Eye Health Progress Report

Key Action Area Three: Improving Access to Eye Health Care Services

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Objective: All Australians have equitable access to appropriate eye health care when required.

Since effective sight preserving interventions exist for many eye conditions, it is essential that Australians can access eye health care services when the need arises. Where eye disease cannot be prevented or treated, the quality of life for people with low vision can be greatly improved through access to appropriate rehabilitation and support.

Australian Government

The Australian Government funds a range of programs aimed at increasing access to eye health and vision care, including through subsidising the cost of medicines and specialist services and improving the cultural accessibility of services.

New Medicare Item Numbers for Opthalmology

Between November 2005 and May 2008 the Department, in consultation with the Royal Australian and New Zealand College of Ophthalmologists (RANZCO), introduced a number of ophthalmology items to increase the number of ophthalmology services with Medicare funding and to improve the quality of care for all Australians.

In the 2006/2007 financial year, Medicare expenditure was over $239 million for optometry services and over $255 million for ophthalmology services.

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Extension of prescribing rights under the Pharmaceutical Benefits Scheme (PBS) to include optometrists as PBS prescribers

Since 1 January 2008, optometrists authorised to prescribe under State or Territory law have been able to apply for approval to prescribe from a limited list of eye medicines on the PBS under the National Health Act 1953. The arrangements for prescribing by optometrists under the PBS also apply for the Repatriation Pharmaceutical Benefits Scheme (RPBS). The estimated cost of this initiative is $11 million over four years.

As PBS prescribers, authorised optometrists are also bound by all relevant State or Territory requirements and regulations. Around 300 optometrists have been approved as PBS prescribers at this stage and this number is expected to grow as the number of optometrists eligible to prescribe under State or Territory law increases.

This initiative will make a positive contribution to eye care for the community, particularly for older people, lower income groups and people in rural areas. It will help to make better use of optometrist services, reduce delays in access to eye treatments, reduce costs to consumers and support continuity of therapy. The changes are consistent with a multidisciplinary approach to health care.

As at May 2008, the current PBS optometrist list includes topical eye drops and ointments which are antibiotics, anti-inflammatory agents, anti-allergy products, and ocular lubricants. There are 17 different drugs, 31 formulations, and 46 products (brands).

The medicines for optometrist PBS prescribing as listed on the Schedule of Pharmaceutical Benefits can be found at http://www.pbs.gov.au

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Visiting Optometrists Scheme

The Visiting Optometrists Scheme (VOS) aims to improve the access of people living and working in rural and remote communities to optometric services. Funding of $11.9 million over four years (2007-08 to 2010-11) has been allocated to the scheme.

New arrangements for the VOS commenced on 1 October 2007, in response to the recommendations of a review conducted by the Department. The new arrangements for the VOS will ensure services are better directed towards areas of greater need, particularly remote and very remote communities, and will increase financial incentives for optometrists to participate in the scheme.

Under the VOS, financial assistance is provided for the costs of travel, accommodation, meals and incidentals, lease of equipment, facility fees, administrative support at the outreach location, and external locum support at the optometrist’s principal practice. In addition, optometrists may also be eligible to receive an Absence from Practice Allowance to compensate for ‘loss of business opportunity’ due to the time spent travelling to and from an approved outreach location to deliver optometric services.

VOS Implementation

The first phase was to invite existing participating optometrists to be ‘grandfathered’ into the new arrangements. In this way, existing services will continue to be provided until 30 June 2010.

Of the 99 eligible optometrists, 67 submitted applications to be grandfathered into the new arrangements. These applications have been assessed and funding agreements for the provision of services from January 2008 to June 2010 have been finalised.

The second phase commenced on 12 April 2008, when the Department advertised a national call for expressions of interest from optometrists willing to provide outreach optometric services under the VOS to identified national priority locations. The Expression of Interest process closed on 23 May 2008.

The list of national priority locations has been determined by the Department of Health and Ageing in consultation with key stakeholders, including the Optometrists Association Australia and Vision 2020 Australia, and targets remote and very remote communities, particularly Indigenous communities, and rural communities with an identified need for optometric services.

It is anticipated that a national call for expressions of interest process will be conducted annually as a means of encouraging optometrists to provide outreach optometric services under the VOS to identified national priority locations.

