When Laureate Professor Hugh Taylor AC sat down with his wife in Europe in the summer of 2006 he came up with a plan. Having founded and led the Centre For Eye Research (CERA) for a decade – which today is one of the world’s top four research centres of its kind – he was looking forward to the next stage of his life.
“I told her I’d like to spend the next five to ten years working to close the gap on eye health for Aboriginal and Torres Strait Islander peoples – I wanted to achieve equal access to services,” he told mivision.
From there the Roadmap to Close the Gap for Vision was born.
Prof Taylor stepped down as Managing Director of CERA in late 2007 and began working on his new venture in January 2008, with the establishment of a group in the Melbourne School of Population and Global Health, the Indigenous Eye Health Unit, also known as Minum Barreng (Tracking Eyes).
Prof Taylor has often described the pathway of care or the patient journey of an Indigenous person in need of eye care services as being like ‘a pipe with multiple leaks
The task ahead was challenging to say the least. At that time, the National Indigenous Eye Health Survey by CERA had found there was six times more blindness in Indigenous adults than non-Indigenous, though Indigenous children had significantly better eye sight. One third of Indigenous Australians were not having eye tests and 94% of blindness was avoidable.
“It then took three years to really look into what the problems were and to come up with recommendations for a way ahead. So by the beginning of 2012, I had a plan that I believed could be fully implemented within five years, which was dependent on a commitment of funding and resources by Government,” Prof Taylor said.
SEALING THE LEAKY PIPE
Prof Taylor has often described the pathway of care or the patient journey of an Indigenous person in need of eye care services as being like “a pipe with multiple leaks”. In 2012 he presented the Roadmap to Close the Gap for Vision with 42 recommendations to seal the leaks, all of which have steadily been worked on.
The delivery of outreach services has improved but we need these services to be increased by a further 20%
The 2020 annual update on the implementation of the Roadmap to Close the Gap for Vision, launched in November 2020, revealed that eight years on, while much has been achieved, there is still work to be done. Of the 42 recommendations reported, 24 have now been fully implemented and 116 of 138 intermediary steps have been taken. The rate of blindness among Australia’s Indigenous adult population has been halved but still stands at three times that of non-Indigenous Australians.
While satisfying to see a shift in services provided, Prof Taylor says the delays in fully implementing the Roadmap are frustrating.
“Delays in Government funding – mainly from the Commonwealth – have been the real thing. With full funding, we could have achieved full implementation within five years, but instead we’ve been on a bit of a drip feed which has meant that we’ve had to progressively implement the plan in incremental steps.”
Acknowledging the passionate support of Federal Minister for Health Greg Hunt, he said an additional AU$10 million or so a year is needed to fully implement the program.
SIGNIFICANT INROADS MADE
Highlights from the annual Closing the Gap on Eye Health report using data from Australian Institute of Health and Welfare (AIHW) tell us that although Australia did not meet its 2020 target, improvements have been achieved:
- Eye examination rates continue to grow, although these still do not meet the population need and further growth is required in both community controlled and other services,
- Trachoma rates in children in outback areas have dropped from more than 20%to less than five, but hotspots increased from 19 in 2018 to 24 in 2019,
- Rates of 715 Annual Health Checks, which include an eye check component and a trachoma check in designated areas, continue to grow as well, but rates are still not at population needs levels,
- Cataract surgery rates for Aboriginal and Torres Strait Islander Australians vary across Australia, with urban regions recording consistently lower rates of population-based needs met compared with regional and remote areas, and
- Coordination of regional eye services now occurs in 59 (92%) of the 64 regions across Australia. These include more than 95% of the Indigenous population. Prof Taylor says it’s still possible to achieve full implementation of the Roadmap recommendations by the end of 2022.
“The delivery of outreach services has improved but we need these services to be increased by a further 20%. We’ve had a great reduction in trachoma, but to go further, we need proper repair and maintenance of washing facilities in schools and homes, and we need to expedite access to cataract surgery through the public health system. All of this requires additional funding, from State and Commonwealth Governments, but mostly from the Commonwealth.”
