Lessening the Load: Collaborating to Tackle Top End Cataract

Surgical treatment is safe, effective and cost-effective, yet access to this surgery is currently inequitable: privately-funded patients are able to have surgery within weeks of diagnosis, but publicly-funded patients can wait anywhere from four to more than 30 months from the time of referral.¹

Eighty per cent of Indigenous people access cataract surgery as public patients, compared with 29% of non-Indigenous Australians.

A private-public partnership is lessening the load on the public system and smoothing the way for more patients to access this sight-saving surgery in the Northern Territory.

They called it ‘The Great Cataract Debacle’. It was back in 2009 and the federal Government cut the Medicare patient rebate for cataract surgery by 50%.

With ophthalmologists threatening to stop providing private cataract surgery, the Australian Society of Ophthalmologists (ASO) knew that public wait lists would quickly blow out and decided something needed to be done. Dr Peter Sumich, now the ASO’s President, came up with the highly emotive “Grandma’s Not Happy” campaign and the ASO went into battle.

Associate Professor Ashish Agar, VicePresident of the ASO, said the evidence presented to government to support continued funding for privately performed cataract surgeries was strong. Data from the time demonstrated that with the Medicare rebate reduction, the number of people accessing privately-funded sight-saving cataract surgery plummeted.

Faced with relentless lobbying and strong public support, the federal Government folded, eventually reinstating all but around 10% of the funding in 2010. Reflecting on the battle, Assoc Prof Agar said, “Determination and public support won”.

From there, the ASO lobbied harder for more equitable access to eye care, successfully negotiating specific funding for cataract surgeries for Indigenous Australians. As a result, IRIS (Indigenous and Remote Eye Health Service) was born.

PUBLIC-PRIVATE PARTNERSHIP DRIVES SUCCESS

Since its establishment in 2010, IRIS has completed over 3,000 cataract surgeries across 26 rural and remote locations. And the trick to its success, Assoc Prof Agar said, is that it is a public-private partnership.

Initially the service, known as IRIS 1.0, was operated by the Australian Government and the ASO. However, to manage its delivery, ASO engaged Vanguard Health, a private organisation that supports public healthcare providers to deliver services to communities in regional and remote Australia.

Later, having proven Vanguard’s capabilities, and with the agreement of the then Ministers for Health and Indigenous Health, a direct relationship was established between the federal Government and Vanguard Health to fund a second iteration of the program known as IRIS 2.0. The ASO stepped back from the day-to-day but retained direct oversight through two of its senior executive members — Assoc Prof Agar and Dr Bill Glasson — Chair and Co-Chair respectively, of the IRIS Taskforce.

Several iterations later, IRIS 4.0 is now underway and contracted by the Australian Government to provide at least 800 cataract surgeries to First Nations people in the Northern Territory by 30 June 2025.

Under this new contract, services have already been provided at Katherine (Big Rivers region), Alice Springs (Central Australia region), and Gove Hospitals (East Arnhem region) and plans are in place to visit additional facilities in the Top End region at Royal Darwin and Palmerston Hospitals.

“Critics may question the need for a publicprivate partnership to coordinate this program, but the reality is that there is no alternative and the IRIS program, as it has been structured, has been very successful in delivering eye services into the most remote areas of Australia. The public system is struggling on every front, and at the end of the day it’s simply about building a program that works on the ground,” Assoc Prof Agar said. “When you’re working in the public hospital system, in multiple regional and remote areas, there are so many moving parts — anaesthetists, devices, facilities, nurses, patients… IRIS through Vanguard has the systems in place to manage these outreach programs efficiently.”

FACILITATING SERVICE

Vanguard Health Chief Executive Officer, Tim Gallagher said IRIS is a small but “really important part” of the business — “10% of volume, 90% by passion” — and it is achieving its goal of facilitating more equitable access to health care.

“This is exactly what the IRIS program was set up to do, because while many ophthalmologists express their interest in providing remote and regional eye care services, the administrative overhead associated with doing so individually is significant,” he explained.

“So, we really see the role that we play is administrative; the logistics, the pulling together of a whole range of stakeholders [into] a collaborative program that works towards one objective in terms of executing a clinic for a certain group of people.

“We take care of all the work that needs to happen before the specialist ophthalmology team gets to a particular location. So, when they get there, they can actually just do the thing that they’re really good at, which is treating people.”