Review of the VOS

The VOS was comprehensively reviewed in 2005-06. The review was undertaken in response to stakeholder concerns that the VOS was outdated, under-utilised and administratively complex, resulting in a relatively low level of participation by optometrists.

The review found that the VOS was a vital and integral component of optometric services provided to Australians living and working in rural and remote locations, however, the scheme did not provide sufficient services to remote and very remote locations, and did not adequately support optometrists.

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South Australian optometry outreach services

Funding of 15,000 (GST exclusive) was provided in 2006-07 for the eye health specialist project in South Australia to support access to outreach optometry services for Nganampa Health Council Clinics as an interim measure while the Visiting Optometry Scheme review was underway.
OATSIH provided one-off funding of $10,000 in 2005-06 to support the provision of optometric and ophthalmology services to remote areas of South Australia, pending the results of the VOS review.

Medical Specialist Outreach Assistance Program

The Medical Specialist Outreach Assistance Program (MSOAP) aims to improve rural and remote community access to a range of medical specialist services by complementing outreach specialist services provided by State and Northern Territory governments. This is achieved by addressing some of the financial disincentives to specialists providing outreach services.

Under the MSOAP, funds are available to reimburse specialists for the costs of travel and accommodation, venue hire and administration, as well as providing compensation for loss of business while travelling
In the period 1 July 2005 to 31 December 2007 nationally, more than $2.19 million was allocated to support 246 ophthalmology services, resulting in over 38,000 people being consulted and treated by an ophthalmologist.

Access to medicines for treatment of age-related macular degeneration

Three new medicines for the treatment of certain patients with age-related macular degeneration (AMD) were included on the Pharmaceutical Benefits Scheme (PBS) in 2007 at an estimated cost of $630 million over 4 years. These are:

• Retaane® (anecortave), listed 1 April 2007 for wet AMD with predominantly classic lesions;
• Lucentis® (ranibizumab), listed 1 August 2007 for wet AMD; and
• Visudyne® (verteporfin), listed 1 August 2007 for wet AMD with predominantly classic lesions, following a transfer from the Medicare Benefits Scheme.

As at 31 March 2008, 8,300 patients had accessed one of these medicines through the PBS.
Although these medicines are not a cure for AMD, they can slow down or reverse its progression, depending on the stage and type of the disease.

On 1 November 2005 new optometry items were introduced into the MBS for domiciliary visits in recognition of the additional costs associated with delivering an optometric service at a patient’s home.

The domiciliary visit item creates a Medicare benefit greater than that provided for a standard consultation item. This is of particular assistance to patients who are disadvantaged or isolated.

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Funding for Aboriginal Community Controlled Health Services

Aboriginal Community Controlled Health Services funded by OATSIH deliver comprehensive primary health care, inclusive of a focus on eye health.

In addition to funding primary health care, Aboriginal Community Controlled Health Services are able to access Expansion and Enhancement funding to augment their eye health service delivery.

Central Australian Initiatives

OATSIH funded the Fred Hollows Foundation to coordinate a program of concentrated eye surgery sessions (‘eye surgery blitzes’) at the Alice Springs Hospital, running over three weeks in May, September and November 2007 to reduce waiting lists for eye surgery in Central Australia. The three surgical sessions conducted a total of 145 additional surgeries, primarily cataract, in 2007. Another eye surgery blitz was conducted in April 2008, achieving 57 procedures over five days. A further two eye surgery blitzes are planned for August and October 2008.

OATSIH is funding Central Australian Aboriginal Congress to pilot a two year project for the employment of a full time optometrist to deliver optometry services and training in Central Australia. The optometrist will focus on the detection and treatment of diabetic retinopathy. Recruitment for the position is underway, with an optometrist expected to commence in July 2008.

Funding of $198,896 has been provided under the Eye Health Demonstration Program to the International Centre for Eyecare Eduation, University of New South Wales to raise awareness of the importance of eye care and to increase access to eye care services by Aboriginal and Torres Strait Islander people in the Northern Territory. This will be achieved through the development and implementation of a training program aimed at further developing the skills and knowledge of Regional Aboriginal Eye Health Co-ordinators from the Northern Territory and selected Aboriginal Health Workers from the Darwin Region.

