment at competitive rates. Against this, several participants disliked the restrictions associated with working within this environment and two people expressed concern that the future of the profession was being shaped by corporate power-holders without optometry training. Participants working within the corporate sector were also more likely to describe symptoms of repetitive strain injury and burnout, suggesting that higher consultation rates may exact a physical and psychological toll on optometrists. The part owner of a corporate practice described the pressures of corporate optometry:

It does sometimes feel we are being managed rather than being partners. An example of that is that I would love to work part-time – but [corporate] have a rule that director optometrists must work 40 hours a week. I would like to job share but that is not an option. If you want to do that then you have to sell your shares. I think that (corporate) people might burnout a little bit quicker. I know a few colleagues who have been pushing themselves too hard. I would include myself in that. (Participant No 13, male, 30 plus years’ experience, part-owner corporate practice)

The comments from both independent optometrists and corporate optometrists suggest that the arrival of large corporate optometry chains and the increased competition for customers has heightened performance pressures within optometry, by escalating the customer service requirements for independent optometrists and creating increased managerial oversight of corporate optometrists’ work patterns.

New Zealand optometrists have traditionally prepared for retirement by selling their share in their business onto the next generation of optometrists, often through a model relying on gradually increasing the next generation’s ownership of the business while new and established partners work alongside one another. This model has been seriously disrupted by the entry of optometry chains and changing work patterns that mean that recent optometry graduates are less likely to see practice ownership as their natural career path. Owners of independent practices perceived succession planning as a more intractable problem than owners of corporate practices. Given that many owners of independent practices are nearing the end of their careers and have large amounts of capital tied into their businesses, succession planning is an important issue. The former part-owner of an independent practice who had sold it to a corporate five years earlier explained:

It’s increasingly difficult being an independent practice owner. My personal ambition would have been to have someone say “Yes I would like to buy into this practice.” As I was given the opportunity to buy into the business. But it isn’t the reality today. Graduates aren’t looking to do that and the difference between what they earn in a salaried position and what they might earn as a shareholder in a business has become much less. So there’s not much in it for them. It was time to exit – the price we could get would probably have become less over time. (Participant No 22, male, 30 plus years’ experience, former part-owner of independent practice, currently working part-time as employee at corporate).

In contrast, the part-owner of a corporate practice who was planning to retire shortly argued that selling his share in the business would be relatively straightforward, because the corporate provided low interest loans to optometrists to buy into a practice and guaranteed to buy back shares in the event of death or retirement, thus safeguarding his financial security.

The six recent graduates all perceived the future of private optometry as dominated by corporate optometry chains. All expressed concerns about the future of small independents even when they worked within, and preferred, independent practice. Three participants were clear that they expected, and wanted, to remain employees throughout their careers, focussing entirely on the healthcare aspects of optometry. The three other participants talked about buying a practice of their own, although this was expressed as a relatively vague aspiration focussing at least ten or twenty years into the future. The participants who spoke of owning a practice all worked at independent optometrists. Their reasons for wanting to buy centred on their dislike of work patterns within corporate optometry rather than a desire for actual business ownership. A female graduate working for an independent explained:

I think the future will be harder for small independents … because we will always be more expensive than a corporate. … I get 45 minutes to see my patients, which I wouldn’t get in a corporate environment. I enjoy that. … I might like to partner in an independent one day because you have more control over what you do. Otherwise you are controlled by someone in a boardroom making decisions for you. (Participant No 10, female, 1 years’ experience, employee independent practice).

To conclude, most participants thought that corporate optometry chains would eventually dominate the lower end mass market for retail optometry, leaving independent optometrists operating within a niche market catering for relatively affluent, older clients. While owners of independent practices generally felt that the market had reached a new equilibrium, several older participants were concerned about their ability to sell their businesses when they retired. Some recent graduates expressed mild interest in owning practices in the future but tended frame this around to their identity as healthcare professionals and the desire to retain control over the way they practised optometry rather than to any actual ambition to own a business.

Discussion

The retail environment for optometry has changed dramatically since the entry of large optometry chains into New Zealand, with considerable downward pressure on prices for both eye examinations and products. This has heightened the contradictions between optometrists’ roles as highly qualified healthcare professionals and as specialist retailers.

The interview findings revealed that all participants were keen to identify themselves primarily as healthcare professionals, stressing their professional training and expertise while distancing themselves from their less prestigious identity as specialist retailers. Optometrists in independent and corporate settings shared a common cause here, as emphasising their healthcare credentials, expertise and the increasing range of healthcare services offered by optometrists strengthened the legitimacy and prestige of the profession. As several medical sociologists have observed, these discourses of professional expertise are not simply rhetorical devices designed to convince outsiders of the profession’s status. They are also important mechanisms which professions use to construct their own identity and socialise their members (Warnock 2005; Martin et al. 2009). These discourses therefore affect the ways in which professions respond to external threats to their economic status or professional standing.

