Evaluation of the Medical Specialist Outreach Assistance Program and the Visiting Optometrists Scheme

Page last updated: 28 February 2012

Executive summary

The Department of Health and Ageing (DoHA) engaged Health Policy Analysis to undertake an evaluation of the Medical Specialist Outreach Assistance Program (MSOAP) and the Visiting Optometrists Scheme (VOS). This report represents the final deliverable for the project.

MSOAP and VOS are two important programs that have been implemented to overcome some specific barriers faced by people living in rural and remote Australia. The programs are for they are targeted at facilitating access to medical specialist and optometry services for people living in these communities. They are administered separately, but have overlapping reach. They have been implemented in a context where many other initiatives and programs have been established to address similar or related objectives.

The evaluation was intended to address key aspects of the operations of these programs. It aimed to:
    • Identify opportunities for improving coordination of services between the two programs.
    • Look for opportunities to streamline administration of both programs.
    • Examine the potential impact of the Health Reform Agenda on both programs.
    • Determine whether the model of service delivery under each program is effectively, efficiently and equitably meeting the needs of clients and other stakeholders.
There were specific questions established for the evaluation. To address these questions, Health Policy Analysis designed a mixed method evaluation approach, including a literature review and document analysis, interviews with an extensive range of stakeholders across the country, call for and analysis of written submissions from stakeholders, surveys of service providers (both MSOAP and VOS), analysis of program data and Medicare Australia data, and case studies of seven communities across Australia and one national program (Tele-Derm). Overall, 66 interviews were held with 57 organisations and 160 individuals. Written submissions were received from 23 organisations or individuals. In addition, 59 individuals were interviewed for the case studies.

Program context

In examining the context for MSOAP and VOS, we highlighted the key challenges for rural and remote populations in a number of areas such as demography, health status and workforce. We found that Australians living in rural areas rate more poorly than Australians living in major cities across a range of health status measures. These include: life expectancy, self-reported health status, cancer incidence and chronic disease prevalence. They also tend to have poor determinants of health, including tobacco use and risky or high risk alcohol consumption. A major contributor to the lower relative health status and determinants of health of rural and remote regions is the high proportion of Aboriginal and Torres Strait Islander people who tend to have poor health living in these regions compared with metropolitan regions.

Another challenge is the viability of specialists and optometrists to practice in rural and remote regions, which is effected by having sufficient volumes of patients, and the likelihood of patients having private health insurance (which limits the practitioner to bulk billing). In addition, professional and social issues play a part in specialists’ and optometrists’ decisions to practice in these regions. The challenges for private practice specialist medical practitioners and optometrists in providing services to rural and remote populations are reflected in MBS expenditure figures and in analyses of location of the medical workforce across remoteness areas.

Over the years, governments (including Commonwealth and state and territory) have invested in a variety of programs to address rural health issues and to expand the health workforce and/or access to health services for rural and remote populations. These schemes may be in the form of incentives provided in mainstream programs (such as MBS), or targeted programs.

The recent national health reforms have introduced Local Hospital Networks (LHNs) and Medicare Locals. In particular, Medicare Locals are aimed at achieving greater integration between primary, secondary and tertiary health care provider organisations, and improving co-ordination of care across these. The health care reforms have the potential for greater engagement of various players in planning and service development to meet local needs. However, the effects are as yet unknown.

Literature review

From the literature we found that there have been few systematic reviews of outreach specialist services; and that these have suffered from insufficient numbers of studies or papers meeting the criteria for good quality intervention studies. Nevertheless, the conclusions have generally been positive for overall effectiveness and cost effectiveness. A key concern is that the opportunity costs of specialists being absent from their usual place of practice or those with alternative investments that could have been made have not been sufficiently explored. Alternative means of delivery have also been explored, including telemedicine and upskilling of primary care providers to provide some specialist care.

Apart from the systematic reviews, there have also been individual studies of specialist outreach, including outreach provided in remote Australian settings. The findings from these individual studies have also been generally positive. Examples of benefits from these models include improved access, reduced costs, early detection of chronic disease and skin cancer, and more effective management of chronic diseases.

The literature on telemedicine also found significant benefits of this approach for patients and carers. However, the full impact of telehealth cannot be adequately measured due to the lack of properly designed studies comparing the approach to conventional modes of service delivery.

