Towards a National Eye Health Plan for Australia 2005 to 2010 Submission to the Australian Government Department of Health and Ageing Brotherhood of St Laurence August 2005
The Brotherhood of St Laurence The Brotherhood of St Laurence (BSL) is a Melbourne-based community organisation that has been working to reduce poverty in Australia since the 1930s. Our vision is an Australia free of poverty. Our work includes direct service provision to people in need, the development of social enterprises to address inequality, research to better understand the causes and effects of poverty in Australia and the development of policy solutions at both national and local levels. We aim to work with others to create: an inclusive society in which everyone is treated with dignity and respect a compassionate and just society which challenges inequity connected communities in which we share responsibility for each other a sustainable society for our generation and future generations. Our services, generally targeted to people on low incomes, include employment services, family and children s programs, community building initiatives, research and advocacy, and aged and community care services. The BSL has an interest in the provision of affordable and appropriate eye care services in Australia, because of both its work to ensure low-income earners are not disadvantaged, and its acquisition of a wholesale optical frame business, Mod-Style, in 2000. Mod-Style is a supplier of frames to the Victorian College of Optometry Low Cost Optometry Service in Melbourne and the Victorian Eye Care Service in rural Victoria. As part of Mod-Style s development as a social enterprise, the Brotherhood of St Laurence conducted research in 2004, exploring a wide range of issues which prevent low-income earners from accessing eye care services in Victoria. The findings from the report Seeing clearly: Access to affordable eye care for low income Victorians have been used to inform this submission. are identified in direct response to the consultation paper. Low income earners: a group at particular risk The BSL applauds the specific identification of Aboriginal and Torres Strait Islanders and the aged as groups at risk of eye disease. However, we believe that socially and economically disadvantaged groups should also be identified as an at-risk group in the national plan. It is widely recognised that poor social and economic circumstances affect health throughout life. According to the World Health Organization (WHO), people further down the social ladder usually run at least twice the risk of serious illness and premature death as those near the top. As documented in the Consultation Background Paper, shared risk factors for common eye disease include, alcohol consumption, smoking, poor diet, lack of exercise, cardio-vascular disease and diabetes. All of these risk factors have been identified by the WHO as having a higher incidence in low socioeconomic groups, in developed countries. Both the Centre for Eye Research Visual Impairment Project (VIP) (Taylor 2000) and the Blue Mountains study (Thiagalingam et al. 2002) identified links between low socioeconomic status and eye disease. The Blue Mountains study found that people with lower educational attainment or receiving a government pension are more likely to have uncorrected or under corrected refractive error and the VIP researchers found that the correlation between visual impairment and lack of private health insurance reached statistical significance. For people living on low incomes, the impacts of vision loss including increased falls, diminished independence and health consequences such as depression can place further strain on already stretched resources and may increase social exclusion. Vision problems can also affect capacity to 2
work and to carry out daily activities. Children may experience delayed educational, physical and social development. Low-income and disadvantaged groups that were identified by the BSL research (2004) as most at risk of eye disease include those living in supported residential services or aged care facilities, homeless people and culturally and linguistically diverse communities, particularly newly arrived migrants and refugees. Groups at particular risk Specify low income earners as a group at particular risk of developing eye disease and requiring targeted attention. Reducing the risk Target low income earners and community service workers with public awareness activities focused on relevant lifestyle risk factors. Cost and choice of glasses and services Issues relating to the cost and choice of glasses should be given higher priority as a barrier to access. BSL research identified the perceived and actual cost of eyewear as a major issue for people not having their eyes examined and not purchasing prescribed glasses. Many low-income people we spoke to had no prior knowledge of subsidised eye care services such as the VES and believed that they could only access glasses through private optometrists where the average cost of bifocal glasses is $143.10 (HCF Health Insurance 2002). Some rural pensioners who were eligible for the VES service had visited optometrists participating in the scheme but had not been told about the subsidised service. Among those consumers who had prior knowledge of the VES, many were disappointed with the selection of frames. This particularly applied to parents purchasing glasses for their children and teenagers. Both groups were concerned that VES glasses would stigmatise the wearer as poor and we heard many stories of young people not wearing their VES glasses. Parents described going into debt to purchase more appealing glasses and many put glasses on lay-by, often experiencing long delays before they could afford to pay them off. Consumers over 50 years of age seemed quite satisfied with the appearance of standard VES glasses. For vulnerable groups, including people living in boarding houses, pensioners in supported residential services and indigenous community members, even the out-of-pocket cost of basic VES spectacles ($28.50 for standard lenses and $42.00 for bifocals) was seen as a major obstacle. In addition low income earners not eligible for the VES encountered considerable financial hardship and disadvantage purchasing frames through private providers. Ready-made glasses, bought without a prescription, are a common eyewear option for low-income earners. However, due to conflicting views between optometrists and ophthalmologists regarding the appropriateness of their use it is difficult for consumers to make an informed choice about the benefits and potential risks of ready-mades. RANZCO endorses the view of US colleagues that: Ready-to-wear reading glasses are effective, safe, and economical. Self-selection and overthe counter purchase of these glasses appear to be medically acceptable, cost-effective and in the best overall interest of the public. 3
