Shaun Tatipata writes:
With some elective surgery recommencing this week after the COVID-19 shutdown, it is critical that health authorities prioritise equity of access for Aboriginal and Torres Strait Islander people. Without this, there is the very real risk that Aboriginal and Torres Strait Islander people will be left behind again by the hospital system. For eye health, this could set back a decade of work to close the gap.
The Fred Hollows Foundation has been proud to partner with the Aboriginal community controlled health sector and the broader eye health sector to steadily close the gap in vision loss and blindness for Aboriginal and Torres Strait Islander people. In 2008, Aboriginal and Torres Strait Islander people were six times more likely to suffer from vision loss or blindness than other Australians. In 2016, the rate had reduced to three times.
Cataract surgery vital
Cataract surgery is one of the elective surgeries set to recommence this week, and cataract is one of the leading causes of vision loss and blindness for Aboriginal and Torres Strait Islander people. Despite our progress in closing the gap, there is still a significant difference in access to cataract surgery for Aboriginal and Torres Strait Islander people compared to other Australians. Just 59 per cent of Aboriginal and Torres Strait Islander people who need cataract surgery will get it, compared to 89 per cent of other Australians, and they will wait 40 per cent longer. Almost 70 per cent of Aboriginal and Torres Strait Islander people who need cataract surgery have not yet received a diagnosis.
There a number of factors that contribute to these statistics. Living in remote or very remote areas is a significant barrier to accessing public eye care – there simply are not enough services. Communities wait for outreach ophthalmology services to visit once or twice a year just for an initial diagnosis and to progress to the next stage of the treatment pathway. Once booked in for surgery, patients and their carers travel long distances to regional centres or cities, often confronting additional hidden costs, such as travel, food and accommodation.
Bias towards urban and private services
Equity of access to timely ophthalmology services is also compounded by that fact that around 84 per cent of ophthalmologists are located in metropolitan areas and 84 per cent of ophthalmologists’ full-time equivalent hours are spent in the private sector. Aboriginal and Torres Strait Islander people are less likely to have private health insurance and therefore are more likely to seek care at a public hospital.
These barriers will not disappear after COVID-19. Given Aboriginal and Torres Strait Islander people struggle to receive equitable access to cataract surgery in so-called ‘normal’ times, this will only worsen as our health system recovers from the pandemic and recommences standard services. In reality, private hospitals will have the greatest capacity to restart elective surgeries. So without a deliberate strategy, we can also assume elective surgery for Aboriginal and Torres Strait Islander people will become an unintended and ongoing casualty of the current pandemic.
Equity of access to elective surgery must be a core part of our COVID-19 recovery, and the capacity of private hospitals to contribute must be part of the solution.
Need to expand agreements
Careful planning is needed to ensure that the public and private system can share the load of the ever-increasing backlog of elective surgery. The Commonwealth and state and territory governments have already negotiated agreements with private hospitals to integrate their resources and capacity as part of the COVID-19 response. This included private hospitals providing services for public patients and the category 1 elective surgery. Now is the time to expand these agreements to include supporting category 2 and priority category 3 surgeries for public patients.
We will also need to address the backlog of Aboriginal and Torres Strait Islander patients from remote communities, who will continue to be unable to access elective surgery because of travel restrictions in the short term.
New models of care
This will require an investment in alternative models that can both address a backlog of patients in a short amount of time, as well as provide a culturally responsive model of care for Aboriginal and Torres Strait Islander people. ‘Intensive’ eye surgery weeks are one such model – these allow patients from the same community or location to travel together and access cataract surgery earlier than what is possible through the routine pathway for care. Dedicated Aboriginal and Torres Strait Islander surgery lists are another option, coordinating patients from urban Aboriginal community controlled health services.
The Fred Hollows Foundation has advocated for such models since 2007. At the outset, these models were conceived as a short-term measure to reduce wait times. They have evolved into culturally responsive models of care that address some of the key barriers facing Aboriginal and Torres Strait Islander people in accessing cataract surgery in the mainstream health system.
Put patients at the centre
This approach is relevant now more than ever. This model puts patients at the centre, and provides crucial non-clinical support and coordination to assists patients with the logistics of accessing surgery. A recent study in the Medical Journal of Australia supports this, recommending greater financial investment in non-clinical support to help Aboriginal and Torres Strait Islander people access and attend eye care appointments.
Now that we are in a position to resume elective surgeries, it is critical that both the public and private health sectors work with Aboriginal and Torres Strait Islander people towards equity in elective surgery, and in health generally. Now is the time for transformative action, and private hospitals and private ophthalmologists need to be on the frontline with us.
Shaun Tatipata is the manager of the Indigenous Australia Program at The Fred Hollows Foundation. Shaun is an Aboriginal and Torres Strait Islander man with family connections in Cape York, Torres Strait and South Australia. He has worked in Aboriginal and Torres Strait Islander health for over 18 years. He trained as an Aboriginal health worker, and has delivered primary health care services and outreach programs in both the Aboriginal community controlled health sector and with jurisdictional governments across the country. Prior to working at The Fred Hollows Foundation, Shaun was an Eye Health Coordinator at the Danila Dilba Health Service in Darwin.