UNDER PRESSURE

A collapsed economy and an ageing population are putting a lot of pressure on ophthalmologists in Ireland, and patients with eye diseases are finding it increasingly difficult to obtain treatment through the public health system. The Irish health system is caught in a situation where it has ever dwindling funds and a dwindling workforce to deal with an ever-increasing number of patients requiring treatment for an increasing number of indications.

The proportion of the population over 65 years of age has been steadily increasing in Ireland over the past decade, rising from 11.1 per cent in 2002 to 11.7 per cent in 2011, and it is predicted to reach 16 per cent by 2026. The ageing of the population brings with it an increasing prevalence of eye diseases such as cataract, age-related macular degeneration and glaucoma. “Since their income or their pension is either not going up or is actually being reduced, many elderly patients can no longer afford to pay their insurance premiums and must resort to the public health system,” said Peter Barry FRCS, St Vincent’s University Hospital and Royal Victoria Eye and Ear Hospital, Dublin, Ireland.

More patients, fewer doctors

Ireland has a total of 120 ophthalmologists to serve a population of around 4.6 million. A report from the Irish College of Ophthalmologists estimated that an additional 19 consultant ophthalmologists and 14 community ophthalmologists would be necessary to achieve best practice patient ratios. Moreover, as things currently stand new appointments are not being made to replace consultant eye doctors who retire. As of December 2012, 4,266 people were on waiting lists for cataract surgery, and 19 per cent of patients were waiting for over six months. That was after an average sixmonth wait from the time they get a referral from their family doctor to the time they are actually seen by an ophthalmologist.

Adding to the caseload are those patients with many retinal conditions which are now treatable by medical means, but on a chronic basis for the lifetime of the patient. For example the indications for anti-VEGF injections now include exudative macular degeneration, diabetic macular oedema, retinal vein occlusion and choroidal neovascularisation from pathological myopia. “The exponential growth in the number of patients presenting with these medical retinal conditions is really causing the system to shudder because once they are with you, they are with you indefinitely,” Dr Barry said.

The cumulative effect of the increasing demands and decreasing returns has been a very disillusioned generation of trainee ophthalmologists who feel that their best options for pursuing their career will be in other, more prosperous countries. In fact, half of doctors trained in Ireland are now working abroad and half of doctors in Ireland received their training in other countries. “I think that doctors have to do everything that they can to ensure and preserve the teaching and training of the next generation. This next generation needs to have something to look forward to in order to prevent them from voting with their feet and moving to countries like the US, Canada and Australia which are currently draining hordes of young Irish medical trainees,” Dr Barry said.

Fewer opting for elective procedures

Refractive surgery is also feeling the brunt of Ireland’s straitened economic circumstances, since it is almost entirely made up of elective procedures generally not covered by insurance, said Arthur Cummings FRCS, Wellington Eye Clinic and UPMC Beacon Hospital, Dublin, Ireland. “The volume of LASIK absolutely mimics and reflects the consumer confidence grid. If consumers are confident and have expendable income, they will find LASIK more affordable, otherwise they simply don't have it done until later,” he told EuroTimes. He noted that several refractive surgery centres in Ireland have closed over the last five years, especially the last year or two. "The Irish market was over-saturated during the boom years. At one point there were some 14 laser clinics in the greater Dublin area. The population of this catchment area is only about 1.5 million," he said.

One or two of the centres have gone into administration and some have consolidated in recent times. "Some of the remaining refractive surgery centres have adopted a range of strategies to attract patients, including reducing fees and offering alternative treatments. Some of the centres are still reportedly struggling," he added. Dr Cummings said that the Wellington Eye Clinic had a decline in LASIK patients in 2008-2009, but that since that time business has remained stable. He attributed the stability to the decreased competition as well as a policy that insures that all patients receive the best available treatment at a competitive price representing value to the patient. The option of femtosecond laser-created flaps has been the sole addon optional expense. Another of their policies, which they introduced in 2004, was to provide refractive laser enhancements without charge, giving patients greater security in their investment.

“There are pressures on us, but for the time being we've been holding our own because we absolutely focus on quality service provision and compete on that basis,” he added.