Operation of MSOAP


MSOAP was established in 2000 by the Commonwealth Government to increase access to specialist services in rural and remote regions of Australia. The original objectives of the program have not changed over time. They include:
    • Increasing visiting specialist services in areas of identified need.Supporting medical specialists to provide outreach medical services in rural and remote areas.Facilitating visiting specialist and local health professional communication about ongoing patient care.Increasing and maintaining the skills of regional, rural and remote health professionals in accordance with local need.
(DoHA Department of Health and Ageing)
Since its establishment, there have been expansions made to the program, including Indigenous Chronic Disease (MSOAP-ICD) in 2009-10, and Ophthalmology and Maternity services in 2010-11. The expansion of the program provides targeted support in specific areas of need, and also brings GPs, nurses and allied health practitioners within the scope. Details of program allocations up to 2011-12 are shown in Table 1.
Table 1 – MSOAP program expenditure 2000-01 to 2010-11 and budget allocations 2011-12
  2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
  $m $m $m $m $m $m $m $m $m $m $m $m
MSOAP Core 3.5 8.2 12.4 12.5 14.6 15.5 18.2 16.2 19.2 19.4 19.7 19.7
MSOAP ICD                   1.4 7.8 19.5
MSOAP Ophthal.                     0.1 0.2
MSOAP Maternity                       3.4
Total 3.5 8.2 12.4 12.5 14.6 15.5 18.2 16.2 19.2 20.1 27.6 42.8

Source: Program data provided by DoHA (2005-06 to 2011-12); Morey Australia 2003 p 61 (2000-01 to 2003-04 – Note there were significant underspends in 2000-01 and 2002-03).
From 1 July 2012 a Rural Health Outreach Fund will be created that consolidates the activities of five existing programs, including MSOAP and its extensions, with the exception of MSOAP-ICD.

MSOAP and its extensions principally operate under a ‘fundholder’ model. In each state/the Northern Territory, a fundholder (or two fundholders in New South Wales and Queensland) are appointed by DoHA to administer the program. Fundholders were identified early in the program’s establishment and have changed only marginally since that time. Fundholders manage the program, including planning, contracting with and paying outreach service providers.

Advisory fora for MSOAP have been established in each state and the Northern Territory. The advisory consider proposals and advise on needs and priorities. Recommendations of service proposals may be endorsed by the advisory fora, but are approved by DoHA.

Stakeholder views on MSOAP

Key issues raised by stakeholders included:
    • Variation in how the program is run across states/the Northern Territory has led to differences in the identification of need and development of services to address that need. While there is a need to adapt services to local requirements, national standards would improve planning and priority setting. Overall there is a need for better mechanisms for identifying priorities and gaps in outreach services that will most impact gaps in health status for rural and remote populations.
    • Integration of visiting services with local primary care services is important for service effectiveness. MSOAP has been a vehicle through which primary care and specialists have been able to develop relationships and shared care arrangements. It will be important to emphasise these issues in the development of services in the future.
    • The program needs to recognise and support coordination at the local (community) level, particularly for Aboriginal and Torres Strait Islander health services, and services in remote Australia. Some stakeholders believe these current gaps are not so much about clinical support at the local level but practical coordination. For example, ensuring local physical facilities are not over-subscribed, advising visiting service providers that a planned visit will be problematic (e.g. due to sorry business, or availability of a driver to transport patients to the health clinic).
    • The program needs to recognise and support coordination and sharing of information at the regional level. For example, there is a need for better mechanisms for sharing information about all outreach services going to each locality (including outreach services not funded by MSOAP or VOS).
    • There should be one fundholder in each jurisdiction. Depending on which organisation is the fundholder, there may be a need for mechanisms to ensure state/territory and/or private sector specialist services are appropriately integrated with the program.
    • Administrative costs should be reduced for service providers, fundholders and DoHA by reducing the number of fundholders, reducing the number of funding agreements and reducing and rationalising the reporting requirements under funding agreements.
Most stakeholders feel that the program has room for future growth, though proper guidance is needed for it to be effective.

MSOAP effectiveness and cost effectiveness

The evaluation concludes that MSOAP is having a material impact on access to specialist services for rural and remote Australia. Overall, it is estimated that MSOAP Core has reduced the gap in access to specialist service between major cities and rural and remote Australia by 0.6 percentage points for inner regional areas, 2.2 percentage points for outer regional, 2.1 percentage points for remote and 9.4 percentage points for very remote. The relative importance of MSOAP varies across these areas. Under the assumption a proportion of MSOAP services are not billed to Medicare, MSOAP represents 0.7% of specialist services in inner regional, 3% in outer regional, 4.2% in remote and 28.7% in very remote areas (Figure 1).

