Cataract surgery: communication, referrals and lifestyle
A trio of ECPs came together to discuss how private providers can support the NHS in the delivery of cataract surgery
In partnership with SpaMedica, OT hosted a roundtable discussion with three ECPs on what myths need to be busted when it comes to the use of private providers for NHS cataract care, the impact of referral pathways, and how patient lifestyle plays an increasingly important role.
Dispelling myths around non-NHS settings
- Karen Davies, optometrist with two private practices in Oxfordshire
- Gurj Bhamra, ophthalmic director at Specsavers, with three practices on the Cheshire/Shropshire border
- Hayley Moore, an optometrist, WOPEC lead assessor and optical consultant in Essex.
The lack of clarity over what it means to receive NHS care in a non-NHS setting is something that is seen regularly, according to optometrist and WOPEC assessor, Hayley Moore. “Even though I’ve initially said that these are their NHS options, there’s a big myth from patients that they feel they’re going to have to pay,” she said.
Moore explained that she “finds it helpful to relate cataract surgery to other services that patients might be more familiar with that are non-hospital based, like diabetic screening or going to have a normal blood test.”
Optometrist and practice owner, Karen Davies, also finds that the question of payment is one of the first things she is asked – in fact, “that’s probably the biggest thing that people are concerned about,” alongside questions about the cataract surgeons themselves, including why they aren’t working in the local hospital, and what level of qualifications they have.
Davies answers the latter question with reassurance that SpaMedica’s cataract surgeons, many of whom also work within the NHS, have years of experience and have chosen to specialise, focusing on their key area “day-in and day-out.”
Emphasising the specialism and clinical focus provided by non-NHS settings helps patients to understand the need further, Moore added, as does the reassurance that the non-NHS option means that they are likely to be waiting to be contacted about their operation for a matter of weeks, rather than months.
Local knowledge, too, can be helpful when explaining this pathway to patients. As it becomes better known, Moore is increasingly finding that patients’ relatives or friends have had treatment at the Chelmsford SpaMedica hospital, which provides reassurance. Letting them know about practical aspects, such as their ability to park right outside, also adds confidence and familiarity, she has found.
Referrals and communicationPatient choice is hugely important when it comes to elective surgeries such as cataracts, so what do our panel members consider the key factors that should be considered when referrals are made to commissioned providers for NHS treatment?
This question has been key for ophthalmic director Gurj Bhamra’s patients, too. He explained that when he initially started referring patients to SpaMedica, the closest facility was in Bolton, over an hour away. “People were quite put off by the distance,” he said. “However, the moment you tell them SpaMedica will pick them up and drop them off, that quickly persuades them.” He added that now a SpaMedica facility has opened closer to his practices, the issue of transport comes up less often.
How long they will be in hospital and the success rate, too, are frequent questions for Davies, as well as whether she has seen other patients who have had successful surgery in the setting that is being discussed. “We’ll say yes,” Davies said, “because we’re referring more and more people there, and we’re seeing the results coming back.”
Bhamra is positive about the level of communication that he has found from SpaMedica and other private providers. “If we want to get more information about the patient or where they’re up to in terms of referral, they’re very good in terms of communicating with us as to what stage of the process they’re in, what the next step is, and so on,” he said.
He also emphasised that going paperless and making all referrals online has aligned with SpaMedica’s referral pathway. Now, his practices use a questionnaire that is sent to the patient via email, allowing them to detail medication and other relevant details before they visit the practice.
“That helps a lot on our side,” Bhamra said, “because we can go through the counselling process and what cataract surgery involves when we’ve got the patient in our seat. It frees time for us to go through any concerns that they’ve got, and anything else that they want to discuss.”
He added: “We’re more than happy to speak to SpaMedica, in the rare event there is a post-operative complication. Generally, though, they tend to manage those themselves. I don’t remember the last time I saw a post-cataract complication from them. They do tend to look after the patient in that respect.”
In terms of referral management, Davies explained that the closure of the local hospital for cataract surgeries during the pandemic was her impetus for upping the number of referrals she made to private providers. Local GPs being unable to refer patients on to the hospital, “was one of the turning points for us in making sure that we are opening it up to other providers, where the wait times were much less.”
She added: “That works extremely well, because most people, once they know they have cataracts, do want to get it done as soon as possible. It took almost a year before the local hospital was able to accept referrals again, which means their backlog is quite long. So, since lockdown we’ve been referring to the other providers more and more.”
The better the relationship and the more you speak to the private provider, the better it’s going to make your referrals, and the less chance a patient will not be able to be treated at that setting
When it comes to choosing which patients can be referred to SpaMedica, everyone agrees that their communication has been positive: Bhamra is able to call or text optometrists working within SpaMedica with questions, and he emphasises how easy it is to speak to the organisation’s regional representatives. “You can get in touch and they’ll get back to you quickly with anything you need, whether it’s getting more information from a referral that we’ve made, or a letter that we haven’t had back from the hospital,” he said. “They’re good in that respect.”
