When I first rang IRIS patient Astrid Stadelman (a method of interview dictated by COVID-19) the first thing she asked was, “When is IRIS coming back to Katherine?”. I enquired as to whether she needed her other eye treated. “No,” she said, “You were all just such wonderful people I wanted to see you again!”
Such is the genuine heart-felt reaction that the IRIS program generates.
But this emotion isn’t just reserved for patients. Clinicians who staff the program are equally enthusiastic.
“It just makes such a difference to people’s lives,” says Dr Bill Glasson, Co-Chair and Queensland Lead of the IRIS program. “Patients are often led in because they can’t see well enough to walk in unassisted, but then they walk out by themselves. The next day when we take the pad off their eye, often we don’t even need to ask them if they can see better… their face says it all. That’s why we do it. That’s why we keep coming back to IRIS.”
Dr Glasson’s sentiments were echoed by fellow Co-Chair and NSW Lead Associate Professor Ashish Agar. “From a clinician’s perspective, what is so attractive about the IRIS model is that it’s a very focussed program, with a focussed outcome. IRIS enables us to do our job efficiently, by addressing the logistical challenges that limit the accessibility of Indigenous patients to specialist care. As doctors we want to treat patients, and anything that allows us to concentrate on that is a far better use of tax-payers’ money.”
What is it about IRIS that works so well?
The Indigenous and Remote Eye Health Service (IRIS) was established in October 2010 as a joint venture between the Federal Government, specifically the Minister for Health and Ageing, and the Australian Society of Ophthalmologists (ASO). It was a cooperative agreement to improve eye services to Indigenous and non-Indigenous Australians living in regional, rural and remote parts of Australia. The cornerstone of this program was to alleviate disadvantage for those at risk of suffering poor eye health. Because the leading cause of preventable blindness is cataracts, representing 31% of the total cases, IRIS focuses on providing cataract surgeries to Indigenous Australians in rural and remote areas with the highest level of demand and longest wait times.
Despite the success of the first IRIS program – which delivered over 15,000 eye health services (including 2,000 eye operations) in 26 rural and remote towns across Australia with a fleet of 195 items of ophthalmic equipment worth AU$1.07 million – the funding agreement between the Australian Government and the ASO for delivery of the IRIS program ended in September 2014 and the Government did not re-fund the service.
While there are many services which help Indigenous eye health, IRIS just goes in and gets the job done
The impact of the IRIS program can be seen in the Australian Institute of Health and Welfare Indigenous Eye Health Measures report. The report showed that the median waiting time for elective cataract surgery for Indigenous Australians dropped from 140 days to 112 days in 2012 – 2014 (when IRIS was operational) and then rose again to 142 days in 2015 (after the IRIS service ceased). Over the same period of time, there was no significant change in the median wait time for non-Indigenous Australians (84 – 88 days).
Fast forward and after a hiatus of several years, IRIS was re-funded again, under IRIS 2.0. This time, health services agency Vanguard Health secured a $2 million Federal Government grant to re-establish IRIS. Vanguard Health was contracted to deliver 500 cataract surgeries in priority areas across rural and remote Australia by 30 June 2020. This deadline was extended to 31 December 2020, due to COVID-19 restrictions.
The IRIS program will deliver its 500th cataract surgery in Katherine this month, on 23 November, and is estimated to exceed its target by nearly 10%. If it wasn’t for COVID-19, this figure may have been as high as 20%! With so many government funded programs failing to achieve their targets, IRIS is a true shining star in the galaxy of government health initiatives.
“IRIS is notable in terms of government programs, in that pure action has been funded. That is extremely important for an Indigenous health program… that it is so focused on direct health service delivery, minimising the wastage and bureaucratic red-tape that can divert funds from patient care,” said A/Prof Agar.
Dr Glasson agrees. “Tangible outcomes are what IRIS has always been about,” he said.