Estimated relative impact of MSOAP Core on access to specialist services assuming a proportion of MSOAP services are not billed to Medicare, 2009-10
Figure 1 – Estimated relative impact of MSOAP Core on access to specialist services assuming a proportion of MSOAP services are not billed to Medicare, 2009-10

In addition to improving access, the program has had a number of additional benefits including:
    • Strengthening the capacity of primary care through upskilling, the provision of a consultation and liaison service outside the actual visit and other shared care style arrangements. This can result in a more capable primary care service with the confidence to manage more complex patients on an ongoing basis.
    • Increasing the attractiveness of primary care and therefore having an impact on the primary care workforce.
    • In some regions, where there is high turnover in primary care staff, providing continuity in managing patients with ongoing needs.
    • Reducing costs to patients and their families, the health system and the broader community through avoiding travel to regional or metropolitan centres to access specialist care.
The effect of the program on health outcomes is unknown and difficult to assess. Specialist services cover a wide range of conditions and interventions, some of which are short term and others ongoing.

The cost effectiveness of MSOAP services was also considered. The average cost per patient consultation, based on actual reported patients and expenditures, is estimated at $93 (excluding fundholder and DoHA administration costs). This ranges from $71 per patient consultation in inner regional locations to $157 in very remote regions. If administration costs are included, it is estimated that the average cost per patient under the core program in 2009-10 was $112, with $13 per patient consultation associated with fundholder administration and $5 per patient consultation associated with DoHA administration. This ranged from $86 per patient consultation in inner regional areas to $190 in very remote areas.

This compares with an average specialist consultation medical benefit payment of around $69 per consultation and average patient out of pocket contribution of $30 per consultation. MSOAP direct costs are close to double the consultation fee, but around 60% higher than the consultation fee in very remote areas.

Alternatives to outreach specialist care include patient assisted travel and accommodation (average cost of $200 per patient assisted trip), consultations by telemedicine and use of primary care provider only. These options are not mutually exclusive and combinations are feasible. Other benefits of outreach care need to be considered, including how outreach services strengthen and support primary care providers both through the visit (upskilling, case planning) and after the visit (consultation and liaison). Outreach services represent a cost effective alternative to patient assisted travel, and GP only care.

However, various configurations of shared care and telemedicine (many of which are currently supported in the program) should also be considered. The program needs to be able to support alternative mechanisms of delivering outreach services where these may represent a more effective or efficient option.

As discussed below, there are strategies that could be adopted that would improve overall cost effectiveness of the program by reducing costs.

There is some evidence that the current allocation of funds does not reflect relative need fully, both across jurisdictions and within jurisdictions. Various factors affect this. However, there is an opportunity to update weightings to reflect better information on relative cost and need for specialist services.
A range of recommendations on MSOAP have been made and these are shown below. Top of page

Recommendations related to MSOAP

General recommendations

1. New funding under the Rural Health Outreach Fund should be targeted at regions and communities with the highest levels of need. Better mechanisms are required to assess levels of need and gaps in access; and take into account the cost of service delivery in more remote locations. This may mean that the funding formula used for allocating funds between jurisdictions may need to change. Changes to allocations between jurisdictions should be achieved through targeting the allocation of new funding, rather than distribution of existing funding.

2. To improve the effectiveness of outreach services, the types of service eligible for support should be extended. The following extensions are recommended:
        1. Under the Rural Health Outreach Fund, eligibility should be extended to services involving clinical support staff accompanying the medical specialist, including nurses and allied health, where the clinical support staff member is usually required for the delivery of the clinical services provided by the medical specialist.
        2. Telemedicine services should continue to be supported where these are not eligible for subsidy under Medicare.
        3. Under MSOAP-ICD, eligibility should be extended to include support for local coordination of outreach services. This would largely relate to funding of local staff in Aboriginal and Torres Strait health services (both non-government and government) to assist with local coordination issues including: scheduling of visiting specialists and patients, ensuring physical space is available for a specialist visit, ensuring visiting specialists are aware of cultural or other events that might impact patient attendance, reminding patients when a specialist visit is imminent, arranging or providing transportation so patients are physically able to attend clinics, and assisting with follow-up issues after a specialist visit.
        4. Under the Rural Health Outreach Fund and MSOAP-ICD, funding should be provided for regional outreach coordinator positions, focussed on outreach services into remote and very remote communities.
        5. The Commonwealth Government should consider opportunities to support outreach Ear Nose and Throat (ENT) specialist outreach services for Aboriginal and Torres Strait Islander peoples under MSOAP.
3. State, territory and Commonwealth governments should consider opportunities to use the administrative arrangements available under MSOAP for outreach dental health services for remote communities.
4. DoHA develop mechanisms for sharing comprehensive information about outreach health services available in all rural and remote communities across Australia. Although not specifically within the scope of this review, this should also apply to locally available services. There are several components in achieving this recommendation, including:
        1. Contracts with service providers participating under MSOAP and VOS should stipulate that information about the visiting service they have agreed to provide will be made available to the public and shared for planning and coordination purposes.
        2. Information on outreach services outside MSOAP is also required (e.g. those supported by the state/territory health authorities).
        3. Comprehensive information should be openly available to the public and health service providers.
        4. Good mechanisms are required to ensure information is current.
5. When selecting or reviewing specialists participating in MSOAP, fundholders should examine the billing practices, particularly where this affects access by very disadvantaged groups.

