GUEST BLOG: Ian Powell – The wider implications of eyecare privatisation

On 5 March the Government through Health New Zealand (Te Whatu Ora) formally called for ‘Requests for Proposals’ (RFPs) for outsourcing (privatising) ophthalmology services in Aotearoa New Zealand’s public health system.

Despite it being April Fools’ Day, the deadline was 1 April: Call for bids to privatising public eyecare.

Successful RFPs would lead to funding contracts for an initial period of five years with a right of renewal for a further five years. In other words, effectively long-term privatisation of publicly provided eyecare.

Understanding ophthalmology

As I reported in a Newsroom column discussed further below:

An ophthalmologist is a medical doctor who has undertaken additional specialist training in the diagnosis and management of eye disorders. As a medical speciality the clinical practice of ophthalmology has gradually evolved over the years from being mainly surgical to mainly medical. It is also one of the more capital-intensive branches of medicine.

There are about 12,200 vocationally (specialist) registered doctors (including general practitioners) in Aotearoa New Zealand. Ophthalmologists comprise about 175 of this total. Many work across public (for Health New Zealand) and private sectors (about 85 work primarily in the 90 or so private ophthalmology clinics).

Eyecare trauma a significant public health problem

Eye or ocular trauma is a significant public health problem in New Zealand. Tens of thousands of injuries are reported over 10-year periods. Primarily they are managed in community settings or hospital emergency departments. 

In its publication The Briefing the Otago Medical School based Public Health Communication Centre, optometry academics published a timely piece on the failure to invest in eye health (5 May).

Written in the context of the then forthcoming Budget it provided a timely warning about the state of public eye health in Aotearoa New Zealand’s health system: Laments failure to invest in routine eyecare.

Dr Lucy Goodman, Research Fellow, Optometry and Vision Science, Auckland is one of the authors of this issue of The Briefing

Their summary comment was that there was

…very little public funding for routine eye care, creating significant cost barriers for our population, especially Māori, Pacific Peoples, and low-income families. Recent research indicates that investing just 1.2% of the NZ health budget could fund more than two million eye examinations and more than 60,000 spectacles each year. This investment would promote healthy vision, reduce inequities, and deliver long-term economic benefits from reduced injuries, improved mental wellbeing, and stronger workforce participation. 

Emphatically breaking, and breaking down, the story

The story was broken later the same day by a vigilant Louisa Wall in a paywalled article published in The Post.

Kaitiaki Hauora spokesperson Louisa Wall analytically cuts to the chase

Louisa Wall is a spokesperson for Kaitiaki Hauora (Together for Public Health) , a newly formed group campaigning to protect and enhance the public health system, including against privatisation.

Previously I welcomed its formation as a voice the public health system badly needs in an Otaihanga Second Opinion post (29 March): A powerful voice for the health system.

Wall begins her incisive piece with the following:

Aotearoa New Zealand is at a turning point in the future of its public health system. The decision by Health New Zealand to seek private providers for ophthalmology services is not a routine procurement exercise. It is a policy shift away from public provision with significant implications for equity, accountability and te Tiriti obligations.

The request for proposals aims to establish a national panel of private providers to deliver ophthalmology services across all four Health NZ regions. This covers the full continuum of care, from diagnostics and clinic-based treatment through to surgical procedures such as cataract operations. In some cases, providers are invited to take on full responsibility for patient pathways, including wait lists, specialist assessments, and follow-up care.

This is not supplementation. It is substitution. Core public hospital functions are being opened to private control.

Former Health NZ Chair Rob Campbell is now Chair of Kaitiaki Hauora; an interesting irony

Further:

The justification offered is capacity. Health New Zealand has acknowledged it does not have the workforce or infrastructure to meet current demand. That is not contested. What is contested is the choice to respond by outsourcing rather than rebuilding public capability.

Outsourcing is a political decision. It restructures how care is delivered and who controls it. Once private provision is embedded, it shifts incentives, accountability and ultimately power within the system.

And:

The result is a self-reinforcing cycle where underinvestment drives outsourcing, and outsourcing is then used to justify further underinvestment.

What’s more:

This move is not confined to ophthalmology. It sets a precedent. Establishing a national outsourcing model for a core hospital specialty normalises private delivery within the public system. Once normalised, it becomes easier to extend this approach to other services. Change happens incrementally until it becomes structural and difficult to reverse.

The broader context matters. Workforce shortages, fiscal constraint and rising demand are being met with market-based responses instead of sustained public investment. This reflects a political choice about the role of the state.

And concluding:

What is at stake is not just who delivers eye care, but whether Aotearoa remains committed to a public health system that is equitable, accessible, and grounded in collective responsibility.

With elections looming, we call on all parties standing to commit to halting this decision and protecting a public health system that serves everyone, not private interests.

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Privatisation by stealth rather than diagnosis

Eight days later (9 April) I entered the debate with a column published by Newsroomunder the heading ‘Privatising public hospital eye care by stealth, not diagnosis’: Stealth, not diagnosis.

Although the RFP process allowed for the potential of one national private provider of hospital eyecare, the dispersed nature of the private eyecare sector suggested that RFPs were likely to be predominantly regional or even more locally based linked to a specific public hospital.

I warned about the risks of eyecare privatisation

I observed that:

The [new] ‘service providers’ to be appointed to the panel are most likely to come from existing private clinic owners or newly established consortiums based on clinic groupings. A consequential ethical issue is that they are, directly or indirectly, also likely to be potential beneficiaries; rather akin to foxes being put in charge of hen houses.

I discussed the practical issues privatisation endeavours would be confronted with including:

• whether there would be sufficient critical mass in the private clinics to generate the necessary capacity to assume the additional responsibility of operating a public hospital ophthalmology service; and
• the already stretched small size of the overall ophthalmological workforce;

Health Minister Simeon Brown and his government have a strong but misplaced ideological belief in privatisation being the solution for many of the problems of the public system

I also observed that:

The planned outsourcing is akin to a doctor treating a patient without first doing a diagnosis. Health New Zealand’s justification is that its ophthalmology services can’t meet population demand. But this is an outcome, not a cause.

My final point of advocacy was that:

Health NZ should learn from the past and diagnose the problem better. It can’t overturn simplistic Government ideology but it should have the courage to advise the Government on what it won’t want to hear.

Phil Pennington follows up on ophthalmology privatisation

On 12 April Radio New Zealand investigative journalist Phil Pennington followed up on the issue, which included a link to my above-mentioned Newsroomcolumn: Health New Zealand to send more eye operations to private sector.

Astute observation from the eyecare frontline

My Newsroom column prompted a number of mainly supportive published comments over the concerns I raised.

Eyecare medical specialist Dr Antony Suker’s observation resonates

Of particular interest was Nelson ophthalmologist Dr Antony Suter. In a pertinent observation that deserves to be taken seriously he said:

I’m an ophthalmologist who works in both public and private sectors. Health New Zealand has encouraged better clinical networks between the different public departments which allows the potential for us to give better access to sight saving care to the NZ public… and yet the powers that be that are responsible for funding health care still seem unable to understand that our specialty is anything more than just pumping through the straightforward cataract operations that can be outsourced at great expense to our private businesses to give cute production numbers to The Minister.

Dr Suter’s thoughtful observation resonates. It needs to resonate with the Minister of Health and Health New Zealand as well.

Reject simplistic ideology and stealth; instead start first with diagnosis. Those suffering from eyecare trauma would be the beneficiaries instead of profiteering interests.