Response to Productivity Commission Issues Paper:
The Health Workforce
from
Optometrists Association Australia

Summary
The current Australian optometric workforce is adequate to meet the eye care needs of the Australian community, however there are opportunities for improving the delivery of eye care, including:
•	Extending therapeutic drug prescribing rights to optometrists in all States and Territories
•	Extending the Pharmaceutical Benefits Scheme to cover medications prescribed by optometrists
•	Increasing access to public hospitals for optometrists, both for the provision of eye care services and for education of optometry students
•	Providing locum support for rural optometrists.

Optometry is the first line of eye care service delivery in Australia.  The wide geographic distribution of optometrists and the age profile of practising optometrists mean optometry is well placed to ensure quality primary eye care services to Australia’s ageing population in coming years.  Optometrists embrace the principles of collaboration and co-operation with other professions in the changing health workforce.  Optometrists Association Australia believes worthwhile improvements in eye care are readily achievable through extending nationally therapeutic drug prescribing as now practised by optometrists in Victoria and Tasmania, extending PBS benefits and improving the access of optometrists to hospitals.  As described below, these measures should be cost saving.
The current optometric workforce
There are sufficient optometrists to meet the demand for optometric eye care services, both now and in the foreseeable future.
There is a high concentration of optometrists in the urban areas of the East coast, particularly in Melbourne, Sydney and Brisbane, where the Australian optometry schools are located.  Despite this, there is no evidence of major shortages in other areas.  The number of optometrists is largely proportional to the population throughout the country, with the ratio on most areas being close to 1:10,000, which is generally regarded as adequate.
In rural areas, optometry faces similar problems to many other health professions.  The main issues faced by rural communities and the optometrists who live and practise in them is not insufficient numbers of optometrists to provide adequate eye care services, but rather problems such as succession planning, and finding locums to cover for holidays or illness.
The current state of the optometric workforce is summarised in Appendix A.
Factors affecting demand
The vast majority of optometrists practise in the private sector, so the supply of and demand for optometrists is largely determined by market forces.
The demand for optometrists is determined principally by the need for eye care and vision correction.
The need for regular eye care increases with age, particularly after a person reaches their mid-forties.  Everyone aged over 50 either uses or would benefit from some form of vision correction.  The incidence of eye diseases such as glaucoma increases threefold with every decade.  An ageing population will therefore increase the demand for eye care.  The age distribution of optometric patients reflects this, as illustrated in Appendix B.
Indeed, the Australia Government’s consultation paper ‘Towards a National Eye Health Plan for Australia 2005 to 2010’ estimates that as the population ages, vision impairment will emerge as the most prevalent health condition among older people. 
The need for vision correction appears at an earlier age than common eye diseases such as cataracts and age-related macular degeneration, so optometry is already dealing with increased demand caused by demographic changes in the population.
Another factor influencing demand for optometric services has been changes in the work patterns of the Australian population.  With increasing numbers of people working in service industries and in office positions, and the widespread introduction of technologies such as personal computers, the visual demands placed on the average Australian have increased.  These increased demands, as well as the increasing awareness of the importance of regular health care, has increased the population's demand for optometric services over the growth expected from simple demographic changes.

