«Victorian ophthalmology services Report on stakeholder consultation Department of Human Services HLW01 / 0363843 Victorian ophthalmology services ...»
16 August 2004
Victorian ophthalmology services
Report on stakeholder consultation
Department of Human Services
HLW01 / 0363843
Victorian ophthalmology services
Report on stakeholder consultation
Table of contents
Overview of stakeholder views
Specific proposals for further consideration
Background to this consultancy
Scope of the consultation
Interpreting qualitative research
Framework for this report
Eye disease in Victoria
Ophthalmology services in Victoria
Overall stakeholder comments about Victoria’s ophthalmology services
Predicted changes to ophthalmology services
Access to ophthalmology services
General access issues
Access to primary ophthalmology services
Access to the Victorian Eyecare Service
Access to secondary ophthalmology services - metropolitan
Access to secondary ophthalmology services - rural
Gaps in secondary ophthalmology service provision - rural
Access to tertiary ophthalmology services
The balance of public and private patients in public hospitals
Efficiency of ophthalmology services
Funding and price
Appropriateness of ophthalmology services
Acceptability of ophthalmology services
Effectiveness of ophthalmology services
Safety of ophthalmology services
Governance and leadership
Competence, education and research
Education and training
Future ophthalmology service system improvements
Primary ophthalmology services
Secondary and tertiary ophthalmology services
The future role of the RVEEH
Improving rural service delivery
Appropriate public/private balance
Governance and leadership
Attachment 1: Respondents to the Department’s discussion paper
Attachment 2: Individuals and groups who participated in interviews
Attachment 3: Workshop attendees
Attachment 4: Comprehensive report of consumer consultations
Attachment 5: Quality Framework dimensions and key organisational elements...........62 Attachment 6: Key performance indicators suggested by stakeholders
Executive summary Overview of stakeholder views In its 2003 publication Metropolitan Health Strategy, Directions for your health care system the Victorian Department of Human Services identified the need to develop a state-wide service planning framework for ophthalmology.
This report documents the outcomes of a state-wide consultation, conducted by Phillips Fox Lawyers in conjunction with Campbell Research & Consulting, about ophthalmology services.
Together with the results of a technical planning analysis and review of ophthalmology models of care, the results of the consultation will inform the development of an Ophthalmology Service Planning Framework.
A wide range of health care professionals, health care managers, consumers and consumer advocates participated in the consultation, through face-to-face interviews, workshops and written submissions.
All stakeholders consider that the quality of ophthalmology providers in Victoria is very high and that, overall, the Victorian ophthalmology service system provides excellent service. There is, however, widespread recognition that future demand for ophthalmology services will necessitate significant changes to the service system.
Stakeholders consider that everyone should have access through the public health care system to information and preliminary assessment, but that a lack of ‘health literacy’ for clients and health providers impairs access. There is strong support for ensuring access to services by the visually impaired and the socially disadvantaged, and for the provision of free eyewear for the most vulnerable members of the community. There is also support for Government taking a more active role in eye care health promotion.
Optometrists are highly regarded for their expertise and accessibility, and are recognised by many stakeholders as an under-utilised resource. Many providers suggested that there should be clear co-management guidelines between ophthalmologists and optometrists. Many stakeholders believe that other health care professionals including general practitioners, orthoptists and nurses also have considerable potential to contribute to more efficient, effective and accessible service delivery, and there is support for establishing and evaluating new models of multi-disciplinary care.
Most general metropolitan hospitals currently provide a full range of integrated ophthalmology services (consulting, emergency and surgical). The majority of providers believe that integrated ophthalmology services should continue to be locally accessible in all general metropolitan hospitals.
Stakeholders reported significant problems with access to both outpatient and inpatient services in many public hospital settings. Waiting times for outpatient appointments in many hospitals are unacceptably high, and surgical waiting times for public patients vary considerably across the system. Combined outpatient and surgical waiting times in many major metropolitan and regional hospitals are considered to be excessive.
114357638 \ 0363843 \ HLW01 / 16 August 2004 1 Victorian ophthalmology services Report on stakeholder consultation Most regional centres provide comprehensive inpatient ophthalmology services, and some visiting surgical services are also in place in sub-regional centres. Some regional centres do not provide inpatient ophthalmology services, however, because hospitals and ophthalmologists have been unable to agree on a price for public patient surgical procedures. These regional ‘gaps’, combined with strong financial incentives for ophthalmologists to undertake fee-forservice work in smaller sub-regional and rural hospitals, have resulted in unusual patterns of referral within and between regions.
All stakeholders consider that this situation is extremely unsatisfactory and that the Ophthalmology Service Planning Framework must make provision for comprehensive services in all regional centres. Elective surgical services are considered essential to the attraction of ophthalmologists to provide medical and emergency services.
Services in sub-regional and smaller rural centres are highly valued by most stakeholders, although some stakeholders question the efficiency of a widely distributed service system, preferring instead a concentration of services at higher volume regional centres, for efficiency and quality reasons.
Some health service managers remain concerned about excessive medical costs and value for money for ophthalmology surgical services, and are seeking a higher level of direction and support from the Department of Human Services in an effort to ensure affordable services.