The Optometrists Association Australia has a different opinion and does not endorse the use of ready-mades, asserting that they are a poor optical choice: They have the same prescription in each lens but 75 per cent of people requiring a vision correction require lenses with different powers in each eye. They do not have any correction for astigmatism (which) 80% of people require Ready-made spectacles make no allowances for the different distance between people s eyes, and can cause some strange optical effects and discomfort and headaches if worn for extended periods. (OAA 2003) It warns that buying ready-made glasses without a professional eye examination could result in serious eye conditions including glaucoma and cataracts going unnoticed. Five key action areas Include access to affordable and appropriate eyewear in the action improving access to eye health care services. Improving access to eye health care services Include affordability of eyewear in the list of factors influencing access to eye health care. Broaden the reference to subsidised spectacles programs are accessible to disadvantaged groups to include specific disadvantaged groups in metropolitan and rural areas, including residents of supported residential services and aged care facilities, the homeless and disabled and people living on low incomes generally, including families and young children. Improving the systems and quality of care Include in the challenges for eye health services the conflicting views surrounding the appropriateness of ready-made glasses as an affordable eyewear option and specify as an action assessing the potential use of ready-made glasses. The potential role of community services workers in awareness raising and referral pathways The National Framework for Action needs to be based on a partnership approach: the best outcomes will be achieved through all players working in partnership towards agreed objectives. To this end, it is important that community service workers and organisations are identified as key players in the implementation of the plan. Community services workers have the skills and networks to engage with diverse communities. They often work closely with community members to assist in building capacity, advocating on behalf of disadvantaged groups and disseminating information. They also often function as referral pathways to other services. The BSL research found, however, that agencies and workers who assist people living on low incomes including employment, youth and social workers, staff at aged care facilities and SRSs and teachers felt they had limited knowledge of eye health issues or referral pathways for their clients. Many community services workers interviewed did not see the connection between eye disease and a person s general health status and that, in turn, vision loss may impact on a person s emotional, 4
social and physical well-being. There also appeared to be limited knowledge of eye health services. Many were unaware that eye examinations at optometrist were subsidised through Medicare, that practitioners commonly bulk billed or that the Victorian Government funded a low-cost eyewear program through the Victorian College of Optometry. Reducing the risk Include in health promotion messages not only information about risk factors but also information about services (including low-cost options), the roles of eye health providers, Medicare subsidies and bulk billing rates. Include community services in the list of sectors important for raising public awareness. Increasing early detection Take steps to build community services workers understanding of the importance of regular eye checks, so they feel empowered to advise clients about why they should have an eye examination and how they can access services. Improving the systems and quality of care Specify, as an action under service integration, promoting collaboration between mainstream eye health services and community services organisations. Involve community services organisation in increasing a consumer focus. Low vision services The BSL sees the omission of any reference to low vision services as an oversight in the consultation papers. Low vision services should be given equal priority to the promotion of eye health and the prevention of avoidable blindness, as these services are vital to the long-term health and well-being of the visually impaired and their active participation in society. Cultural appropriateness Recognition of the importance of culturally appropriate and accessible services for culturally and linguistically diverse (CALD) communities is to be commended. The BSL agrees that this will only be successful if the workforce is trained to provide culturally sensitive care. The consultation paper has, however, limited the need for culturally appropriate services to two distinct groups Aboriginal and Torres Strait Islanders and CALD communities. BSL research identified that eye health practitioners would benefit from education programs to sensitise them to the needs of low-income and disadvantaged groups, including the disabled, homeless and young people. Another key component of a culturally inclusive health service, particularly for newly arrived refugees, is interpreting and translation services. BSL research identified that access to translation and interpreting services was an obstacle in some Victorian eye health services. For emerging communities there are often few providers who speak their native language. For example, the Optometrists Association Australia lists only three Arabic-speaking optometrists in Victoria. Community workers advised the BSL that waiting times at metropolitan VES clinics were significantly longer if their client needed an interpreter. This was confirmed by VES staff who 5
