A national strain on paediatric ophthalmology services is a symptom of greater systemic issues and funding uncertainty in public eye health. Industry figures discuss what’s needed to strengthen the subspecialty and why there’s still hope.
The paediatric ophthalmology workforce shortage has been described as a complex issue. But what’s clear is that it’s an issue exacerbated by limited training posts, government funding uncertainty, and a lack of incentives.
RANZCO describes it as an “impending critical shortage of paediatric ophthalmologists” in its ‘Vision for Australian Eye Healthcare to 2030 and Beyond’ report.
So how did we get here? In this report, the college outlines the current shortfalls within paediatric ophthalmology, including the maldistribution of ophthalmologists across urban and regional locations, a critical shortage of paediatric subspecialists, and a lack of funded training positions in the public sector. A 2021 RANZCO survey of public ophthalmology departments revealed 39% of them did not provide paediatric services.
It’s not a new issue. In 2012, it was reported the critical workforce issue facing ophthalmology is the small number of paediatric subspecialists in Australia – a mere 20 full-time equivalents. It was noted this workforce is nearing retirement, which will affect training supervision capacity – a vicious cycle.
More recently, the NSW Government’s inquiry into healthcare, launched in August 2023, sought to identify ways to improve healthcare distribution in the state. RANZCO didn’t miss the chance to highlight the steps required for equitable access to ophthalmology services.
Authored by NSW branch chair Associate Professor Ashish Agar and RANZCO CEO Mr Mark Carmichael, they drew attention to the “worsening shortage” of paediatric ophthalmologists, caused in part by a “chronic” lack of funding in the NSW ophthalmic public health sector.
A complicated issue
Dr Anu Mathew, paediatric ophthalmologist and director of ophthalmology at the Royal Children’s Hospital in Melbourne, says the workforce shortage is multifaceted – one facet being the subspecialty failing to appeal to new cohorts of medical students and ophthalmology registrars.
The treatment of children is relatively complex as specialists must be equipped with a unique combination of skills. Building rapport with children is challenging, as is ensuring their cooperation. Therefore, creativity is key to working with a child.
“When you examine a baby, you might need to do so while breastfeeding, while showing them a video, while singing a silly song or you might have to engage a toddler by talking about the colour of their shoes,” Dr Mathew says.
“There’s just an entirely different set of skills involved with examining paediatric patients that only comes through experience. It’s something you can’t learn in a lecture or a textbook.”
Dr Caroline Catt, paediatric ophthalmologist, and chair of the Australian and New Zealand Paediatric Ophthalmology Society (ANZPOS), says paediatric ophthalmology is an intellectually stimulating, complex area of ophthalmology that requires sound clinical knowledge, excellent communication skills, intuition and compassion.
To attract more trainees and registrars, she suggests increasing their initial exposure to the subspecialty. With a typical paediatric training rotation lasting three-months for an ophthalmology registrar, she says this is insufficient to develop the interest – or skills – required to practise in the subspeciality.
“Exposing trainees to the subspecialty through a minimum of six months would go a long way to expanding and future-proofing our excellent, dedicated and hard-working current workforce,” she says.
Dr Mathew concurs: “The longer exposure means that they’ll be more comfortable with these skills and therefore more likely to enjoy it.”
For Dr Mathew, training does not necessarily have to be in one block but can be two three-month rotations.
“In Victoria, we’ve had a few registrars come in and do their training during their early years and then come back later,” she says. “Those registrars have found that highly useful because they’re building on their knowledge. They go away to reflect on their training, and come back with more experience. They’re well-equipped to learn more the second time around.”
Dr Catt says the American Academy of Pediatric Ophthalmology and Strabismus (AAPOS) has explored increasing the length of training and has found early exposure to the subspeciality coupled with good mentorship are essential to attracting more trainees.
“In Australia, RANZCO supports a minimum of six months of paediatric ophthalmology training in the five-year training program and are working towards making this opportunity available for all trainees.”
Dr Mathew adds that shortages extend to fellowship opportunities, with funding, space and a lack of interest straining the subspeciality.
“We should have at least two fellows in Victoria, ideally at both children’s hospitals.”
Dr Catt adds: “At The Children’s Hospital at Westmead, we have one paid fulltime fellowship position. For several years, this position was filled but unpaid, which is illustrative of the passion and dedication that paediatric ophthalmologists have for their subspecialty and their patients.”
To incentivise uptake of paediatric ophthalmology in Victoria, Dr Mathew says there is a non-training registrar position available for junior doctors at the Royal Children’s Hospital. The post, which sees them practise paediatric ophthalmology for a year, gives the junior doctor initial exposure to subspeciality before they begin the ophthalmology training program.
Beyond a lack of exposure, Dr Catt says funding limitations for public hospital positions on both a senior and training level, in addition to a preference for working with adults, are also driving the shortage.
Dr Mathew agrees, stating the paediatric subspecialty sometimes may not be appealing as others such as corneal or vitreoretinal surgery that have more cutting-edge treatments available.
The nature of the subspeciality means children will take more time than adult patients. Thus, Dr Catt says dedicated government funding would attract more trainees to paediatric ophthalmology.
“Expanding public hospital funding and resourcing would allow for the employment of more senior clinicians, opening of more public hospital outpatient clinics and operating theatre lists, and funding of more trainee positions would support an increased training rotation,” she says.
In 2014, RANZCO with the support of the Australian Society of Ophthalmologists (ASO), successfully lobbied for an increase to the paediatric ophthalmology patient rebate – which saw it rise 50%. However, this increase does not cover review appointments, which still take considerably longer than adult appointments.
“We get more Medicare rebates for new patients – we get paid one and a half times as compared to an adult patient. However, for review appointments, you get paid the same amount as an adult patient, but a paediatric appointment always takes longer,” Dr Mathew says.
