In England, NHS-funded surgical eye care at the end of the 20th century came from the local general hospital. The much loved eye hospitals up and down the country closed decades earlier (with some notable survivals, including Sunderland and Moorfields). What drove centralisation was the need for beds and safe anaesthetics. What has driven recent decentralisation is day surgery under local anaesthetic, lack of investment in NHS infrastructure, realisation that elective care is disrupted by acute care on the same site, and that sometimes care closer to home is better. This move has been led by growing private sector investment in NHS funded care. Together with patient choice, this has pushed up standards of service and improved physical environment. Patients need a helping hand in understanding choice in their area, and optometrists acting as the primary care referrer need to know what ophthalmology services are available locally. Here are some factors that might influence choice:
Quality
There is under-recognised variation in quality of outcome. Both organisational and individual surgeon factors are relevant. Anecdotal feedback from local experience is still the commonest way to judge, but slowly the data is catching up. Look at CQC ratings and reports, and surgeon complication rates on the National Ophthalmology Database. Outcome measures are getting better all the time (and now include complexity of case mix). Patients need help in judging quality, and historically still attend NHS services given poor ratings, possibly out of misplaced loyalty.
Accessibility
How quickly and easily can the patient be seen, and provided with follow up and emergency care if needed? Waiting times have been massively disrupted by Covid-19 in most NHS hospitals. Information on next available appointments is available on eRS, which most optometrists cannot access. NHS.uk publishes wait times for ophthalmology services overall.
Restrictions
The majority of NHS commissioners attempt to restrict access to cataract surgery. In doing so they disregard NICE guidance that states ‘Do not restrict access to cataract surgery on the basis of visual acuity’. NICE also states the second eye is to be treated under the same criteria as the first. Challenging commissioners is beyond the capacity of most patients.
Expectations
The NHS provides cataract surgery with a standard monofocal lens. Though a good refractive outcome is possible, for example with mini-monovision, careful planning beyond a basic spherical aim is often overlooked, and at this time patients are not allowed to ‘top up’ the basic NHS Lens.
For chronic disease care, patients will get used to seeing a new clinician every time they attend, but they never get to like it.
So far, no mention has been made of private care. But all points above can be taken to a new level by those able to pay. The General Medical Council obliges doctors to explain to patients all treatments available for their condition, even if it is not NHS funded.
This puts doctors in a difficult situation. They must explain that if the patient pays, they can get a different level of service and the very advantageous outcomes possible with new premium lenses – while at the same time being able to profit from that choice if they offer private work.
It is an ethical minefield made much easier if the patient has some understanding of the choice before they are referred. If the patient decides to go private, the quality call is very important as private data is harder to come by. Despite recent criminal cases, patients erroneously believe money buys better care.
Here are my pointers to a good private service:
- Local reputation and anecdote. Good NHS work leads to good private work, but this link may not exist.
- National reputation – an acknowledged expert by peers. But check the reputation is not historic.
- Is private outcomes data reported? Is it externally monitored or self-reported? Is it easy to find?
- Does the surgeon work solo or in a team or partnership? Colleagues provide control, oversight and teamwork and a group may be CQC registered and inspected.
- Does the surgeon promise a tightly controlled scope of expert practice?
- If the surgeon is working in a private hospital then that hospital takes responsibility for quality of care, so the hospital should publish evidence.
- Look at PHIN (private healthcare information network). This is still in its infancy re independent data but may get better.
- Await the government response to the Paterson report, better governance of the fringes of private sector work should ensue.
- Whichever service patients choose, optometrists are a prime information source and integral to a referral process that now largely excludes GPs.
Tim Manners, consultant ophthalmologist at Newmedica.