The supply of optometrists is principally controlled by the number of optometrists graduating from the three Australian optometry schools, supplemented by small number of immigrant optometrists, principally from New Zealand, Britain and South Africa.  The number of new graduates emerging from the Australian optometry schools (located at the University of Melbourne, the University of New South Wales and Queensland University of Technology) is mainly determined by the schools annual intake of students.  These are determined by each school individually, using their own criteria, and Optometrists Association Australia has essentially no input into these decisions.
Measures to improve provision of eye care
There are a number of measures which could improve access to and the quality of eye care include extending prescribing rights to optometrists, providing PBS benefits for medications prescribed by optometrists, and improving optometric access to hospitals.
Therapeutic drug prescribing rights
In recent years there have been moves to allow optometrists to prescribe certain therapeutic drugs, such as antibiotic eye drops, to treat eye diseases such as conjunctivitis.  Optometrists in Victoria and Tasmania have been prescribing eye medications to treat eye infections, allergic reactions of the eye and, in some circumstances, glaucoma for several years.  Legislation to similar effect has been passed in the ACT, New South Wales, the Northern Territory and Queensland, and has been announced in South Australia. 
The prescription of topically applied ocular drugs by optometrists:
•	improves access to comprehensive eye care
•	reduces delays in implementing treatment resulting from the need to attend another practitioner for prescription of necessary medicines
•	provides better rural eye-health care outcomes where access to eye care is limited or non-existent
•	frees valuable specialist medical resources for better use
•	lowers the cost of eye care to patients
•	lowers the costs of eye care paid for through Medicare.
Extending prescribing rights to optometrists in all States, and ensuring that the range of drugs that optometrists can prescribe is uniform across the country, will enhance the provision of eye care to community.  This will be particularly beneficial as the population continues to age, and eye diseases become more prevalent in the community.
Extending PBS benefits to include optometric prescriptions
As noted above, all States and Territories with the exception of Western Australia have passed legislation allowing optometrists to prescribe a range of therapeutic drugs to treat eye disease, or have announced their intention to do so.
The medications that optometrists may prescribe attract a PBS subsidy when prescribed by medical practitioners but do not attract a PBS subsidy when prescribed by optometrists.
This is patently unfair to the patients attending optometrists. Patients are being deprived of PBS benefits because they choose to attend an optometrist rather than a medical practitioner. The medication prescribed is the same yet one patient will receive a benefit while another is denied a benefit. Pensioners and people in rural communities are particularly affected by this inequity, as access to medical eye care is extremely limited in these areas.
Extending the PBS program to cover prescriptions written by optometrists provides an opportunity to extend the reach of the PBS, improving access to health care while also generating minor budgetary savings.
Extending PBS benefits to cover prescriptions written by optometrist would:
•	remove the need for patients attending optometrists to attend a second practitioner for the prescription of medications that optometrists can prescribe in order to obtain PBS benefits.
•	promote equity —  the patient would not be denied PBS benefits in circumstances where the practitioner of choice is an optometrist and the drugs concerned are on the PBS schedule.
•	complement State government efforts to improve the delivery of eye care.
•	lower cost to the patient of medications prescribed by optometrists.  Nearly all of the prescriptions written by optometrists are for scheduled drugs that do not exceed the cost of the PBS general co-payment — so the largest effect will be from patients able to access the PBS concession rate. 
•	lower cost of medical attention to the patient.  Patients will not have to pay differences between Medicare rebates and doctors’ fees for consultations following referral by optometrists solely for prescription of medications.
•	generate savings to the Commonwealth as optometry consultations are substituted for general practice and medical specialist consultations.
The benefits of extending PBS benefits to prescriptions written by optometrists would be greater in rural and remote regions where specialist eye care is not readily available.
Therapeutic agents prescribed by optometrists are substitutes for those prescribed by medical practitioners, rather than generating any additional demand.  The conditions of the eye that require therapeutic care cannot generally be influenced by supplier-induced demand, so it is expected that enabling more providers able to prescribe the range of therapeutic agents available to optometrists would not lead to greater consumption.
Extending PBS benefits to prescriptions written by optometrists would improve delivery of necessary medications to the community while lowering expenditure.
Hospital access
Optometrists are currently not utilised in any great numbers in the hospital system.  There are two main areas in which optometric access to hospitals would benefit the community.
Undergraduate training
Incorporation of hospital experience into optometry courses would enhance the education of undergraduate optometry students.  One of the difficulties faced by all optometry courses is providing students with experience diagnosing and treating a wide range of ocular conditions.  Hospital eye clinics are the only places where a regular supply of patients with active ocular disease can be seen.
There have been some advances in this area in recent years, with undergraduate optometry students at the University of New South Wales attending diabetes clinics at a local hospital, and optometrists undertaking the postgraduate ocular therapeutics course at the University of Melbourne participating in clinics at the Royal Victorian Eye and Ear Hospital.  Unfortunately, there is resistance to hospital education for optometrists from some sectors of the medical profession, particularly The Royal Australian and New Zealand College of Ophthalmologists. 
Provision of eye care services
The provision of eye care services in public hospital is currently performed by ophthalmologists, assisted by orthoptists.  Very few optometrists are utilised by hospitals.  Medical opposition to the employment of optometrists in hospitals has led to inefficiencies in the provision of eye care.
There is some overlap in the services provided by optometrists and ophthalmologists, but in most cases the roles of the two professions are complementary, with optometrists providing primary eye care, and ophthalmologists providing secondary and tertiary care.  Utilising both professions in public hospital eye departments would be a more rational use of limited health care resources.
There are two main areas where optometrists could make a significant contribution to hospital eye care.  Waiting lists for ophthalmic surgery are currently very long in most areas of Australia, resulting in situations where patients with cataracts, for example, must endure many months of poor vision while waiting for surgery.  Suitably qualified optometrists could deal with many of the patients presenting at hospital eye clinics, freeing ophthalmologists to make better use of their surgical skills.
Waiting lists for refractive care (prescription of glasses or contact lenses) at public hospitals are even longer than those for surgery.  For example, pensioners who want to attend the outpatient clinic at the Royal Victorian Eye and Ear Hospital to obtain new spectacles face a waiting list of around two years.  Employment of optometrists to diagnose and treat refractive errors and minor eye conditions could help to reduce these waiting lists, improving the provision of eye care to the community.
Locum support for rural optometrists
One of the problems facing rural optometrists is the difficulty of finding a locum practitioner to cover for periods when the principal optometrist is absent from their practice, whether illness, leave or to pursue professional development.  Recognising this problem, the Victorian Government has provided financial support for a program, administered by the Victorian Division of Optometrists Association Australia, to provide locum services in rural Victoria.  The locum service employs two part-time optometrists to provide relief for rural optometrists, typically for a two week period.
This program has been a great success.  In the first 12 months following its launch in 2003 it provided 42 weeks of relief for rural optometrists, and provided services to over 2000 patients.  The Victorian Government has renewed the program's funding, recognising its value to the community.
The program has also been greatly appreciated by rural optometrists.  One optometrist, conducting a solo rural practice, reported that the locum program had allowed him to take his first real break in 18 years.
Rural optometrists in all states and territories face similar issues to those in Victoria, and establishment of similar programs nationwide would assist in maintaining the viability of rural practice.  State and Federal Governments could provide funding and support for establishing rural locum programs, based on the successful Victorian model.

