Glaucoma Tug-of-War

Patient safety in Australia is protected by long-established procedures centered on the fundamental principle that medical practitioners are allowed to independently treat serious medical conditions while allied health professionals assist in the treatment, and in many cases are the primary providers of care. Glaucoma treatment offers a good example of this approach: ophthalmologists have taken responsibility for diagnosis, initial treatment and oversight of patient management, with optometrists seeing the patient regularly to ensure compliance and, when necessary, referring him or her back to the ophthalmologist for review and adjustment of treatment. This model of care was developed over many years and is set out comprehensively in the National Health and Medical Research Council (NHMRC) Guidelines for the Screening, Prognosis, Diagnosis, Management and Prevention of Glaucoma.

The Challenge

On November 23 2012, with no prior warning, the status quo for glaucoma care was turned on its head. The optometry profession is regulated by the Optometry Board of Australia (OBA); “Regulation of Health Practitioners” (see page 52) explains the structure of the regulatory arrangements.

On that date, the OBA submitted a proposal to The Australian Health Practitioner Regulation Agency (AHPRA) requesting that optometrists be able to independently treat patients with chronic glaucoma or those at risk of developing the disease, something that was previously only undertaken by medically-trained ophthalmologists. The OBA, a bureaucratic organization established to administer the registration of optometrists, was (however inadvertently) putting patients at risk across all areas of specialist medicine in Australia.

In response, RANZCO lodged a comprehensive submission to AHPRA focusing on the education and training of ophthalmologists and optometrists, and on the risk to patient safety. As Stephen Best noted, “An optometrist has typically studied for four or five years to earn an undergraduate degree, after which time he or she can prescribe and fit glasses or contact lenses. An ophthalmologist is a medical doctor who, in addition to gaining a medical degree in six years, has undertaken five years of specialist training in the diagnosis and management of disorders of the eye and visual system. In the course of their specialist training, an ophthalmologist will typically have seen more than 7,000 ophthalmic patients.”

Regulation of Health Practitioners

• The Health Practitioner Regulation National Law and its recognized health professions are represented by National Boards that are regulated under the National Registration and Accreditation Scheme. 
• The Australian Health Practitioner Regulation Agency (AHPRA) supports these National Boards, which have the responsibility for regulating their respective health professions, to protect the public and set standards and policies that all registered health practitioners must meet. 
• The AHPRA legislation grants equal status to both allied health and medical discipline Boards. (The optometry profession is governed by the Optometry Board of Australia [OBA]). It also enables groups to increase their scope of clinical practice without expert oversight or clinical review. 

Despite RANZCO’s arguments, the OBA submission was endorsed by AHPRA. The result is that optometrists with minimal hours of additional therapeutic training can now diagnose and treat glaucoma with no oversight from an ophthalmologist. Many in the Australian eye-care community have expressed shock at this turn of events. For example, Steve Hambleton, President of the Australian Medical Association, said that, in making its decision, the OBA had failed to safeguard the interests of those suffering glaucoma, now and in the future. “This is not an example of health reform. This is an example of the fragmentation of health care, which is the enemy of quality care, the enemy of efficient care, and the enemy of affordable care.”

The Response

At present, RANZCO, together with the Australian Society of Ophthalmologists (ASO), is appealing against the OBA’s decision, in the interests of patient safety. RANZCO is encouraging continued collaboration between the two professions to prevent the creation of a two-tier health system in Australia. On Thursday, 20 June, 2013, the OBA was served notice that ASO and RANZCO are jointly launching a Supreme Court action with respect to the OBA’s unilateral decision, which has been endorsed by the Australian Health Practitioner Regulation Agency (AHPRA), to increase optometrists’ scope of practice to independently diagnose and manage glaucoma.

ASO and RANZCO have begun lobbying politicians and senior departmental executives to ensure that they are aware of the health risks involved for the Australian population. The two organizations continue to work together preparing numerous submissions and engaging with key stakeholders through correspondence and face-to-face meetings. As Stephen Best explains, “RANZCO does not believe that it is in the patients’ interests for optometrists to seek to increase their scope of practice through legislation rather than clinical education.”

Ophthalmologists greatly appreciate the valuable role of optometrists in screening for eye-care diseases and believe that an integrated eye-care model gives the patient the best possible outcome. The move by the OBA not only puts this model at risk but also threatens the relationship between optometrists and ophthalmologists. It also highlights a disturbing loophole in the administration of Australia’s healthcare system.

David Andrews is the Chief Executive Officer of the Royal Australian and New Zealand College of Ophthalmologists.