In recent years, the Optometrists Association Australia (OAA) and the university-based schools of optometry have fought valiantly for optometrists to be granted therapeutic prescribing rights. Now that the battle has been won in most Australian states…we look at the impact of this highly charged issue.
In 1995, Victorian Parliament passed a legislation to permit qualified optometrists registered in the state of Victoria to prescribe Schedule 4 (S4) drugs for the treatment of ocular disease. However, to settle regulations, to reach an agreement regarding educational requirements and to form a drug list specifying the available drugs for optometrists to prescribe required a further four years. It was therefore only from the year 2000 that Victorian optometrists were truly able to prescribe therapeutic drugs. Nonetheless, it was this acquisition of optometric prescribing rights in Victoria that catalysed the next series of rapid developments in Australian optometry as a therapeutic profession.5
Most other states and territories in Australia followed the Victorian example and also passed legislation to give optometrists the right to prescribe S4 drugs. These changes occurred in Tasmania in 1996, in New South Wales in 2002 and Queensland in 2003. The ACT looked into the issue in 2002 but legislative changes were only made in 2005. Similarly, the Northern Territory began to consider changes in 2003 but only passed legislation after December 2006. Prescription rights for South Australian optometrists were attained even later, in 2007. Optometrists in Western Australia are yet to be given prescribing rights.6 However, legislation governing the prescription of Schedule 4 drugs in Western Australia was reconsidered in the year 2006 and submissions on proposed amendments to the Poisons Act were made in 2007.7
Prescribing rights were gained by optometrists in some states prior to others because each state has a different Act which governs the use of therapeutic goods. Each state must therefore go through a complex process of putting forward a motion for a Bill to remove restrictions on therapeutic drug use by optometrists.8, 9 This Bill must then be passed by a majority in both the lower and upper houses, and royal assent by the governor must be given before it can become an Act. Regulations must then be made by executives pursuant to the Act and an agreed drug list formed.5, 9
it was this acquisition of optometric prescribing rights in Victoria that catalysed the next series of rapid developments in Australian optometry as a therapeutic profession
Therapeutics Introduced to Optometry
There may be queries as to why therapeutics has been introduced into optometry. The main reason for this development in optometry is to provide an improved standard of eye care within the community. That is, to offer the public easier access to primary eye care at a lower cost.3
Data from the Bureau of Statistics suggests that the Australian population is ageing as a result of decreased fertility rates and increased life expectancy. The number of people in the Australian population aged 65 years and over rose from 151,000 in 1901 to 2.3 million in 1999. By the year 2021, this figure is predicted to increase by a further 18 per cent.10
Ageing is often associated with a higher prevalence of disease.10 Therefore, a subsequent concern which arises following the growth of an aging community is that health care needs may grow to outstrip the number of health care professionals available. Eye care in Australia is one of the areas in which the validity of this concern has already been evidenced. Current data suggests that there already are too few ophthalmologists to provide the primary, secondary and tertiary ocular disease management required within the community. With the expected growth of the ageing population, it is expected that there be will even higher demands on ophthalmologists for eye care management in the future.11
Therapeutic endorsement of optometrists provides an adequate means of addressing this issue11 as it reduces the workload in ophthalmology. For example, a therapeutically endorsed optometrist would be able to provide treatment for ocular conditions such as bacterial conjunctivitis, viral conjunctivitis or blepharitis without requiring secondary intervention from an ophthalmologist.5 For progressive ocular diseases like cataract and glaucoma, a therapeutically endorsed optometrist would also be able to play a larger role in initial and post-operative co-management. This task transfer to optometrists thereby permits ophthalmologists to dedicate their time towards secondary and tertiary management of more severe ocular conditions as well as to performing surgical procedures.11, 12
Consequently, giving optometrists prescribing rights not only ensures that patients with minor ocular conditions and those that require long term review have easier and faster access to treatment, but it also reduces the waiting period for patients who do require secondary eye care and the attention of an ophthalmologist.
