Blind eye turned to a crisis of vision
Dairy farmer Koby Brown went blind in one eye after his treatment was delayed. His complaint to the Health and Disability Commission put the spotlight on a national crisis in eye health care and the slow response by regional and national health agencies.
Koby Brown was just 20 years old when he was diagnosed with glaucoma in September 2014. The eye disease can cause blindness but treatment with eye drops and regular monitoring of the pressure on the optic nerve can preserve a patient’s sight.
Brown was supposed to be seen in six months from the time of the diagnosis but ended up waiting one year.
By the time he saw another ophthalmologist in September 2015, the optic nerve was permanently and irreversibly damaged.
It soon became clear Brown’s experience was not a ‘‘one off’’.
An independent review of the Southland District Health Board (SDHB) service in 2016 showed 34 patients had faced the same devastating outcome.
It was Brown’s complaint to the Health and Disability Commission (HDC) that prompted the SDHB to commission the independent review but another review had been completed in 2015 on five serious adverse event reports relating to loss of vision.
As early as 2013 ophthalmologists around the country had raised alarms about the snowballing patient numbers with their DHBs, Ophthalmology New Zealand chair Dr Michael Merriman said.
Ten years ago a treatment to stave off blindness in patients with Age-related Macular Degeneration (AMD) became available in New Zealand.
The treatment involved regular injections of a drug, Avastin, with a lifelong regime of eight injections per year required, on average.
Like glaucoma, timely regular appointments are crucial to the successful management of the condition.
Demand for the injections was expected to increase by 15 per cent in the next year.
Private consultations with an ophthalmologist cost between $100-$300, and many patients were referred to a public hospital service by an optometrist or GP, Merriman said
‘‘We were all, within our hospital groups, saying we can see this coming, how are we going to manage it … and then when it became clear the DHBs had their hands tied and felt they didn’t have the funding to do anything we then felt we had to take it to the government,’’ Merriman said.
In a submission to the HDC following Brown’s complaint, the SDHB ophthalmologist who diagnosed him summarised the eye department’s problem. ‘‘There has been an ongoing increase in the number of patients benefiting from these injections, however no recognition/resources/ understanding (DHB or nationally) that most patients continue to need review/ further injections, probably life-long.’’
Christchurch ophthalmologist and former New Zealand branch chair of the RANZCO Dr James Borthwick said he told former Minister of Health Jonathan Coleman about the pending crisis in 2015.
He believes the then Minister asked the Ministry to look into it.
Merriman said Brown’s case and the 2016 independent review by SDHB helped underscore how critical the issue was at a national level.
However, it was not until 2017 that the Ministry of Health responded to a request for additional funding by the Royal Australian and New Zealand College of Ophthalmologists (RANZCO).
A total of $2m was made available to DHBs to address the eye appointments backlog which had ballooned to 10,223 patients by May 2017.
Ministry of Health chief medical officer Dr Andrew Simpson said progress since then to reduce the backlog had been ‘‘good’’ with the number of ‘‘at risk’’ patients down to 5028 by the end of February.
DHBs were required to report on waiting list numbers to the Ministry for a two-year period ending in June. They were expected to have zero patients waiting 50 per cent longer than the recommended time by then.
RANZCO NZ branch chair Dr Brian Kent-Smith said the one-off funding had been critical in reducing the out of control waiting times but he was concerned the progress would not be sustained.
With no official target for elective follow-up appointments, DHBs were less incentivised to keep on top of these.
‘‘This $2m, all it did was shone a light on the problem and essentially strongarmed the DHBs to put more money into eye care. Our concern is the moment the foot comes off the accelerator it will just balloon again.’’
Most DHBs had utilised the funding to employ additional staff including ophthalmologists, optometrists, and specialist nurses.
The New Zealand Association of Optometrists (NZAO) has been pushing for DHBs and the Ministry to better utilise the skills of over 500 optometrists who were trained and qualified to diagnose and monitor glaucoma.
Brown’s case and the HDC decision showed the systems to date had not worked and that Brown was not the only one harmed by ‘‘the failures’’, NZAO national director Dr Lesley Frederikson said. ‘‘It is evident that signs of the failures were noticed well in advance of the current actions to resolve the problems.
It is disappointing that consideration of optometry as part of the solution is not noticeable especially when one takes into account the five year Bachelor of Optometry program at the School of Optometry and Vision Science and the Gazetted scope of practice for optometry.’’
A report by EY on a model of care for treating AMD, commissioned by the former National Health Committee (disestablished in March 2016) was provided to the Ministry late last year.
A spokesman said the Ministry was ‘‘working through it to see how best to proceed’’.
Kent-Smith said it was a significant piece of work which would provide a much needed blueprint for treatment of the disease by all DHBs.
A draft copy of the report concluded a revised model of care could accommodate increased patient numbers without additional funding until 2020-2025. Kent-Smith said RANZCO had not seen the final version and he believed the report was sitting on the Minister’s desk. He did not think effective treatment provision for an increasing number of AMD patients would be possible without a funding increase.
It is unknown how many people with glaucoma or AMD have gone blind as a result of overdue appointments as no agency was required to collect this data.
A national review to determine this would be a massive job requiring access to thousands of individual patient files, Kent-Smith said.
ACC received 16 treatment omission claims for injuries of blindness or visual disturbance, or disease progression for glaucoma between January 1 2014 and April 18, 2018.
The HDC received 30 serious ‘‘adverse event reports’’ regarding ophthalmology services in 2016-2017, however reporting by medical practitioners was not mandatory.
‘‘This $2 million, all it did was shone a light on the problem and essentially strongarmed the DHBs to put more money into eye care. Our concern is the moment the foot comes off the accelerator it will just balloon again.’’ Dr Brian Kent-Smith