Thousands of elderly people with cataracts have been left at enhanced risk of falls and lower quality of life as a result of increased screening ahead of operations, an investigation by the British Medical Journal (BMJ) has found.
Despite the introduction of revised National Institute for Health and Care Excellence (NICE) guidelines on cataract surgery in 2017, that deemed the operation to be cost effective and not limited to those with the most severe vision loss, the BMJ’s report found that more people were being screened and those who did not meet visual acuity thresholds were being denied surgery.
One in five patients (22%) had a pre-approval check after being referred, a rise from 7% of patients who were screened in 2016-17. Nearly 3,000 patients saw their ophthalmologist’s request for the procedure rejected outright, twice as many as two years ago.
Royal College of Ophthalmologists (RCO) president Mike Burdon said he had made it his mission to convince clinical commissioning groups (CCGs) to stop rationing cataract surgery and not to label it a procedure of ‘limited clinical value’ before he stepped down as from the role in 2020. Burdon, who also chaired the NICE guidelines committee, explained the approach was ‘unjustified whatever way you look at it’ and added it was a false economy for CCGs to apply criteria for cataract operations as a method of controlling costs.
The BMJ’s findings added to data revealed in March by the Medical Technology Group (MTG) which showed more than half (104) of the 195 CCGs in England restricted access to cataract surgery. MTG’s research showed that CCGs included it on lists of ‘Procedures of Limited Clinical Value,’ normally reserved for complementary therapies or cosmetic procedures where there was little evidence to prove their cost effectiveness or clinical benefit.
Ignoring guidelines
Burdon said the BMJ’s research showed evidence that commissioners were ignoring NICE guidelines: ‘Health economists spent 18 months reviewing the evidence for cataract surgery on both first eye and second eye, and they convincingly concluded that there was no justification to ration cataract surgery on the basis of acuity. This was independent of ophthalmologists, including myself.
‘What is the point of NICE doing detailed evaluation if CCGs are just going to knowingly ignore that advice? The health service budget is limited, but you should make those spending decisions on the basis of the clinical evidence. Cataract surgery comes out as probably the most cost-effective thing in the NHS.’
Defending the rationing, NHS Clinical Commissioners chair Graham Jackson said: ‘Unfortunately the NHS does not have unlimited resources, and ensuring patients get the best possible care and outcomes against a backdrop of spiralling demands, competing priorities, and increasing financial pressures is one of the biggest issues CCGs face.
‘Cataract surgery specifically is an area that is often subject to prior approval. Such clinical decisions are critical in deciding when a patient has reached the stage that an operation will be the best option. Performing surgery is not without risk; a clinical threshold is a good way of defining which patients.’
This sentiment was echoed by Bruce Braithwaite, consultant surgeon and secondary care consultant NHS Derby and Derbyshire CCG Nottingham. He explained there were insufficient resources for every patient to have the treatments they and their surgeons might wish for and added that the problem was not unique to ophthalmology.
‘NICE guidance is just that, guidance. It is not an instruction to commissioners. NICE guidance is advice for best practice if it is seen to be affordable by those responsible for implementation within the NHS,’ said Braithwaite.
‘Specialists must accept that they and their associations are part of a much larger healthcare community and the available resources have to be allocated by those in the statutory position to do so. This debate will continue until our elected representatives in government are honest with the public about what the NHS can provide.
‘Until that time, leave it to the commissioners to use the systems of rationing they feel are appropriate. Alternatively, perhaps the Royal College of Ophthalmologists can suggest a way to reduce the costs of providing cataract services by 50% and then twice as many people can have the treatment for the same expenditure.’
Postcode lottery
The BMJ’s investigation also found widespread local variation in how referrals were processed by CCGs, with some requiring no prior approval or individual funding request to refer patients, but others processing and rejecting hundreds of referrals in this manner.
The figures showed that the highest proportion of rejected cases came in Telford and Wreckin and Coastal West Sussex. Each CCG rejected more than one in five (22%) patients seeking funding for an operation, because it was not routinely funded.
Telford and Wreckin issued 352 rejections from 1,580 requests while Coastal West Sussex received 1,255 requests and rejected 275. In Sutton, South London, just 252 cases were rejected from 14,418 requests (2%).
The data resonated with MTG’s research on local variance. It found that Basildon and Brentwood CCG restricted access to cataract treatment while nearby Barking and Dagenham CCG offered the procedure to all patients.
Clinical editor Bill Harvey's comment:
‘Using an arbitrarily selected high contrast acuity target as a threshold for deciding upon eligibility for cataract surgery is a nonsense. When NICE introduced its revised guidelines for cataract referral, I think all practitioners heaved a sigh of relief that the need for assessing the full impact of cataract progression upon sight and life was recognised.
This allowed us to continue to make referrals based upon patient need and not austerity-constrained budgets. As with most areas where clinical decisions are influenced by annual budgets, the long-term cost of non-referral easily outweighs initial costs of having cataracts removed. Well done to the RCO for publicising this.’