Cataract surgery rationing

Summary

Cataract surgery is the most common surgical procedure undertaken in the UK. It is routine surgery, often requiring no overnight stay, and can transform quality of life. But some NHS commissioners are restricting access to it, in breach of NICE guidelines and the NHS target to treat everyone within 18 weeks of their referral. This postcode lottery needs to stop.

What's happening

Every year around 400,000 cataract operations take place in England, 42,000 in Scotland, 20,000 in Wales and 8,500 in Northern Ireland. 

Cataract surgery is a quick, routine operation to replace the clouded lens of the eye with a clear plastic replacement lens. It is normally carried out under local anaesthetic and most patients can go home the same day. The success rates are high and the complication rates very low¹. The surgery can transform people’s quality of life by restoring their sight – and therefore their ability to work, drive, and enjoy their lives to the full.

NICE (the National Institute for Health and Care Excellence) has produced guidelines for cataract surgery, including the clinical criteria for surgery. NICE’s February 2019 quality standard² clearly states that “adults with cataracts [should not be] refused surgery based on visual acuity alone.” In other words, if a cataract is seriously affecting the patient’s quality of life or their ability to function then surgery may be justified, even if their visual acuity is better than that of some people who aren’t eligible for surgery.

NICE adds that:

“The decision to undertake cataract surgery should be based on discussions with the person about the effect of cataract on their quality of life, the risks and benefits of surgery and what may happen if they choose not to have surgery. Measurement of visual acuity often fails to detect vision problems that may benefit from cataract surgery (for example, glare and loss of colour vision). The decision should include consideration of a patient's quality of life and symptoms such as difficulty with reading, night driving, work or home activities, glare and loss of contrast, despite appropriate optical correction. Restricting access to surgery based on visual acuity alone has an impact on quality of life for some people with cataracts. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.”

This guidance allows for consideration of the potential negative effects of delaying surgery. As an example, a patient in the early stages of dementia could benefit from surgery and might justifiably be offered it before their visual acuity has deteriorated to a level normally considered automatically eligible. This is because they might not be able to understand and comply with surgery at a later date. 

Despite NICE’s clear guidance, some healthcare commissioners apply simplistic criteria for access to cataract surgery – based on visual acuity alone – which are designed to limit the numbers of operations and therefore save money. The AOP and many others have drawn attention to this postcode lottery in the past^3,4.

AOP members are also reporting that where their patients are offered surgery, they are facing unacceptably long waits for treatment in some parts of the UK - in breach of the NHS commitment to treat patients within 18 weeks (around four months) of their referral to a consultant. Members in Cumbria, Devon, Kent and parts of London and Kent have reported that waiting times of nine months are common. In Northern Ireland we have heard of waits as long as two years. 

But this is a postcode lottery. Our members in Hull and East Yorkshire, Manchester and Liverpool have reported that patients are receiving surgery within the 18 week target time. Waiting times have been growing in Scotland but the Scottish Government is taking action by investing in improving waiting times, including in ophthalmology.

We accept that this “rationing by delay” is not a deliberate policy. It is a by-product of the fact that all patients are on average waiting longer in the NHS, and that the 18 week referral to treatment target is being met for fewer patients than in the past⁵. But it is not acceptable.

What should happen

Patients’ access to cost-effective and transformative treatment for cataracts shouldn’t depend on where they live. All NHS commissioners should follow the NICE guidelines and work to provide surgery to those who need it, within the 18 week time frame. 

Hospitals should be resourced to have the capacity to treat everyone who is eligible for surgery according to NICE guidelines within the 18 week target. This will prevent them needing to choose which patients they will treat, and when.

References

1. Royal College of Ophthalmologists, National Ophthalmology Database Audit, 2018 
2. National Institute for Health and Care Excellence, Serious Eye Disorders Quality Standard [QS180] Quality Statement 2, Referral for cataract surgery, February 2019
3. Optometry Today, CATARACT PATIENTS DENIED SURGERY, June 2019
4. Michael Burdon, President, Royal College of Ophthalmologists, End the postcode lottery for cataract surgery, BMJ Letters, May 2019
5. NHS England, Consultant-led Referral to Treatment Waiting Times Data 2019-20 

October 2019

Read the rest of AOP position statements