6. Population weights used to determine the allocation of MSOAP Core and MSOAP-ICD funding across jurisdiction be updated to better reflect relative needs across remoteness regions and the higher cost of supporting outreach services in more remote regions. There should be consultation with all relevant parties before changes to the underlying formula are implemented. Resulting changes to allocations between jurisdictions should be achieved through targeting of new funding, rather than distribution of existing funds.

Assessment of need

7. While understanding local circumstances is vitally important in planning outreach services, assessment of need should be improved and be undertaken within a common national framework. The framework should be developed during the 2012 calendar year through a collaborative process involving all MSOAP fundholders and each advisory forum. The framework should provide guidance on:
        1. the key steps in planning outreach services
        2. suggested planning benchmarks (see below)
        3. processes for obtaining input from local stakeholders on priorities
        4. other issues that impact the setting of priorities
        5. criteria for assessing individual proposals.
8. A common national approach be established through which data required for planning is collated and made available on a regular basis to fundholders and other for planning purposes. Core planning data is required at a common geographic unit. The geographic unit could be the Statistical Local Area (SLA) or an equivalent. Data available at this level needs to be compiled from a variety of sources including those set out in in Table 70. Many of these components are already available through national data collections. Others will require the development of appropriate systems for collating data.

9. A common national approach be established through which data required for planning is collated and made available on a regular basis to fundholders and other for planning purposes. Core planning data is required at a common geographic unit. The geographic unit could be the Statistical Local Area (SLA) or an equivalent. Data available at this level needs to be compiled from a variety of sources including those set out in Table 70. Many of these components are already available through national data collections. Others will require the development of appropriate systems for collating data.

10. Planning benchmarks for visiting services should be developed across the most common specialist services. The benchmarks could identify a core set of required specialist services, and an appropriate level of visiting on an annual basis by the most common specialities by community size. These benchmarks would be provided as a guide only and could be modified by appropriate factors to reflect local circumstances and requirements. The planning benchmarks could also be supplemented by outlining possible alternatives to outreach services. The benchmarks should be developed during the 2012 calendar year through a collaborative process involving all MSOAP fundholders and advisory fora.

11. Fundholders should review processes for consulting with local stakeholders in developing service proposals, to ensure these processes are effective and appropriate. In each jurisdiction consultation on priorities at the local level should engage:
        1. existing local health planning fora where these exist
        2. Medicare locals and/or divisions of GP
        3. LHNs
        4. Aboriginal and Torres Strait Islander health services.
12. It is recommended that under the administrative allowance for MSOAP-ICD some funding be made available for state level Aboriginal and Torres Strait Islander health organisations to assist with consultation with Aboriginal and Torres Strait Islander communities and health services in the identification of priorities across the jurisdiction and consideration of specific service proposals.

Advisory forum

13. The membership of each advisory forum should be reviewed. The membership should have a stronger representation of organisations and services based in rural settings, including Aboriginal and Torres Strait Islander health services and Medicare Locals.

14. In each jurisdiction, an MSOAP working group should be established involving the state/NT DoHA office, the fundholder, the state/NT health authority and the state level Aboriginal and Torres Strait Islander health organisation. The working group should meet regularly and consider drafts of papers and plans, identify issues prior to the full advisory forum, and deal with matters that do not require reference to the advisory forum.

