RCOphth President Professor Bernie Chang explains the positive action being taken by NHS England through its cataract specification, which the College has supported to develop.
With the publication last week of its service specification for cataract surgery, NHS England has taken an important step in beginning to address the challenges to long term sustainable patient care created by the growing role of independent sector providers (ISPs).
What is the cataract service specification and how will it change things?
The specification, linked to above via the Eye Care Hub, aims to ensure all providers of cataract surgery in England meet certain standards and requirements. These include the delivery of training, the handling of post-surgical complications, as well the requirement that there is no financial link between the provider and any referring organisation.
It was fantastic to see so many of you join an NHS England webinar two weeks ago to discuss this and how we can make eye care more equitable, accessible and sustainable. Together with others in the College, I have worked closely with NHS England to develop this specification. I believe it has the potential to tackle many of the issues that RCOphth members are concerned about, but implementation will be key.
That is why College will now be engaging directly with integrated care systems to raise awareness of the specification and ensure its standards are followed in the commissioning process. We will also continue to make the case to NHS England and other policymakers across the four nations that the sustainability of comprehensive ophthalmology services into the future will require proper investment in NHS eye care units and their workforce.
Recognising the challenges created by the growing role of the independent sector
While ISPs have undoubtedly helped to manage the long cataract backlogs, we have been aware for some time of the challenges created by the growing role of ISPs, and have been working collaboratively to try to address them. In a 2020 College survey of ophthalmologists in training undertaken during the pandemic, 72% said they did not achieve all their training objectives in their most recent placement, with 55% of these citing lack of surgical opportunities.
We recognised then that engagement with the independent sector was important. The College supported Health Education England and NHS England with their recent guidance on the placement of doctors in training in the IS, as well as publishing our own guidance setting out how cataract surgery training can still be delivered in high volume settings.
A number of members have raised directly with me and other senior College officers, as well as NHS England, that the growth of ISPs has created issues with the delivery of ophthalmology services in their area. We will seek to help by escalating issues with NHS England where needed, so please do email me at [email protected] if you think we can help.
The pandemic drastically accelerated a trend towards greater ISP provision of NHS cataract surgery in England, with the figure reaching almost 50% by April 2021 – up from only 11% in 2016. That is why in November 2021 we published Three Steps to sustainable patient care – setting out the need to take stock and address the implications of this sudden shift. We highlighted the need to increase access to training in ISPs, pointing to the lack of opportunities reported by trainees. We also emphasised the need for a “level playing field” for all providers to ensure fair patient access. By this, we mean selection criteria need to include a greater case mix and referral pathways must be fair and transparent. We were also clear that ISPs needed to do more to safeguard quality and safety by submitting data through the National Ophthalmology Database, and ensuring systems are in place to manage complications.
Cataract specification should provide a better framework
We are pleased that NHS England took on board these points raised by the College, and addressed many of them in its cataract service specification.
Key aspects of the specification include that:
- All cataract providers must offer surgical training to ophthalmologists in training if they perform more than 50 cataract cases per year.
- Services should not be commissioned if there is a financial link between the provider and any referring organisation, and commissioners should ‘be mindful of perverse incentives and conflicts of interest. For example…if the organisation providing the triage is also a provider of cataracts’.
- Providers should manage post-operative complications or ensure arrangements are in place to manage them, including when out of hours.
- Providers are expected to make routine data submissions on audit and training, including to the National Ophthalmology Database.
Although the specification, which can be viewed in full with a supporting guidance document on the Eye Care Hub, will need to be locally tailored, NHS England is clear that its requirements should be implemented when commissioners and providers are designing services.
I am confident that this specification can help to deliver a more sustainable eye service if delivered effectively. We know there are other issues to be resolved – such as how referral criteria and the tariff operate – but it is clearly a big step in the right direction.
What next?
Implementation of the cataract specification will be key. RCOphth will work closely with NHS England, commissioning bodies such as integrated care systems and ISPs to ensure the requirements of the specification are understood and put into practice. As clinicians, you can help with implementation locally by contacting your clinical lead or regional representative to highlight examples where the requirements of the specification are not being implemented.
The College will also continue to press for better resourcing of NHS eye care units and their workforce. We know that this is absolutely key to enabling us to continue to deliver comprehensive patient care beyond cataracts for all those who need it, irrespective of where they live or how complex their case is.
Thank you all for your support and hard work. We will continue to keep you updated with further developments and where you can feed in.