Australian Capital Territory

A major initiative to create a fully fledged Department of Ophthalmology at Canberra Hospital commenced operation in January 2008. The $2 million investment in equipment and staffing will provide a comprehensive vitreo-retinal service not previously available in the ACT. Further appointments in other sub-specialty areas are being sought, in Paediatrics, Cornea and Glaucoma. The Department now has 2 registrars, and college accreditation of their positions will commence in 2009. A third registrar will also commence in 2009. At present the Department has 2 staff specialists and 5 visiting medical officers.

There has been a thorough assessment of projected requirements to 2020 to assist ACT Health in developing its $300 million Capital Asset Development Plan. This complete overhaul of the Canberra Hospital site will see 300 beds and 10 theatres added to the existing 500 beds and 10 theatres, as well as new Ambulatory Care facilities. Detailed specifications have been provided as to the Department of Ophthalmology’s requirements.

Initiatives to recruit and assist new ophthalmologists to commence private practice in the ACT, aiming to address the workforce shortage created by recent and projected retirements, include advertising through the College and word of mouth enquiry at conferences. An Oculopastics sub-specialist commenced in April 2008. It is envisaged that the training of Registrars within the Department of Ophthalmology will also assist this process in the long term.

Ophthalmologists from Canberra Eye Hospital (Private group practice) provide monthly Clinics at Goulburn, Cooma and Young, as well as a monthly Theatre list at Goulburn.

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New South Wales

Outback Eye Service

The Outback Eye Service provides ophthalmic outpatient services to rural and remote NSW and undertakes ophthalmic surgery at Bourke District Hospital on a regular basis. Cataract removal is the most common surgery performed.

Outreach Services

The Eye Clinic at the Children’s Hospital at Westmead reports that outreach ophthalmic services are offered at Mt Druitt and Campbelltown hospitals, staffed by a paediatric ophthalmologist, orthoptist and ophthalmic nurse. This provides quality paediatric eye services in areas where there very few or no such services available publicly or privately. Outreach orthoptic services are also offered for early childhood secondary screening services to four local community health services. This secondary screening ensures that babies and infants with eye and vision problems are identified early and referred for follow up. It also assists in identifying babies and children without eye and vision problems, thus reducing over referral rates.
The NSW Medical Services Outreach Assistance Program funds two specialists providing a monthly ophthalmology outreach service to Griffith. In 2007, the service undertook over 600 consultations.

The links are forstered with Vision Australia, Glaucoma Australia, Retina Australia and Guide Dogs to ensure that consumers have ready and easy access to acute services. For instance, Low Vision Clinics are provided at Sydney Eye Hospital in cooperation with Vision Australia. Additionally, the Hospital is working on non-operative management of macular disease in collaboration with the University of Sydney. The Hospital offers phone counselling as part of the pre and post admission services and for the wider community. Medical eye services are provided by the Hospital to Redfern Aboriginal Medical Services, Justice Health and Greater Western Area Health Service. Outreach nurse rural clinics are provided in Wollongong, Toucal, Mudgee, Orange and Greater Western Area Health Service.

The Broken Hill Health Service a new position has been created for an ‘Eye Nurse Co-coordinator’. The objective of this position is to provide a nurse to take the lead role in the coordination and management of all ophthalmology services. The Tibooburra Health Service promotes its Ophthalmologic and Optometric clinics through out the district by mail box drops to all households.

Rural Area Health Services are working to increase access to eye health and/or vision care by investigating appropriate service delivery models such as telemedicine and providing outreach services in some isolated areas including Aboriginal and Torres Strait islander communities. A referral/appointment fast track service is in place with local ophthalmologists for Aboriginal clients using diabetes clinics.

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Shared Care Model for Management of Glaucoma

NSW Health Optometrists Drug Authority Committee in collaboration with the Royal Australian and New Zealand College of Ophthalmologists, the School of Vision Science at UNSW and the NSW Optometrists Registration Board endorsed a shared care model improving access to eye services for glaucoma patients.

Northern Territory

Trachoma Initiatives

Training was provided for trachoma screening and management programs to health workers in urban and rural/remote areas, improving the access for NT residents to trachoma screening and programs, in particular in Aboriginal communities.

A central trachoma resource was provided for liaison with organisations throughout the NT to improve their capacity to manage trachoma. This includes Government managed health centres, Community Controlled health centres and Aboriginal Medical Services and as part of Healthy School Aged Kids screening.

