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Rapid Responses: Rapid Responses published:
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Streamlining cataract services – A long-lived change?
- Dawn A Sim, Christina Dinah, Geeta Menon (22 January 2007)
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Demand for cataract surgery: patient perspectives require research
- Daniel Longo (22 January 2007)
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'Cataract caution'
- Simon P Kelly, Brenda Billington, Richard Smith, Rhod Daniel (23 January 2007)
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Are specialist cataract nurses really the key.
- Simon E Horgan, Adam Hustler, and Dario Inzerillo. (30 January 2007)
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Re: Are specialist cataract nurses really the key.
- Adrian Tey, Roshini Sanders (6 February 2007)
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Dawn A Sim, Senior House Officer Moorfields at St George's Hospital, London SW170QT, Christina Dinah, Geeta Menon
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I congratulate Tey et al on their multifaceted approach towards improving cataract services. Our experience at Frimley Park Hospital, Surrey, with a pilot scheme of direct-optometrist cataract referrals also saw a shorter mean waiting time from referral to surgery (74.9 vs 94.9 days), and a higher uptake of surgery (89.5% vs 82.1%), when compared to the traditional GP referral route. However, pick-up rates from the local optometrists though high in the first 12 months of its introduction, halved in subsequent year. We suggest that streamlining of services though effective, requires continual education, promotion and coordination between services to ensure its longevity. Competing interests: None declared |
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Daniel Longo, Professor of Family Medicine University of Missouri-Columbia, School of Medicine, Columbia, Missouri 65212 USA
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In this important article one is struck with the various issues involved in the demand for cataract suregry in the UK.(1) However, this article as well as the literature in general is missing an important piece --- the patient perspective. That is, we need to understand the impact of such surgerical interventions on the activities of daily living of those who were previously visually impaired and now benefit from the tremendous improvement, if not almost total restoration of vision for many, from this intervention. As a health services researcher who examines patient perspectives of care, and has recently personally experienced the incredible benefits of cataract surgery, I find I am amazed that such an issue remains unstudied. For me, the surgery has resulted in a tremendous improvement in vision in that I only need reading glasses at times depending on print size. Further, there are tremendous other benefits, such as waking in the morning without searching for glasses, avoiding mistaken understand in reading, and so on that have occurred. Clearly, this surgery has also benefited me in terms of work and thus has greatly benefited my productivity, efficiency and accuracy. This are benefits that in the aggregate cannot but have important implications for all countries. And, if quantified and better understood may in fact influence countries where the demand for the intervention exceeds supply, to reconsider its importance for patients and the country at large. (1.)Adrian Tey, Barbara Grant, Dawn Harbison, Shona Sutherland, Patrick Kearns, and Roshini Sanders Redesign and modernisation of an NHS cataract service (Fife 1997-2004): multifaceted approach BMJ 2007; 334: 148-152 Competing interests: None declared |
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Simon P Kelly, Consultant Ophthalmic Surgeon Bolton Eye Unit, Bolton Hospitals NHS Trust, Bolton. BL4 OJR, Brenda Billington, Richard Smith, Rhod Daniel
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Dear Editor The improvement report in relation to cataract surgery (Reference 1) is further evidence that the Independent Sector Treatment Centre (ISTC) programme was an expensive over-reaction to the need to increase rates of cataract surgery as argued by the Royal College of Ophthalmologists (the College) and others in evidence to the Health Select Committee. (Reference 2) Many ophthalmology departments had improved cataract surgery pathways, as part of Action on Cataract, an NHS initiative supported by the College, (Reference 3) before the ISTC programme was proposed. Modest sums of capital pump-primed increased cataract surgical activity by improved facilities and pathway re-design. As this report (Reference 1) confirms, such targeted investment quickly pays for itself. The experience in NHS ophthalmology units elsewhere is similar. Had the Department of Health followed the advice of clinicians, the Royal Colleges and BMA when the cataract and other ISTC schemes were proposed, we believe that improved access to cataract surgery would have been realised with much less expenditure, without adverse effects on surgical training and without destabilising NHS eye departments. However, an alternative direction was taken. (Reference 4) Despite the paucity of clinical outcome data, a cause of increasing concern (Reference 5), and the lack of evidence of cost effectiveness of Phase 1 of the ISTC programme, further investment in cataract surgical facilities continues in Phase 2. In the meanwhile, for long term stability of the Service, we believe that the best option for the public is to support local NHS units. It is such self improved units that brought down cataract waiting times, such