Victorian ophthalmology service planning framework

Victorian ophthalmology service planning framework

Victorian ophthalmology service planning framework

Published by the Victorian Government Department of Human Services Melbourne, Victoria This publication is copyright, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968. Authorised by the State Government of Victoria, 595 Collins Street, Melbourne. This document may also be downloaded from the Department of Human Services web site at www.health.vic.gov.au/ophthalmology Copyright State of Victoria 2005 October 2005 (050908)

Contents 1 Executive summary 1 1.1 Background 1 1.2 Methodology 2 1.3 Ophthalmology services in Victoria 2 1.4 Discussion and recommendations 3 2 Introduction 9 2.1 Policy context for the future directions of ophthalmology services 9 2.2 Eye care initiatives 11 2.3 Methodology 13 2.4 Report structure 14 2.5 Scope and definitions 14 Eye care professionals 14 Ophthalmology service system 16 3 Ophthalmology services in Victoria 17 3.1 Geographic distribution of services 17 3.2 Current service provision 19 3.3 Predicted changes to ophthalmology services 20 4 Discussion and recommendations 21 4.1 Access 21 Waiting times for services 21 Elective surgery management and referral 24 Eye care literacy 26 Referral pathways 27 Cost of eye care services 28 Service distribution 30 Royal Victorian Eye and Ear Hospital 35 Forecast demand for eye services 36 Forecast prevalence of eye health conditions 39 Cost of vision loss 42 4.2 Appropriateness 43 Utilisation rates 43 Models of care and workforce roles 46 Workforce 48

4.3 Efficiency 49 Technical efficiency: models of care and work settings 49 Allocative efficiency 52 Funding and price 52 4.4 Acceptability 55 4.5 Effectiveness 56 4.6 Safety 57 4.7 Information management 58 4.8 Competence, education and research 59 Education and training 60 Research 63 4.9 Consumer involvement 64 4.10 Governance and leadership 66 5. Implementation plan 67 5.1 Health service strategic plans and statement of priorities 67 5.2 Implementation plan 68

Appendices 1. Ophthalmology Service Planning Advisory Committee membership 69 2. Terms of reference for service planning framework 70 3. List of responses to the discussion paper 71 4. List of attendance at stakeholder consultation meetings 72 5. Quality framework dimensions and organisational elements 75 6. Statewide provision of ophthalmology services 2002 03 77 7. Ophthalmology DRGs and ESRGs 1999 2000 to 2002-03 81 8. Detailed ophthalmology forecasts 84 9. Estimated resident population 2003 and 2016 87 10. Key performance indicators suggested by stakeholders 90 Glossary of terms 93 References 96 Websites 98

Victorian ophthalmology service planning framework 1 1 Executive summary Nearly half a million Australians have impaired vision, with the prevalence of vision loss trebling for every decade of life after 40 years of age. The ageing of the population will lead to a doubling of eye disease by the year 2020. Three quarters of visual impairment, however, can be prevented or treated. There are high costs associated with vision disorders, with an estimated total cost in Australia in 2004 of $9.85 billion. Nationally, the direct health costs of treating eye disease are estimated at $1.8 billion, more than health spending on diabetes and asthma combined. Hospital costs are the largest direct health cost at $692 million with cataract the largest single direct health cost condition at $327 million. Indirect costs of visual impairment are estimated at $3.2 billion. The Victorian ophthalmology service planning framework (the framework) provides a planning framework for the delivery of public ophthalmology services in Victoria to the year 2016. The framework aims to guide the future provision of care through design of the service system, the development of an appropriate workforce to support it, and address long-standing and emerging issues for the delivery of ophthalmology services. 1.1 Background The framework has its foundation in recent government policy. The Metropolitan Health Strategy, Directions for your health system (MHS), released in October 2003 by the Department of Human Services (the department), identifies the need to establish service planning frameworks for a range of clinical specialities, including ophthalmology services. The MHS also provides directions for specialist hospitals, including the Royal Victorian Eye and Ear Hospital (RVEEH). It recommends that specialist hospitals be collocated or affiliated with a general tertiary hospital and that a review and a service plan of the RVEEH be undertaken to identify its future role and optimal location. It also recommends that the RVEEH continue its role in providing complex care, training and research in ear, nose and throat (ENT) services and ophthalmology. A number of initiatives are being undertaken by government and non-government organisations to prevent avoidable vision loss through strategies to improve awareness of eye health and access to services. The Victorian Government has provided funding over three years towards the Vision Initiative, which is run by Vision 2020 Australia. There is also work underway to develop a National Vision Plan.