The annual report identifies that trachoma – a blinding eye condition caused by infection with the bacterium Chlamydia trachomatis – has been eliminated in some 200 communities however Prof Taylor predicts it will be the end of 2022 before all communities are clear of the blinding disease. To a great degree, this is because of rules surrounding the proper repair and maintenance in houses and schools in Aboriginal communities which impact dayto- day hygiene – rules that make little sense.
“Australia is the only developed country to still have the eye disease trachoma, and housing and environmental health are key to eliminating it,” Prof Taylor said.
“The homes and facilities are owned by the Government and as such, tenants are forbidden to repair them. If a tap leaks or something breaks, they must wait for a tradesman, and sometimes this can take three to six months. In that time, they may become frustrated and / or they may move to a neighbouring house. The problem escalates when houses become overcrowded; inevitably something else breaks and so all the occupants move on to another neighbouring house.
Community ownership and engagement is critical… we must be doing these things with people, not to them, that’s really important
“The solution to this is not rocket science – there need to be people in the community who are trained and empowered to take care of minor maintenance issues. This will protect health and safety and minimise over-crowding,” Prof Taylor said.
He says progress this year (2021) will to some extent, depend on the route that COVID-19 takes us down in the coming months.
Indeed COVID-19 presented a mixed bag of results for Aboriginal and Torres Strait Islander eye health in 2020. It led to reduced access to eye screening, examinations and surgery, all resulting in greater backlogs and patient waitlists. However, on the flipside, it drove improvements such as the provision of soap, washing facilities and additional cleaning in schools and communities – all important in controlling infection and maintaining eye health.
Reflecting that an Aboriginal and Torres Strait Islander community led approach helped keep communities safe during COVID-19 he added, “This community controlled and led model must be continued and reinforced when it comes to housing if we are to eliminate trachoma.”
ACCESSING EYE SERVICES
Evidencing the results that can be achieved with a community led approach, is the annual report which shows that the number of community members accessing primary health assessments via Aboriginal Community Controlled Health Organisations continues to increase each year.
Importantly, to eliminate avoidable blindness, those primary health assessments need to include eye screening as routine to ensure eye diseases such as cataract and diabetic retinopathy are picked up and referred on early.
“We need primary health care providers to understand that vision screening for patients with diabetes for example, is as important as a blood pressure test or checking a patient’s weight – and that vision problems need to be referred on early. This is happening to some extent with KeepSight, which is terrific, but we need to do more – we need to empower more linkages within the Aboriginal Community Controlled Health Organisations.”
Additionally he said, “The inclusion of an eye check in these exams requires safe pathways, and ready access, to specialist eye care at no-cost to patients because cost is a major barrier to accessing services.”
Prof Taylor describes the cost of eye health services as a “weighty failure of our public hospital system”.
Due to costs, many Aboriginal and Torres Strait Islander Australians with cataract are unlikely to pursue cataract surgery in the private hospital system, therefore relying on the public hospital system. There they experience longer waiting times than other Australians, with median waiting times for cataract surgery of 140 and 92 days, respectively. Additionally, wait times vary between states and territories, ranging from a median waiting time of 37 days in Western Australia to 301 days in Tasmania.1 These are the waiting times for surgery, then there are the even longer waiting times to be seen in a public outpatient clinic before being put onto the surgical waiting list.
Similarly prohibitive costs of anti- VEGF therapy in the private system mean Indigenous people with diabetic retinopathy are often unable to access necessary treatment and therefore more likely to lose sight.
“The Royal Victorian Eye and Ear Hospital is an exemplary model of a public hospital, providing eye surgery and anti-VEGF to Indigenous Australians, however not enough of our public hospitals are doing the same,” Prof Taylor said. “For the last year or two the Eye and Ear has been running a regular eye clinic at the nearby Victorian Aboriginal Health Service.
“The public hospital system is shirking its responsibility – it needs to be providing these services free of charge to people in need.
“Models of care, workforce support, training and investment in capacity building are also key… Community ownership and engagement is critical… we must be doing these things with people, not to them, that’s really important.”
WHAT YOU CAN DO
Australia’s smaller, more remote communities need more visits from eye care providers delivering services that are sustainable and integrated into the health system rather than being stand-alone.
