Feature, Report

A pivotal opportunity to transform Australia’s eye health

One of the most important presentations at this year’s 52nd RANZCO Congress was the launch of the college’s Vision 2030 and Beyond plan to overcome Australia’s long-standing and complex eye health equity issues.

RANZCO’s inaugural virtual congress has been hailed “a huge success”, with hundreds of delegates tuning in to view four days of lectures and events.

The digital event – which ran in place of a face-to-face event originally planned for Brisbane due to the Omicron outbreak – kicked off on Saturday 26 February, with more than 200 people attending Alcon’s hosted morning symposium, and more than 300 for the Opening Plenary.

Prof Nitin Verma.

In addition, well over 400 signed in for the Dame Ida Mann Memorial Lecture with Dr Alex Hewitt, with numbers remaining strong throughout, given it was a digital conference.

In the Opening Plenary, RANZCO president Clinical Professor Nitin Verma said he hoped this would be the first and final full virtual congress, with the last face-to-face event held in 2019. RANZCO’s 53rd congress is scheduled for later this year 28 October to 1 November 2022 in Brisbane.

In his presentation, Verma acknowledged 25 fellows who had recently passed away and, in particular, the sudden death of renowned Sydney cataract, corneal and refractive surgeon Dr Con Moshegov. He also acknowledged the many ophthalmologists listed in the Australia Day and Queen’s Birthday honours, with the most notable of these being the 2020 Australian of the Year Dr James Muecke.

The congress also provided the platform for RANZCO’s comprehensive launch of its Vision 2030 and Beyond plan focused on eyecare equity and sustainability.

Verma chaired the session, which then included lengthy presentations by speakers Dr Kristen Bell (service delivery), Dr Justin Mora (workforce & training), Associate Professor Prof Ashish Agar (Closing the Gap). Other key areas of the plan include global eye health, preventative healthcare, sustainability. In this report, Insight covers service delivery and workforce & training.

Verma said a lesson from pandemic is that delayed access to outpatient services results in poor outcomes – with issues around inequality and access being a major driver in often totally unnecessary and preventable vision loss.

“In 2021, RANZCO met with the Minister for Health and outlined inequity and access to eyecare and that, as a nation, we are not adequately prepared to face the future,” Verma said.

“We were asked to develop a plan, not only to close the eye health gap for Aboriginal and Torres Strait Islander peoples, but to ensure equitable access to all Australians to stop avoidable blindness and visual impairment. This is the aim of the Vision 2030 and Beyond plan, a plan based on collaboration and consultation, to be delivered by the eye health sector and allow us as a nation to future-proof not only the eye health of our country, but also the region of Australia’s influence and responsibility.”

Ophthalmology service delivery in Australia

Dr KRISTEN BELL is calling for an Atlas of healthcare delivery to help address healthcare variance, depending on where people live.

Dr Kristen Bell.

In her presentation on service delivery issues, Dr Bell – the Vision 2030 and Beyond clinical lead – said ophthalmology differs from other specialties, with 80% being outpatient care-based and 20% surgical. Chronic sight threatening conditions such as diabetic retinopathy, glaucoma, and age-related macular degeneration make up the bulk of ophthalmic service delivery, with acute care often bypassing surgery and emergency to the outpatient setting.

She said multiple data sources show gaps in public ophthalmology services, noting that most adult and paediatric services are overwhelmed, and over 50% of existing service don’t offer comprehensive care. There’s also a maldistribution of outpatient services between and within Local Hospital Networks (LHNs) and longer waits for public inpatient services in inner and outer regional Australia.

She also pointed out that reportable data – such as elective wait times – failed to include outpatient and procedural wait times, leading to long wait times and making the bulk of ophthalmology services effectively invisible, with no data to drive growth of outpatient services. The “wait for the wait” – time between referral and wait list – is unseen, with an internal RANZCO survey finding more half of public eye clinics do not offer comprehensive service and there’s no delivery standard to ensure services are complete.