Previously, despite being able to reach an accurate diagnosis on a patient’s condition, an optometrist was required to refer a patient on to an ophthalmologist or a general practitioner (GP) for therapeutic treatment. With prescription rights, referral would not be necessary and adequate treatment may be implemented on the patient’s first time of presentation. This prevents unnecessary referral and saves the patient additional time and trouble from having to see the ophthalmologist or GP. This issue is particularly significant in the rural community, as in small towns an ophthalmologist may only be available once every fortnight and there are often travel issues, with many ophthalmologists located greater than one hour away. As optometrists are geographically much more evenly distributed within Australia, acquisition of prescribing rights therefore allows for more accessible treatment for patients with minor ocular conditions.5, 12
Introduction of therapeutics into optometry is also likely to improve management of ocular conditions. Currently, GPs in Australia are known to write over one million prescriptions each year for chloramphenicol for patients who present with red eyes.5 Without using a slit-lamp, it is very difficult to rule out whether these patients have non-bacterial inflammatory or viral conditions that do not actually require treatment with antibiotics. As optometric practices are much better equipped with instrumentation required for a thorough eye examination,12 it is easier to attain accurate diagnosis of the condition and unnecessary antibiotic use may be avoided.
Education acts as the foundation for any profession.1 In order to maintain the quality of a profession, certain educational requirements must be fulfilled. Prior to being able to obtain drug prescribing authority, an optometrist must meet the competency standards which have been developed by the OAA and specified in the legislation governing each state. 1 The competency of a qualified optometrist is verified by providing evidence of the completion of an educational program or degree related to ocular therapeutics which is recognised and accredited by the Optometry Council of Australia and New Zealand.
Recognised qualifications include the:
- “Postgraduate Certificate in Ocular Therapeutics (University of Melbourne)
- Graduate Certificate in Ocular Therapeutics (University of New South Wales)
- Graduate Certificate in Ocular Therapeutics (Queensland University of Technology)
- The Auckland Programme in Ocular therapeutics (University of Auckland)
- Bachelor of Optometry (University of Melbourne)
- Bachelor of Optometry (University of Auckland)”13
The birth of therapeutics in optometry has brought about a number of significant changes in the optometric courses offered. Following the legislative change in Victoria in 1996 which gave qualified and appropriately trained optometrists the authority to prescribe S4 therapeutic drugs, the Postgraduate Certificate in Ocular Therapeutics (GCOT) was introduced by the University of Melbourne.5, 14 The aim of the course was to allow registered optometrists to obtain therapeutic prescribing rights to treat ocular diseases. The first cohort of optometrists with full therapeutic endorsement graduated from this degree in the year 2000. Later in 2002, the undergraduate course was extended from four to five years to incorporate ocular therapeutic training.2
As the legislation allowing prescription of S4 drugs by optometrists occurred at a later date in New South Wales, it was only in 2007 that graduate ocular therapeutic training became available at the University of New South Wales.2 The Bachelor degree offered at the university was also extended from four to five years to incorporate therapeutic training. The first cohort of optometrists of this five year Bachelor of Optometry will be graduating in 2010.2, 14 Similar changes have been implemented by the Queensland University of Technology, with their four year course also converting to a five year course from the year 2008.14
Without question, acquisition of prescribing rights means that optometrists now require an increased level of experience in diagnosing and treating various ocular diseases. To improve the standards of care provided, the emphasis in optometric education must be shifted towards medical and clinical teaching.15
Nowadays, optometrists taking the post-graduate ocular therapeutics course at the University of Melbourne attend the clinics at the Royal Victorian Eye and Ear Hospital while at the University of New South Wales, postgraduate optometrists attend clinics at the Royal Hobart Hospital.
However, the opportunity for these clinical experiences with ocular disease management is quite difficult to attain as even today, sectors of the medical profession are still opposed to the idea of providing hospital education for optometrists. Perhaps with time, such opportunities will become more readily available.14
Impact on the Profession
The introduction of prescribing rights in optometry impacts the profession in several ways. Optometrists with prescribing rights may have greater job satisfaction as they would be able make use of their knowledge on ocular disease and play a more significant role in the management of eye health. Additionally, as the scope of optometric practice is extended, more opportunities may arise for optometrists to develop their career to further supplement their knowledge on diseases of the eye.3 Of course, accompanying such developments is a consequential increase in clinical responsibility. A therapeutically endorsed optometrist must keep themselves updated with knowledge of new available treatments and clinical techniques to ensure that their patients receive the best eye care possible at all times.3
Based on data from studies in Missouri, U.S., where optometrists have been allowed to prescribe therapeutic agents since 1986, it is suggested that gaining prescription rights also leads to an increase in the number of presenting patients. This may impact upon the profession in a number of ways. While it presents with the potential for generating more income and gaining more experience for the optometrist, there may also be possible complications relating to increased workload or increased staffing demands.16, 17
A study conducted in Australia in the year 1998 found that 88 per cent of the optometrists surveyed were in favour of gaining prescription rights for Schedule 4 drugs. There were some optometrists however, who indicated that they did not want to be involved with therapeutic management at all. One reason for this lack of interest in attaining therapeutic prescribing rights was due to cost. It was pointed out that training fees would be required in order to continue in therapeutic education while additional time off work would also be needed in order to take part in the course, leading to a loss of income during this period. Secondly, a number of optometrists argued that they did not want the increase in associated responsibility or to deal with the threat of malpractice claims. Although these results were attained from surveying a group of registered optometrists, it is safe to assume that there are a few graduating therapeutically endorsed optometrists who may also have these same concerns.