2 Victorian ophthalmology service planning framework 1.2 Methodology To inform the development of the framework, the department undertook broad stakeholder consultation, which included: establishing an Ophthalmology Service Planning Advisory Committee with representation from key stakeholder groups widely circulating the Victorian ophthalmology service planning framework discussion paper and inviting written submissions engaging Phillips Fox Lawyers (Dr Heather Wellington) and Campbell Research and Consulting to undertake broad stakeholder consultation through workshops and interviews developing a stakeholder consultation report entitled Victorian ophthalmology services: report on stakeholder consultations, September 2004. For the purposes of this framework, the term ophthalmology services has been defined to encompass medical and non-medical eye health care and related services provided by a range of health care professionals. It includes services provided by specialist and sub-specialist ophthalmologists, general practitioners (GPs), orthoptists, optometrists, ophthalmic nurses and health care professionals working in emergency departments. 1.3 Ophthalmology services Ophthalmology services are predominantly ambulatory, with a high rate of same day surgery and a large proportion of eye disease managed on an outpatient basis. While ophthalmology services are generally well distributed across the state, there is a high concentration of service provision at the RVEEH, including treating 49 per cent of the state s ophthalmology emergency presentations, 70 per cent of outpatient encounters and 42 per cent of public inpatient separations. Future changes predicted to have an incremental but important impact on ophthalmology service delivery include: more emphasis on preventive models of care; an increase in ambulatory/day procedure service provision; a greater focus on multidisciplinary collaboration and holistic disease management models; an increase in the need to provide consumers with information to assist them in understanding eye disease and expectations of outcomes from treatment; and optometry having a major effect on ophthalmology practice, resulting from the ability to prescribe Schedule 4 medications. The research and consultation process has identified a number of strengths, along with a range of issues to be addressed within the current ophthalmology service system. While the current system has served Victoria well, addressing some issues promises to deliver further improvements, ensuring future demands are met. Strengths of the service system in Victoria include: a high level of service provision across the state, when compared nationally and internationally; a highly trained and skilled eye care workforce; a distributed service system with many public hospitals providing some services; a strong track record in service delivery and professional education provided at the RVEEH; and research networks of high national and international significance.

Victorian ophthalmology service planning framework 3 1.4 Discussion and recommendations Service access While waiting times for elective surgery in Victoria compare well to those in other states and territories, variations in waiting times to access services create inequity in the service system. Factors including variations in referral processes, patient categorisation and elective surgery management processes impact on the equity of the service system. Outpatient and elective surgery management will benefit with the development and adoption of guidelines to inform ophthalmology practices. Recommendation 1. Develop consistent guidelines and practices for accessing public ophthalmology outpatient services and elective surgery to ensure that access is equitable, appropriate and based on clinical need. Barriers for consumers accessing eye care services and low cost glasses A lack of eye care literacy, for both consumers and providers, is a recognised barrier to accessing eye services. Improving practitioners understanding of the roles of different eye care professionals, and reducing fragmentation between professional groups, will improve referral pathways. Programs under the Vision Initiative are being developed to educate both consumers and providers about the roles of different eye care professionals and improve consumers eye health literacy. Recommendation 2. Improve eye health education and promotion programs for consumers and providers through support of the Vision Initiative. Affordability has been identified as a barrier to accessing eye care, with considerable criticism about the cost of glasses. The cost of glasses acts as a deterrent for many who need eye care and corrective lenses. The government-funded Victorian Eyecare Service (VES), which provides low cost glasses to concession card holders and their children under 18 years of age, makes a significant contribution towards accessing low cost glasses. Certain population groups, however, still face difficulties accessing eye care services. It was noted that a greater proportion of rural residents access the VES than metropolitan residents. Recommendation 3. Improve and promote access to low cost glasses.

4 Victorian ophthalmology service planning framework Access While ophthalmology services are well distributed across the state, a strategic approach to service distribution which takes demographic changes in to account is an important part of delivering a high quality and equitable health service. Some health services have stopped directly providing elective ophthalmology services and while these health services have developed linkages with other health services to varying degrees, it is important that these closures do not reduce access to services in geographic areas. Self-sufficiency is a measure of the degree to which people can access services close to home. Self sufficiency varies across the state, with 99.7 per cent of metropolitan residents who received ophthalmology inpatient services receiving these within metropolitan Melbourne, while 77 per cent of rural residents received services within rural Victoria in 2002 03. The Hume and Gippsland regions were the least self-sufficient at 60 per cent and 63 per cent respectively. There is a strong view amongst stakeholders that all major metropolitan and regional hospitals should have a full range of primary and secondary services, including nonadmitted consulting, emergency and surgical services. Establishing primary and secondary services in all public general tertiary hospitals will increase local access to services and reduce the need for referral to other health services for care. There is a role for both large and small rural health services in providing ophthalmology services. The challenge is to ensure that services are planned and delivered in a coordinated way within a region or sub region. Paediatric services Children aged 0 to 14 years constitute only a small proportion of ophthalmology services. Nearly 4 per cent of ophthalmology separations and over 5 per cent of ophthalmology Medicare Benefits Schedule (MBS) claims were for children in 2002-03. Paediatric inpatient services are concentrated centrally, with the Royal Children s Hospital (RCH) treating 37 per cent and the RVEEH treating 16 per cent in 2002 03. Due to the specialist requirements for treating paediatric patients, there is strong support for the RCH to continue its role as the key provider of public specialist paediatric ophthalmology services.