Outreach services

In Central Australia weekly visits to remote communities are organised between Alice Springs Hospital and the Aboriginal Medical Services Alliance NT to assess eye health and refer patients for follow up treatment/procedure as required. Around 500 patients were seen through these visits.

With a funding contribution from the Medical Specialist Outreach Assistance Program, 51 Ophthalmology services (91 sessions) were provided over the period July 2007 - April 2008 in the Top End (Darwin, East Arnhem and Katherine). Ophthalmology services are linked with OATSIH Eye Coordinators in remote NT regions.

In collaboration with the Fred Hollows Foundation, additional surgical access has been provided to patients in Central Australia. In 2007, 395 procedures were undertaken in Central Australia, an almost 100% increase from 2006 (214).

Optometry services

Amendments to the NT Poisons and Dangerous Drugs Act have been introduced to allow Optometrists to prescribe a limited range of therapeutics. Optometrists now provide a visiting service, part-funded by Medicare. Wherever possible, Optometrists provide visiting services in conjunction with Ophthalmologists.

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Queensland

Rural and remote nurses in Queensland’s South West (Charleville) have been trained to perform perimetry and take retinal photographs which are forwarded to an Ophthalmologist for interpretation. This is part of the “B-well” community strategy, which has significantly reduced the need for patients to travel to receive care. Nurses in major metropolitan hospitals are performing A scans and taking fundal photographs for diabetic patients to assist with improving access to services.

The Visiting Optometrists Scheme has provided resources for specialist outreach outpatient clinics and surgery to be performed in rural and remote districts in Queensland including, Cape York, Charleville, Mackay, Mt Isa, Roma, Torres Strait Islands.

Cape York Regional Eye Health Program

Cape York Regional Eye Health Program is a federal/state co-operative run by the Wuchopperen Health Service. The program visits 29 remote communities (Birdsville to Lockhart River) through the services of 4 Optometrists and 6 Ophthalmologists. The Optometrists take a leading role in the provision of primary eye care. Optometrists and health care workers visit remote communities every year to examine patients, prescribe glasses, fit them up for surgery and look after basic eye care. During one week in September, patients needing surgery are transported to Weipa for their operations (mainly cataracts and laser treatment for diabetic retinopathy).

South Australia

In relation to children in South Australia a referral pathway has been agreed to increase the access for parents to eye health care professionals by including a direct referral to an Optometrist. This referral option is available from 18 months of age onwards. The Optometrists Association developed a list of Optometrists in the state with an interest in assessing children which has been provided to Children, Youth and Women’s Health Service nurses.

Ophthalmologists in country areas network regarding children’s eye care. Paediatric Ophthalmologists visit Broken Hill, Alice Springs and Port Augusta to provide outreach services and teaching in these locations. The four Paediatric Ophthalmologists who work in public and private sector hub from the Women’s and Children’s Hospital to four geographical zones in the metropolitan area thereby providing convenient metropolitan services also.

Optometry Practice Act 2007 gave SA optometrists prescribing rights for the first time. Appropriately qualified and endorsed optometrists will now be able to treat a range of eye diseases and prescribe relevant therapeutic drugs. The result is that the community will be able to access timely treatment with one primary health professional equipped to correct diagnose and treat the condition in the one visit. It has particular relevance in country regions and remote communities.

Changes to the Optometry Act also gave orthoptists rights to prescribe glasses. These changes were effective as at 22/10/07.

For aged care, the project aims to identify a workable and sustainable model that will get patients to an optometrist when they need it.

SA has implemented the revised federal model of the Visiting Optometrists Scheme. To date applicants wishing to receive funding to deliver eye care to regional towns and aboriginal communities have lodged their request and these are currently being assessed.

The SA government funded a pilot project by Anglicare in 2006 to deliver eye health care to people with intellectual disabilities in sheltered accommodation and the homeless.

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Tasmania

Ongoing Programs with Annual Funding

DHHS funds the following activities:

• Royal Guide Dogs Association of Tasmania to:

• provide information and referrals for services and equipment for people and develop community awareness and education on the special needs of those with vision impairment and the most appropriate ways of meeting those needs; and
• contribute to national and international research, development and training in the fields of mobility, sight enhancement and technology that leads to the availability of optimum resources for people who have vision impairment.
• RPH Print Radio to:

through radio broadcasting, provide information to people with significant visual impairment, including readings from local newspapers, current magazines, government information and special areas of interest.

