This year is shaping up to be critical for optometry. First the GOC has announced a fundamental review of optometry education. Secondly, the Royal College of Ophthalmologists has finally woken up publicly to the potential role of optometrists in alleviating the demographic pressure on ophthalmic services. Much it must be said, arising from its own previous reluctance to devolve more to primary care optometrists and ipso facto losing control.
How timely then, to receive The History of Australian Optometry written by Professor Barry Cole; arguably, if not the father then at least the midwife of the scientific and political arm of Australian optometry for nearly 60 years. In this 310-page authoritative tome, Cole details a uniquely personal view from the perspective of someone who was part of pretty much all the important decisions and discussions of the past 60 years. It is important to realise from the outset that in clinical, educational and arguably political terms Australian optometry leapfrogged over UK optometry around 30 years ago and has continued to develop a wider scope of practice.
Of course it might be deemed I am somewhat biased as I often tell people, if they are interested, I got my degree in Cardiff but my education in Melbourne. I arrived at the Victorian College of Optometry (VCO, now ACO) at the top end of Lygon Street, Melbourne, in the June of 1982, just less than a year after registering with the GOC. I found a fascinating country made up of a federation of seven states who each did things rather differently. With that history, the clinical developments in a devolved Scotland or Wales did not take me by surprise.
Cole has divided the book into 16 chapters and an appendix, and after an initial discussion of optics and early spectacles in antiquity, briefly covers a US history unfamiliar to British optometrists. The early history of optometry in Australia reflects a largely UK-centric view albeit influenced by the ‘tyranny of distance’ that made the use of mail order push-up optometers an early solution to the lack of access to sight testers. Perhaps a very early forerunner of the internet.
Moving swiftly on, it is important for the UK reader to be reminded that UK optometric registration as a profession was the very late afterthought of a private member’s bill that came into being the day I was born (Opticians Act, July 7, 1958) whereas Australian States had been registered for many years, starting with Tasmania in 1913 with the last registration being the Northern Territory in 1958.
For me the most fascinating elements were the development of an educational and research base, of widening scope of practice and of seemingly endless arguments with government and medicine in particular, which seemed determined to undermine progress. Funnily enough, maybe as a result of Australia’s forthright and competitive style, each setback made the profession stronger and arguably it even benefitted from the RANZCO (Royal Australian & New Zealand College of Ophthalmologists) ban on CE being delivered by ophthalmologists to optometrists. The disease, diagnostic and treatment CE either had to be self taught and good or it had to be imported.
There is no doubt Australian optometrists have more than punched their weight in the world of research. Most British optometrists will be familiar with the names of Brien Holden and Nathan Efron and many will have seen them speak. Those of Lederer, Westheimer, Henry, Collin, Bailey, Brown and Mitchell are much less well known but are giants upon which disciplines of low vision, visual acuity measurement, corneal lymphatic drainage, retinal cell function and psychophysics are founded. Those logMAR charts I was ridiculed bringing back into the UK in 1983 are now the only proper way to measure VA and they are part of every orthoptic assessment of amblyopia and every antiVEGf clinic assessment of VA.
Funny to think UK optometrists find themselves being shown a system that was developed and embedded in Australian training over thirty years ago.
Cole himself is best known for his work on colour vision which arose because of the triumvirate of Cole, Henry and Efron in the early 1960s, having acquired a Nagel anomaloscope, felt this was an under-researched area worth pursuing. A chance meeting in a wine bar led to a lifetime’s association with the Australian Road Research Board and further developed their colour vision interest. One day Cole was trialling his newly acquired plate tests on a member of the reception team who seemed singularly incapable of answering the plates correctly. Frustrated, it dawned on Cole that this lady had an extremely rare tritan colour vision deficiency and the team then made their names mapping the entire family pedigree discovering that unlike other colour deficiencies, the condition was autosomal dominant. Up to that point, inherited tritanopia had been claimed to be a myth and that all tritan defects were in fact acquired, Cole and his team disproved this. This was an early case of Australian optometry battling against the status quo, notably medicine, and winning.