The emphasis of corporate chains on retailing, along with offers of free, or substantially reduced costs of eye testing, has the potential to damage both the healthcare status of optometry as a profession and the economic viability of small independent optometry practices. Participants’ strong allegiance to their healthcare identity can be conceptualised as both a reflection of the increasing academic and medical expertise of the profession and a way of countering the devaluing of optometry associated with corporate optometry’s price cutting approach to healthcare and product retailing. A heightened commitment to the healthcare aspect of professional identity may also diminish younger optometrists’ readiness to commit to buying into practices in the future and increase their willingness to remain employees throughout their careers. This could obviously affect the long-term viability of independent optometry by reducing the ability of current owners to sell their practices when they retire.

Independent optometry practices within New Zealand have traditionally relied on establishing long-term relationships with customers living within the local community. They have been strongly embedded within their local contexts, using personal connections and local reputation as mechanisms for creating and maintaining a viable business. The rapid growth of international optometry chains with limited local commitment is disrupting this pattern of business relationships. User behaviour is also changing, with younger customers being more likely ‘shop around’ for the best priced eye care package and to use corporate chains rather than independents (Shickle et al. 2014). In response to these changes, independent optometrists have tried to differentiate their position, catering primarily for an older and more affluent clientele who remain loyal to specific practices and optometrists. However, these customers are also attractive to optometry chains seeking to grow their client base and are being courted through targeted advertising campaigns and free eye tests. For independent optometry practices to survive, challenges will include deflecting corporate attempts to woo these clients as well as attracting and retaining new clients from a younger demographic.

While optometrists working in small independent practices are often concerned about the future of this business model, those working in corporate environments face different challenges. Despite being less concerned about business management and economic survival, several optometrists working in the corporate sector highlighted their lack of independence and their inability to influence clinically related and commercial decisions made by Head Office staff. The key challenge for them is ensuring that their expertise and clinical concerns are adequately represented when decisions are made by corporate managers without direct experience of their particular situations.

This study was a small-scale, exploratory investigation of the ways in which New Zealand optometrists are responding to changes within the market environment for retail optometry. The small participant numbers and unequal distribution of participants between different categories are obvious limitations of the study. Further research into this area could build on this study through a large-scale survey of New Zealand optometrists in private practise. Some of the key issues which could be explored further are:- the physical and psychological stresses associated with the more rapid consultation times in corporate practices and the possibility of increased optometrist burnout; the possible erosion of clinical autonomy within a corporate environment; the succession planning problems faced by owners of independent practices and the ways in which concurrent changes in optometry training and the retail environment are influencing the professional identity and career plans of newly qualified optometrists.

This research focussed on the changes that increased corporatisation is bringing to retail optometry within New Zealand. Many writers have argued that the commercialisation is occurring across a wide range of healthcare specialities ranging from complementary medicine (Collyer 2004) to more mainstream areas like radiology (Fleishon et al. 2019), dermatology, plastic surgery, dentistry and pharmacy (Konda et al. 2019). Most writers are critical of these developments, arguing that the profit motive underpinning large-scale providers is incompatible with cost-efficient healthcare (Frith 2016). These analyses generally compare privatised healthcare with state funded care rather than comparing the services provided by corporate providers and independent practitioners operating within the private sector (Waring and Bishop 2013; Mercille 2018). Given that small independent healthcare providers can rarely match the buying power of large corporates the effects of corporatisation on private healthcare provision may be more nuanced, especially within healthcare sectors supplying expensive technological aids that consumers can purchase more cheaply from large healthcare retailers.

Within New Zealand, the audiology profession is currently following a very similar trajectory to that of optometry, with an increasing number of corporate providers such as Bay Audiology offering free, or heavily discounted, hearing tests and rapid technological advances in hearing aids. A recent review by Yong et al. (2019), for the World Health Organisation, noted that the number of hearing impaired individuals is rising rapidly as population’s age but that only around 20 percent of hearing impaired adults use aids. Low uptake is primarily due to the prohibitive costs of hearing aids coupled with a lack of state funding and regulatory criteria that only allow qualified audiologists to prescribe hearing aids. Within New Zealand, Wallace et al. (2019) reported similar findings. Their study revealed that corporate providers are becoming increasingly prevalent within private audiology and that limited public funding for hearing aids is restricting their availability. This pattern is similar to the patterns observed in studies of the corporatisation of optometry. Changes within New Zealand audiology could, perhaps, be further explored to reveal whether the conflicts between practitioners’ healthcare and retail identities are also present within private audiology practices.

In conclusion, this research explored the ways in which optometrists balance their identities as healthcare professionals with business considerations, and manage the ethical, commercial and practical tensions created by rapid changes in the market. While an uneasy balance has been achieved, with both corporate chains and independent practices finding niches that enable their success, tensions remain and affect both the ways in which optometrists manage their professional identities and the ways in which they organise their working lives.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Dianne Gardner http://orcid.org/0000-0003-0677-9548