C L I N I C A L
A N D
E X P E R I M E N T A L
OPTOMETRY EDITORIAL
The boundaries of optometric practice Clin Exp Optom 2014; 97: 97–98 Andrew Harris BScOptom FACO GradCertOcTher National President Optometrists Association Australia Change is inevitable. Paradoxically, it can be described as a societal constant. People and their communities can embrace change, attempt to bend it or simply resist it. The prospect of change can be exciting, confusing and confounding. This is often because change is complex and its many variables can make risk versus reward difficult to calculate and easy to blur. Inevitably, vested interests are affected by change and so, it is natural for vested interests to ensure they are better off (or at least no worse off). Not surprisingly, change management is often political. Change to the way eye care is delivered in the community is no different. Eye care is very different today from 10 or 20 years ago, let alone a century ago. Optometry’s role in eye-care delivery has inevitably altered too. Traditionally, optometrists delivered refractive care to the community. While this has embraced advances in spectacle lens and contact lens technology, low-vision services and public health refractive services, it has also given the profession a platform to deliver a broader scope of primary eye care to the community. The way optometry is practised has to remain relevant and valuable to the community. This requires optometry and other vested interests to be flexible and respond efficiently to embrace and harness change. Within the health-care system, knowledge and technology, the training of health professionals and the processes of funding have all altered dramatically in the past 50 years. From the inception of Federation an emerging middle class with an aspiration for an egalitarian society has driven an Australia that among other things encourages equal access to health services with world-class outcomes for all. This is all very well but the health system faces daunting challenges in the next few decades. An aging population with more chronic disease will demand the
DOI:10.1111/cxo.12145 same access and outcomes that have existed in past years. Demand on health resources and services from all age groups will continue to grow dramatically as new medical treatments emerge. The system has to become more efficient and productive. It will have to use the entire health workforce and exploit all of its skills, equipment and expertise, and reduce duplication and turf protection. Looking at the delivery of eye care to the community in the past and the space that optometry has filled within in it is instructive when looking to the future. The scope of optometric practice has changed. Optometrists have been pushed by their leadership to embrace new evidence and research, acquire new skills and to be willing to invest in equipment and their own further training. This leadership also pushed for relevant legislative change. An early example of legislative change was ‘winning’ the right to refer directly to an ophthalmologist. This was achieved in 1970 with much opposition throughout the 1960s from medicine. This was legislative recognition that optometrists had a genuine contribution to make to the best vision care for the community. The inclusion of optometry into the National Health Scheme in 1975 after a hard political fight recognised the value of the profession to the community. It altered the scale of eye care delivered by optometry and coincided with optometry’s enthusiastic forays into low vision and contact lens practice. Over the last 20 years, there have been advances within the industry that have had an effect on the practice of optometry. The improvement in cataract surgery has had a profound effect on demand for ophthalmological services. It has required efficient and accurate referral by optometrists, improved patient outcomes and allowed optometrists to refer patients earlier with success being the norm. Cataract surgery is the most frequent and most successful procedure performed in the country. It has a positive effect on the community and has improved the
© 2014 The Author Clinical and Experimental Optometry © 2014 Optometrists Association Australia
working relationship between optometry and ophthalmology. Over my professional life, the name for age-related macular degeneration (AMD) undergone different incarnations but useful treatments have arrived. Administering antivascular endothelial growth factor injections are using huge ophthalmological resources. Technologies such as ocular coherence tomography can improve the accuracy of referral for people with conditions such as AMD and other macular conditions, to better differentiate between those that can be treated and those that cannot. Although it is early days, the uptake of this new technology by optometrists has already been quite spectacular. In general, equipment that is now required to perform a comprehensive eye examination is making a greater demarcation between eye care from an optometrist and a general practitioner (GP). Visual field instruments, slitlamps, binocular indirect ophthalmoscopes, pachymeters and gonioprisms are required to deliver care consistent with the evidence base underpinning glaucoma diagnosis and evaluation of retinopathy. Care plans from GPs involving optometrists for people with conditions such as diabetes and the Optometry Medicare Benefits Schedule reflect this change, as do GP referrals to optometrists for corneal foreign body removals, presumed vitreous detachments and the like. On the ground, there are osmotic forces at work that influence practice, referral pathways, patient choices and the division of labour for all health providers. This is not a new phenomenon. In the mid-nineteenth century, trial sets typically had no cylindrical power lenses and there was a fairly well recognised view that patients requiring lenses other than spheres should be seen by an oculist, the forerunner of an ophthalmologist.1 If there had been no change from this practice, we would have a very inefficient eye-care system and tertiary eye care would be swamped by referrals for astigmatic refractive correction. It’s an extreme example that demonstrates that Clinical and Experimental Optometry 97.2 March 2014
