Cataract surgery is the most common operation performed, with approximately 400,000 operations delivered per year in the UK. It is one of the most cost effective and successful operations in modern healthcare. Delays or restrictions to cataract surgery for those who will benefit from the procedure can limit people’s ability to lead independent lives and care for others, to work and drive, they are twice as likely to have falls and can have significantly reduced quality of life, with increased levels of depression and anxiety. This is not only bad for patients but also is not a cost effective use of limited resources across the wider health and social care systems.
In 2017, the NICE guideline for the management of cataracts in adults confirmed that the use of visual acuity1 thresholds for restricting cataract surgery is not justified, based on a comprehensive analysis of the available evidence including health economics. NICE stated that cataract surgery should not be restricted on the basis of visual acuity and that the decision to refer and perform surgery should be based only on shared decision making with patients and their families or carers, taking into account their symptoms and clinical situation, effects on activities and quality of life, and the risks of surgery.
The Royal College of Ophthalmologists (RCOphth) undertook a survey of ophthalmic clinical leads shortly after the release of this guideline and found that there was widespread restriction to surgery on the basis of visual acuity. 66% of responding units (87 of 140 units in England and Northern Ireland) had restrictions to surgery with similar rates for first and second eyes. In some cases (4% first eyes, 20% of second eyes) the vision had to be severely reduced (6/18 or worse) before surgery was permitted.
More than one year after the NICE guideline was published, the RCOphth has presented the same question to clinical leads once again to see if the situation has improved. When comparing the follow up cohort of responding units, we found that disappointingly 62% of units are still restricting access to cataract surgery. This slight improvement represents only a 5% increase in units changing to being NICE compliant. Despite the well-publicised 2017 guidance, it is evident that commissioners continue to ignore NICE guidelines and ration one of the most cost-effective procedures on the NHS.
Following a Freedom of Information request it was recently reported in the media that at commissioning level 53% of CCGs in England are restricting access to cataract surgery in direct contravention of NICE guidance. The RCOphth follow up survey further confirms this picture from ophthalmologists working locally at trust level. Until NHS England mandates the uptake of NICE Guidance compliance is not likely improve significantly.
These findings show that the NICE guidance recommending no restriction of cataract surgery based on visual acuity, has had very limited impact and commissioners are still inappropriately rationing cataract surgery in the majority of eye units. NICE’s role is to provide national guidance and advice to improve health and social care. Where this guidance is ignored, patients are not receiving equitable care based on the best evidence on clinical and cost effectiveness. It is essentially a postcode lottery.
Building the capability to support older people
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 and policymakers act now to ensure sustainable, equitable and efficient cataract services. Undertaking cataract surgery at the appropriate time for patients will have widespread health and economic benefits and will be increasingly important as we all live longer in supporting the population to age well2. The RCOphth wishes to support commissioners and providers to ensure optimum use of resources and has published information and tools including:
- Commissioning guidance for cataract surgery which reflect the recommendations from NICE
- Sustainable cataract services – a handbook for commissioners and providers on how to undertake a whole pathway approach to deliver efficient high quality cataract care
- The Way Forward documents which identify current examples of efficient and cost-effective pathways and multidisciplinary care models across primary and secondary care.
- Quality Standard for cataract surgical services
The use of non-hospital professionals in cataract pathways is supported by the CCECH’s SAFE Framework.
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 [email protected].
- 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.
- Healthy ageing and caring.