Indeed, in a world where the delivery of Indigenous health care is often dictated by multiple stakeholder rules and regulations (such as federal and state governments, the Aboriginal health care service and other local governing bodies) and there is much overlapping and subsequent wastage of resources dedicated to compliance, rather than service delivery, IRIS makes a refreshing change to the Indigenous health care landscape.
IRIS is all about doing the work and not just talking the talk. “One of the biggest problems Indigenous health care has faced for decades is that an awful lot of time is spent talking about things and that can be at the expense of actually doing them. Fred Hollows was such a success because when he saw a problem in the bush, he went out and fixed it. The IRIS program is the closest thing we have today capturing the spirit of our pioneering Indigenous eye health workers,” said A/Prof Agar.
WHY IRIS WORKS SO WELL
IRIS is Accessible
IRIS is all about bringing the service to the people, not taking the people to the service. This borderless service goes where no one else will go. Traditionally, state borders represented a barrier to providing effective treatment services due to governance issues. However, most Indigenous people do not recognise state borders. They travel freely between the states. The IRIS service enables them to access services wherever it is most convenient to them, regardless of which state it is in, compared to the state they actually reside in.
Bringing the service to the people and working closely with their specific Indigenous community organisations also means that IRIS is able to overcome the natural nervousness about undergoing surgery remote from their families and communities. They are far more likely to agree to the surgery if they remain ‘generally’ within and surrounded by their communities.
Moreover, IRIS virtually eliminates the wait times remote and Indigenous people need to serve to access these sight-saving services, compared to if they had to access them via the usual public health system.
IRIS is Affordable
The portability and efficiency of the IRIS service makes it one of the most costeffective health care interventions from a governmental point of view.
“Eye surgery can make the difference between an individual being able to contribute to society in a fruitful and productive manner, versus them being a burden on society’s resources,” says Dr Glasson. And, as Associate Professor Agar points out, “IRIS is one of the best uses of government money in terms of the costs of training someone to be an ophthalmologist. At the end of the day we are doing exactly what we are trained to do.”
IRIS Works with Local Communities
IRIS doesn’t just work with local communities – it goes out of its way to embrace them in its service delivery. IRIS leverages existing local health governance and local community services responsible for health planning and delivery to deliver a precise and tailored response. IRIS addresses known service gaps and unmet needs. It supports patients through their entire eye health care journey and allows the team to address, and overcome, some of the other issues that traditionally block patients’ attendance at clinics. Extensive stakeholder engagement ensures that IRIS is able to capitalise on existing networks, partnerships, infrastructure and industry support. Together, this means that IRIS has more momentum than a Dubbo dust-storm! While there are many services which help Indigenous eye health, IRIS just goes in and gets the job done. IRIS is the glue which holds them all together and it’s the right glue to fix the problem of Indigenous eye health. IRIS is the Indigenous eye health service version of Nike: it just does it!
IRIS is Trusted
From its inception, it was apparent that Indigenous people tended to cling to incertitude when it came to health care service delivery providers. The original IRIS program was devised following intensive discussion and guidance from Indigenous advisers, where repetition and reliability were seen to be the principles of a successful and effective Indigenous eye health service. The repetitive nature of the IRIS visits means that the local community, and local health service have quickly become confident enough to seek help for their vision problems. As the IRIS service delivered on what it promised, it was thus also seen as reliable, and this helped contribute to it becoming a service that Indigenous people could trust.
Recognition of the IRIS logo has also played an important role. With experts estimating that up to 70% of adults in remote Indigenous communities are illiterate, many potential patients are unable to read the signs that say IRIS is in town… but they can – and do – recognise the logo.
Finally, the results speak for themselves. In today’s society, word of mouth plays an extremely important role in decision-making. However, in Indigenous communities this role is even more significant. Today, many people use the IRIS service because someone they know has already used it… and so they already know that it works. The irony of the development of this trust is the increasing numbers of patients who now don’t automatically express their huge delight on the recovery of their sight. IRIS has become such a trusted service that sometimes the reaction can be much more matter-of-fact: “You made my friend see, you said you were going to make me see… and you have… and that’s what I was expecting!”