Victorian ophthalmology service planning framework 5 Recommendation 4. The following health services should ensure the provision of primary and secondary services for their tertiary campuses, including 24-hour on call, inpatient, outpatient and emergency consulting and surgery: Metropolitan RVEEH Western Health Northern Health Melbourne Health Austin Health Eastern Health Bayside Health Southern Health Peninsula Health Rural and regional The implications for the five major regional hospitals to provide the range of services specified above will need to be considered in detail. Regional hospitals will play an important role in the provision and coordination of services across their region. Elective surgery may be provided in alternate settings to the tertiary site or regional hospital, such as in same day and elective surgery centres or other rural hospitals. The Royal Children s Hospital should continue its role in specialist provision of paediatric ophthalmology services. A distributed service system should be maintained through the provision of a range of primary and secondary services at rural hospitals.

6 Victorian ophthalmology service planning framework Royal Victorian Eye and Ear Hospital The majority of stakeholders believe that the RVEEH provides a very good service for tertiary patients. For efficiency and quality reasons, there is considerable support for maintaining a specialist tertiary hospital with a concentration of highly specialised services, possibly collocated with a general tertiary hospital. There is support for the maintenance and growth, over time, of integrated services in all metropolitan and regional tertiary general hospitals. As recommended in the MHS, the RVEEH requires a detailed service plan and review to determine its future role and optimal location. The detailed service plan for the RVEEH will determine its catchment for primary and secondary services. There is support for the RVEEH to continue an active teaching and research role and to assist in ensuring equitable service provision across the state, through outreach services and other mechanisms. Recommendation 5. The RVEEH should continue its role in teaching, research and specialist provision of ophthalmology services. The RVEEH will provide primary and secondary services to its local population and provide elective surgical services to a broader population. Demand for eye services Eye disease is forecast to double by the year 2020, which will lead to increased demands for eye care services. The Visual Impairment Project (VIP) found that the incidence of visual impairment and blindness increases threefold with each decade of age after 40 and that the ageing of the population will see the prevalence of eye disease double by 2020. Consistent with the VIP, the department s inpatient forecasts (2003 04) indicate public and private ophthalmology separations will grow by 3.4 per cent per annum, and bed days will increase by 2.9 per cent per annum to 2016 17. This growth is led by cataract procedures with a forecast growth in separations of 4.2 per cent per annum or a doubling by 2016 17. Models of care and the role of eye care professionals Models of care for ophthalmology service have undergone significant changes in the past two decades with an increasing trend toward ambulatory care. Ambulatory eye care services are provided as a day attendance at a health care facility or at a person s home. Within the context of ambulatory care, the emergence of new ophthalmology models of care locally, nationally and internationally, has created debate about the appropriateness and effectiveness of these new models. Condition-specific models of care for cataract surgery including pre and post operative care, the management of refractive error, and the screening for and management of glaucoma and diabetic retinopathy have been highlighted. Debate relates to where services are provided, whether in hospital or community settings, who provides the service, and the clinical care pathway.

Victorian ophthalmology service planning framework 7 There is considerable stakeholder support for high volume elective surgery facilities for ophthalmology services. As a large proportion of eye surgery is done on a same day basis, significant opportunity exists for further expansion of services without high capital investment. The use of dedicated elective theatres enables a critical mass of patients to be treated whose procedures will not be cancelled due to priority being given to emergency cases from other specialties. There are further opportunities to better utilise the skills of the current workforce through a reconfiguration of workforce models. There is a general recognition that there is a good supply of eye health care professionals with specific ophthalmic training and skills, including ophthalmologists, optometrists, orthoptists and ophthalmic nurses. Consultations suggest general support for looking at options to make better use of medical and non-medical staff in the delivery of eye care. Recommendation 6. The following will increase the capacity of the system to provide for future demand: establishment and expansion of services in general tertiary hospitals development and expansion of models of care that promote effective and efficient delivery of eye care services increased use of elective surgery centres for ophthalmology surgery (in particular cataract surgery) establishment and/or expansion of workforce models that make best use of the existing workforce in public hospitals and in community settings (optometrists, orthoptists and nurses undertaking greater roles in the provision of eye care). Funding The cost of service provision varies between hospitals. Through efficiencies in work practices or staffing arrangements, some hospitals achieve costs that differ markedly from the casemix payment. Salary arrangements for surgeons have been noted as a significant factor in whether a hospital is able to deliver the service within the casemix payment, with some hospitals providing sessional payments and others fee-for-service. Recommendation 7. Develop a funding model that supports the system structure.

