Insight regularly publishes inspiring stories of charitable work and outreach programs. The eyecare sector is a generous one, but is that work masking a darker inconvenient truth for Australians living in the nation’s regional, rural and remote areas?
The Tyranny of Distance sounds like an epic novel, a tale of high-seas adventure and thrilling journeys to exotic locations on the other side of the world.
But sadly, for many Australians it is a term denoting something rather more dystopian: a desperate thriller in which health outcomes are uncertain, the danger is very real, and the threats grow the further you move from the relative safety of the nation’s main centres.
Poor health outcomes and even higher mortality rates are a fact, not a fiction, for many.
The shocking tale is outlined in the numbers.
According to the Australian Institute of Health and Welfare (AIHW), more than 7 million people (29% of the population) live in regional and rural Australia.
Those people face challenges accessing health care, including eye health services, which can lead to higher levels of chronic disease and injury, and shorter lives.
The statistics make it clear: the further you are away from the main centres, the shorter your life is likely to be.
In AIHW 2021 data, age-standardised mortality rates increased as remoteness increased for males and females.
Compared with all of Australia:
• People living in inner or outer regional areas had a mortality rate 1.1 times as high.
• People living in remote areas had a mortality rate 1.2 times as high.
• People living in very remote areas had a mortality rate 1.5 times as high.
It’s a similar story in eye health.
Writ large early in RANZCO’s Vision for Australia’s Eye Healthcare to 2030 and Beyond is one simple statement: “Timely access to eye healthcare prevents more than 80% of permanent visual impairment and blindness.”
But further reading reveals that access is neither timely nor effective, especially in Australia’s smaller, more distant communities.
People in the cities may grumble about wait times at their local hospital, but they appear to be the lucky ones.
Recent data shows people waiting an average 69 days for cataract surgery in the city, with that nearly doubling in the outer regions (129 days) and very remote communities (114 days).
Some areas have practically no access to ophthalmology services, according to RANZCO.
“Approximately 30% of the entire population and more than 60% of the Aboriginal and Torres Strait Islander population, which is more regionally based, have no or very limited access to publicly funded outpatient services in the area they live,” it said in its report.
“Some inner urban, many outer urban, and most regional Local Health Networks (LHNs) do not fund public ophthalmology outpatient services at all. These services represent 80% of ophthalmic healthcare delivery.”
RANZCO outlines a number of reasons for this failure, including a lack of an over-arching plan for national service delivery and poor funding of the LHNs.
“The chronic lack of investment in public ophthalmology services across Australia . . . has driven a substantial and increasing imbalance in the ophthalmology workforce between the public and private sectors.”
That means almost 90% of the work ophthalmologists do is in the private sector and often beyond the financial grasp of many who rely on public services.
The picture is not much better in the optometry sector.
In a recent global survey, Australia was one of just 46% of nations to meet the mark on the recommended optometry ratio: one professional for every 10,000 citizens.
But it appears Australia’s commendable ratio of 1:3,897 is heavily focused on the main streets and thriving malls of its bigger cities, rather than the quieter roads of its regional, rural and remote centres.
Government figures from 2019 show that the ratio of optometrists for every 100,000 people was 20.7 in metropolitan centres, above the 19.1 average for all Australia.
That actually increased to 22.7 in its larger rural centres, but it was downhill from there: 18.3 in regional centres, 17.6 in medium rural towns, 3.7 in small rural towns, and 8.5 in remote communities.
While some reports have tipped an oversupply of optometrists, one major study commissioned by Specsavers suggested a developing deficit over the next 20 years, with its impacts hitting hardest in the regions and beyond.
The 2023 analysis by Deloitte Access Economics forecasts a shortage of 1,102 full-time equivalent optometrists in 2042, with more than 800 of those in the regions.
Concerned about this inequitable access to eye care, the company offers optometrists significant packages and support for those willing to relocate and practice outside of the big cities.
And like a number of eyecare providers, Specsavers is also trialling the use of technology to support remote optometry work in which a patient can be assessed within their own community by an optometrist who is located many miles away.
That might be part of a future solution, but let’s first get a better understanding of the present threat to eye health and its impact on vulnerable communities.
Road blocks and blind spots in the regions
There is more than a hint of resignation in Dr Andrew McAllister’s voice.
It was there in a recent RANZCO podcast on the health of regional ophthalmology and it’s there now as he speaks with Insight.
It’s a resignation borne of frustration from constantly butting heads with bureaucracy in a vain attempt to bring accessible eye health services to his region.
Dr McAllister is an ophthalmologist and retinal subspecialist with his own practice in Toowoomba, a Queensland city with a population of about 170,000 serving the large catchment of Darling Downs, with close to 300,000 people.
Despite that size, the region has no public ophthalmic services, with patients without private cover needing to travel more than one and a half hours from Toowoomba to Brisbane for care, and a great deal more if they live further out.