97
Editorial Harris
there will be changes in the skill base of a profession that reflect change in knowledge and community demand. Despite the common sense nature of this picture and the greatly improved patient outcomes, changes in the scope of optometric practice have been characterised by controversy. Notwithstanding optometry’s aforementioned mid-nineteenth century anxiety dealing with astigmatism, optometrists have long catered for refractive care of the community. Ophthalmology has also provided refractive care for at least the last 100 years, in which time there has been considerable overlap in the roles undertaken by optometrists and ophthalmologists. This is a significant reason why so much of the change in the practice of optometry has met with opposition from organised medicine. Many of the changes to make better use of optometrists’ skills in line with its contemporary knowledge and equipment have required alterations to the regulation of the optometric profession. It is then a matter for government and its advisors to assess the benefits to be derived for the community in changing the scope of optometric practice. This involves considering ease of access, cost effectiveness and patient and community outcomes. Unfortunately, the process is not exclusively rational, it is political. The fight to allow optometrists to use ocular diagnostic drugs gives a more contemporary context on changing practice in optometry. Given the Australian Federation and its consequent state-based health regulations (up until the 2010 National Registration & Accreditation Scheme) the use and regulation of ocular diagnostic drugs by optometrists was negotiated in each state over 20 years. The logic of incorporating the use of ocular diagnostic drugs in an eye examination performed by an optometrist was simple but is worth restating. There is benefit in providing a cycloplegic refraction for younger hypermetropes. There was a huge public health benefit in providing applanation tonometry to presbyopes and other patients receiving refractive care as a way of screening for glaucoma. Obviously, making an assessment for glaucoma is much more sophisticated in this day and age but using an anaesthetic was as important then as it is now. Dilating pupils to effectively look for diabetic retinopathy, to examine an optic nerve head or detect anterior chamber flare is expected of optometrists by contemporary standards of patient care and yet a law passed in 1963 in New South Wales Clinical and Experimental Optometry 97.2 March 2014
98
to allow use of these diagnostic drugs in an optometric eye examination was not adopted in practice until the 1980s. This delay was due to organised medical opposition. Looking back, that opposition looks to be insular and ignorant, or cynical and selfserving. History does not look kindly upon that campaign. There is a similar narrative that would explain the legislative change allowing optometrists to prescribe S4 therapeutic eye drops. It was a process that had legislative success in Victoria in 2000 following a predictable decade-long argy-bargy with organised medicine, a process that was repeated in every state with a resultant lack of national consistency (both in terms of drug lists and timing). The inconsistency was only ironed out by National Registration introduced in 2010. The delays in reaching national consistency in the drugs that could be used by optometrists denied patients a Pharmaceutical Benefit Scheme (PBS) rebate if their prescription was written by an optometrist or necessitated a wasted visit to a medical practitioner. In achieving PBS rebates for patients, the same arguments were played out with the result that some drugs prescribed by an optometrist attracted a PBS rebate from 2007, some do not to this day and others required specific circumstances or conditions to be met. The discussions continue. Yet, this change has been embraced by the professionals that care for the community. There is recognition that both current and future demands on ophthalmological services (both private and public) require co-operation between ophthalmologists and optometrists, the proper use of each others’ skills and efficient practice. The simple task of an optometrist treating herpes simplex keratitis by providing a script for acyclovir frees up an ophthalmological service that can be put to alternative tasks. Duplication is removed improving efficiency. The same applies to accurately and appropriately referring cataract patients to public hospitals. Public hospitals are now involving optometrists in the referral process to reduce unnecessary referrals. Some patients with diabetes in the Queensland public health system are being given the option to have their fundus assessed by a local optometrist. There are more arrangements where both private and public patients are having cataract after-care delivered by a local optometrist. Public optometry and tertiary eye-care institutions are forming relation-