“We do need fly-in-fly-out optometrists and ophthalmologists in small communities because there isn’t enough work for someone full-time, but they need to make a regular and ongoing commitment,” Prof Taylor said.
Stressing the importance of involving registrars in visiting programs, he said “This will enable them to see what the issues are, to see what can be done and to see how rewarding it is”.
We also need to remember that three quarters of Australia’s Indigenous population lives in urban areas, meaning eye health services in cities must also be bolstered.
This is the perfect opportunity for optometrists and ophthalmologists, who are unable to participate in visiting specialist service programs, to contribute to closing the gap in their own area.
“Be in touch with your local Aboriginal Community Controlled Health Organisation and let them know that you can provide an occasional clinic in their centre or that you would welcome any members of their community that they want to be seen.”
With cost uncertainty being a major barrier for many Aboriginal and Torres Strait Islander people, bulk billing of optometry and ophthalmology services and access to the subsidised spectacle scheme is essential. Equally essential is to advise your local Aboriginal Community Controlled Health Organisation of this so they can empower members of the community to pursue treatment with confidence.
Providing a culturally safe environment within your practice is imperative to closing the gap at a local level, and this can be easily achieved.
“Make sure your staff are welcoming so that people feel safe in your rooms. Display an Aboriginal flag or ethically sourced artwork in your practice and download the miniature ‘tent’ desktop resource, available from Optometry Australia, which will help your staff ask patients to identify as Aboriginal or Torres Strait Islander.”
The card, developed with Aboriginal and Torres Strait Islander community consultation and input from Indigenous Eye Health at The University of Melbourne can be downloaded free from the Indigenous Eye Health website and from the Optometry Australia website.
In August 2019, the Australian Government committed, in The Longterm National Health Plan, to a health investment of $435 billion over four years in an effort “to build the world’s best health system”. This included an investment, over four years from 2019-20, of $4.1 billion in dedicated health programs for Indigenous Australians – an annual increase of around 4% – to accelerate progress towards the Closing the Gap targets.2
In the 2020-21 budget the Government announced an investment of $46.5 million over four years to “enhance the next phase of Closing the Gap” by supporting Aboriginal and Torres Strait Islander Community Controlled Organisations to build their capacity and business models.3
Yet we can still do better.
“We’re waiting on the Council of Australian Governments to release an update on The Long Term National Health Plan ‘to eliminate avoidable blindness by 2025’. It should have been released during 2020 but I’m hopeful for 2021,” said Prof Taylor. “If there is a proper implementation plan in place, I feel sure it can happen – we can close the gap by 2022.”
Along with the plan, continued documentation of the Roadmap’s impact on avoidable blindness will be essential to build a system that can be maintained and drive action. To date, this has been done through the National Indigenous Eye Health Survey (2008); and the National Eye Health Survey (2015). The results from the second National Eye Health Survey will be delivered sometime in 2022 at the earliest.
“We need a score card that details what has been done, and what still needs to be done.
“Understanding the gaps, understanding where things are falling behind, drives action.
“With a bit more work and a bit more effort I’m sure we will close that gap and bring equity in eye health,” said Prof Taylor.
Even when the gap for blindness has been closed, there will of course, be more to do.
“The learnings from delivering eye health can be leveraged for other specialist care. We are looking at how to link primary care with a visiting specialist service – if it works for eye care, the lessons we learnt will be very relevant for other specialist care,” Prof Taylor said.
Now eight years into the roadmap he formalised back in 2012, Prof Taylor has no plans to step back from his work as an advocate and advisor. Which is just as well. It’s clear that Australia needs his guidance and commitment to get the leaky pipe of Indigenous eye health services well and truly sealed.
- Australian Commission on Safety and Quality in Health Care, www.safetyandquality.gov.au/sites/default/files/ migrated/4.6-Cataract-surgery.pdf
- www.health.gov.au/sites/default/files/australia-s-longterm- national-health-plan_0.pdf
- ministers.pmc.gov.au/wyatt/2020/2020-21-budgetsupporting- future-indigenous-australians