In 2022-23, the Queensland Government spent $84.24 million through the Patient Travel Subsidy Scheme (PTSS) to support people needing to travel for specialist public healthcare, including ophthalmology. The subsidy covers part of their travel and accommodation costs.
Patients driving past one of the six private ophthalmologists in Toowoomba and continuing down the Warrego Highway to Brisbane cost taxpayers just under $6.8m that year.
And the figure is set to rise after the government this year committed to covering the entire accommodation cost of a patient’s first four days, at a commitment of $70.3m over the next four years. That means the annual cost of the PTSS is likely to go beyond $100m.
That still leaves many patients with much to pay from their own pockets, with some needing to stay a week and more in Brisbane, meaning obvious financial impacts through loss of income and other costs, including food and hospital parking, which can be $100 a day.
None of that makes sense to Dr McAllister and others, who have spent a great deal of their own time caring for those communities missing out, and bashing against those bureaucratic brick walls, from every conceivable angle.
“The patients don’t need to go to Brisbane for emergency surgery,” says Dr McAllister. “Having the specialist skills that I’ve got as a retinal surgeon means that we can definitely treat patients locally.”
For those specialists, the tyranny of distance is the defeat of logic and common sense. And the silence from those entrusted with ensuring public access to healthcare.
It all comes at great cost to “marginalised” regional and remote communities.
“These people living in rural areas, they don’t always seek care because of difficulty in transport, distance of travel, and quite often you’ll see some chronic diseases that haven’t been treated as well as they should have,” he says.
Motivated by his father, a long-serving GP in the region, and ophthalmology mentor Dr Bill Glasson, Dr McAllister applied for a public ophthalmology role when he first moved back to Toowoomba in 2019.
But in a sign of what was to come over the next five years, “the role was rescinded due to a lack of funding”. That left him with no other option than to move into private practice.
It has been a similar refrain for every idea put forward by Dr McAllister and his colleagues over those years. Even when they have offered their services for free.
“I’ve offered to see patients in my rooms and set up everything myself, and because I’ve got my own practice and the expense associated with that, I was quite happy to start a clinic for the public hospital based in my private rooms initially, until I had something set up.”
The answer back from Queensland’s public health executives has always been a polite thanks, but no thanks: there is money to transport and house patients from the deepest parts of this large region but none to set up or subsidise public services closer to home.
That is unlikely to change, even when the region gets a new hospital – expected to be some time in the next decade.
When locals pushed for ophthalmic services in that plan, the answer was the same as that given to Dr McAllister’s petition of the state government in 2023: there is no money to fund public ophthalmology in Toowoomba or in other equally struggling regional centres.
If the government is relying on private practice and the generosity of industry outreach and charity to pick up the slack, Dr McAllister says that too is starting to look shaky.
Among Toowoomba’s ophthalmology community is at least one practitioner well into his 70s.
And as is the case in other regions, recruitment is tough.
“I’ve been advertising for ophthalmologists for at least the last 18 months; it’s been extremely hard,” says Dr McAllister.
“We’ve had no interest from locally trained ophthalmologists to settle here in Toowoomba.”
There has been some interest overseas but, ironically, given the paucity of public services, the area does not qualify as a “region of need”, meaning applications for registration are not supported.
It would be understandable if Dr McAllister suffered a little ‘PTSS-D’. It appears he and many others have been left to carry the burden of not only filling the many gaps in available care but also planning for ophthalmology’s uncertain future in his region.
“The system is really kind of failing the area,” he laments.
But as well as the resignation in his voice, there remains some resilience.
“I guess I’ve got to a point where we’ve looked at multiple ways to try and get around on this, and you know, there’s no point whingeing and banging your head,” he says.
“You take things in your own hands and come up with a solution that you know is going to be beneficial for the local population, even when the health department isn’t that interested.
“Until there is a genuine interest from the public hospital and from the politicians that look after this area, it’s really just up to us as individuals to start making changes.”
Should’ve gone to the regions…
On the surface, optometry looks pretty healthy in Australia.
The country is comfortably meeting the recommended international ratio of professionals to patients, and there appears to be no shortage of practices and practitioners.
But even at Specsavers, the nation’s largest provider of eyecare with almost 400 locations across all states and territories, there are troubling clouds on the horizon.
Like other businesses and industries, it is struggling to find optometrists and eyecare professionals willing to stray too far beyond the bright lights of Australia’s biggest centres.
Dr Ben Ashby, the company’s director of clinical services for ANZ, says 40% of its Australian locations have an unfilled optometry vacancy over the course of the year, with more than 60% of those outside the major cities.
That’s despite Specsavers promoting the benefits of regional communities, offering support to relocate, and other inducements, including regular trips home and extra leave.
“Many Australians, predominantly in regional and rural areas, are not able to access timely, preventative eyecare within their communities, simply because there is no optometrist available,” he says.
“In 20 years, 2 million Australians will need eye tests but will not be able to access them.”
To help fix that, Specsavers has been trialling a remote model of care in several Victoria, Tasmania and NSW regional locations.