8 Victorian ophthalmology service planning framework Performance monitoring A performance monitoring system ensures accountability for the efficient and effective use of resources. A performance monitoring system would include a range of clinical and non-clinical performance measures that could be monitored at a local, regional and statewide level. Ophthalmology management measures, including waiting times for elective surgery and activity data, are already collected by health services and reported to the department. However, patient outcome measures are not routinely collected by health services and require development. Possible performance outcome measures would include monitoring the appropriateness, acceptability, safety and effectiveness of ophthalmology clinical interventions. A performance monitoring system requires meaningful performance measures, data collection systems, reporting requirements and mechanisms. The development and operation of a performance monitoring system will require the involvement of clinicians, professional colleges and associations, hospitals and health services. Recommendation 8. Develop a performance monitoring system for ophthalmology management and patient outcomes. Service leadership and coordination Greater statewide coordination and leadership in planning for service growth is needed to ensure high quality and accessible ophthalmology services. There is general agreement among stakeholders that the department, hospitals and health care professionals have a shared interest and responsibility in ensuring optimal use of resources within the system. It is recognised that leadership capability needs to be developed with more system-wide goal setting and accountability. It was agreed that governance arrangements could be instituted at a regional and/or statewide level. There is support for more system-wide leadership from the RVEEH. Recommendation 9. Develop a capacity for statewide leadership in public ophthalmology service provision to provide ongoing direction in models of care, education and support systems for service providers.

Victorian ophthalmology service planning framework 9 2 Introduction The Victorian ophthalmology service planning framework provides a planning framework for the delivery of public ophthalmology services in Victoria to the year 2016. The framework aims to guide the future provision of care, both in the design of the service system and the development of an appropriate workforce to support it. It aims to address long-standing and emerging issues faced when delivering ophthalmology services. 2.1 Policy context for the future directions of ophthalmology services The framework has its foundation in government policy that has been developed in recent years. In 2001, the Victorian Government released Growing Victoria Together, a statement of the Government s strategies and priorities for the next ten years. In its Departmental Plan 2004 05, the Victorian Department of Human Services (the department) established objectives that reflect the strategic directions laid down in Growing Victoria Together. These objectives include: building sustainable, well managed and efficient human services providing timely and accessible human services improving human service safety and quality promoting least intrusive human service options strengthening the capacity of individuals, families and communities reducing inequalities in health and wellbeing. The Metropolitan Health Strategy, Directions for your health system (MHS), released in October 2003 by the department, sets the key directions and objectives for metropolitan health services over the next five to ten years. A principal objective of the MHS is to position the health system to best meet future demand for services while ensuring those services are safe, of high quality, responsive to individual needs, and delivered in a timely, responsible and efficient manner. The MHS identifies four strategic directions to position the health service system in Victoria to meet future demand for services. These include: increasing capacity of the current service system redistributing and reconfiguring existing capacity of the service system substituting and diverting existing services to new, more appropriate services developing new service models.

10 Victorian ophthalmology service planning framework Under the strategic direction of redistributing and reconfiguring capacity, the MHS identifis the need to establish service planning frameworks for a range of clinical specialities, including ophthalmology services to be a priority. Other directions include: a review and a service plan outlining the future role and optimal location for the Royal Victorian Eye and Ear Hospital (RVEEH) specialist hospitals to be collocated or affiliated with a general tertiary hospital the RVEEH to continue its role in providing complex care, training and research in ear, nose and throat (ENT) services and ophthalmology. The MHS acknowledges the important role of specialist hospitals in training, workforce and research. The department s document Metropolitan Health Strategy, Directions for your health system: ambulatory care services, 2003 provides direction for ambulatory services. Ambulatory care describes care that takes place as a day attendance at a health care facility or at the consumer s home. Directions for ambulatory care are as follows: ambulatory care services should be provided in a community-based setting unless considered inappropriate for safety, quality of care and efficiency reasons management processes and models of care should ensure continuity of care across hospital and community based settings service practice and distribution should ensure equitable, timely and appropriate access community-based ambulatory services should be collocated and/or integrated with hospitals where there are service and patient/client synergies, to improve continuity of care, maximise limited staffing resources, reduce professional isolation and enhance service organisation and coordination ambulatory services should be planned to meet the specific population health needs of a defined geographic catchment area, while maintaining flexibility to respond to changes in service demand. The Hospital Demand Management (HDM) strategy was established in October 2000 in response to increases in demand and deterioration in access to acute public hospital services. The HDM strategy aims to strengthen the capacity of the health system to manage increasing demand pressures in six key ways: funding targeted growth in the activity performed within hospitals substitution through expansion of non-bed-based models of care encouraging clinical practice change to achieve best practice funding the Hospital Admission Risk Program (HARP) to improve health outcomes and reduce the avoidable use of hospitals providing improved working conditions that attract and retain nurses expanding opportunities for people to access elective surgery.