15. The key functions of the MSOAP advisory fora should be to:
      1. Consider and recommend broad priorities to be addressed under the MSOAP programs over a three year period, based on a comprehensive analysis of need undertaken at the commencement of that period.
      2. Consider and recommend service proposals.
    At the commencement of the three year period, a three year plan should be considered. This should identify service proposals to be supported for the period without further reference to the advisory forum, service proposals to be supported for a 12 month period prior to review by the advisory forum, reserve service proposals that can be supported during the year depending on funding without further reference to the advisory forum.
    In years 2 and 3, the advisory forum should review new proposals or major variations in services, but should not be required to revisit service proposals approved for the three year period.
16. Advisory fora meetings should be scheduled so that the three year and annual plans are considered in April prior to the commencement of the financial year, and these are approved one month prior to the commencement of the financial year.

17. Guidelines on management of conflicts of interest should be included in the terms of reference of advisory fora.

18. Depending on circumstances and agreement, there should be an option for secretarial support for the advisory fora to be provided by fundholder rather than the state/NT office of DoHA.

19. A joint committee involving appropriate members of the MSOAP advisory forum, representatives of the optometry profession and other appropriate people should meet regularly to consider eye health issues and priorities for the state/territory. This committee should also include a member who is involved directly with the IRIS task force. The committee should be supported by the MSOAP fundholder. The committee should consider priorities for eye health services in the jurisdiction and make recommendations to the local MSOAP advisory forum on specialist eye health services being considered for support under MSOAP and to DoHA on services being considered for support under VOS.

Recruitment of service providers

20. Fundholders and advisory fora should regularly review the mechanisms through which they recruit service providers to ensure:
        1. The mechanisms are open to possible new service providers.
        2. Where fundholder arrangements are being rationalised that there are good linkages into either the public or private sectors.
        3. There are relationships with fundholders in other states where there may not be an adequate supply of service providers within the state/territory.
        4. There is an appropriate system for managing succession when service providers decide not to continue providing outreach services.

Fundholder arrangements

21. One fundholder organisation should be supported in each jurisdiction. This will reduce costs and potentially improve coordination.

22. Management of the Kimberly Paediatric Outreach Program should be devolved to the Western Australia fundholder.

23. The New South Wales component of the Paediatric Surgery Outreach Program provided by New South Wales service providers should be devolved to the New South Wales fundholder, and the Victorian component should remain with the Victorian fundholder.

24. Management of the Baker IDI funding agreement should be reviewed at the end of the funding agreement, with a view to devolving management of the funding agreement to the Northern Territory fundholder.

25. Mechanisms are required to ensure coordination of the IRIS initiative with jurisdictional based fundholders (see recommendation 18 above).

26. Better linkages and cooperation between fundholders should be encouraged through holding a face to face meeting with relevant DoHA officers on a biannual basis, and joint initiatives in areas such as information systems developments.

Streamlined administration

27. One set of guidelines should be developed for all the MSOAP programs, highlighting any differences in eligibility or other issues.
28. All MSOAP programs should be integrated into one funding agreement between DoHA and the relevant fundholder, with details of annual allocations specified for relevant subprograms, specified in an attachment to the funding agreement. Variations in funding allocations should be managed through an exchange of letters agreeing to a variation to the funding agreement.

29. Funding agreements between DoHA and fundholders should be for a three year period with an option to extend for a further three years following review.

30. Reporting under the funding agreement should be rationalised. The structure of reports should be integrated so that there is one report including all subprograms. Details of subprograms should be specified in the report. The following integrated reports should be required under the funding agreement:
        1. A three year service plan to be submitted prior to the commencement of each three year cycle, together with data extract on proposed services for the national database.
        2. Annual update plan to be submitted prior to the commencement of years 2 and 3 of the three year cycle, together with data extract on proposed services for the national database.
        3. Quarterly income and expenditure statements.
        4. Annual audited statement.
        5. End of year report (including final report).
        6. Continuous or monthly data extract to national database.
31. Service proposals should be able to be approved for a cluster of locations (or a circuit) for a single service provider. However, reporting on services should always be in terms of visits to individual locations.

32. A higher threshold for requiring approval by DoHA of a variation in a specific service proposal be set, specifically:
        1. Within any financial year, fundholders should have the capacity to approve a change in the mix of service locations visited within a service proposal, without referral to DoHA. (This does not include the addition of new locations.) However, an ongoing change in the mix of services at locations should be referred to the advisory forum for consideration in the next annual/triennial plan.
        2. Within any financial year, fundholders should have the capacity to approve an increase or decrease of up to three visits to the specified location(s) for a service proposal, without referral to DoHA. However, an ongoing change in the level of visits for a location should be referred to the advisory fora for consideration in the next annual/triennial plan.
        3. Three year and annual plans should specify reserve services. Fundholders should have the capacity to initiate funding for these services without further reference to DoHA, in order to ensure funds are expended within the year.
33. Fundholders should be encouraged to develop three year contracts with service providers where they have been approved under the three year plan. Appropriate provisions for managing non-provision of services or changes in circumstance should be included in the contract.

