BMJ  2007;334:107 (20 January), doi:10.1136/bmj.39093.388900.80

Editorials

Surgery for cataract

Reorganisation of in-house services is an efficient way to improve quality and increase volume

Cataract is the most common cause of visual impairment throughout the world.¹ In the United Kingdom the prevalence of visually significant cataract is 30% in people over the age of 65.² Modern cataract surgery rapidly improves vision, can be performed as a day case procedure, and has a low rate of complications. The demand for cataract surgery in the UK exceeds its availability, and the best way to organise services to meet the demand is unclear. In this week's BMJ a study by Tey and colleagues reports on how reorganisation of their existing National Health Service ophthalmic service increased the quality and volume of cataract surgery.³

The demand for cataract operations has increased, and the number of procedures performed annually in the UK increased by 50% between 1990 and 1997.⁴ However, the rate of cataract surgery for older people in the UK remained disproportionately low. In 1997 it was still fewer than 2000 per 100 000 for over 65 year olds compared with a government target of 3200 per 100 000, and waiting times were longer than 200 days.⁵ The government responded to the deficit by increasing funding for cataract surgery.⁴ The main aims were to improve referral to secondary care, reduce the number of patient visits before and after surgery, and encourage development of efficient, high volume, cataract only operating lists. Cataract surgery would be performed not only in general ophthalmic operating theatres, but also in cataract treatment centres that could be part of the normal local ophthalmic service or in the independent sector. By 2003 annual targets for cataract operations were exceeded,⁶ and by 2005 the maximum wait for surgery was less than three months for all age groups.^{6 7}

Despite these promising results the role of the independent sector, specifically the contribution of independent sector treatment centres in increasing capacity, has been questioned. A report by the House of Commons Heath Committee concluded that they were poorly integrated into the NHS, and that the decision to go ahead with phase one of the independent sector treatment centre programme was "a leap into the dark."⁸

An independent sector treatment centre operating in an area with no capacity problem is a prime example of poor integration. It may result in little or no reduction in the waiting time for cataract surgery at the expense of financial destabilisation of local NHS hospitals.⁸ Also, there will be a loss of training opportunities for junior doctors in the long term, which may lead to a shortage of appropriately trained surgeons.⁹

Separating elective and emergency care does have benefits. For hospital cataract services, much can be gained from having an in-house treatment centre, where only cataract operations are performed.^{3 10} The study of Tey and colleagues describes such a model, which has improved the efficiency and quality of care and increased training opportunities for junior ophthalmologists.⁹ This model can be set up at relatively low cost, it increases throughput, and more importantly it is fully integrated with the local service.⁹ Long term results from a similar treatment centre show that the effect can be maintained, with rates of access to cataract surgery among the highest in the country.^{10 11}

During the past three years the number of people having cataract surgery has stabilised in England and Wales and waiting times have shortened—median waiting times are around 70 days.⁶ Currently 95% of UK cataract procedures are still performed in (NHS) hospitals, but should more cases be performed in treatment centres? ⁷ Similar problems with cataract surgery waiting times occurred in Canada, and were resolved by using high volume cataract centres. Waiting times have reduced but there are concerns that this may be at the expense of funding for other ophthalmic treatments, and ultimately there will be excessive unused capacity.¹²

The study by Tey and colleagues suggests that treatment centres within hospitals provide value for money and can deal with the surgical backlogs efficiently and effectively. However, the UK government is keen to extend patient choice and increase the number of independent treatment centres. Independent sector treatment centres certainly have a role in improving access to all forms of surgery, but only if they can integrate into local services and take into account local needs.

¹ Eye Infirmary, Sunderland SR2 9HP

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Competing interests: None declared.

References

1. Thylefors B, Negrel A-D, Pararajasearam R, Dadzie K. Global data on blindness. Bull World Health Organ 1995;73:115-21.[ISI][Medline]
2. Reidy A, Minassian DC, Vafidis G, Joseph J, Farrow S, Wu J, et al. Prevalence of serious eye disease and visual impairment in a north London population: population-based, cross sectional study. BMJ 1998;316:1643-6.[Abstract/Free Full Text]
3. Tey A, Grant B, Harbison D, Sutherland S, Kearns P, Sanders R. Redesign and modernisation of an NHS cataract service (Fife 1997-2004): multifaceted approach. BMJ 2007 doi: 10.1136/bmj.39050.520069.BE[Abstract/Free Full Text]
4. Department of Health. Action on cataracts: good practice guidance. London: DOH, 2000. www.dh.gov.uk/assetRoot/04/01/45/14/04014514.pdf
5. Department of Health. NHS drive to end long waits for eye operations. Press release. London: DOH, 2003. www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4046841&chk=j%2B1XKd
6. Department of Health. Hospital activity and episode statistics. London: DOH. www.dh.gov.uk/PublicationsAndStatistics/Statistics/HospitalEpisodeStatistics/fs/en
7. Department of Health. Faster access and more choice for cataract patients. Press release. London: DOH, 2005. www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4102616&chk=fMQsuJ
8. House of Commons Health Committee. Independent sector treatment centres. Fourth report of session 2005-6. Vol. 1. www.publications.parliament.uk/pa/cm200506/cmselect/cmhealth/934/934i.pdf
9. Au L, Saha K, Fernando B, Ataullah S, Spencer F. "Fast track" cataract services and diagnostic and treatment centre: impact on surgical training. Eye 14 Jul 2004 [Epub ahead of print].
10. Cresswell PA, Allen ED, Tomkinson J, Chapman FM, Pickering S, Donaldson LJ. Cost effectiveness of a single function treatment center for cataract surgery. J Cataract Refract Surg 1996;22:940-6.[ISI][Medline]
11. Bailey K, Deane M, MacKnight N, Chappel D, Wilkinson J. Cataract surgery in the North East of England. North East Public Health Observatory. Paper 04, 2004. www.nepho.org.uk/index.php?c=634.
12. Bellan L. Cataract surgery in Canada. Can J Ophthalmol 2004;41:539-41.

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