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Victorian ophthalmology services 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
1 Executive summary 1
1.1 Background 1
1.2 Methodology 2
1.3 Ophthalmology services 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 12
2.3 Methodology 14
2.4 Report structure 15
2.5 Scope and definitions 15
Eye care professionals 15
Ophthalmology service system 17
3 Ophthalmology services in Victoria 18
3.1 Geographic distribution of services 18
3.2 Current service provision 20
3.3 Predicted changes to ophthalmology services 21
4 Discussion and recommendations 22
4.1 Access 22
Waiting times for services 22
Elective surgery management and referral 26
Eye care literacy 28
Referral pathways 29
Cost of eye care services 30
Service distribution 32
Royal Victorian Eye and Ear Hospital 37
Forecast demand for eye services 38
Forecast prevalence of eye health conditions 42
Cost of vision loss 45
4.2 Appropriateness 46
Utilisation rates 46
Models of care and the role of eye care professionals 50
4.3 Efficiency 55
Technical efficiency: models of care and work settings 55
Allocative efficiency 58
Funding and price 58
4.4 Acceptability 61
4.5 Effectiveness 62
4.6 Safety 63
4.7 Information management 64
4.8 Competence, education and research 65
Education and training 66
4.9 Consumer involvement 71
4.10 Governance and leadership 73
5. Implementation plan 74
5.1 Health service strategic plans and statement of priorities 74
5.2 Implementation plan 75
1. Ophthalmology Service Planning Advisory Committee membership 78
2. Terms of reference for the Victorian ophthalmology service planning framework 79
3. List of responses to the discussion paper 80
4. List of attendance at stakeholder consultation meetings 82
5. Quality framework dimensions and organisational elements 85
6. Statewide provision of ophthalmology services 2002–03 87
7.Ophthalmology DRGs and ESRGs 1999-00 to 2002-03 91
8.Detailed ophthalmology forecasts 94
9.Estimated Resident Population 2003 and 2016 97
10. Key performance indicators suggested by stakeholders 100
Glossary of terms 103
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.
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.
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.
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.
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.
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.
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.
3. Improve and promote access to low cost glasses.
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 non-admitted 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.
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.
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:
– 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.
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.
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.
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.
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.
7. Develop a funding model that supports the system structure.
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.
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.
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