Dec 2016

Eye on optics
by
Chalkeyes
There’s a saying, maybe Taoist, that ‘if you
carry on the way you are going you will get
to where you are going to’ and this may be
true for the provision of eye care services in New
Zealand.
New Zealand has a unique
mix of public and private
sector funding. Like the
UK, it has a universally free
public sector, but the private
sector provides a much
larger slice of the total care
given than in the UK. In
Australia the margins are
blurred by Medicare, which
funds most of the total
care given, although this is
supplemented by private
contributions. In the UK it
is common for user-pays
private care to be given
in public hospitals, but in
New Zealand that is taboo,
apart from a handful of private providers who
contract some clinical services. But it is becoming
more and more common for our, dare I say, failing
public sector to contract out both clinical and
surgical services to meet a quota specified by the
Ministry of Health, to avoid retaliatory funding
cuts. In my opinion, nearly all public sector eye
care services are failing in New Zealand, especially
in the provision of follow up appointments in
routine eye care – an opinion supported by the
recent furore about the significant delays in
treatment at our southern hospitals last month
(see story p3).
With a few exceptions, the public sector eye
clinics are ‘paper bound’. This makes the rapid
review of records and test results very difficult.
It makes clinical audit almost impossible, except
for laboriously kept records on applications,
which seldom interoperate, or with even more
laboriously reworked paper records. In practice,
the plethora of paper forms and electronic
transactions in separate silos hinders rather
than helps the doctors and has recently been
identified as a cause of physician burnout. Yet
specialists and hospitals refuse to change to
the more efficient paperless systems that are
now readily available, partly, I believe, because
they shortcut established financial and power
In practice, the plethora
of paper forms and
electronic transactions
in separate silos hinders
rather than helps the
doctors and has recently
been identified as a cause
of physician burnout.
hierarchies, which therefore act as ‘destructive
technology’ for the status quo.
Issues of power, control and lack of foresight
abound. Traditionally the relationship between
ophthalmologist and
optometrist has been
adversarial. This drama is
still playing out but the
optometrists have ‘won’
on a number of issues,
which is a good thing if we
are to tackle the problems
in our healthcare system.
For example, optometrists
are now ranked equal
with ophthalmologists by
government in planning for
eye care’s future and some
have prescribing rights on
some medications, including
glaucoma medications,
though they have to have
attended additional courses.
The ideal review interval after changing
treatment for glaucoma is six weeks. This is
unachievable in the public sector, where there
are great wait-lists-in-the-sky of unallocated
follow-up appointments. So you would
think there would be a good opportunity for
therapeutically-qualified optometrists to pick up
this work but, unlike Australia where Medicare
funds optometrist visits, Kiwis must fund their
own optometry visits, and most New Zealand
pensioners do not have the funds for regular
optometrist visits, or indeed at all in many cases,
sadly!
There are other unexplored options for the
future of eye care services, however. The clinical
service could be outsourced to external providers
through the internet. Tests such as visual field
interpretation, reporting on photographs and
scans could all be outsourced. The ground
work for this has already been done for other
specialties such as radiology and cardiology,
so it shouldn’t be that hard for optometry
methinks. Again, funding would be a problem,
but a price war in such services would bring
down prices. Maybe, horror of horrors, we could
even encourage ‘virtual medical tourism’, with
basic facilities like field and OCT machines being
publicly-funded, but reporting done by the
cheapest bidder, perhaps in a remote location –
Fiji seems nice! This would involve de-regulation
of eye care and might bring local optometrists
and ophthalmologists closer together finally,
after more than a century of unnecessary turf
wrangling!
There has been an argument that high-tech
services should be centralised and people outside
our few larger centres bussed or flown in for
treatment. But as soon as the argument swings
in that direction, it seems to Chalkeyes that it just
becomes a big resource grab by the larger centres.
An unholy alliance has developed between some
ophthalmologists and DHB managements, in
some cases to protect the extant order which
‘works’ best for them, and not necessarily
the patient. While the formally adversarial
relationship between
ophthalmologists
and DHBs persists,
a ‘way through’ for
public services is rarely
discussed. Indeed, there
is an assumption on
the ‘market’ model that
services are worth much
more than the public
sector funding allocation.
Sometimes there is even
feuding between private
institutions (for example,
St George’s and Southern
Eye in Christchurch) which
leads to, in my opinion, an
unnecessary duplication
of facilities. And our
Southern providers are
not alone, other private
eye clinics have also found
it necessary to build
their own new, concrete
Paperwork, as much a cause of burnout as too many patients
palaces – the cost of which will all be factored into
the bill for the consumer.
Arguably the New Zealand public sector has
never met the demand and is not designed to.
Demand has hugely increased and expectations
have changed as a greater proportion of the public
learn there is a lot more that can be done to help
them. But if we carry on the way we are going,
then access to contemporary standards of eye care
will simply be unobtainable for the majority of
the population, with all the unattended morbidity
this will bring. Somehow we must bring all the
people involved, and their skills, together to
deliver a standard of care, which keeps up with
the pathology in our populations.
Keep an eye on this column to learn more
about Chalkeyes’ master plan. ▀
Welcome to Eye on optics by Chalkeyes, a new column brought to you by the team at NZ Optics.
Inspired by the once legendary (and anonymous) Chalkie who used to grace the back page of that
once wonderful, independent battler for all things business in New Zealand, The Independent
Business Weekly, the views expressed by Chalkeyes are his, or hers, alone and not necessarily the
views of NZ Optics. Anyone wishing to comment on Chalkeyes’ views should email a brief letter to
the editor at info@nzoptics.co.nz.
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All the best and Merry Christmas, from Lesley, Jai, Nick, Susanne and Tracey.
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