Over the past few weeks the realities of the financial challenges facing the NHS have become increasingly evident. Analysis by the Nuffield Trust estimates that hospitals will have to achieve twice the level of efficiencies achieved in recent years, to have any hope of closing the £22 billion funding gap by 2020. Furthermore, that without extra funding or unprecedented savings and a steep reduction in patient demand, major cuts in services are inevitable. Evidence is already emerging that treatment waiting times are increasing and rationing is becoming more pervasive.1 This week's blog considers one example of this rationing, cataract surgery, the leading case of reversible blindness and visual impairment worldwide. This issue resonates personally with me, as I saw first-hand the distressing impact that this condition can have on a loved one.
My grandmother, or Nan as we called her, was an amazing woman whose main focus in life was to support her family. She met my grandfather in the early 1930s and her only child, my mother, was born in 1936. Following the Second World War my Nan and granddad spent the rest of their working lives working in the local cotton mill. They devoted much of their lives supporting my mother and her six children to lead happy and fulfilled lives. They loved reading, playing cards and the highlight of their week was the local darts match (Nan, at four foot eleven, was famous for her 'bullseye' finish). After the death of my granddad from motor neurone disease our family and her weekly darts match become even more important to her. All this changed in the early 1990s when she developed cataracts and her world started to close in on her.
I saw first-hand how debilitating losing your sight can be and gradually my Nan's world shrunk as she became fearful of going out, even with help. No longer able to read, watch television, play cards or compete in her beloved darts matches she became isolated in her own home. During the early 1990s the waiting times for the treatment that could have prevented this deterioration were extremely long and Nan died before she could have the operation. In one of our last chats together she told me that one of the hardest things about losing her eyesight was the feeling that she had lost her identity.
Cataracts affects a third of people aged over 65 and can significantly undermine their ability to live a normal life, work, or drive at night. Simply put, a cataract is the lens becoming cloudy, most often as a result of ageing. Poor vision related to cataracts is a risk factor for falls and traffic accidents, which may lead to hospital admissions and limit independence. The only effective treatment for cataracts is surgery to remove the cloudy lens and replace it with an artificial lens implant. Ophthalmologists perform the short operation, in a hospital day case setting. Cataract surgery is generally very successful and serious complications are rare.
Following the Labour Government's 1997 landslide election victory on a mandate of '24 hours to save the NHS', the NHS enjoyed ten years of six per cent year on year increases in funding and headlines on waiting times disappeared. To find ourselves in 2016, facing similar headlines as the 1990s, is depressing and difficult to justify to patients and taxpayers. In August 2016 media headlines once again highlight concerns about NHS rationing of this (effective) cataract treatment. These concerns led to the Royal National Institute for the Blind, writing an open letter to the Health Secretary warning that widespread 'arbitrary rationing' is leaving thousands of patients at risk of 'social isolation and falls' and that 'spending now to save someone's sight makes financial sense as it costs health and social care budgets more to treat someone who has lost their vision.'2
The UK also performs relatively poorly compared to European peers. OECD data show that in 2014 Britain was 22nd out of 30 countries with just 731 operations per 100,000; meanwhile Portugal carried out 1,273, France 1,168, Germany 1,006, Denmark 933, Hungary and Italy 870, all countries with similar proportions of people age 65 and over. Moreover three in four hospitals in England are now rationing the procedures, despite the cost of an NHS operation being as little as £800.3 Many desperate patients are having to navigate complicated bureaucratic hurdles to prove they need the operation, others feel they have no option that to go private – paying around £2,400 on average (costs in UK private hospitals range from £1,200 to £4,295 per eye).4
One of the reasons the UK rate is so low is believed to be shortages of ophthalmologists. The UK ophthalmologist-per-patient rate is the lowest in Europe at 2.51 per 100,000, followed by the Netherlands at 3.13 per 100,000 and Ireland, 3.99 per 100,000. Greece has the highest ratio at 14.34 per 100,000. Italy and Spain 12.20, Germany and France 8.72 per 100,000. Given this wide ranging difference in supply, this situation is unlikely to be rectified simply by employing more surgeons; more effective surgical practices are needed.
Furthermore, there are currently no national guidelines on eligibility for this vital surgery leaving individual trusts to determine their own policies. The National Institute of Health and Care Excellence was expected to publish the first ever cataract guidance to try to address this arbitrary rationing in 2016 but this is now not expected until 2018. The guidance is expected to state that patients must be referred for surgery if their sight is severely affecting their quality of life and impairing work or hobbies, with patient's individual circumstances being considered (including other health conditions and whether they still work or care for a loved one).
A solution to this dilemma could also be introducing more efficient and cost-effective cataract operations. Indeed, since 2011, think tanks like the King's Fund and Reform have been extolling the virtues of a highly efficient and cost effective approach to cataract surgery developed by the Aravind hospital group in India. It delivers cataract operations at a sixteenth of the cost, with no loss in quality and lower infection rates.5 6 Surely some of the lessons from this much studied approach could be applied in the NHS.
For the sake of the increasing number of older people whose lives are being blighted by this common and treatable problem of ageing, improvements in access and productivity need to be expedited and everyone who needs this relatively cheap and quick operation should receive it. Not only will this improve the quality of their lives, it will help them remain more independent and productive while reducing the likelihood of them needing more expensive health and social care support. I owe it to the memory of my Gran to ensure that this issue remains in the public eye and, by doing so, to reduce others having to watch a loved one's independence and sense of self disappearing.
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