ships and working co-operatively. The use of ocular diagnostic drugs, the ability to prescribe ocular therapeutics that attract a PBS rebate and serendipitous access to refractive care is a more pragmatic and efficient model of eye care. The aging population presents huge challenges to diagnosing and treating people with glaucoma. The Optometry Board of Australia passed a regulatory change that allows optometrists to initiate glaucoma treatment. The Royal Australian and New Zealand College of Ophthalmology and the Australian Society of Ophthalmologists are challenging the validity of the decision in the High Court. In contrast a press release from The American Academy of Optometry reads, ‘The American Academy of Optometry is pleased to announce the initiation of collaboration with the American Academy of Ophthalmology to advance mutual continuing education programs for enhanced patient care.’2 In Australia, optometry and ophthalmology have never worked more effectively in everyday practise. Ophthalmologists participate in educating optometrists, are available to discuss issues and patient care, work pragmatically to find efficient patient pathways using optometrists’ skills to provide world-class care for our shared patients. In contrast, at the organisational level, the processes bringing about change in optometric practice in Australia remain sadly adversarial, resource intensive and glacial. In my view they have been highly unsatisfactory, especially when examining the ultimate outcomes that benefit Australian society. As chair of Optometrists Association Australia, I can only ask my Board and Executive to find a better way. I hope our counterparts in ophthalmology will do the same. The result will be better eye care sooner. A static health system is an inefficient health system. Boundaries should be defined to provide excellent eye care where it is needed, when it is needed and at the lowest cost. Goodwill and good collaboration between optometry and medicine can help to make systems safe, efficient and effective. REFERENCES 1. Alden W. The Human Eye: Its Use and Abuse. Cincinnati: W Aldens, 1866. 2. Joint news release. American Academy of Ophthalmology and American Academy of Optometry to Explore Educational Opportunities to Advance Quality Eye Care Collaboration. Dec 4 2013. http://www.aaopt.org/Media/Default/pr/ Press%20Release_Final.pdf
© 2014 The Author Clinical and Experimental Optometry © 2014 Optometrists Association Australia
A N D
E X P E R I M E N T A L
OPTOMETRY EDITORIAL
The boundaries of optometric practice Clin Exp Optom 2014; 97: 97–98 Andrew Harris BScOptom FACO GradCertOcTher National President Optometrists Association Australia Change is inevitable. Paradoxically, it can be described as a societal constant. People and their communities can embrace change, attempt to bend it or simply resist it. The prospect of change can be exciting, confusing and confounding. This is often because change is complex and its many variables can make risk versus reward difficult to calculate and easy to blur. Inevitably, vested interests are affected by change and so, it is natural for vested interests to ensure they are better off (or at least no worse off). Not surprisingly, change management is often political. Change to the way eye care is delivered in the community is no different. Eye care is very different today from 10 or 20 years ago, let alone a century ago. Optometry’s role in eye-care delivery has inevitably altered too. Traditionally, optometrists delivered refractive care to the community. While this has embraced advances in spectacle lens and contact lens technology, low-vision services and public health refractive services, it has also given the profession a platform to deliver a broader scope of primary eye care to the community. The way optometry is practised has to remain relevant and valuable to the community. This requires optometry and other vested interests to be flexible and respond efficiently to embrace and harness change. Within the health-care system, knowledge and technology, the training of health professionals and the processes of funding have all altered dramatically in the past 50 years. From the inception of Federation an emerging middle class with an aspiration for an egalitarian society has driven an Australia that among other things encourages equal access to health services with world-class outcomes for all. This is all very well but the health system faces daunting challenges in the next few decades. An aging population with more chronic disease will demand the