He added: “It’s not just after they’ve done the surgery that we receive the letters, it’s pre-surgery too, to let us know what’s going on when.”
Moore finds that there are few restrictions on the kinds of patients who can be referred to the group. “Going to continued professional development evenings at SpaMedica, and seeing the facilities and talking to the surgeon and the hospital optometrists, has dispelled a lot of myths for me,” she said. “Because I’ve struck up a relationship with the staff at the local hospital, I just text them if there’s a question. The better the relationship and the more you speak to the private provider, the better it’s going to make your referrals, and the less chance a patient will not be able to be treated at that setting.”
She added: “I’ve been pleasantly surprised by their parameters. I find them very encompassing of most patients that you’re going to see in a typical High Street setting.”
Hayley Moore’s tips for improving referrals
- Visit the clinic to better understand the patient journey both pre-assessment and post-operatively. I’ve needed reassurance on what they would do if the patient had a post-operative complication. Speak to the surgeons to understand that better
- Grasp the practicalities that matter to a patient: things like parking, accessibility, and how the patient journey runs in that setting are vital
- Annotate the type of cataract that you are seeing in your referral letter, because certain types, for example a posterior subcapsular cataract, are more difficult to treat
- Clearly state if patients have other existing ocular conditions. A condition I look for, particularly in older females, is pseudoexfoliation syndrome, because that can make it more difficult, with higher risk of intraoperative complications
- If you don’t get a good view, even on dilation, make sure you put that in your referral letter. SpaMedica have the facilities for optical coherence tomography (OCT) pre-operatively. If you make it clear that you haven’t visualised the fundus particularly well, they have the information to make that decision at the clinic
- If you have done OCT, document it: that the macular was clear, there was no sign of macular degeneration
- If the patient meets the criteria to have both eyes treated, make sure you annotate this carefully in your referral, so there’s no doubt in the initial referral that the second eyes are to be included as well.
Communication post-operationBhamra emphasised that “it’s absolutely vital that there remains a chain of communication between both us and the treatment/surgery provider.” It is something that, with a clear specialism and a smaller setting, the ECPs agree that SpaMedica is well-placed to provide.
Patients are expecting their optometrist to have been kept up to date by the hospital too, Davies said: “I find it very useful, and actually patients expect us to have it. They come in expecting us to know that they’ve had their cataracts done. Now, we’ve got the communication to say, ‘yes, they have been done.’ You’re on a better footing with your patient, to start talking post-operatively with them.”
Moore believes that there are benefits for the clinician as well as the patient. “Having feedback on any referral or treatment that has been done is good for your own self-reflection and your own further learning, and so that you can refine your future referrals,” she said. “I think a lot of doctors in the NHS do ask for that feedback. But sometimes it’s just so busy, and there are so many patients, that it can just get lost in the admin process. SpaMedica does that communication well, but it is a smaller setting; it is something that’s more niche and specialist.”
She added: “Having that joined up approach between primary and secondary care is vital. It improves everything: the patient journey, referral management, follow-up. Everything is better when you’ve got a more joined up approach.”
Lifestyle criteriaThe panel agrees that lifestyle questions are now appearing more in the conversations they are having around the need for cataract surgery than they have in the past. It is something that is an extremely welcome change.
“Before, it was quite strict in terms of which patients we could send in and the visual acuity (VA) requirements,” Bhamra said. “That has been slightly relaxed in our area, when we’ve had meetings with the NHS hospitals and SpaMedica. They’re now more considerate of the patient’s lifestyle and how it’s affecting them, rather than going by an arbitrary 6/12 figure. I think they’re a bit more inclusive as to who they include in their referrals. I think it's a good thing for the patient and for us as well.”
Often in the past, he explained, patients would say that they were struggling to see into the distance or to read, and he was not able to do anything as the NHS was not an option. “Now,” he said, “we can explain the problems that they’re having, and they are more likely to be accepted for cataract surgery.”
Davies agreed: “We were always restricted by VA before. If we sent anything in, it was often sent back with a letter saying that we should not have made the referral, which was quite soul destroying when we could see how it was affecting the patient’s lifestyle. The other option was going private.”
She added: “Now, it has changed quite a bit. With the different ages of people presenting, and what they’re doing and how it’s affecting them, we’re able to refer much more easily, and they’re having their cataracts done sooner. I find it much better.”
She continued: “Look at the factors: if a patient is still working, versus if they’re retired. As optometrists, you know you get some patients who are -2.00DS prescription and they will quite happily walk around unaided, whereas other patients who are minus two wouldn’t dream of being without their glasses. It’s exactly the same thing with cataracts. You'll get some patients whose VA is 6/15, and they’re saying they’re not having issues at all. It’s only when you bring it up that they’re even really aware of it. Whereas you’ll get other patients whose VA is 6/9, and they’re struggling. I think it’s really great that some CCGs seem to really be embracing those lifestyle questions more, and taking that into consideration.”