Bell added that many outer urban areas and regional LHNs do not fund ophthalmology outpatient services at all.

She presented maps of Australia showing very few public care areas outside of urban areas. Northern Territory and Western Australia fund outreach from Darwin, Alice Springs and Broome, respectively, while Tasmania has recently started funding an additional service in the northwest of the state, giving these three jurisdictions the best regional coverage. But across Australia, 30% of entire population and 65% of Indigenous patients have no or limited access to a publicly funded local outpatient service.

Estimated resident population heat map, with public hospitals marked in blue. Those with eye outpatient clinics are starred – and are located centrally within these larger metropolitan areas across Australia.

Part of the problem, Bell said, is that local LHNs don’t have delivery maps for specific services, resulting in high healthcare variance, with service delivery largely based on how things have been done in the past. Also contributing to the problem is the fact new hospital developments, such as Fiona Stanley (WA), Gosford (NSW), and Sunshine Coast Hospital (QLD) don’t include eye outpatient services, meanwhile there have been threats and closures to public departments such as Royal Adelaide Hospital, and St Vincent’s Hospital in Sydney.

Bell outlined three solutions that would improve service delivery of ophthalmology in Australia.

Solution 1 – healthcare variation

Develop an Atlas of healthcare delivery standard by specialty, patient demographics and geographic area to enable the delivery of safe, high-quality care in the right place at the right time – with appropriate demographic and geographic calibration.

She said this would provide LHNs a detailed map of public outpatient and inpatient services that must be delivered in within that area, addressing healthcare variation and providing equitable access to service at the local level.

Solution 2 – increase outpatient visibility

Formal acknowledgement of outpatient services as high value healthcare activities which prevent people from developing more serious comorbidity and reduce mortality, and reduce the rate of more expensive treatments. Bell also said it was necessary to include outpatient and procedural waitlist data in the Australian Institute of Health and Welfare dataset.

She said governments recognise there are problems, noting the current system is fragmented making it difficult for well-coordinated care. Part of the problem is the complex split between Commonwealth and State governments and the not-for-profit and private sectors, regarding who is responsible for planning, funding and delivering services.

“A reform roadmap has been developed that challenges us to consider innovative models of care and flexible funding arrangements,” she said.

Solution 3 – deliver equitably at the LHN level

Bell called for governments to commit to providing services, as defined by the Atlas and being held accountable for it. Planning and implementation should take place at LNH level, while adequately resourcing existing services, high value patient-centred models of care such as outer urban and inner regional clinics, collaborative care models, multidisciplinary clinics, liaison workers and patient transport.

An impending ophthalmology workforce shortage

Dr JUSTIN MORA says ophthalmologists with a regional background are 2.7 times more likely to settle in regional Australia.

Dr Justin Mora.

In his presentation, Dr Justin Mora, the RANZCO censor-in-chief and Qualification and Education Committee chair, said the ophthalmology workforce is under threat due to a lack of investment.

He highlighted ‘Australia’s Future Health Workforce Report into Ophthalmology’, released in 2018, which projects doctor workforces out to 2030. It recommended trainee intake numbers needed to increase by three each year from 2019 to address the impending workforce shortage. It also demonstrated a lack of funded training positions in the public sector, impending critical shortage of paediatric ophthalmologists and an over-reliance on international medical graduates (IMGs), and a “profound” maldistribution of full time equivalent (FTE) public-private ophthalmologists.

In relation to this final point, Mora said just 16% of total ophthalmology FTE work in the public system. A 2017 RANZCO survey found 45% work in public sector in some capacity.

“There is an assumption this is due to ophthalmologists not wanting to work in the public sector, but we relish the opportunity to increased collegiality, teaching and contributing to their communities. We can see 45% work in public in some capacity, and at Westmead, half of supervising consultant staff have worked in an honorary capacity for no pay for years,” Mora added.