DOI:10.1111/cxo.12145 same access and outcomes that have existed in past years. Demand on health resources and services from all age groups will continue to grow dramatically as new medical treatments emerge. The system has to become more efficient and productive. It will have to use the entire health workforce and exploit all of its skills, equipment and expertise, and reduce duplication and turf protection. Looking at the delivery of eye care to the community in the past and the space that optometry has filled within in it is instructive when looking to the future. The scope of optometric practice has changed. Optometrists have been pushed by their leadership to embrace new evidence and research, acquire new skills and to be willing to invest in equipment and their own further training. This leadership also pushed for relevant legislative change. An early example of legislative change was ‘winning’ the right to refer directly to an ophthalmologist. This was achieved in 1970 with much opposition throughout the 1960s from medicine. This was legislative recognition that optometrists had a genuine contribution to make to the best vision care for the community. The inclusion of optometry into the National Health Scheme in 1975 after a hard political fight recognised the value of the profession to the community. It altered the scale of eye care delivered by optometry and coincided with optometry’s enthusiastic forays into low vision and contact lens practice. Over the last 20 years, there have been advances within the industry that have had an effect on the practice of optometry. The improvement in cataract surgery has had a profound effect on demand for ophthalmological services. It has required efficient and accurate referral by optometrists, improved patient outcomes and allowed optometrists to refer patients earlier with success being the norm. Cataract surgery is the most frequent and most successful procedure performed in the country. It has a positive effect on the community and has improved the
© 2014 The Author Clinical and Experimental Optometry © 2014 Optometrists Association Australia
working relationship between optometry and ophthalmology. Over my professional life, the name for age-related macular degeneration (AMD) undergone different incarnations but useful treatments have arrived. Administering antivascular endothelial growth factor injections are using huge ophthalmological resources. Technologies such as ocular coherence tomography can improve the accuracy of referral for people with conditions such as AMD and other macular conditions, to better differentiate between those that can be treated and those that cannot. Although it is early days, the uptake of this new technology by optometrists has already been quite spectacular. In general, equipment that is now required to perform a comprehensive eye examination is making a greater demarcation between eye care from an optometrist and a general practitioner (GP). Visual field instruments, slitlamps, binocular indirect ophthalmoscopes, pachymeters and gonioprisms are required to deliver care consistent with the evidence base underpinning glaucoma diagnosis and evaluation of retinopathy. Care plans from GPs involving optometrists for people with conditions such as diabetes and the Optometry Medicare Benefits Schedule reflect this change, as do GP referrals to optometrists for corneal foreign body removals, presumed vitreous detachments and the like. On the ground, there are osmotic forces at work that influence practice, referral pathways, patient choices and the division of labour for all health providers. This is not a new phenomenon. In the mid-nineteenth century, trial sets typically had no cylindrical power lenses and there was a fairly well recognised view that patients requiring lenses other than spheres should be seen by an oculist, the forerunner of an ophthalmologist.1 If there had been no change from this practice, we would have a very inefficient eye-care system and tertiary eye care would be swamped by referrals for astigmatic refractive correction. It’s an extreme example that demonstrates that Clinical and Experimental Optometry 97.2 March 2014
97
Editorial Harris
there will be changes in the skill base of a profession that reflect change in knowledge and community demand. Despite the common sense nature of this picture and the greatly improved patient outcomes, changes in the scope of optometric practice have been characterised by controversy. Notwithstanding optometry’s aforementioned mid-nineteenth century anxiety dealing with astigmatism, optometrists have long catered for refractive care of the community. Ophthalmology has also provided refractive care for at least the last 100 years, in which time there has been considerable overlap in the roles undertaken by optometrists and ophthalmologists. This is a significant reason why so much of the change in the practice of optometry has met with opposition from organised medicine. Many of the changes to make better use of optometrists’ skills in line with its contemporary knowledge and equipment have required alterations to the regulation of the optometric profession. It is then a matter for government and its advisors to assess the benefits to be derived for the community in changing the scope of optometric practice. This involves considering ease of access, cost effectiveness and patient and community outcomes. Unfortunately, the process is not exclusively rational, it is political. The fight to allow optometrists to use ocular diagnostic drugs gives a more contemporary context on changing practice in optometry. Given the Australian Federation and its consequent state-based health regulations (up until the 2010 National Registration & Accreditation Scheme) the use and regulation of ocular diagnostic drugs by optometrists was negotiated in each state over 20 years. The logic of incorporating the use of ocular diagnostic drugs in an eye examination performed by an optometrist was simple but is worth restating. There is benefit in providing a cycloplegic refraction for younger hypermetropes. There was a huge public health benefit in providing applanation tonometry to presbyopes and other patients receiving refractive care as a way of screening for glaucoma. Obviously, making an assessment for glaucoma is much more sophisticated in this day and age but using an anaesthetic was as important then as it is now. Dilating pupils to effectively look for diabetic retinopathy, to examine an optic nerve head or detect anterior chamber flare is expected of optometrists by contemporary standards of patient care and yet a law passed in 1963 in New South Wales Clinical and Experimental Optometry 97.2 March 2014