As part of that trial, nearly 500 people have visited a clinical practice where a technician supports an optometrist working from an off-site location.
Communicating via live video-conferencing, the optometrist and technician organise OCT, tonometer and autorefractor tests, ask basic questions of the patient and then review the clinical results.
Dr Ashby says the pilot has shown that remote eyecare detects eye conditions at rates equal to traditional in-person eye consultations.
Despite that success, he says it is not a replacement for in-person eyecare in regional areas but rather “a viable solution to help bridge the gap in underserviced areas . . . so patients do not have long wait times and experience unnecessary barriers to routine care simply because of where they live”.
The company has identified more than 100 locations that could use the remote eyecare model, but it is not funded by Medicare, meaning the service would not be financially viable.
“Without Medicare funding, the financial cost to roll this out would not be sustainable,” says Dr Ashby.
The company has joined others in the industry, including Optometry Australia, in calling on the Federal Government to include this model in the MBS so that people living in regional and remote areas can have access to the service.
Governments state and federal root of the problem
Specsavers and Optometry Australia are not alone in prodding the states and Commonwealth to step in and step up to deliver timely and effective eyecare in regional, rural and remote areas.
A failure in leadership by those in charge of healthcare in Australia is probably the main complaint for Dr Kristin Bell. This has resulted in a lack of governance and poor accountability over the equitable funding and delivery of healthcare.
“I think you can point to one particular group, and that’s the health ministers and the health secretaries of Australia,” says the Hobart ophthalmologist, who is also RANZCO’s Vision 2030 and beyond clinical lead, regional education chair and lead of its regionally enhanced training network.
She sees public ophthalmology as a struggling tree tended by an indifferent gardener.
That lack of leadership and attention has undermined all that might have given it life. Not just the tree but the roots that support its weight, the branches that dictate the health and effectiveness of its reach, and the workforce needed to ensure all are healthy and sustainable.
The 2020-25 National Health Reform Agreement was supposed to be that core document from which other branches of state and federal government would ensure the healthy spread of equitable funding and services, including ophthalmology, into and across all of Australia.
But that has not happened, says Dr Bell.
“There is simply no governance or checks and balances to make sure that they’re actually doing that in regional areas,” she says.
That lack of a plan and the accountability that might have gone with it has allowed state and regional health powerbrokers to turn inward, centralise funding and delivery, and practically ignore the regions.
“It’s left up to the Local Hospital Network (LHNs) to decide what service they’ll deliver,” says Dr Bell. “And at times they just entirely withdraw services because they don’t have to provide them.”
A recent report commissioned by the National Rural Health Alliance estimated each person in rural Australia was missing out on $850 in healthcare funding each year – about $6.5b annually.
No plan, no accountability, and no collection of data to help officials better understand the impact of that deficit.
“They’re not including waitlists for outpatient services, so how can you actually see if services like ophthalmology are equitably delivered?”
It’s tempting to suggest that it’s the sector itself and private individuals that have had to step in to the vacuum left by this indifferent government gardener. That the tree would indeed wither and maybe die without that effort.
Dr Bell doesn’t agree.
“I think we are just making sure we’re not part of the problem, and we really want to be part of the solution,” she says. “We’re all doing our bit, running collaborative workshops with Optometry Australia, Orthoptics Australia, a number of the NGOs, GPs and non-ophthalmic specialists.
“We’re doing all the things we can do on our side. And then on top of that, we are using our voice to advocate as much as we can, and we partner with others as well to try and amplify that voice.”
The governments respond
The Commonwealth and the state governments insist they are listening.
Queensland Health says it is committed to providing high-quality eyecare to all Queenslanders.
A spokesperson said that, in the 2023-24 financial year, it had performed more than 13,000 elective ophthalmology surgeries, effectively managing the waitlist, despite a 3% increase in demand.
“As a largely decentralised state, we do face unique challenges in delivering healthcare,” they said. “To ensure equitable access to eye care,especially in rural and remote areas, we deploy visiting ophthalmologists to provide essential services in regions like Thursday Island and Weipa.
“We are also actively working with tertiary education providers to increase the number of medical student placements.”
The spokesperson also said the Surgery Connect pathway had allowed public patients to access care in private hospitals, with 5,188 ophthalmology patients benefitting In 2023-24, in regions such as Cairns, Mackay, Townsville, and the Sunshine Coast.
The national Department of Health and Aged Care said it funded a number of eyecare outreach programs for indigenous communities in regional, rural and remote areas.
It was also spending $3.2m in the second nationwide survey of eye and ear health, as part of its commitments to United Nations goals towards eradicating avoidable blindness.
It was also working to implement priority actions under the National Strategic Action Plan for Macular Disease, with a focus on at-risk populations.
Regarding workforce issues for all medical specialists, the government had invested $708.6m over four years through its Specialist Training Program, “to extend vocational training for specialist registrars into settings outside traditional metropolitan teaching hospitals”.
And it was financially supporting organisations like RANZCO to increase ophthalmology training in regional, rural and remote areas.
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