34. An approach to invoicing and reporting by service providers should be developed that involves a capacity to include multiple locations in one invoice (e.g. a circuits or cluster of visits). Associated reporting of activity should be disaggregated by individual locations visited, but with a capacity to report multiple locations in one form. Systems for on-line submission of reports and invoice should be developed.

Data management

35. A national MSOAP database is required for all programs. The database should have the following features:
      1. The application should be secure, but accessible through the internet.
      2. Details of the original service proposal approved and the history of approved changes to a service proposal need to be recorded.
      3. Details of visits (including dates), consultations, payments and service provider comments on visits need to be recorded in a separate table.
      4. Data should be able to be entered on-line or in batch mode by fundholders.
      5. Approved service provider details should be updated at the time the proposal is submitted to DoHA (e.g. with the three year or annual plans), or when the fundholder approves a minor variation.
      6. Data on visits (including dates), consultations, payments and service provider comments should be updated by fundholders on a monthly basis.
      7. Fundholders should be able to extract their data for their own analysis.
      8. DoHA state offices should be able to run reports and extract data. Top of page

Operation of VOS

VOS commenced in 1975 and is enabled under section 129A of the Health Insurance Act 1973. The aim of VOS is to “to improve the access for people living and working in remote and very remote communities to optometric services” and the objectives are to:
    • Improve the eye health of Australians living and working in remote and very remote areas, and rural communities with an identified need for optometric services.
    • Increase visiting optometrist services in areas of identified need.
    • Support optometrists to provide outreach services.
    • Encourage and facilitate integration and communication between visiting optometrists, local health providers and other visiting health professionals about ongoing patient care.

VOS operates as a grant scheme through which funding agreements are developed with optometrists who agree to provide outreach services to localities without access to optometry.
In 2010-11, annual allocations were $2.8 million for Core VOS and $1.2 million for extension of the scheme targeted at Aboriginal and Torres Strait Islander people (VOS IA) (Table 2). These allocations will increase to a total of $5.8 million in 2013-14, with the majority of expansion occurring through VOS IA. By 2013-14, VOS IA will account for 46% of the total VOS allocation. Actual expenditure for the scheme has frequently fallen short of budget allocations, by an average of 20% over the last four financial years. Under the current arrangements DoHA expenditure for the management of VOS is estimated to be around $550,000-$570,000 per annum.
Table 2 – Visiting Optometrists Scheme allocations and expenditures 2007-08 to 2013-14 (excluding Departmental administration)
  2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

VOS – Core

2,256

2,416

2,588

2,767

2,528

2,963

3,138

VOS – Indigenous Australians

 

 

 

1,262

1,866

2,577

2,678

Total

2,256

2,416

2,588

4,029

4,394

5,540

5,816

In 2010-11 there were 73 optometrists or optometry organisations that participated in VOS (VOS optometrists). Sixty-two of these participated in Core VOS and 17 participated in VOS Indigenous Australians (with six participating in both programs). Eleven VOS optometrists (15%) visited 10 or more locations and accounted for 46% of program expenditure. Many of these optometrists have an exclusive focus on delivery of services to rural and remote communities. Together the 11 VOS optometrists visit 343 locations across Australia, mostly in remote and very remote regions.