Describing IRIS as “an anchor point”, he said IRIS enables specialist teams — which include ophthalmologists, ophthalmology registrars, nurses, registered nurses, orthoptists, and optometrists — to contribute to achieving real patient outcomes through the delivery of eye clinics and surgical services directly in remote and rural communities across Australia.

“We create an opportunity for them to step in and make a contribution to closing the gap without also negatively impacting their own businesses because, like everyone, they have businesses that pay their mortgage and pay their kids’ school fees, and those sorts of things.”

CULTURAL SAFETY AT THE HEART

Vanguard Health and IRIS Surgical Services Manager, Jennifer Meier said bringing additional resources into rural and remote communities is essential to reduce the growing wait times for cataract surgery, but it must be delivered in a culturally safe way.

To do this, she and her team collaborate with Aboriginal Community Controlled Health Organisations (ACCHOs) and local health services to provide a seamless service for patients that removes the complexities and stress associated with getting to and from their remote communities to a hospital for treatment.

“Our patients want to be able to undertake activities that connect them to country, like gardening and fishing, which have become challenging with a vision impairment,” Ms Meier said.

“In the Big Rivers Region, we’ve found there may be hesitancy to go and see a doctor, or that there are misunderstandings about what is involved in cataract surgery. To help overcome these barriers, we work with the ACCHOs to support patients attend appointments and access informative education about what happens when you have cataract surgery.”

To support the ACCHOs, Ms Meier and Emma Crowley, Communications Manager for Vanguard Health, are producing information sheets and a series of short videos, which will be translated into a number of Aboriginal languages.

“They will explain what a cataract is, what’s going to happen at your appointment, how to look after your eye, those sorts of things. The content will use visuals to help patients who speak languages other than English to clearly understand and consent to the surgery,” Ms Crowley said.

Patients are also at the centre of surgery scheduling. Typically, those who have travelled furthest are seen first to minimise time off country. Additionally, IRIS tries to schedule patients from the same community groups together.

“We try to cluster patients so there’s some sort of collegiality. When patients are sitting in the waiting room, it is much nicer for them when they have someone to talk to,” said Ms Meier. “At the heart of it, everything is done for the patients, it’s all about cultural safety.”

In Ms Crowley’s experience across various aspects of healthcare, “this is what makes such a big difference to the success of the program”.

“The patients feel so safe with the team who understands them. They’ve got support networks there, whether it’s peers from their community, whether it’s the Aboriginal Community Controlled Health Organisations that they see more regularly, whether it’s a translator or a member of staff who they know from their own community that works at the hospital.”

As a consequence of this delivery model, she said, “We have a lot of patients that are having second eyes done that are telling their family, ‘there’s nothing to be scared about. It was such an easy thing, go get it done, don’t delay’”.

And as well as providing sight-saving surgeries, Ms Crowley said IRIS team members engage with patients to increase their understanding of ocular health and the role they play in maintaining their own eye health by managing blood sugars and any additional comorbidities.

IMPROVING QUALITY OF LIFE

Katherine Hospital is one of the public hospitals working with IRIS to deliver the surgeries. Angela Brannelly, Regional Executive Director, Big Rivers Region, NT Health, oversees the hospital and has witnessed the significant difference IRIS is making to outcomes by providing patients with better quality of life and engaging with resident hospital staff.

Katherine Hospital, she explained, has an elective ophthalmology surgery list, with procedures performed by visiting surgeons from Royal Darwin Hospital.

A recent service provided by IRIS and another visit scheduled for this year “means people get access to their surgery a lot quicker… so instead of 20 patients having cataract surgery over a potential six-to-12- month period, they are done in a week”.

As well as shortening wait lists, she said IRIS complements the service provided by Royal Darwin Hospital financially because it is funded by the federal — rather than the Northern Territory — Government.

Additionally, the onsite theatre team benefits from being exposed to more surgeries and learning new skills from the visiting surgeons, anaesthetists, orthoptists, and nurses.

“Engaging with IRIS was a no brainer,” Ms Brannelly said. “It is very good for us; working with, and learning from, the visiting teams contributes to improved quality and safety… IRIS will bring a theatre nurse, they’ll bring an anaesthetist, they’ll bring the surgeons, and they all just seamlessly work with the hospital’s theatre team.”

Ms Brannelly said patient feedback also confirms the value of the service.