Tasmanian Eye Health and Care Initiative

This project will also provide the opportunity to identify gaps in services, ways to facilitate access and the removal of barriers that create duplication and inefficient use of resources.

Victoria

Victorian Eyecare Service (VES)

Aged Care has a recurrent budget for $5.1 million to manage the VES. This service provides low cost eye care services including spectacles at nominal cost for persons with a health care card or pension concession card. It also includes specialist diagnostic and treatment services, including low vision services. Approximately 70% of clients are 65 years and over.

The Victorian College of Optometry administers the VES. It provides services at Melbourne Optometric Clinic in the metropolitan area (main site in Carlton and several sites in Community Health facilities), and outreach services (for people living in residential aged care facilities and Supported Residential Services). Rural services are provided by private optometrists, who are subsidized. Other specialist services are provided through the Aboriginal Health Service, a disability service and a service for homeless people.

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The Vision Initiative

As part of TVI, Vision 2020 is working in collaboration with the Neighbourhood Renewal Program to facilitate appropriate referrals to low vision services.

Elective Surgery Access Policy

In June 2005, the Department released the Elective Surgery Access Policy. The policy provides advice to health services on best practice waiting list management and promotes consistent and equitable access to services regardless of the hospital or the procedure for which the patient is waiting. The policy emphasises the active management of patients waiting for elective surgery and treatment within clinically desirable time frames.

Elective Surgery Access Service program

The Elective Surgery Access Service (ESAS) program provides options to have treatment transferred to designated centres where patients have not been able to receive timely treatment (Defined as within 30 days for urgent patients, 90 days for semi-urgent patients and 365 days for non-urgent patients). The ESAS also provides a mechanism and policy framework for the transfer of long waiting elective surgery patients between health services, expanding the choice of options for patients. Eligible long waiting patients who agree to participate in ESAS are transferred to ESAS designated centres that have identified and funded additional capacity. To facilitate the transfer of patients, and support waiting list management, the department also funds ESAS Coordinators at 18 health services.

Funded services include:

• The Alfred Centre, which in 2007-08 was funded to treat more than 600 state wide Ophthalmology referrals, making up more that 30% of the state wide work funded at the centre.

• The Cranbourne Integrated Care Centre (CICC) which has made significant gains in reducing waiting times for patients requiring cataract surgery. This centre was one of the first centres to introduce a new model of care for cataract surgery that adopted the concept of a one-stop shop approach. This meant that patients could have their eyes tested, get their diagnosis, run through surgery options and book a time for their surgery in the one day. The CICC also takes referrals directly from optometrists in some cases.

Prior to the establishment of the Eye Unit at the CICC, the service provided 550 cataract operations per year. In 2006-07, the CICC performed more 1,800 such procedures.

The median time to treat semi-urgent Ophthalmology patients admitted in Victorian public hospitals in 2006-07 was 11 days. The median time to treat non-urgent Ophthalmology patients admitted in Victorian public hospitals in 2006-07 was 84 days.

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Western Australia

Reform of outpatient services

In WA there has been a focus on reducing the number of unnecessary repeat visits and increasing to at least 30% new patient assessments through outpatients. This work is progressing rapidly and now being linked to ‘Clinical Prioritisation’. Access to ophthalmology services is included in these reforms and waiting times are reducing. The full implementation of the WA Primary Care Strategy and the e-Health reforms will facilitate referral by general practitioners to services provided by WA Health and handling of electronic referrals and potentially retinal images.

Waiting list strategies

WA has embarked on major initiative to reduce waiting times for all surgery. Enhanced provision of cataract surgery was identified as a priority from the Draft WA Health Eye Services Development Plan. Over-boundary cases for cataract surgery have fallen consistently over the last 2 years. Current initiatives partnered to the Commonwealth Government Waiting list reduction program include provision of additional microscopes and lists at the two elective surgery sites at Osborne Park and Kaleeya Hospitals.

Rural Service Enhancements

Regional services planning and the increased use of telehealth are being combined to improve services provided to the rural sector in Western Australia. Service planning by region is being undertaken by country health services. Provision of ophthalmology services and linkages to the early assessment programs outlined above are being developed. Planning for additional surgical services in the regional resource centres is being considered as part of the workforce planning for regional services and includes the provision of specialist ophthalmology services in line with the recommendations developed in the WA Eye Health Services Development Plan.
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