VOS effectiveness and cost effectiveness

Overall, approximately 22,400 patients were provided with VOS supported outreach services in 2010-11. Approximately 28% of these identified as being Aboriginal or Torres Strait Islander. Nine per cent of patients seen under the VOS program were located in inner regional areas, 40% in outer regional, 20% in remote and 31% in very remote areas. Approximately 59% of Indigenous Australians seen by VOS optometrists live in very remote locations.
Optometrists supported under VOS Core provided 19,022 patient consultations of which 21% (4,016) identified as Aboriginal or Torres Strait Islander. Services supported provided as part of the VOS IA provided an estimated 3,359 consultations to patients of whom 67% (2,267) identified as Aboriginal or Torres Strait Islander.
The average subsidy for the provision of VOS services to each patient is $146 across the program. This varies by remoteness area, from $87 in inner regional to $101 in outer region, $212 in remote and $254 in very remote locations. DoHA administrative costs are estimated at $26 per patient seen, which, when combined with the costs for the provision of VOS services, totals an average cost of $172 per patient.
Overall, VOS services (using the data for 2010-11) represent a level of provision ranging from 0.5 services per 1,000 people in inner regional areas, 4.3 in outer regional, 13.5 in remote and 39.9 in very remote areas. Relative to the underlying rate of use of optometry services in each remoteness area, it is estimated that VOS supported services increase the level of provision by 0.2% in inner regional areas, 1.6% in outer regional, 6.2% in remote and 20.3% in very remote areas (Figure 2). Relative to the level of service provision in major cities VOS supported services increase the level of provision by 0.2% in inner regional areas, 1.5% in outer regional, 4.6% in remote and 13.5% in very remote areas.
The evaluation concludes that there are gaps in access to optometry services for rural and remote populations which are most significant for outer regional, remote and very remote areas. VOS has a material impact in reducing these gaps. Its impact is greatest for populations in very remote areas where VOS improves access by approximately 30%.
VOS supported services and estimated total optometry services per  1,000 population age adjusted by remoteness areas, 2010-11
Figure 2 – VOS supported services and estimated total optometry services per 1,000 population age adjusted by remoteness areas, 2010-11

Overall, VOS is vital in providing support for outreach optometry services. VOS by itself cannot address all the issues in eye health, particularly the many challenges for the eye health of Aboriginal and Torres Strait Islander people.
The evaluation concludes that at this point in time the scheme should continue as a discrete scheme and not be absorbed into the Rural Outreach Fund. The principal areas VOS can improve its effectiveness are through:
    • A more comprehensive and open approach to planning and developing services. One of the most important contributions that VOS can make is to ensure that services are developed and funding allocated to localities and communities with the poorest level of access.
    • Ongoing monitoring of VOS effectiveness through the creation of a small set of performance indicators for the program.
    • Creating greater flexibility to support the most cost effective outreach services for particular communities.
    • Improved sharing of information between outreach eye health providers (VOS optometrists, ophthalmologists and others), primary care health services and communities.
    • Contributing funds, along with MSOAP, to research options for improving the effectiveness of outreach services, for example, in how the concept of eye health registers might be developed to ensure services are well targeted, how information can be better shared between optometrists and ophthalmologists, how rates of ‘did not attend’ can be reduced, the role optometrists can play in eye health awareness and education.
Outside the program, the key issues to emerge for governments are:
    • The need for clearer and ongoing support for the regional eye health coordinator role.
    • The need for state/territory level coordination of eye health services.
    • Improved and more consistent access to subsidised spectacles for people living in rural and remote Australia.
Recommendation related to these and other issues related to VOS are set out below.Top of page

Recommendations related to VOS

General recommendations

36. VOS remain a discrete program with a separate budget allocation.

37. New funding under Core VOS and VOS IA should be targeted at regions and communities with the highest levels of need. Better mechanisms are required to assess levels of need and gaps in access, taking into account the cost of service delivery in more remote locations and align optometry outreach with other outreach eye health services.

38. To improve the effectiveness and cost effectiveness of outreach services, the types of service eligible for support should be extended to include support for local optometrists willing to provide optometry services in local AMSs, where this is supported by the Aboriginal and Torres Strait Islander health service. In this situation support for the optometrist should be based on an estimate of the cost to the business associated with this arrangement.

39. DoHA implement an approach for sharing comprehensive information about outreach optometry services available in all rural and remote communities across Australia. The following steps are required:
    1. Funding agreements with VOS optometrists should stipulate that information about the visiting service they have agreed to provide (the schedule of visits, where the service will be provided, details of how to contact the optometrists to make an appointment) will be made available to the public and shared for planning and coordination purposes. The funding agreements should provide a requirement to update this information when it changes.
    2. Comprehensive information on visiting services should be openly available to the public and health service providers through a web site and/or interactive map.

Assessment of need


40. DoHA initiate steps to create a comprehensive database for planning VOS and other eye services by integrating the relevant data at the SLA (or equivalent) and/or locality level, as described in the report.

41. DoHA establish a system for generating reports annually from Medicare data that provides key tables on eye health services at the SLA (or equivalent) level, as described in the report.

42. Based on analysis of the planning database the VOS National Advisory Committee specify planning benchmarks for the provision of outreach optometry services for localities of different population sizes. These benchmarks should take into account (a) the gap in access to optometry services for remote and very remote locations (b) the current impact of VOS (c) the extent to which current gaps can be addressed with available (including addition) VOS funding; and (d) the higher likelihood of outreach service disruptions in very remote areas, for example, due to cultural and community issues and the weather.