One defining feature of Australian optometry was the inbuilt bias of the health system that meant patients could get a reimbursement of ophthalmology refraction but not optometry. All this changed with the thunderclap that was the Gough Whitlam government. Overturning 40 years of conservative hegemony, this radical government was impressed by optometry and disillusioned with the medical closed shop who did little to argue their case. The advent of Medicare brought optometry into the public health fold and apart from a few upsets, has not looked back. Ultimately, Australian optometry had the vision of a fully clinical therapeutic scope of practice.
Culturally, Australia tends to take a view of ‘where do we want to be’ rather than ‘how far can we get with what we’ve got’ and, knowing ophthalmology would be 100% hostile (in the three years I was there I never saw a single Australian ophthalmology speaker at any CE conference) brought in the expertise of American gurus.
In 1983 I saw Lou Catania inspire a generation of Victorian optometrists to embrace therapeutics at a series of lectures held at the combined VCO and Department of Optometry. Therapeutic legislation followed state by state but was essentially there within 10 years. At present more than 90% of all Victorian optometrists are therapeutically certified and all Australian courses graduate optometrists who are therapeutically certified at registration. It is, of course, a registered degree with nothing resembling the pre-reg year or registration examinations delivered by a profession body.
Some of the interstate differences have eroded with trans-national body the Optometric Council of Australia and New Zealand (OCANZ), which accredits schools and overseas migration requirements. Not surprisingly the advanced nature of Australian and New Zealand optometry has led to criticism that migrating optometrists from the UK and Ireland in particular are not trained to the same level.
I do think one element of Australian practice which was underdeveloped, despite commercial groups like OPSM, was that of spectacle retailing. Optometrists certainly relied on the income from spectacle and appliance sales but saw themselves as clinicians primarily. By the late 1990s this was ripe for change. It may interest readers to note the word Specsavers does not appear in the index to this book, despite the group now having been Australia’s biggest retail chain for some years and from a standing start. They should not feel too worried, there is no mention of their rival OPSM (owned by the Luxottica supply chain) either. Does this matter? In terms of research, education, scope of practice and the political battles, no, because these groups have added nothing to that part of the debate nor to the development of the profession clinically. Clearly advantage has been taken of the high level of clinical development of Australian optometrists and certainly when I left the commercial aspects were one area where I think Australian optometry did lag behind.
One important element to bear in mind is the unique Australian health care component called bulk billing. In bulk billing, a fee is negotiated at federal level or more likely imposed, just as in the UK. The practitioner can then choose to bulk bill the government 85% of that fee for all of their patients so there are no out-of-pocket costs and the patient is erroneously allowed to believe their service was ‘free’.
Alternatively, they can bulk bill only those with designated low income, the rest paying the full fee and claiming reimbursement from Medicare. There was an advantage over the useless GOS system by having a menu of fees including repeat examinations, return for diagnosis and dilation, orthoptic treatment and contact lens fitting. Crucially no one was allowed to charge more than the designated fee, in effect, a glass ceiling. In 2014 the rebate was reduced by 5% and the levels froze, with the thrown crumb that the glass ceiling was removed.
Prior to the arrival of Specsavers, a majority of optometrists only bulk billed those on low incomes. Thus patients knew the nominal value of the service before they reclaimed it. Some optometrists, perhaps with more of an eye to retail or in poorer areas, did bulk bill everyone. With the Specsavers’ business model being built on no or minimal fees for services and a price only for product, the company had a field day bulk billing everyone. Suddenly the perception that they were cheaper could take hold and with control of the supply chain, franchisees could in theory make up the loss by adjusting margin and volume, though there is no evidence this happened.
Their unpopularity within the profession in general arose from this apparent abrogation of all that had been fought for in establishing optometry as a fee-based profession under Medicare. This is all water under the bridge, and the rest is history. The removal of the glass ceiling in the 2014 federal budget allowed independent practices to resume differentiation via fees and re-embark on further development of the clinical and medical model of practice. It is no surprise to find that, like the UK, the overwhelming investment in clinical equipment such as OCT is taking place in independent practice.
A review of this book is all the more fascinating when the overwhelming predisposition of UK optometry has been to look to lead Europe for the past 40 years. This has been very helpful to our European colleagues but has arguably held back our clinical and educational development. Certainly professional bodies have largely ignored development by leaders of world optometry in the USA, Australia, Canada and New Zealand.
Perhaps Brexit might just concentrate minds on taking to the helicopter and re-establishing a common horizon we can work towards.