The influential thinktank Reform has published a report highlighting the scale of follow-up backlogs in England, with ophthalmology the specialty with the most patients waiting for follow-up appointments. RCOphth Policy Manager Jordan Marshall summarises the key points from the report and what needs to happen next.
When waiting lists are reported in the media, the figure focused on is usually the number waiting to begin treatment. This BBC article from July 2023 is typical – which cited 7.47 million waiting to start treatment.
A new report from the prominent thinktank Reform has highlighted what it calls ‘The hidden waitlist’. These are the estimated 11 million patients that are waiting for follow-up appointments at NHS trusts in England, with ophthalmology the specialty with the highest number of patients waiting follow-ups.
Reform particularly stress the risks associated with delays to follow-up appointments in ophthalmology, drawing on RCOphth research when noting that ‘permanent harm from avoidable visual loss is 9 times more likely in follow-up patients than in new patients’.
Over the last two years, we have argued that we need a much stronger focus on follow-up waiting lists. In our November 2022 submission to a Public Accounts Committee Inquiry on managing backlogs, we pointed to ‘a huge hidden backlog…not accounted for in NHS England statistics’. We emphasised the need to ‘focus recovery efforts on diagnostic and follow-up delays, not just surgical backlogs’ and for NHS England to publish ‘more granular data on outpatient waiting lists including risk stratification and follow-up delays – as Wales does’.
We are pleased that this issue and the need for better data reporting is now being brought to wider attention, with the report’s findings (including the long ophthalmology follow-up backlogs) being covered in The Telegraph, The Times and Daily Mail.
Ophthalmology is particularly dependent on follow-up appointments as the best way to manage chronic eye diseases which can lead to irreversible loss of sight, such as glaucoma and age-related macular degeneration. Ophthalmology has a ratio of 3.3 follow-up attendances for each first attendance. This is notably higher than the 2.3 rate across all specialties, and significantly higher than most other large outpatient specialties. This is appropriate as regular assessment and treatment is needed to prevent permanent sight loss.
What is needed to better prioritise follow-up waiting lists?
As our population ages over the next twenty years and patient need for timely eye care increases, it will be more important than ever for NHS ophthalmology units to be well resourced – in terms of having both the requisite clinic space and consultant ophthalmologists – to deliver and coordinate the management of care to prevent avoidable sight loss.
Over the last couple of years however, much of the post-COVID recovery focus in England has been on cataract waiting lists rather than the follow-up backlogs. This is borne out by the fact that there were over 600,000 NHS-funded cataract procedures delivered in 2022/23 – a 40% jump from 2018/19, when just over 430,000 procedures were performed. England is a huge outlier here – the other UK nations actually delivered fewer cataracts in 2022/23 compared to pre-pandemic figures from 2018/19.
While efforts to bring down the cataract waiting lists are essential and welcome, this cannot come at the expense of tackling follow-up backlogs, where our highest-risk patients often are. We have consistently detailed to policymakers the challenges that have arisen from the surge in independent sector provision of NHS-funded cataract surgery in England, and this data from Reform will add weight to the argument some have made that action on follow-up waiting lists in England may have been neglected in favour of focusing resources on cataract surgery. As well as driving better data collection and reporting on follow-up waits, it is important that NHS England acts to ensure its guidance and investment better prioritises follow-up patients.
As we highlighted in our February 2022 guidance on reducing outpatient follow-ups, there are other steps that ophthalmology departments, trusts and policymakers can take to tackle outpatient follow-ups which include:
- Delivering diagnostic services outside of the hospital, either through virtual clinics, which can be delivered as part of community diagnostic centres (CDCs) or in community settings such as optometry practices. This will need to be underpinned by an increased focus by trusts on the recruitment of ophthalmic technicians and other healthcare professionals to support diagnostic data collection and analysis, more joined-up IT infrastructure, as well as ensuring ophthalmology is prioritised within the rollout of CDCs. In addition, agreement needs to be reached with commissioners to contract optometrists to ensure appropriate patients are discharged to their care with the governance structure, integrated care pathway and oversight in place to enable safe, high quality care in the community.
- Offering patient initiated follow-up (PIFU) appointments where clinically appropriate. Eye disease can be non-symptomatic until it is at an irreversible stage, so PIFU will not be appropriate in such circumstances. Our April 2023 case study from King’s Mill hospital shows how PIFU can be successfully implemented in general ophthalmology, as part of a wider set of actions.
- More robust discharge guidelines and referral refinement criteria, working closely with primary care to enable patients to be treated in primary eye care where clinically appropriate. Local triage guidelines need to be agreed between primary care optometrists and the hospital eye service, and joint risk stratification frameworks should underpin these guidelines.
We will continue to work with all stakeholders to ensure that the issue of follow-up backlogs in ophthalmology is properly monitored and acted on. While we encourage NHS England to undertake regular monitoring and publishing of this data, our British Ophthalmological Surveillance Unit (BOSU) is launching a study into patient harms caused by delays in review or treatment. We hope you can support this study by reporting cases through the BOSU email reporting system over the next 12 months, helping us to build a more accurate picture about patient harms resulting in delays to treatment and the need for a better approach.