Victorian ophthalmology service planning framework 11 This service planning framework for ophthalmology services aims to address issues specific to delivering ophthalmology services in Victoria within the context of these government policies. 2.2 Eye care initiatives There are a number of initiatives being undertaken by government and non-government organisations to prevent avoidable vision loss through strategies to improve awareness of eye health and improve access to services. These initiatives include: Vision 2020 Australia the Vision Initiative being implemented in Victoria a National Vision Plan for Australia. Vision 2020 Australia was established in 2000 as part of Vision 2020: The Right to Sight, an initiative of the World Health Organisation (WHO) and the International Agency for the Prevention of Blindness. Vision 2020: The Right to Sight was established in 1996 and aims to eliminate avoidable blindness and vision loss by the year 2020. Vision 2020 Australia is a national partnership of more than 40 Australian-based organisations involved in eye care service delivery, eye research, education and development, low vision support, vision rehabilitation, professional assistance and community support. It aims to build strong foundations for a cohesive and collaborative public health approach within the eye health sector in Australia, and support the same in selected international communities. Vision 2020 Australia seeks to eliminate avoidable blindness by the year 2020 and ensure that blindness and vision impairment are no longer barriers to full participation in the community. In Victoria, the State Government has provided $1.8 million over three years towards the Vision Initiative run by Vision 2020 Australia. The Vision Initiative, which commenced in 2003, takes a collaborative public health approach to increase awareness and education of the public, health professionals, and other sectors about the importance of eye care. The program is run in collaboration with eye health care providers, researchers and rehabilitation and support services. The goal of the Vision Initiative is: To prevent avoidable blindness and to reduce the impact of severe vision loss for all Australians. The Vision Initiative is currently being implemented in Victoria and is expected to be implemented in other states and become a national program. It focuses on the five conditions that cause 80 per cent of vision impairment in Australia: uncorrected refractive error cataracts diabetic retinopathy glaucoma age-related macular degeneration.

12 Victorian ophthalmology service planning framework There is work underway to develop a National Vision Plan for Australia. This work commenced following the World Health Assembly resolution WHA56.26 passed in May 2003 to eliminate avoidable blindness. The resolution calls on WHO member states to: establish a national Vision 2020 plan by 2005 in partnership with the WHO and in collaboration with non-government organisations (NGOs) and the private sector establish a national coordinating committee or blindness prevention committee to help develop and implement the plan begin implementing the plan by 2007 include effective information systems with standardised indicators and periodic monitoring and evaluating, aiming to show reduced magnitude of avoidable blindness by 2010 in the plan support mobilising resources to eliminate avoidable blindness. As part of Australia s commitment to the WHO Resolution, the Commonwealth Government sponsored the inaugural National Vision Forum in March 2004. More than 85 participants from the eye care and related health sectors attended the forum to discuss the development of a National Vision Plan. Forum members agreed to establish a task group which would develop a submission outlining the purpose, scope and content of a national plan to be submitted to government. The task group developed the submission which outlined the collaborative views of the community and the eye health sector in relation to the formulation and content of a National Vision Plan for Australia. It was presented to the government for inclusion on the agenda at the Australian Health Ministers Conference (AHMC) meeting held in July 2004. The agenda item was passed by AHMC members and the National Vision Plan for Australia is being finalised for tabling at AHMC later this year. Discussions are currently underway between the Commonwealth and State Government health departments to determine strategies for developing and implementing a national plan. A key strategy towards achieving a National Vision Plan for Australia is the national implementation of the Vision Initiative. The Vision Initiative is seen as a benchmark for public eye health programs and discussions are currently underway between Vision 2020 partners, stakeholders and other State Governments for similar programs to be implemented in other states. These initiatives provide strong support for enhancing the delivery of ophthalmology services in Victoria.