So why is public ophthalmology FTE not growing? Mora said the problem is a lack of public jobs due to a chronic lack of investment in public services. As the workforce has increased, the public FTE has remained relatively fixed because there are no governance measures to ensure growth in existing services to increase capacity.

Ophthalmology trainee intake numbers needed to increase by three each year from 2019 to address the impending workforce shortage.

He said public services are usually available in teaching hospitals in cities and have limited capacity to expand their footprint. Consequently, there are long waiting lists for in and outpatient services, with a disproportionate impact on low income, Aboriginal and Torres Strait Islander communities and outer urban and regional patients.

Actions to date

Mora said RANZCO has been lobbying for the creation of additional training posts in every jurisdiction at the LHN level with little success. This is due to a lack of growth in funding for public hospitals for trainees and consultant FTE, equipment and supporting staff, insufficient space in existing departments and operating lists, and LHNs refusing to take Commonwealth Specialist Training Program (STP) funding as this does not fully cover the cost of employing a trainee registrar.

“We have 20 fewer trainees currently than we need, according to workforce report, to avoid a shortage of ophthalmologists by 2030,” Mora said.

“Colleges are caught in the middle between Commonwealth workforce expectations, which RANZCO wishes to prosecute, and jurisdictional funding availability. RANZCO on one hand is required to increased positions by the Commonwealth, while there is no governance mechanism that allows this to happen at the LHN where funding for most specialist training FTE is provided.”

Mora said solutions to the impending overall workforce shortage and maldistribution need to recognise overall workforce distribution and sustainability are inextricably linked with equitable public hospital service delivery.

As part of the solution, Mora said there needed to be KPIs for workforce and training at the LHN level, which needed to be embedded in the National Health Reform Agreement.

Across Australia, Mora said ophthalmology inpatient surgical services are delivered using an outsourced-to-private funding model. He said there is a need to incentivise public service provision by specialist ophthalmologists.

“Sixteen per cent of ophthalmologists practise in regional locations, despite 29% of the Australian population being regionally based. Specialists not settling regionally is an ongoing problem. Of ophthalmologists who trained and graduated between 2013-16, 90% now reside in urban areas; we know ophthalmologists with a regional background are 2.7 times more likely to settle in regional Australia, but just 9.3% have a regional background,” Mora said.

With this in mind, RANZCO has introduced selection points for trainees with a regional background, and now more than 40% of trainees selected in the past two years had a regional background. This was recently strengthened by allocating eight regional points out of a total of 100 in the RANZCO selection process.

Mora said workforce planning constraints are brought about by a short-term Commonwealth funding delivery and planning model for specialist training via the STP. He said measures that allow forward planning of workforce for a minimum of eight to 10 years are needed to provide more certainty for employers.

Solutions overview

1. Increase the number of trainees with a regional background – completed.

2. Strengthen comprehensive ophthalmology training – completed.

3. Increase the number of regional training posts with the aim of one full year of training at a regional post.

4. Establish the Regionally Enhanced Training Network – completed.

Mora said, if adopted, point three would build regional training posts in crucial areas from the ground up and force teaching hospitals to adopt a workforce-poor regional area. RANZCO is also looking at establishing a bi-national virtual teaching program to start from 2023 allowing trainees to attend teaching no matter where they are based.

From the government, Mora said KPIs for training, including in regional Australia, would drive growth of regional FTE, and prevent hospitals from declining STP funding such as currently happening at Modbury Hospital in Adelaide.

A Commonwealth commitment to fund additional STP-Integrated Rural Training Pipeline (IRTP) posts from 2026 would allow for 20, rather than 10, regionally enhanced registrars by 2027.

“RANZCO also requires a commitment from states to establish the positions of regionally enhanced trainees in major city hospitals for that component of their training from 2025,” Mora concluded.

RANZCO’s launch of the Vision 2030 and Beyond plan can be accessed at: ranzco.edu/home/community-engagement/

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RANZCO appoints Mark Carmichael as new CEO

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