As such, it is hard at current to estimate the number of optometrists in Australia who would actually prescribe S4 drugs on indication in their practice. In the U.S., although optometrists have the option of attaining prescribing rights through continuing education, not all choose to do so. This has led to the development of a two-tiered system. As the optometric profession in Australia cannot force optometrists who do not want the responsibility of therapeutic drug management to change the way they practice, it is likely that a similar two-tier system will develop also.3
One of the major problems optometry has been facing in its development as a therapeutic profession is the variation in the drugs which are available for prescription within each state. If an optometrist is unable to access the drug required for the most adequate management of a patient’s presenting condition, delayed treatment, as well as unnecessary referral would still occur. Additionally, it must be remembered that a drug which is effective for one patient may not be for another. Thus prescribing drugs based on a restricted list limits the potential for optimal eye care.3, 5 Currently, optometrists practicing in some states are restricted from prescribing certain drugs available in other states despite receiving the same training and qualification.
For example, the use of prednisolone has been restricted in some states based on the argument that such a potent steroid would have the potential for causing side effects such as glaucoma and cataract. However, one can argue that most conditions which optometrists manage in a primary eye care situation would only require short term use of the drug, thus largely reducing potential for the development of various side effects. Recent research has suggested that acute anterior uveitis is best managed through the use of prednisolone. Restriction of its use in some states means that patient referrals would be required for treatment of the condition in these states, while in Victoria, where use of the drug is not restricted, referral would not be necessary.18
With the National Registration system for optometrists starting on 1 July 2010, a general drug list will be formed and this issue of variation in drug lists across the states will soon to be resolved.
In Western Australia, the bill for granting optometrists therapeutic prescribing rights is currently waiting to be passed in parliament. This is expected to occur in the very near future which would allow optometrists in Western Australia to also have access to the prescription of S4 drugs which are set to be available on the generalised drug list.
Not only are adjustments being made in relation to the drugs which optometrists can prescribe, other regulations governing therapeutic prescription are also being reviewed. Changes made to the Victorian Drugs, Poisons and Controlled Substances Regulations in May 2006 gave optometrists in Victoria the right to give repeats on prescriptions, to provide oral instructions to a pharmacist to dispense drugs and a nurse to administer drugs in the event of an emergency.19 The National Health Amendment (Pharmaceutical Benefits) Bill 2007 was altered to allow authorised optometrists, as of 1 January 2008 to prescribe under the Pharmaceutical Benefits Scheme.2 Such changes indicate that therapeutic endorsement of optometrists is only the initial stage in the development of optometry as a therapeutic profession. Further changes in legislation and governing regulations are yet to be expected.
Attitudes of optometrists towards gaining prescribing rights may also change over time. Since the first legislation was passed to give optometrists prescribing rights, over 300 optometrists in Australia have registered to practise therapeutically over a span of seven years.5 As more optometrists become therapeutically endorsed, other optometrists may aspire to be on par with their colleagues and return to further their education and attain the required qualifications.3
Optometry in Australia has expanded vastly in its scope of expertise as a profession since it was first introduced. Therapeutic endorsement of optometrists is one of the most recent and significant developments within the profession. Following such recent legislative changes however, it is inevitable that there are a number of issues still waiting to be resolved.
Nevertheless, therapeutic endorsement of optometrists in most Australian states is set to change the role which optometry plays in eye care health. It presents the opportunity for task transfer from ophthalmologists and GPs of the management of some ocular diseases, thereby providing more accessible and affordable eye care for the public. At the same time, this acquisition of prescribing rights will allow optometrists to make better use of their knowledge and elevate the professional standing of optometry in the community.
Ms Jingjing Huang and Ms Chloe Ko are final year optometry students studying their Bachelor of Optometry and Vision Science at the University of New South Wales. This is their first published work.