Victorian ophthalmology service planning framework 13 2.3 Methodology To inform the development of the framework, the department: established an Ophthalmology Service Planning Advisory Committee (the advisory committee) with representation from key stakeholder groups (membership of the advisory committee is in Appendix 1) developed terms of reference in consultation with the advisory committee (refer Appendix 2) developed and widely circulated the Victorian ophthalmology service planning framework discussion paper (the discussion paper) and invited written submissions undertook broad stakeholder consultation. The discussion paper provided a basis for analysis and consideration of current ophthalmology service provision and related services in Victoria. It drew on the views of stakeholders, analysis of datasets and a review of the literature. Its aim was to identify and discuss the key current and future issues that effect ophthalmology practice in Victoria. The discussion paper was widely circulated to stakeholders and 49 submissions were received. A list of individuals and organisations that responded to the discussion paper is included in Appendix 3. The department contracted Phillips Fox Lawyers (Dr Heather Wellington) and Campbell Research and Consulting to undertake the stakeholder consultation. To determine stakeholder views on issues pertinent to the delivery of ophthalmology services, the consultants reviewed stakeholder feedback on the discussion paper and engaged key stakeholders through a series of workshops and face-to-face interviews. Stakeholder views were elicited through: a review and analysis of responses to the department s discussion paper five forums, three in rural areas and two in metropolitan areas, with a range of service providers one forum with consumer representative groups two forums (one metropolitan and one rural) with consumers a number of face-to-face interviews with individual providers and small groups. Data from stakeholder consultations and submissions were collated by the consultants and presented back to the department in a report entitled Victorian ophthalmology services: report on stakeholder consultations, September 2004. A list of individuals and groups who participated in interviews and workshops is included in Appendix 4.

14 Victorian ophthalmology service planning framework 2.4 Report structure Section 3 of this report is presented in the structure developed by the Victorian Quality Council, Better quality, better health care: a safety and quality improvement framework for Victorian health services (VQC, 2003). The safety and quality framework document was developed as a component of a strategic approach to improving the safety and quality of patient care in Victoria. While it has been developed for application by health services rather than across a health system, it identifies six dimensions of quality - safety, effectiveness, appropriateness, acceptability, access and efficiency - and four key organisational elements - governance and leadership, consumer involvement, competence and education, and information management - which are important considerations when ensuring a safe and high quality health system. These are equally applicable to system-wide safety and quality of care. Definitions of the six dimensions of quality and four key organisational elements are provided in Appendix 5. 2.5 Scope and definitions Eye care professionals In this framework, the term ophthalmology services has been interpreted to encompass medical and non-medical eye health care and related services provided by a range of health care professionals. It includes services provided by specialist and sub-specialist ophthalmologists, general practitioners (GPs), orthoptists, optometrists, ophthalmic nurses and health care professionals working in emergency department settings. Definitions of these professions are provided in Table 1.

Victorian ophthalmology service planning framework 15 Table 1: Eye care professionals Ophthalmologist An ophthalmologist is a medical doctor who is educated, trained and registered to provide total care of the eyes, from performing comprehensive eye examinations to prescribing corrective lenses, diagnosing diseases and disorders of the eye, and carrying out the medical and surgical procedures necessary for their treatment. General practitioner (GP) A GP is a registered medical practitioner who is qualified and competent for general practice in Australia. A GP: has the skills and experience to provide whole person, comprehensive, coordinated and continuing medical care maintains professional competence for general practice. Optometrist Optometrists are non-medical practitioners trained to assess the eye and the visual system, and diagnose refractive disorders and eye disease. An optometrist prescribes and dispenses corrective and preventative devices and works with other eye care professionals to ensure that patients are referred appropriately for diagnostic and therapeutic needs. Optometrists also prescribe drugs for certain eye conditions and monitor long-term eye conditions. Orthoptist Orthoptists specialise in diagnosing and managing disorders of eye movements and associated vision problems. They perform investigative procedures appropriate to disorders of the eye and visual system and assist with rehabilitating patients with vision loss. Orthoptists also diagnose refractive disorders and prescribe glasses on referral from an ophthalmologist or optometrist. Ophthalmic nurse An ophthalmic nurse has completed general nurse training then additional training to specialise in the nursing care of patients who have eye problems, whether they are in hospital, clinics or the community. Ophthalmic nurses test vision and perform other eye tests under medical direction. (NSW Health, 2002; AMWAC, 2000; RACGP, 2002)

16 Victorian ophthalmology service planning framework Ophthalmology service system During the consultation, the ophthalmology service system was conceptualised according to primary, secondary and tertiary service delivery (Table 2). Table 2: Definitions of primary, secondary and tertiary eye care Primary care Primary care is characterised as care provided following self-referral. It includes care provided by community optometrists, GPs and hospital emergency departments for conditions such as refractive error, screening for eye health, monitoring of chronic eye conditions, removing foreign bodies and managing conjunctivitis. Secondary care Secondary care is characterised as specialist care provided following referral from another practitioner, but not including highly specialised care which, because of cost, quality or technical issues, is best provided from a small number of service sites. It includes most ophthalmic surgical and medical services (including monitoring and management of cataract, glaucoma, diabetic eye disease and macular degeneration, management of most eye trauma, and optometry services provided on referral from another practitioner). Tertiary care Tertiary care is characterised as highly specialised care provided in a limited number of locations following referral from another practitioner. It includes monitoring and managing complicated glaucoma, diabetic eye disease, trauma and complicated and/or rare vitreo-retinal and other conditions. This framework is primarily focused on the provision of services funded and/or provided by the public sector. Issues are, however, discussed in the context of the public sector as a component of an overall service system that has a substantial private component.

