Outsourcing ops
It is with interest that I am following the unfolding story about private ophthalmology companies providing NHS cataract services. The Centre for Health and Public Interest (CHPI) report entitled ‘Out of Sight – the hidden impact of cataract outsourcing on NHS eye care departments’ and The Guardian article ‘Boom in cataract surgery in England as private clinics eye huge profits’ both have a similar narrative that private providers are starving the NHS Trusts of desperately needed funds.
The narrative goes that these funds are a cross subsidy for other treatments and are needed to train new ophthalmologists. There is also the inevitable mention of the impact of Covid – in this case the president of the Royal College of Ophthalmologists saying the outsourcing had been ‘a good thing immediately after Covid to get cataract waiting lists under control’.
What impact does optometry have in this pathway?
The Guardian article does mention the role of optometrists within the referral pathway – apparently, we are under obligation to offer a list of five different cataract providers and may well be incentivised to refer to private clinics ‘because they get a fee, typically about £50, for a follow-up appointment, which they would not get from an NHS hospital’.
Apart from this being factually incorrect for many areas of the UK, it implies two incorrect ideas. One is that we are referring patients to private (as against NHS) clinics and secondly that we are only doing this because we get paid.
Firstly, we are not referring to private clinics, we are referring within the NHS for NHS-funded cataract surgery. Secondly, why on earth would an ophthalmologist want to perform cataract surgery and then not have an accurate follow-up/refraction performed afterwards?
Why go to the trouble of surgery to then let a patient have an uncorrected refractive error until their next routine eye exam? And why perform these follow-ups in hospital when we all know the eye departments are overflowing with patients. And why should we not get paid for this service?
Why do we really refer to NHS surgical providers rather than acute trusts?
I can only talk about my experiences here, but I have the choice to refer to the local trust or one of two surgical providers.
What are the benefits of each provider?
The local trust: Waiting lists are usually between of 12 to 18 months. The first the patient hears of their appointment is a letter telling them the time and day of their pre-op, there is no choice with this appointment time. Parking at the hospital is difficult and expensive and the eye department is usually very busy.
Anecdotally, the surgeons whom the patient sees are keen to put them off having surgery (we certainly get more rejections from the local trust than the surgical providers).
Once the surgery has been performed, often the patient is told they will not need distance spectacles and that ready readers will be all they need. They are not informed to have a refraction and the follow-up (if they get one) is by telephone. We do not receive any correspondence about the patient, pre or post-surgery.
The surgical providers: the waiting list is three to four weeks and the first contact the patient has is by telephone to discuss a suitable appointment day and time. Parking is free and the provider will put on transport for the patient if needed.
The clinic environment is calm and according to the patients ‘feels like a private hospital’. Once the surgery has been performed, the patient is told to return to the referring optometrist for a follow-up four to six weeks later to get the best vision from spectacles (should they need them). We receive pre and post-op by letter.
There is literally no comparison in the service the patient and we receive between the trust and the surgical provider, who, it must be stressed, are both providing NHS cataract services. The suggestion that things were different pre-Covid does not stack up either. The local trusts have had very long waiting lists for years.
A suggestion with the CHPI and The Guardian articles is that the trusts will not be able to train new ophthalmologists because they do not see enough cataract procedures.
So, why not incentivise the surgical providers to train the new ophthalmologists? In fact, why not stop the trusts from doing all but the most complicated cataract surgery and free them up to see other ophthalmological diseases?