“I always think about it from a patient perspective, and I think the change that we can give to people’s quality of life through a program like this is invaluable. When you hear people say, ‘I can play with my grandchildren or I can now go and participate in my community’, I can see that it is life changing.

TRUST TAKES TIME

Having been facilitating cataract surgeries for 13 years now (with a few stops and starts due to funding and contracts et cetera), Mr Gallagher says IRIS has established a level of trust with ACCHOs, communities, health services, and ophthalmology teams, that is delivering results.

“When you go out and start visiting the communities and talking to the people that are trying to provide services day-to-day, you see firsthand just how unbelievably difficult it is… It’s a hugely challenging geography to deliver services in just by nature of distances and the logistics in some cases.

“So, we really respect each of these groups… and I think that respect is an important part of our approach. (When we visit a community) we know it is their community and we feel very privileged to be invited guests,” he explained.

“It’s really important to us, in terms of the culture, to be there to help them. We’re not there to direct or in any way dictate. We’re there to support them. When you do genuinely come in to help, they’re nothing but supportive and appreciative. But that level of trust with anyone takes time to build. And I think that’s where IRIS now has some history and legacy of commitment that we can leverage when we start talking to a community.”

Mr Gallagher said the aim is for IRIS to be recognised as the “layer” that assures a consistent model of care, regardless of who the clinicians are or how often they can accommodate visits into their schedules.

“When people see the IRIS logo, they know who we are and they’re clear on how we like things to be delivered so they can trust that even if the people change, the service model is consistent.

“But I don’t really like to promote Vanguard because the bit that we’re doing is not the hard bit. The support from the ophthalmologists has been tremendous… The work that the clinical teams do is the real work. They’re the heroes of IRIS. We just sort of facilitate the pathways and the processes.”

OPPORTUNITIES FOR EXPANSION

While focussed on meeting its targeted 800 cataract surgeries in remote Australia across the next 24 months, Mr Gallagher said the innovative IRIS model is one that could perhaps have even greater impact in the future.

“Vanguard Health would love to grow it as a platform. If we have feedback from ACCHOs and health services and ophthalmologists saying this is a good model, we need to ask, is it something that we could expand to include other specialties by just using the same model and framework?”

With continued support from the current federal Health Minister, the Honourable Mark Butler MP and the Indigenous health team at the Department of Health, this may be a very real possibility.

Reference

1. Huang-Lung, J., White A., McCluskey, P., Keay, L., et al., The true cost of hidden waiting times for cataract surgery in Australia. Public Health Res Pract. 2022;32(3):e31342116. First published 21 Oct 2021. DOI: 10.17061/ phrp31342116.

Helping to Help

By Emma Crowley

A lot of the patients can’t count the fingers of a hand when held up in front of their face.

But when they leave (post-surgery), it’s extraordinary. Because when they take the bandage off, it’s instant: they can read where they haven’t been able to before. It’s amazing to watch.

On the last trip, there was a lady; and she would’ve been in her 70s. When they were first assessing her, she could not see the fingers within centimetres of her eyes. After her surgery, when they took away the bandage, she was in tears and could not stop smiling; she could read a whole sign.

I sat down and did a little interview on video with her and asked her about what she was looking forward to doing. And it was the most incredible thing. It just blew me away. She said, ‘now that I can read again, I’m going to go back and I’m going to help the little ones in the community learn how to read’. And then she said, ‘I love helping people, so I’m going to now go back and work. I had to stop work. I couldn’t see, but now I can go back to work and help people in aged care’.

Going the Extra Mile

By Jennifer Meier

Eye care in the Top End isn’t anything like it is in the city when you can say ‘oh, I can’t attend my surgery this week, slot me in for another day’.

We had one patient who’d been on a wait list for a while, but it wasn’t necessarily because the wait lists weren’t moving. It had just been an unfortunate series of circumstances.

When we were finally able to get her in, she was so relieved. She said, ‘oh, I thought someone would give up on me. I had to cancel three times’.

There are also a lot of patients who move around; they move through country, and it can be hard to find them. We had a gentleman who was a jackaroo, so finding him to get him in for surgeries was really challenging. This is where the ACCHOs shine — they have strong relationships with community and so they knew where he was.

The local hospitals are amazing too — they really go above and beyond to get patients there for surgery. If they know that someone’s around the corner, the staff will actually get in their car, go and get them, and bring them in. You don’t get that service in the city