Victorian ophthalmology service planning framework 17 3 Ophthalmology services in Victoria 3.1 Geographic distribution of services The department has divided the state into eight regions five rural and three metropolitan. The regional boundaries are based on Local Government Areas (LGAs). Figure 1 illustrates metropolitan regions and the location of public hospitals. Figure 2 illustrates rural regions and the locations of public hospitals. Figure 1: Metropolitan regions and the location of public hospitals

18 Victorian ophthalmology service planning framework Figure 2: Rural regions and the location of public hospitals

Victorian ophthalmology service planning framework 19 3.2 Current service provision The distribution and activity of ophthalmology services in Victoria is described in the discussion paper. Some key activity data for ophthalmology service provision in 2002 03 indicate that: ophthalmology services are predominantly ambulatory with a large proportion of eye disease managed on an outpatient basis and a high rate of same day surgery while ophthalmology services are generally well distributed across the state, there is a high concentration of service provision at the RVEEH. The RVEEH treats 49 per cent of ophthalmology emergency presentations, 70 per cent of outpatient encounters and 42 per cent of public inpatient separations the majority of consulting services are provided in private ophthalmology and optometric practices of all encounters with GPs, 1.8 per cent relate specifically to eye conditions; 7.3 per cent of referrals from GPs are to ophthalmologists and 0.9 per cent are to optometrists there were 49,700 ophthalmology inpatient separations, at 102 public hospitals and 76 private hospitals. Twenty-two per cent were from rural hospitals, while the RVEEH treated 19 per cent of all separations there has been a 5.9 per cent per annum increase in ophthalmology separations from 1998 99 to 2002 03. There was 7.9 per cent per annum growth in the rural sector and 5.4 per cent per annum in the metropolitan sector. The growth rate in the private hospitals was 8.1 per cent per annum compared to 3.4 per cent in public hospitals high growth rates were recorded in outer metropolitan hospitals for inpatient separations and emergency presentations overall, approximately 30 per cent of ophthalmology separations from public hospitals are from private or compensable patients the Victorian Eyecare Scheme (VES) provides eye tests and glasses at a nominal cost for Victorians who hold a pensioner concession card or have a health care card and their dependents. The VES is funded through the department and is run by the Victorian College of Optometry (VCO). VES provided 35,256 services in metropolitan Melbourne and 29,180 services in rural Victoria.

20 Victorian ophthalmology service planning framework Table 3: Summary of Victorian ophthalmology service provision in 2002 03 Inpatient separations 49,700 separations statewide 70 per cent cataract procedures 84 per cent same day 96 per cent elective 22,031 separations at public hospitals Non-admitted services 91,480 outpatient encounters provided by 12 public hospitals 35,001 emergency presentations to 35 public hospitals 660,507 ophthalmology MBS claims 1 513,105 consultations 1,078,180 optometry MBS claims 1 MBS data provided from the HIC. Data includes claims for private inpatient procedures captured in VAED. 3.3 Predicted changes to ophthalmology services The research and consultation process identified that the following incremental changes in ophthalmology services are expected, including: more emphasis on preventive models of care an increase in ambulatory/day procedure service provision a greater focus on multidisciplinary collaboration and holistic disease management models an increase in the need to provide consumers with information to assist them understand eye disease and expectations of outcomes from treatment optometry having a major effect on ophthalmology practice, in particular on glaucoma, resulting from the ability of optometrists to prescribe S4 medications increased use of highly specialised equipment for both diagnostic and therapeutic purposes new prostheses, which could improve outcomes and increase demand for the surgical correction of presbyopia more targeted drug therapies an increasing role for molecular engineering techniques and stem cell technology an increase in the ability to correctly diagnose genetic diseases and provide accurate counselling information on prognosis and the recurrence risk.

Victorian ophthalmology service planning framework 21 4 Discussion and recommendations The research and consultation process identified a number of strengths, along with a range of issues to be addressed within the current ophthalmology service system. While the current system has served Victoria well, addressing some issues promises to deliver further improvements, ensuring future demands are met. These issues will be discussed in more detail throughout the following sections. 4.1 Access Access refers to the extent to which a population or individual can obtain health services. This may include when it is appropriate to seek health care and the ability to geographically, physically and economically seek out appropriate care (VQC, 2003). Waiting times for services, along with cost and self-sufficiency, are often equated with the accessibility of a health service. Waiting times for services Victoria manages ophthalmology elective surgery well compared to other Australian states and territories. Data reported by the Australian Institute of Health and Welfare (AIHW) indicates that Victoria has the one of the lowest proportions of patients waiting more than 12 months for surgery in Australia (Table 4). Despite these comparisons, waiting times have been identified as a barrier to accessing public ophthalmology services. In particular, variations in waiting times between organisations has created inequity in access across the state. Table 4: Ophthalmology and cataract surgery waiting list statistics Australian states and territories, 2001 02 (AIHW) Ophthalmology NSW VIC QLD WA SA TAS ACT NT Total Admissions 19,064 13,854 7,313 4,789 3,741 645 720 694 50,820 Days waited at 50th percentile 98 37 26 88 42 154 82 160 57 Days waited at 90th percentile 441 227 464 322 264 557 621 308 395 Proportion waited > 12 mths 19.0 4.3 12.9 5.8 4.3 36.3 27.1 5.5 11.9 Cataract extraction Admissions 14,345 9,232 4,567 3,503 2,431 394 615 487 35,574 Days waited at 50th percentile 159 53 30 113 60 395 98 175 88 Days waited at 90th percentile 471 256 544 322 303 632 638 313 430 Proportion waited > 12 mths 24.1 5.1 16.8 5.2 5.9 56.6 31.2 6.4 15.4