Despite this step in the right direction 10 years ago, there have not been many developments in this space since, adds A/Prof Agar, now vice president of the ASO.
“The college was able to convince the government that if they don’t value a service, it’s going to be difficult for people to provide that service. The government accepted that argument and those changes were made.”
Ultimately, A/Prof Agar says the shortage is not merely a workforce problem but is part of greater systemic issues because of funding uncertainty in public ophthalmology. He says the workforce is not part of a system that supports and accommodates them, with the lack of funding resulting in scarce equipment and dedicated eye clinics in hospitals.
“If you have the right number of people trained, you still need funding for equipment and treatment devices. And you also have nowhere for them to be practising if the public hospital they would work at doesn’t have an eye clinic,” he says.
Similarly, Dr Mathew says if paediatric ophthalmology were to attract enough people to the workforce, healthcare facilities do not have the space to cater for an increased workforce as the subspecialty is typically competing for rooms.
“Even if we had paediatric ophthalmologists keen to work in the public sector now, we still need funding, clinic rooms, and theatre lists to be able to create a job,” she says.
No incentive for rural practise
With maldistribution of ophthalmologists in rural locations, general ophthalmologists with a broad skillset are in high demand for these communities. However, Dr Mathew says they may not feel comfortable seeing children because they’re not frequently flexing their paediatric muscle.
Dr Catt says that anecdotally there is a disparity between urban and regional workforce, but this data is not accurately reported.
Currently there is no atlas to show what services should be delivered, and where they should be delivered.
In addition, the data mandatorily reported from jurisdictions to the Australian Institute of Health and Welfare (AIHW) does not include outpatient waitlist information, which constitutes the majority of ophthalmology services.
“Under the current model, it’s left up to the Local Health Network to determine what services are required. Unfortunately, this sometimes results in services closing. RANZCO is advocating for the development of an atlas of healthcare delivery to guide optimal service delivery in each jurisdiction which would inform where the workforce needs to be distributed,” she says.
There’s also often a gap in resources required to provide paediatric ophthalmology. For example, a specialist anaesthetist and specialist theatre support are required because most surgeries are completed under general anaesthetic rather than day surgery. Often these resources are not available in regional centres.
Some of Dr Mathew’s colleagues have had to refer children under the age of one back to the city to be operated on because they didn’t have the regional resources and support to manage younger children.
“When there’s such a huge demand for ophthalmologists in regional parts of Australia, you must be a jack-of-all-trades and a great general ophthalmologist. This might sometimes dilute your paediatric skills, and unless you specifically try to see more paediatric patients, then the less comfortable you will feel treating them. Which means you’re less likely to see paediatric patients,” she says.
“They have to make a certain effort to keep up their paediatric skills.”
A/Prof Agar explains the regional situation is complex and aggravated by rigid government policy around length of service – or lack of – for the subspecialists.
Current regulations mean that there are regional centres where specialists can’t work at a particular location beyond a six-month period before having to reapply for a Medicare provider number. This discourages subspecialists to settle regionally due to long-term employmen uncertainty.
A/Prof Agar, along with the ASO, has been attempting for many years to support paediatric ophthalmologists who are already practising in regional centres to be able to remain and practise there.
“We know of a major regional centre where Medicare has been unable to give a paediatric ophthalmologist more than six months at a time. So, every six months their future is under a cloud, and this is an area of regional New South Wales where there’s not another paediatric ophthalmologist for hundreds of kilometres,” he says.
He has attributed this employment uncertainty to inflexibility of the system as the rules that define the current system were developed decades ago. He describes these parameters as “a huge beast you can only nudge incrementally”.
It’s a priority
Despite the workforce shortage, paediatric patients continue to receive high-quality care in Australia.
The workforce shortage means that care is centralised, with children and their families having to travel to major population centres to receive their care. They often have to wait longer than they wish in some settings with waitlists blowing out to three months.
“It is important to note that high quality, urgent and emergent care is freely available through public hospital emergency departments all around the country. The workforce we have is highly trained and skilled and delivers care to children in the public and private sectors,” Dr Catt says.
Dr Mathew says paediatric departments do well in prioritising sight-threatening conditions, but those who cannot get an appointment are forced into the private sector which they may not be able to afford and also suffers from long waitlists.
“Despite our long waiting lists, we have a team that is constantly triaging the list to make sure that no child goes blind while waiting,” she says.
“However, there’s a huge number of non-sight-threatening conditions where patients may not get an appointment or are unlikely to get an appointment in a timely manner.”
Dr Catt says one of the biggest challenges in solving the workforce shortage is driving innovative solutions.
For example, in NSW, RANZCO is collaborating with the Agency for Clinical Innovation (ACI) and Neonatology, and NSW’s chief paediatrician to advocate to NSW Health for digital screening of babies and placement of digital camera remote screening in NSW NICUs. This would streamline retinopathy of prematurity screening services and limit the need to transfer babies from one unit to another for screening purposes.
Meanwhile, A/Prof Agar says paediatric ophthalmology needs to be a publicly funded system, with no disparity between public and private services.
“These are kids at the beginning of their lives who have everything going for them. And yet, we don’t have the systems or the funding in place to ensure that they’re able to have a decent high level of eyecare in the first critical months of their lives,” he says.
Even though the sector has a mountain to climb, many are hopeful for the future of the subspeciality.
“This is a good example of the whole sector working together, making it more likely for real progress to occur. We know it’s going to take a lot of advocacy and a lot of work,” A/Prof Agar says.
“But it’s not as though we don’t know how to diagnose or fix or the problem. We simply need the powers that be to say, ‘Yes: A child’s eyesight is a priority, and we’re going to support a public system that enables doctors to save their vision’. If you do that, then everything will fall into place.”
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