units that patients need to call upon in an emergency or for chronic eye disease and such local units that train the next generation of surgeons while meeting waiting time targets. A constructive partnership of clinicians, managers and commissioners is a surer way to achieve sustained improvements in access and quality of care, rather than centrally imposed initiatives and diktat, such as the needless cataract ISTCs. Yours Faithfully Simon P Kelly, Consultant Ophthalmic Surgeon, Bolton Eye Unit, Bolton Hospitals NHS Trust, Bolton. BL4 OJR Brenda Billington, President, Royal College of Ophthalmologists, 17 Cornwall Terrace, London NW1 4QW Richard Smith, Vice President, Royal College of Ophthalmologists, 17 Cornwall Terrace, London NW1 4QW Rhod Daniel, Chairman, Ophthalmic Group Committee, British Medical Association, Tavistock Square, London WC1H 9JP REFERENCES 1) 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;334:148-152 2) 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.pd 3) Department of Health. Action on cataracts – Good Practice Guidance. NHS Executive. Feb 2000. http://www.dh.gov.uk/assetRoot/04/01/45/14/04014514.pdf 4) Kelly SP. Cataract care is mobile. Is the direction correct? Br J Ophthalmol. 2006; 90(1):7-9 5) Mooney H. Data on ISTCs' clinical quality is 'extremely poor', says Healthcare Commission. Health Serv J. 2007; 117 (6039): 5 Competing interests: Conflict of interest declared; The Bolton Eye Unit is An NHS 'Action on Cataract' site |
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Simon E Horgan, Consultant Ophthalmologist Royal Eye Unit, Kingston Hospital, Galsworthy Road, Kingston upon Thames, Surrey, KT2 7QB, Adam Hustler, and Dario Inzerillo.
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Sir, At a time when the trend for commissioning more cataract operations involves using unconventional options such as IS-TCs ( Independent Sector Treatment Centres ), it was refreshing to read of Tey's commendable achievement in delivering a 60% increase in surgery to standards of the highest level from within his own department.(1) We were left wondering, however, whether the increased number of operations since 1997 had more to do with the changing nature of small incision cataract surgery ( now the norm ) rather than the introduction of specialist cataract nurses. Many of the alterations to his service could have been forseen without the need for an expensive pilot study ( £20,000 for 100 patients )and we believe, without the additional annual cost pressure of employing four more specialist nurses. By far the largest increase in surgical workload ( 116 cases per 3 months )was actually undertaken by the consultants themselves, whilst the expansion in number of their specialist registrars over the study period increased training opportunities by a much smaller amount ( 21 cases each rather than 18 ). Finally, it was unclear what proportion of patients received postoperative review exclusively by the nurses, and how many visits were infact required. Yours faithfully,
1. Tey A, Grant B, et al. Redesign and modernisation of an NHS cataract service: a multifacteted approach. BMJ. 2007;334: 148-152. Competing interests: None declared |
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Adrian Tey, SpR in Ophthalmology Ninewells Hospital and Medical School, Dundee DD1 9SY, Roshini Sanders
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Dear Editor, In response to Mr Horgan et al, we would like to point out that we had mentioned that the conversion to small incision cataract surgery had a bearing to the increased number of surgeries performed (page 151 Paragraph 4) As seen in the table comparing 1997 and 2004, there was nearly a 2.5 fold increase in the number of phacoemulsification performed and we do not deny that this has been a large contributing factor to the increase in procedures performed. However, it is with the presence of the newly appointed specialist cataract nurses which has helped in increasing the number of pre surgical assessment of patients and this inadvertently meant more patients invariably listed for surgery. So they are an important part of the ‘cataract team’. The employment of these specialist nurses did not have any impact on annual cost pressures as it was already incorporated as part of the trust annual budget (fortunately). As for the expense of £20 000 used for the initial pilot study, this grant was primarily used for purchase of equipments (slit lamps, lens etc) for the newly formed One Stop Cataract Clinic (OSCC). Undeniably, the largest increase in workload was by the consultants, however we have in this paper suggested that the changes to the cataract service into a high volume service did not have a detrimental effect on trainees operating. In fact, there was more than a 2 fold increase in surgical opportunities for the trainees (43 cases in 1997 to 100 cases in 2004) We are unsure of how Mr Horgan et al came up with the values of 18 cases each in 1997 and 21 cases in 2004, but in 1997 we had 3 operating trainees (1 GPVTS) whereas in 2004 we had 4 operating trainees (including the new SpR). So it would be an average of 14 cases each in 1997 and 25 in 2004. Ergo there was enough surgery for every trainee following the inception of the OSCC hence the opportunity to attract another SpR slot. First day post operative visits were exclusively performed by nurses (domiciliary visits), and on average 1 further visit to the hospital was required between weeks 2 and 4 post operatively depending on individual consultants. I hope this has answered the queries posted. Yours faithfully, Adrian Tey, Roshini Sanders Competing interests: None declared |
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