The Royal Victorian Eye and Ear Hospital is held in very high regard by consumers and the majority of providers, although there are concerns about excessive waiting times for outpatient services. Most providers consider that its sub-specialty clinics are an essential component of a current and future high quality tertiary service system. Its concentration of patients and academic and teaching expertise is seen as vital to continuing high standards of training.
There is a strong but not universal view amongst providers that public hospital services should complement rather than duplicate services available in the private sector, particularly for nonadmitted patient services. Consistent with this view, providers consider that the Royal Victorian Eye and Ear Hospital resources should be more actively targeted towards more complex conditions for which services are not readily accessible in the private, community-based sector, and that emergency department presentations and routine reviews for low level care should be actively triaged and referred to community-based public or private ophthalmology providers.
More active triaging of emergency patients and discharge of patients from public hospital outpatient services is seen as an essential demand management strategy for the future.
Many regional, and some metropolitan, hospitals have limited their volume of public ophthalmology operating because of concerns about its financial sustainability, with excess theatre capacity made available for the treatment of private patients, many of whom are uninsured and, therefore, self-funding. Private patient waiting times in these hospitals are often significantly less than public patient waiting times. Some health service managers are concerned about equity of access and consider that public facilities should be available solely on the basis of clinical need rather than capacity to pay, whereas others consider that the admission of higher numbers of private patients enables better use of facilities and assists in the retention of ophthalmologists, for whom public operating is financially relatively unrewarding.
While ophthalmology surgical procedures are, generally, considered to be efficient in comparison to other surgical procedures, many providers recognise that there is potential to 114357638 \ 0363843 \ HLW01 / 16 August 2004 2 Victorian ophthalmology services Report on stakeholder consultation enhance the efficiency of the system through better co-ordination of care, better use of dedicated facilities and better utilisation of optometrists, orthoptists, nurses and general practitioners. It is recognised that public teaching operating lists are slow and there is potential to replace some registrar training lists with higher volume specialist public operating lists.
There is also support for investigating a state-wide purchase of lens, with potential considerable cost savings.
Providers believe that funding for ophthalmology services is inadequate, especially in rural areas where medical costs are high, and that there should be a specific additional payment for cataract surgery in rural areas where fee-for-service applies.
Most ophthalmologists are convinced that only those patients with a justifiable clinical need are currently receiving surgery in the public system, while other providers and consumers were in favour of a more explicit system of ensuring appropriateness and prioritising need. There is also support for more systematic and transparent evaluation of clinical effectiveness, and various performance indicators were suggested for local, regional and/or state-wide adoption and monitoring.
Leadership and accountability for access, efficiency and other performance parameters currently rests mainly with individual hospitals. Generally, it was agreed that the Department of Human Services, hospitals and health care professionals have a shared interest in ensuring optimal use of resources within the system, and, therefore, a shared responsibility for leading and monitoring system-wide performance. It was agreed that governance arrangements could be instituted at a regional and/or state-wide level.
There is strong but not unanimous support for the maintenance of a specialist tertiary hospital with a concentration of highly specialised services (for efficiency and quality reasons), either in the current form of the Royal Victorian Eye and Ear Hospital or in a streamlined form, possibly more closely co-located with St Vincent’s Hospital. Under this model, most providers also support the maintenance and growth, over time, of integrated services in all general metropolitan general hospitals, and in all regional hospitals.
There was also support for reviewing the potential to collaborate with the private sector in appropriate areas to utilise existing capital and infrastructure for high volume, efficient public operating.
Specific proposals for further consideration The following suggestions were made by stakeholders during the consultation period, and
should be considered further:
General proposals Establish role delineation guidelines to guide decision-making about service provision • in hospitals of different sizes and capabilities, taking into account factors such as the importance of services to the community, and the cost and utilisation of equipment;
Consult with the Royal Victorian Eye and Ear Hospital and the Royal Australian and • New Zealand College of Ophthalmology on ongoing methods of establishing and evaluating new models of care, and on methods of monitoring and improving systemwide performance;
Review payments to hospitals for ophthalmology services generally, and in particular • the payment for rural services, taking into account ‘reasonableness’ of medical payments;
Consult with medical schools on the adequacy of ophthalmology education in • undergraduate training;
Consult with the Royal Australian College of General Practitioners and the Victorian • Divisions of General Practice on ways in which the ongoing competence of general practitioners in eye care can be maintained;
Invest in data collection and management systems for monitoring and improving the • ophthalmology service system, and develop a system of reporting to the Department and the community on key outcomes; and Establish a central and/or regional governance structure for ophthalmology services, • with a focus on ongoing service planning, monitoring of and responding to access, efficiency, safety, effectiveness, appropriateness and acceptability.
Proposals regarding primary ophthalmology services Enhance community education and eye care health promotion;
• Promote the establishment of eye care screening services in community-based • locations, and review the need for eye care screening services in schools;
Review the restriction on prescription of spectacles by orthoptists;
• Monitor the coverage and accessibility of the Victorian Eyecare Service;