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 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!
