Rationing Cataract Ops 'Ignoring Guidelines'

Nicky Broyd

May 30, 2019

An investigation by the BMJ has found commissioners in England ignoring National Institute for Health and Care Excellence (NICE) guidelines by rationing cataract operations through a process of pre-screening.

Cataract operations are the most common surgery performed by the NHS and demand is growing as the elderly population increases. The operations are described by NICE as cost effective with a high success rate.

Continuing Postcode Lottery

Previous concerns about 'postcode lottery' access to eye surgery prompted a revision to the guidelines in 2017 which stated: "The clinical threshold used to access cataract surgery varies across NHS trusts in England. This has resulted in differences in access to cataract surgery, because policies vary in scope and content and are not necessarily consistent with research evidence or guidance provided by the Department of Health in Action on cataracts and the Royal College of Ophthalmologists' Cataract surgery guidelines."

Research by the Medical Technology Group published earlier this year found that more than half of the clinical commissioning groups (CCGs) in England listed cataracts among treatments deemed to be of "limited clinical value".

The BMJ investigation found that among 132 CCGs in England with comparable data, pre-screening before funding surgery had risen to 22% of total cataract operations in 2018-19 compared with 7% in 2016-17.

Among 185 CCGs that provided data almost 2,900 surgery requests were rejected last year.

False Economy

Royal College of Ophthalmologists President Mike Burdon, who chaired the NICE guideline committee on cataracts, told the publication that additional criteria by some CCGs to control costs was a false economy, and this approach was "unjustified whatever way you look at it".

The Royal College of Ophthalmologists issued a statement saying it "has long campaigned on the right of patients to access cataract surgery in a timely manner. CCGs must take notice of the NICE recommendations which reinforce the message that cataract surgery should be delivered at point of clinical need.

"Variation across the country, with CCGs listing cataract surgery as of ‘limited clinical value’ and processes in place to reject referrals for surgery, creates an unjustifiable postcode lottery. For CCGs [to] continue to list cataract surgery as a 'procedure of limited clinical value' reflects a lack of concern for the quality of life of an older and more vulnerable section of our society.

"This is a fundamentally flawed approach as cataracts are progressive and patients will simply have to wait months or years longer for surgery. In the meantime, they will have failed to gain the improvement in quality of life that cataract surgery offers and are at increased risk of falls, injury, and long-term loss of mobility and independence. We call on NHS England to intervene where this is happening and ensure equal access for patients across the NHS."

Graham Jackson, co-chair of NHS Clinical Commissioners, defended the policy, saying that no surgery is without risk, and setting clinical thresholds "is a good way of defining which patients would best be served by (in this case) cataract removal".

A spokesperson for the Department of Health and Social Care said commissioners "should take the latest NICE guidelines into account, to ensure fair and consistent access to the best possible treatment for all cataract patients."

BMJ News: Leading ophthalmologist vows to stamp out “unjustified” screening for cataract surgery. Article.

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