22 Victorian ophthalmology service planning framework Outpatient services Outpatient services in public acute hospitals play a key role in the health system and represent a vital interface between inpatient and community care (Sharwood & O Connell, 2001). They provide specialist medical services, pre and post hospital care, and other medical and allied health services. Long waiting times for initial outpatient consultation has been identified as a key barrier to accessing public services. While there are no routine collections of waiting times for outpatient appointments, a survey of Victorian hospitals that provide public ophthalmology services in January 2004, revealed variation in the average waiting times for non-urgent ophthalmology appointments from five weeks to 42 weeks, with some patients waiting over two years for non-urgent appointments. Many providers suggested that current outpatient waiting times at some public hospitals are unacceptable. Suggestions for acceptable waiting times for non-urgent outpatient appointments ranged from four weeks to three months. There is a view amongst providers that there is too much system-wide emphasis on cataract surgery to the detriment of some rare and treatable diseases. There were concerns that patients with cataract may wait less time for cataract surgery than people with other more serious conditions who require services provided in the outpatient setting. Elective surgery Access to public hospital elective surgery in Victoria is monitored through the Elective Surgery Information System (ESIS). ESIS information is not collected for small rural hospitals. Patients added to an elective surgery list are assigned a clinical urgency category. Specialists assess the clinical urgency of their patient s condition and categorise it as one of three levels. These categories have been developed through the department s HDM strategy and are defined below. A summary of elective surgery waiting times is provided in Table 5. Category 1 (urgent): A condition that has the potential to deteriorate quickly to the point that it may become an emergency. Admission is desirable within 30 days. Category 2 (semi urgent): A condition causing some pain, dysfunction or disability but which is not likely to deteriorate quickly or become an emergency. Admission is desirable within 90 days. Category 3 (non urgent): A condition causing minimal or no pain, dysfunction or disability, which is unlikely to deteriorate quickly and which does not have the potential to become an emergency. Admission is acceptable sometime in the future.

Victorian ophthalmology service planning framework 23 Table 5: Elective surgery waiting list (ESIS, 30 April 2004) 3,816 patients on ophthalmology surgical waiting lists: 3,295 category 3 patients 496 category 2 patients 25 category 1 patients. 2,772 patients (84 per cent of total waiting list) were waiting for cataract surgery Average patient waiting times ranging between: 26 and 245 days for category 3 (non-urgent) 20 and 79 days for category 2 (semi-urgent). 39 (8 per cent) category 2 patients and 150 (5 per cent) category 3 patients were waiting longer than clinically recommended. Average clearance times for cataract surgery of 1.9 months for category 2 patients and 6.4 months for category 3 patients. The majority of ophthalmology elective surgery is classified as category 3. Some inconsistencies in categorisation have been noted across health services, which may contribute to variations in waiting times for elective surgery. Some providers suggested during the consultations that current surgical waiting times in Victoria are generally not too bad and in some areas have improved significantly in recent years. Although surgical waiting times for public patients are generally acceptable, when combined with waiting times for outpatient appointments overall, waiting times in some major metropolitan and regional hospitals are considered to be excessive. Suggestions by providers for acceptable waiting times for non-urgent surgery varied, with lengths of up to 18 months considered acceptable if there is a triage system to expedite urgent patients. Providers advised that in some cases patients are put on the waiting list earlier than the clinical condition would indicate, in anticipation of a long wait for surgery. Consumers cited examples of waiting times of three or four months and generally considered them reasonable for access to treatment in the public system. Consumers perceived, however, that waiting times in the public system varied considerably depending on the specialist seen and the facility where the treatment is provided. The Cranbourne Integrated Care Centre (CICC) at Southern Health commenced delivery of ophthalmology service in 2002 and was established as a designated ophthalmology Elective Surgery Access Service (ESAS) provider. ESAS aims to assist semi-urgent (Category 2) elective surgery patients with prolonged waiting times receive care.