stated that a client had waited for almost a year to see an optometrist because they spoke an African language uncommon in Australia. Clients from CALD backgrounds who want to visit a private optometrist are not able to access an interpreting service. Optometrists are ineligible for the DIMIA fee-free Doctors Priority Line (telephone interpreting service) as they are not classed as medical practitioners. This creates a serious barrier for CALD communities in rural Victoria, where the VES is run through private optometrists. Improving access to eye health care services List access to interpreting services as a challenge in this section. List as an action area the promotion of the Doctors Priority Line for eligible providers and the extension of eligibility to optometrists. Build the capacity of eye health practitioners to deliver services in partnership not only with Aboriginal and Torres Strait Islander primary health care services but also with services for other disadvantaged groups including the homeless, disabled and CALD communities. Improving the evidence base As stated in the consultation papers, in Australia there is ongoing high-quality epidemiological, clinical, economic, health services and evaluation research. One obvious gap is in qualitative research exploring the barriers to use of eye care services by sub-population groups. Understanding further why certain groups are not accessing services will help guide priorities within eye care delivery and assist in the design of awareness raising campaigns. Recommendation Include qualitative research exploring the barriers to eye health service for different subpopulation groups in the research priorities. Outreach services The BSL affirms that all Australians should have equitable access to high quality eye health care services, irrespective of geographical location, socioeconomic status, ethnicity, age or gender. We also agree that professional fragmentation within the sector has constrained service delivery and resulted in some duplication and that more flexible delivery models are needed to increase access. BSL research identified that outreach eye health services are vital for Victoria s most marginalised communities. The consultation paper recognises the need for outreach services to remote and rural communities and for indigenous communities, but does not include outreach services for disadvantaged groups in metropolitan areas. Our research concluded that people who are frail, disabled or have complex social issues have difficulty accessing mainstream services. For example, many aged care facilities and supported residential services (SRSs) do not have sufficient staff to accompany clients to appointments and some disadvantaged groups have difficulty accessing transport or negotiating unfamiliar services. The welcome recent increase in the Department of Human Services funding to the Victorian College of Optometry s outreach programs for disadvantaged groups recognises the value of this kind of service in meeting the needs of disadvantaged groups in metropolitan areas. 6
The BSL acknowledges that outreach services present challenges relating to workforce shortages and uneven distribution of specialist eye care. We also acknowledge that there is need to consider appropriate funding models, as services in the community are more costly to implement. However, the need for outreach services in both rural and metropolitan settings should be considered when exploring new eye care service models, and further training for general and allied health professionals. Improving access to eye health care services Specify the need for metropolitan outreach services. Include outreach services among necessary actions. These could include the development and trial of appropriate services for disadvantaged groups including homeless people, people in aged care facilities and SRSs and those with a disability. Improving the systems and quality of care Broaden the action develop sustainable models for the provision of outreach ophthalmological and optometrical services to remote settings to include outreach services to disadvantaged groups in metropolitan areas. Contribution of the Brotherhood of St Laurence The BSL could assist in the implementation of the plan through: Facilitating partnerships with eye health professionals and community services Undertaking further qualitative research into barriers to eye health services Providing consultation concerning the importation and distribution of low-cost optical frames Supporting the development of outreach services in the communities where we work Advising re services for low-income Australians Offering training to eye health professionals regarding working with low-income and disadvantaged groups References Brotherhood of St Laurence 2004, Seeing clearly, Access to affordable eye care for low-income Victorians, viewed 9 August 2005, <http://www.bsl.org.au/pdfs/changing_pressures_13_1.pdf> HCF Health Insurance 2002, Charges survey information 2002, viewed 9 August 2005, <http://www.hcf.com.au/pdf/extrachargessurvey_2002.pdf>. Livingston, P, McCarty, C & Taylor H1997, Visual impairment and socio-economic factors, British Journal of Ophthalmology, vol.81, no 7, pp.574 8. 7
Taylor, H 2000, Refractive errors: Magnitude of the need, Journal of Community Eye Health, vol.13, no.3, viewed 9 August 2005, <www.jceh.co.uk/journal/33_1.asp>. Thiagalingam, S, Cumming, R & Mitchell, P 2002, Factors associated with undercorrected refractive errors in an older population: The Blue Mountains Study, The British Journal of Ophthalmology, vol.86, no9, pp.1041 51. World Health Organization 2003, Social determinants of health, the solid facts, 2nd edition, viewed 9 August 2005, <http://www.who.dk/document/e81384.pdf>. For further information regarding this submission, please contact Emer Diviney Research and Policy Officer Ethical Business Brotherhood of St Laurence 67 Brunswick Street Fitzroy Vic 3065 E-mail: ediviney@bsl.org.au Phone: (03) 9483 1380 8