IRIS Offers Individualised Solutions
With its unique patient cohort and associated issues, IRIS tailors its services to suit. “Vanguard Health prides itself on its innovative and flexible approach to addressing individual clients’ needs and offering bespoke solutions to healthcare coordination,” says Vanguard Health CEO Tim Gallagher. “In the case of the IRIS program we were aware that many Indigenous men didn’t like wearing sunglasses as they considered them ‘unmanly’. Yet sunglasses are one of the easiest ways to protect your eyes from cataracts. So, we arranged free IRIS sunglasses – along with an education program – to promote sunglass wearing amongst Indigenous men, which has been hugely successful.”
IRIS Has a Great Team
With over 100+ years of experience in every IRIS team, many clinicians involved with IRIS feel it is a privilege to be able to help Australian communities who need it most. IRIS does it better because it’s a coalition of people working in the coalface. Consequently, IRIS has people who are doing the hands-on patient contact and who can see exactly what the issues are. It’s a multidisciplinary team approach comprising of ophthalmologists, anaesthetists, optometrists, orthoptists and specialist nursing staff. The IRIS coordination team also plays a vital role in the service delivery. Often on the ground before the arrival of the eye health surgical team, they provide the conduit between the Indigenous communities, the local communities, the local health services and the patients, and ensure that everything is ready to begin as soon as the surgical team arrives. It’s a collaboration of enthusiastic people who actually understand the issues and then can direct the resources to the points where they are going to make the biggest difference.
THE FUTURE OF IRIS
Despite its obvious success, at the time of writing, re-funding of the IRIS service beyond December 2020 isn’t guaranteed. Critically, without the continuation of the program it will most likely return to the situation pre- IRIS where there were no regular, quality, services to many remote communities across Australia. For Dr Bill Glasson and A/Prof Ashish Agar, and their team, this situation is particularly unpalatable… but for patients like Astrid, Benny, Gary, Zac, Mary, John and thousands of others, it’s downright debilitating. Throughout its incarnations, IRIS has been a true triumph of health care service delivery. Whether this triumph of health care turns into a travesty of health care injustice remains to be seen. Stay tuned…
IRIS SUCCESS STORIES
Alice Springs supermarket worker, Benny, felt that his surgery would benefit his co-workers as much as himself. Not only would his improved vision ensure that he would no longer crash his trolley into the supermarket shelves (oh the irony of having more supermarket shelf re-stacking work half-way through your shift than when it began), Benny also felt that his colleagues would be extremely thankful that he was no longer crashing his trolley into them as well.
For Gary, a car detailer in Katherine, having cataracts removed in both eyes by IRIS meant that he would finally be able to attain a commercial limousine drivers’ licence.
Patient Sandra told doctors that having her cataract removed was like “looking through a new windscreen” at day one post-op, and for Nanna Rosemary, her cataract surgery enabled her to re-gain her drivers’ licence – and her independence.
While cataracts are mostly age-related and generally don’t appear until a person is in their 40s, and they don’t affect eyesight until they are in their 60s, the IRIS program sometimes treats younger patients as well.
Zac, a grader driver with his local council, was in his 40s when his cataracts were first detected. Unsure of why he could no longer see, IRIS staff members diagnosed the condition within minutes and shortly after, arranged surgery. Zac was back at work within a week after the surgery. Without it, he would have lost both his vision and his career.
Mary was 32 when she received treatment. She had been unable to see for the previous three years, due to a blunt-force trauma injury. Her children were six and eight when she had the surgery. She may have missed seeing their past three years, but she wasn’t going to miss seeing the rest of their lives.
And patient John was just 28 when he had his cataract surgery. He felt so good afterward that he asked his doctor if he could play in his local football competition that afternoon. The answer was a resounding, “No!”