The Consulting Room: Dealing with backlog
Nigel Kirkpatrick considers the recovery of eye surgery services since the pandemic began
Author: Nigel Kirkpatrick
Over the next few months, I hope to use a series of articles to discuss the current state of play in ophthalmology in 2022. Obviously, the effect of Covid-19 looms large and I will deal with the specific features of care for our most pressing diseases such as cataract, glaucoma and age-related macular degeneration. My first article puts the Covid-19 related backlogs into a more general context.
As I write, we are just past the point two years ago when eye surgery services were beginning to restart after a prolonged lockdown caused by the arrival of Covid-19. During this period only minimal emergency services were provided for eye casualty and for emergency surgery, such as retinal detachment and trauma.
Although Covid is still circulating, we are at a very different point in its evolution. We have much improved knowledge of its effects and, while it is currently less virulent, resulting in reduced severe lung disease, we have the added protective effect of vaccine programmes to keep us from serious illness and mortality.
Covid has had a huge effect on the waiting list situation in the UK. However, we should not forget that a large part of the waiting list problem was carried forward from a deteriorating picture in the past 10 years. The inability to provide sufficient capacity to match demand resulted in increasing public frustration with access to NHS services in the period running up to the start of the pandemic.
Comparisons of our current waiting list problems to the period in the late 1990s and early 2000s have been made. Back then, Tony Blair’s government launched a new plan to deal with waiting lists by adding the option of outsourcing services to private providers to reduce huge waiting lists. Investment increased to match our European counterparts and targets for healthcare delivery, such as the 18 week ‘referral to treatment’ time, were introduced. There are arguments about the distraction of a target driven culture in healthcare, including the delay of clinic follow up reviews for patients with chronic eye disease, but the effect of the new investment and increased capacity gradually led to a reduction in waiting times over the following decade (see figure 1).
In the past decade waiting lists were at their lowest in 2012 and the 18-week target of 92% of patients receiving treatment within that time frame was achieved between 2011 and 2015.
The restart of surgery in mid-2020 was slow and steady with many NHS organisations still reeling after the first lockdown and having to deal with subsequent virus waves. It is completely understandable that a highly infectious disease resulted in slow delivery of services to allow patient spacing and proper infection control.
At Newmedica, we used the first lockdown period to redesign pathways to make allowances for infection control. We staggered admission times, the waiting room was effectively moved to the patients’ car park, and we delivered our pre-op assessment, including imaging and biometry, immediately prior to surgery, meaning a true one-stop process for treatment. We learned that patients appreciated dedicated one-to-one attention and since 2020 our waiting rooms remain quiet as a result.
The NHS delivered approximately 300,000 anterior segment procedures in England in 2011-12. During the decade prior to Covid the demand increased by about 5% per year and surgery levels were just below 500,000 cases immediately before Covid, according to HES Data. Surgery in 2020-21 suffered a 50% drop and the result has been an increase in the backlog with demand for eye surgery rising to over 600,000 patients waiting by the end of 2021.
How long will it take to reduce waiting times to manageable levels? It seems that the answer to this question is dictated by geography. In England, recent monthly data on eye surgery shows high levels of day surgery activity with a monthly average around 60,000 cases for all types of procedures over the last six months. The estimated demand for a steady state is just below this level and the current surgery rate would suggest the backlog in surgery might clear steadily. How this translates to individual regions of the country is likely to be variable with high levels of provision in some areas and others taking more time to recover.
Local optometrists I’ve spoken to said it is clear that long waiting lists persist in Wales, Scotland and especially Northern Ireland where the time is quoted in years rather than months. Reports of new initiatives to drive down these waits are still not forthcoming.
The message for optometry is that the recovery from Covid is definitely under way in large parts of England, but pockets of delayed treatment may exist in specific areas. Local knowledge is key and optometrists are advised to stay in touch with local providers who can give a clear picture of the services available in your area.
In the next article, I will focus on cataract care specifically and offer some guidance on how optometrists should manage their patients when considering referral for cataract surgery in 2022.
- Nigel Kirkpatrick is a consultant ophthalmologist and medical director at Newmedica.