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66% of Clinical Leads surveyed by the RCOphth confirm cataract rationing is restricting access to surgery

9 November 2017

Cataract surgery: current limitations to patients accessing treatment

Cataract surgery is the most common operation performed, with approximately 400,000 performed per year in the UK and has enormous benefit for patients and their quality of life. It is crucial that patients who will benefit from cataract surgery are able to access it, whether for their first eye or second eye operation. Restrictions or delays to access cataract surgery can limit people’s ability to lead independent lives and care for others, they are twice as likely to have falls and can have significantly reduced quality of life, with increased levels of depression and anxiety.  All have a long-term financial and resource impact on primary, social and community care systems.

The recently released NICE guideline for the management of cataracts in adults demonstrates that the use of visual acuity thresholds for referral or surgery which restricts access is not justified based on a review of available evidence and a de novo economic model developed by NICE Health Economists.  NICE makes the recommendation not to restrict access to cataract surgery on the basis of visual acuity. The decision to refer and then to perform surgery should only be based on shared decision making with patients and their families or carers, taking into consideration the clinical situation including symptoms, effects on activities and quality of life, as well as the risks of surgery.

The Royal College of Ophthalmologists (RCOphth) has undertaken a survey of ophthalmic clinical leads to understand how the current situation of visual acuity thresholds and other imposed restrictions are affecting access to cataract surgery. Of 140 leads contacted in England and Northern Ireland, 87 replied, a response rate of 62%.

Key Findings1

For access to first eye surgery, approximately 34% have no restriction to access, 62% have thresholds of moderate visual acuity2 reduction (vision of 6/9 or 6/12 or worse), but 4% of those clinics surveyed have thresholds of marked acuity reduction that is 6/18 or worse. For second eye surgery, the access requirements are often stricter and often further restrict those in need of cataract surgery. It is important that patients regain as much vision as possible and are able to use both eyes together.  This means that restoring sight in both eyes is essential to good visual function and their quality of life.

In approximately one third of eye units there is no restriction for second eye surgery, in 45% moderate acuity reduction and for 20% of units there is a requirement for marked visual acuity reduction (6/18 or 6/24 or worse). This means that in units where it is harder to access first eye surgery, there is a tendency for the access to second eye surgery to be even more restrictive. The survey did not show any obvious geographical associations, nor any obvious difference in access between large teaching hospitals and smaller district general units.

Download a summary of the key findings: Cataract surgery: current limitations to patients accessing treatment

Administering access to surgery by ophthalmologists

The survey also looked at how ophthalmologists are required to use individual funding request forms (IFRs) and if there is any monitoring of adherence to thresholds for access. The majority of units, 73%, have no specific monitoring of adherence, in 22% clinicians are required to fill in a short form usually with tick boxes for each criterion, and 5% use lengthy IFR forms which is likely to be affecting thousands of patients access to surgery. Surprisingly, there is no obvious relation between more restrictive rules to access and more use of forms.

Where there are visual acuity restrictions imposed by commissioners, we asked whether there were alternative criteria or access to surgery.  Approximately 20% had no alternative access route, and 80% did. Of those who had alternative routes, two thirds are simply based on other symptoms or clinical requirements (such as glare, inability to work or drive, surgery needed to manage other conditions eg glaucoma or diabetic retinopathy screening). Many of these requirements were either managed by clinicians or part of a simple tick box form, but one third who sought alternative routes were required to complete a lengthy IFR form.

There was considerable feedback in the survey that any monitoring or refusal by CCGs was minimal and that most patients who required surgery did obtain it once the process had been followed.

Conclusions

These findings show that the majority of units are being asked by commissioners to restrict access to surgery based on visual acuity thresholds, despite the fact that the evidence in the recent NICE cataract guidelines demonstrates that this is neither good practice nor cost effective to the NHS. The use of criteria is variable and seems to have no clear logic behind it. The survey supports the view that clinicians are already having appropriate, shared decision-making discussions with patients and are not over providing surgery to patients with minimal visual effects or symptoms. It also suggests that many clinical leads in ophthalmic services do not think it is having the desired effect of limiting numbers of cataract surgery performed.

Whilst this is good news for patients, there is the additional burden of extra administration and paperwork, which takes clinicians away from their main role in caring for and treating patients. This puts further strain on already stretched ophthalmic clinical services, it may delay the timing of necessary surgery and appears not to be being monitored or regulated consistently in many areas.

This survey provides evidence that the use of visual acuity restrictions to accessing cataract surgery places an unnecessary burden on the NHS, creates barriers for patients and clinicians and is not justified as the restrictions do not seem to achieve the aim of limiting surgical numbers. The results of the survey provide a baseline for comparison as we determine how well commissioners take up the recommendations of the new NICE guidelines.

Working together to achieve the best outcomes for patients and the NHS

As demand for surgery is predicted to rise by 25% over the next 10 years and by 50% over the next 20 years, it is crucial that commissioners act now to ensure sustainable and equitable cataract services. The RCOphth wishes to work actively with commissioners and providers to ensure optimum use of resources.

The RCOphth will be reviewing additional information and tools for commissioners.  These include:

  • New commissioning guidance for cataract surgery which reflect the new recommendations from NICE
  • A handbook for commissioners and providers on how best to provide efficient cataract care across the whole pathway

Commissioners and hospital managers are encouraged to review the RCOphth’s The Way Forward documents which identify current examples of efficient and cost-effective pathways and multidisciplinary care models across primary and secondary care. The use of non-hospital professionals in cataract pathways is supported by the CCECH’s Primary and Community Ophthalmology Frameworks. The RCOphth also supports secondary cataract care with a Quality Standard for cataract surgical services and a soon to be released ophthalmic services guidance on efficient and safe ophthalmic theatre processes.

If you wish to discuss the report findings in more detail or to receive more information about our approach to commissioning in ophthalmology, please contact beth.barnes@rcophth.ac.uk.

Notes

  1. Data has been rounded up
  2. Visual Acuity Explained: As a simple guide, we refer to the standards for driving. The minimum eyesight standard for driving is to have a visual acuity of at least decimal 0.5 (6/12) (with glasses or contact lenses, if necessary) using both eyes together or, if you have sight in one eye only, in that eye; and have an adequate field of vision. https://www.gov.uk/driving-eyesight-rules
  3. Individual funding request forms (IFRs)can be made by a clinician (doctor or other health professional) if they believe that a particular treatment or service that is not routinely offered by the NHS is the best treatment for the patient, given individual clinical circumstances