What are the key questions that patients who are being referred for cataract surgery should be asked, and what are the key considerations that optometrists should bear in mind when observing lifestyle criteria?
Bhamra points out that sending an extensive questionnaire to the patient ahead of their appointment has eliminated a need to ask about medication, and has saved time across his three practices. “Now,” he said, “we focus on key considerations when observing lifestyle criteria. Rather than it just being a question of it being 6/12; you’ve hit that threshold and we can now refer you, we can discuss the problems they are having, and what aspect of their life they are particularly struggling with: is it driving, is it work? We can really hone in on the specifics, rather than being very process-driven and going by the medications.”
Davies makes sure to ask how the cataracts are affecting patients’ lives, although she often finds that this is covered during history and symptoms. One question she finds essential is whether they actually do want something to be done about the condition, as it is not always the case that they do.
She said: “Quite often we go through these processes, saying, ‘yes, you’ve got cataract, I can get that done, I’ll refer you.’ But actually, there are some people who don’t want it done. They go as far as the hospital, and then come back and say they’ve talked to the surgeon and decided they don’t want surgery and that they’ll wait another few months. One thing I say is, ‘if we refer you and they agree to do the surgery, are you going to want to have it done?’ If they say ‘no, I don’t want it at the moment,” then I say that we’ll review it in six months. There’s no point sending it through if they don’t want to have anything done about it.”
Moore emphasised that patients must be looked at holistically. “It’s about looking at the patient’s eyes and their general health as a whole,” she said. “I’ve had quite a few patients lately referred by the diabetic screening service because they’re unable to get clear pictures.”
She added: “You’ve also got the consideration of patients with, say age-related macular degeneration – if there’s a cataract in the way it’s much more difficult to monitor any changes in the vision, particularly if they’re initially a little bit more subtle, they’ve only just started to develop, or there’s a shallow bit of fluid there.”
She references new research that suggests delaying cataract surgery is associated with an increased risk of dementia, and how that has made her think again about a patient she recently saw who was living with both conditions.
“We talked it over with her son,” Moore explained, “and he said she’s managing okay. Looking at the VAs, we said we'd leave it another 12 months. But actually, that was a really interesting piece of evidence, and maybe that’s going to change my mind on that.”
She added: “I think it’s important to keep up to date with everything: other ocular conditions and how cataract removal can benefit either the management or your treatment of other ocular conditions.”
A fuller picture
With increased screen use during the pandemic, the panel have been seen younger patients coming into practice with suspected cataracts after noticing subtle differences whilst working or driving – but this is not the whole story.
Davies is also seeing an older demographic asking for cataract surgery – “85- to 90-year-olds who are wanting to have something done.” She explained that a 96-year-old recently presented at her practice, stating that they were “fed up and wanted something done about it now.”
“I am seeing both ends of the spectrum, in terms of where the cataract is,” Davies said. “I think a lot of it has got to do with lifestyle. People are living longer, and they are more active in their life, and therefore they want better vision.”
Moore agreed: “A lot of people’s lifestyles changed because of the pandemic,” she said. “They’re on screens more; patients who might have been out and about and using their vision in a more general field are now much more screen-based, and they’re noticing the glare, they’re not as comfortable on the screens as they used to be. I think that has definitely highlighted it for younger patients.”
She added: “With older patients, we’ve come out of the pandemic, they’ve had a couple of years where they’ve been sheltered away, and now they want to enjoy doing things and having better vision to do them with.”
Davies also believes that advancements in the way eyes are tested, and potentially how practitioners speak to patients, has made people more aware of the potential for cataract surgery. “We mention it to them a lot more,” she said. “When we are doing the eye examination, we are discussing these conditions with them. We’re doing more enhanced examinations now, so we’re seeing things much sooner and raising it with them. So, it comes up in conversation.”
Bhamra also believes that patients are more educated, and consequently less worried, about cataracts than they might have been in the past. It is something he puts down to increased knowledge, gained through smartphones and frequent internet use. “I used to have people not really understanding what a cataract was,” he said. “Now, with Google and other resources that are out there, they know what’s involved with cataract surgery. They know what the process is; how quick, easy and pain-free it is. They’re not as scared as they used to be.”
He added: “Now, people can see online reviews from hospitals and they are a lot more reassured about what’s involved and the success rate. That they know that the success rate is one of the best of any NHS procedures out there. They know it’s the most commonly performed surgery in the NHS. Patients are just generally a lot more informed as to what goes on.”
Moore added that in the past patients asked whether surgeons would “have to pop my eye out onto my cheek to do the surgery.”
“Now,” she said, “it’s all done through keyhole techniques. Patients talk to their friends, and realise it’s so much more of a straightforward procedure.”
Moore added: “For me, the biggest indicator that a patient is ready or needs to have a referral for cataract surgery is if they’ve attended sooner than their sight test recall, stating difficulties with their vision. That is such a big indicator. If a patient comes in and they’re really struggling, enough to bring their appointment forward, that’s when I really sit up and listen.”