RANZCO has laid out its blueprint to improve access to ophthalmology in Australia’s most populous state. Its submission highlights a “chronic” lack of funding in the NSW ophthalmic public health sector, contributing to a “worsening shortage” of paediatric ophthalmologists, and calls for outsourced-to-private services in regional areas to alleviate pressure.
The NSW Government launched its Special Commission of Inquiry into Healthcare Funding on 24 August 2023 to identify areas of opportunity for equitable healthcare in the state.
In the RANZCO submission, NSW branch chair Associate Professor Ashish Agar and CEO Mr Mark Carmichael said the ophthalmic public health sector has failed to deliver adequate services due to a “lack of funding, accountability of NSW Health governance structure, and maldistribution of eyecare services and workforces”.
The submission states that funding uncertainty has compromised the quality of service delivery. To prevent this, RANZCO suggests that NSW Health commit to medium- to long-term planning for a higher level of funding certainty.
“At least medium-term (four-to five year) financial certainty is required to adequately plan service delivery, secure and retain the skilled workforce needed in our public hospitals, and keep medical facilities adequately appointed to enable the delivery of safe, high-quality healthcare,” the college said.
It was recommended that this expectation be outlined in a set of compulsory governance requirements that would be detailed in the National Health Reform Agreement (NHRA).
Nationally, public eye healthcare services are delivered within each Local Hospital Network (LHN), but RANZCO has identified governance shortfalls where the NHRA has emphasised the need for equitable delivery of services without enforced mechanisms to ensure this.
The college said that a lack of public (ophthalmology) outpatient and procedural waitlist data “results in low visibility of and thus poor transparency regarding outpatient and procedural service delivery”.
“This is particularly impactful for ophthalmology as outpatient services represent 80% of ophthalmological service delivery encompassing cost-effective, sight-saving treatments for highly prevalent, blinding conditions such as diabetic retinopathy, glaucoma, and age-related macular degeneration.”
As such, the college suggested mandatory reporting of this data, as well as an Eye Health Services Delivery Plan for NSW for a state-wide overview of eyecare delivery.
“This would facilitate NSW Health in working with the eye healthcare sector to design and equitably provision timely, cost-efficient, collaborative eye healthcare services across the state underpinned by the principles of the right care, at the right time and in the right place,” RANZCO said.
“This plan would link service delivery in primary and community care clinics, outer urban collaborative care clinics, the private sector, and public hospital ophthalmology departments.”
Additionally, RANZCO has highlighted NSW Health’s allocation of funding in public hospitals and community settings. For example, public healthcare funding is concentrated towards acute and elective inpatient services. This is disadvantageous for ophthalmology services because 80% of services are outpatient-based, with 20% of surgery completed using a day surgery model.
The chronic underfunding, according to RANZCO, has resulted in a shortfall of public ophthalmology services which has pushed most specialist ophthalmology full-time equivalents (FTE) to the private sector.
The paediatric problem
Furthermore, RANZCO raised concerns about the workforce composition to deliver a comprehensive scope of ophthalmology services. The paediatric ophthalmology sub-speciality is especially in chronic short-supply due to limited training opportunities.
“Presently, not all ophthalmic trainees in NSW can access a dedicated paediatric ophthalmology training rotation and when they do this rotation is for just three months. This is a key contributor to the worsening shortage of paediatric ophthalmologists in NSW. This has become a circular problem, which needs to be addressed urgently with additional funding of public hospital paediatric ophthalmology services,” RANZCO said.
Paediatric ophthalmology also hasn’t been able to attract enough newly graduated fellows to train in the subspecialty.
“Consequently, the paediatric subspecialty workforce is ageing and is not sustainable and there are insufficient subspecialists to meet the population’s requirements for these services,” the college said.
Another major concern RANZCO highlighted was the largely absent investment in public hospital infrastructure and equipment to increase ophthalmology services, with new hospitals and outpatient departments being constructed without consideration of including a public ophthalmology outpatient department.
As such, most regional and outer urban LHNs don’t fund public outpatient services, which is also devastating to Aboriginal and Torres Strait Islander peoples.
“This means that 37% or three million people need to access services elsewhere increasing the risk of prolonging visual impairment and blindness. The wait for cataract surgery is the longest in inner and outer regional NSW due to underinvestment in regional services,” the submission stated.
“One third of Australia’s total Indigenous population live in NSW, and three quarters of this population have no access within their LHD to public ophthalmology outpatient services.”
Thus, RANZCO recommended NSW Health concentrate additional public ophthalmology services in localities where they are needed most and provide appropriate resources to existing paediatric ophthalmology services.
For regions with population catchments of less than 200,000, and/or LHNs without public hospital outpatient and/or inpatient ophthalmology services, the college proposed LHNs deliver public services via outsourced-to-private outpatient and inpatient services.
“[This] model of care for outpatient services would make the most efficient use of the limited regional specialist FTE resource,” RANZCO said.
To meet growing demands, RANZCO has called for scope-of-practice optimisation, especially in poorly serviced areas, with the implementation of collaborative care models. This entails ensuring optometrists, orthoptic nurses, general practitioners and other health professionals are practising to their fullest scope.
“The scope-of-practice for each health professional group must be clearly defined to ensure that a high standard of care is maintained,” RANZCO said.
These models can alleviate the strain on private and public clinics, with some aspects of care redirected to other practitioners.
“This results in more efficient utilisation of health resources, reduced healthcare system costs, improved access to specialist services, and increased patient attendance and convenience.”
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