43. VOS state reference groups/joint eye health planning committees be provided with analyses of planning data discussed above and be requested to provide advice on priority localities/circuits. The joint eye health committees should be requested to advise on:
        1. The number of visits required for each locality per year, based on the planning benchmarks proposed in the previous recommendation and other information available locally to the committee.
        2. The priority to be accorded a particular locality.
        3. Whether and how the locality should be grouped with other localities in advertising for VOS service proposals, and if so the priority for the circuit as a whole.
44. Following consideration of advice from joint eye health planning committees, the VOS National Advisory Committee develop recommendations on a national list of priority localities including an indicative number of outreach visits require per year for each locality, and the potential grouping of the location into a circuit. The recommendations should be released publicly seeking comments from the public and other stakeholders. The VOS National Advisory Committee should consider feedback on the proposed priorities prior to providing its final recommendations to the Minister’s delegate.

Roles and operation of advisory structures


45. The membership of the VOS National Advisory Committee be revised to include:
        1. the Minister’s delegate
        2. three officers from DoHA, including from: a state/Northern Territory office, OATSIH and the Office for an Ageing Australia
        3. two representative from the Optometrists Association of Australia
        4. a representative from Vision Australia
        5. a representative of primary care service providers based in rural and remote Australia
        6. a representative of Aboriginal and Torres Strait Islander health services nominated by NACCHO
        7. a representative from IRIS.
46. The role of providing advice from state/territory level on priority locations and assessment of service proposals allocated to the state/Northern Territory joint eye health planning committee proposed in recommendation 18 above.

Administrative processes

47. DoHA implement an arrangement through which one single national fundholder is appointed, following a competitive tender process, to administer the following aspects of VOS:
        1. receipt and processing of service proposals/applications
        2. development of funding agreements with service providers
        3. receipt of tax invoices/reports
        4. payment of service providers.
    The Department should retain its roles and responsibilities in relation to:
        1. Supporting the VOS National Advisory Committee and associated state/territory level advisory groups in their roles in identifying and approving priority localities.
        2. Approval of service proposals under the program.
48. A VOS web site be established, either by the Department, or by the proposed VOS national fundholder, through which potential or VOS optometrists can access a VOS budget calculator, lodge service proposal applications and lodge tax invoices and associated reports.

49. The VOS application form be simplified as suggested in the report.

50. VOS funding agreements be further simplified as suggested in the report.

Data collection and management

51. A national VOS program database is required which has the following features:
        1. Details of the original service proposal approved and the history of approved changes to a service proposal are recorded.
        2. Data submitted online by VOS optometrists are automatically populated into the system.
        3. Details of visits, numbers of patients seen, payments and service provider comments on visits are recorded.
        4. DoHA state offices should be able to run reports.
52. Following consultation through the Optometry Association of Australia, the structure and content of activity reports by optometrists be restructured as proposed and include additional data on the number of newly diagnosed cases of eye conditions identified other than refractive error (e.g. diabetic retinopathy, glaucoma, cataract) and the number of patients referred to an ophthalmologist.

Future directions

The final chapter of the report considers three issues that cut across both VOS and MSOAP. These are:
    • Constraints of the capacity to expand or maintain the programs.
    • Creating ongoing mechanism for improving management, promoting innovation and sharing information about the programs’ achievements.
    • The opportunities health reforms offer for the programs.

Recommendations applying across MSOAP and VOS

53. MSOAP advisory fora and the VOS National Advisory Committee monitor the capacity for MSOAP and VOS to maintain its workforce and expand service provision.
54. A proportion of MSOAP and VOS funds be allocated to investigate and evaluate strategies that could improve aspects of the effectiveness of outreach services. Funding projects should be allocated, following a competitive tender process, to organisations or consortia capable of undertaking high quality applied research in this area. Advice on priority issues to be examined should be discussed and recommended by the MSOAP advisory fora and the VOS National Advisory Committee, but could include some of the topics outlined in the report.

55. The Department prepare an annual MSOAP and VOS statistics report which provides summary statistics of services supported under the scheme, including patients seen.

56. As recommended previously, membership of MSOAP and VOS advisory fora be enhanced to include representatives of Medicare Locals and Aboriginal and Torres Strait Islander health organisations. DoHA and the advisory fora continue to monitor the effectiveness of representation and engagement of these organisations, and recommend on changes as appropriate.Top of page