98
to allow use of these diagnostic drugs in an optometric eye examination was not adopted in practice until the 1980s. This delay was due to organised medical opposition. Looking back, that opposition looks to be insular and ignorant, or cynical and selfserving. History does not look kindly upon that campaign. There is a similar narrative that would explain the legislative change allowing optometrists to prescribe S4 therapeutic eye drops. It was a process that had legislative success in Victoria in 2000 following a predictable decade-long argy-bargy with organised medicine, a process that was repeated in every state with a resultant lack of national consistency (both in terms of drug lists and timing). The inconsistency was only ironed out by National Registration introduced in 2010. The delays in reaching national consistency in the drugs that could be used by optometrists denied patients a Pharmaceutical Benefit Scheme (PBS) rebate if their prescription was written by an optometrist or necessitated a wasted visit to a medical practitioner. In achieving PBS rebates for patients, the same arguments were played out with the result that some drugs prescribed by an optometrist attracted a PBS rebate from 2007, some do not to this day and others required specific circumstances or conditions to be met. The discussions continue. Yet, this change has been embraced by the professionals that care for the community. There is recognition that both current and future demands on ophthalmological services (both private and public) require co-operation between ophthalmologists and optometrists, the proper use of each others’ skills and efficient practice. The simple task of an optometrist treating herpes simplex keratitis by providing a script for acyclovir frees up an ophthalmological service that can be put to alternative tasks. Duplication is removed improving efficiency. The same applies to accurately and appropriately referring cataract patients to public hospitals. Public hospitals are now involving optometrists in the referral process to reduce unnecessary referrals. Some patients with diabetes in the Queensland public health system are being given the option to have their fundus assessed by a local optometrist. There are more arrangements where both private and public patients are having cataract after-care delivered by a local optometrist. Public optometry and tertiary eye-care institutions are forming relation-
ships and working co-operatively. The use of ocular diagnostic drugs, the ability to prescribe ocular therapeutics that attract a PBS rebate and serendipitous access to refractive care is a more pragmatic and efficient model of eye care. The aging population presents huge challenges to diagnosing and treating people with glaucoma. The Optometry Board of Australia passed a regulatory change that allows optometrists to initiate glaucoma treatment. The Royal Australian and New Zealand College of Ophthalmology and the Australian Society of Ophthalmologists are challenging the validity of the decision in the High Court. In contrast a press release from The American Academy of Optometry reads, ‘The American Academy of Optometry is pleased to announce the initiation of collaboration with the American Academy of Ophthalmology to advance mutual continuing education programs for enhanced patient care.’2 In Australia, optometry and ophthalmology have never worked more effectively in everyday practise. Ophthalmologists participate in educating optometrists, are available to discuss issues and patient care, work pragmatically to find efficient patient pathways using optometrists’ skills to provide world-class care for our shared patients. In contrast, at the organisational level, the processes bringing about change in optometric practice in Australia remain sadly adversarial, resource intensive and glacial. In my view they have been highly unsatisfactory, especially when examining the ultimate outcomes that benefit Australian society. As chair of Optometrists Association Australia, I can only ask my Board and Executive to find a better way. I hope our counterparts in ophthalmology will do the same. The result will be better eye care sooner. A static health system is an inefficient health system. Boundaries should be defined to provide excellent eye care where it is needed, when it is needed and at the lowest cost. Goodwill and good collaboration between optometry and medicine can help to make systems safe, efficient and effective. REFERENCES 1. Alden W. The Human Eye: Its Use and Abuse. Cincinnati: W Aldens, 1866. 2. Joint news release. American Academy of Ophthalmology and American Academy of Optometry to Explore Educational Opportunities to Advance Quality Eye Care Collaboration. Dec 4 2013. http://www.aaopt.org/Media/Default/pr/ Press%20Release_Final.pdf
© 2014 The Author Clinical and Experimental Optometry © 2014 Optometrists Association Australia