Appendix A
The Australian optometric workforce, 2005
•	There are currently 3,738 optometrists registered in Australia.  As some of these optometrists are registered in more than one State or Territory there is a total of 4,356 registrations.
•	There are 2,866 optometrists who report their primary activity as clinical practice.  In addition there are a number of optometrists whose primary activity is in other areas, such as academia, who also conduct part-time practices.
•	New South Wales, Victoria and Queensland on average are well-served with fewer than 8,000 people per effective full-time optometrist, the ACT, Northern Territory and Western Australia have between 8,000 and 9,999 people per optometrist, whilst South Australia has over 10,000 people per optometrist.
•	The majority of practitioners (over 80%) are aged below 50 so that retirement in the next 10 years is not likely to be a significant problem in optometrist to population ratios.  After 10 years retirement will tend to have an impact.
•	The optometric workforce has always been predominantly male.  The numbers of females are increasing – they are younger and more likely to work part-time – this has implications in terms of maternity and family leave.  If current trends continue the number of males and females are expected to be equal around 2013.
The distribution of optometrists in relation to population is shown in the table below.
State	Registrations*	Active optometrists	Optometrists per 10,000 people	Effective full-time optometrists
per 10,000 people	
Australia	4356	2866	1.4	1.3	
ACT	90	41	1.3	1.0	
NSW	1667	1112	1.7	1.5	
NT	113	19	1.0	1.0	
Qld	820	574	1.5	1.4	
SA	246	163	1.1	0.9	
Tas	107	59	1.2	1.1	
Vic	969	673	1.4	1.2	
WA	344	225	1.2	1.1	
*(includes optometrists registered in more than one jurisdiction)

Appendix B
Optometric services per capita, 2003-2004
The table and graph below show the number of optometric Medicare services and the number of services per capita in Australia in the 2003-2004 financial year.  As can be seen from the data, the bulk of optometric services are provided to patients aged over 45 years.

Age group	Services	Services per 100,000 people	
0-4	36823	2906	
5-14	483096	17454	
15-24	443200	16233	
25-34	459207	15184	
35-44	598312	18934	
45-54	975014	34439	
55-64	782396	36864	
65-74	571997	40629	
75-84	347540	33857	
85 +	88578	18299	
All	4786163	22987