Clinical Commissioning Groups limit access to cataract surgery in England

September 11, 2019

Despite its cost-effectiveness and high-success rate in improving visual function, patients in England are being denied vital cataract surgery by their local Clinical Commissioning Group (CCG).

Despite its cost-effectiveness and high-success rate in improving visual function, patients in England are being denied vital cataract surgery by their local Clinical Commissioning Group (CCG).

The Royal National Institute for the Blind (RNIB) estimates that there are around 677,000 people in the UK living with a cataract, 568,000 of which are in England. Cataracts are heavily linked to age, and more than half of the 568,000 affected will be people aged 80 years and over.

Strict access on second-eye surgery

The Royal College of Ophthalmologists states that it is important that patients regain as much vision as possible and are able to use both eyes together.

However, a survey it conducted among ophthalmic leads in 2017 found that some Clinical Commissioning Groups (CCGs) apply even stricter access to patients needing surgery on a second eye, meaning patients can have a cataract removed from one eye, but are then left with impaired vision in the other. When one eye has poorer vision, it is harder to use both eyes together to judge distances, known as stereopsis. This impairment of binocular vision increases risk of trips and falls.

Against NICE guidelines

Now, patients across England are being denied vital cataract surgery by their local CCGs, with over half including the procedure in lists of treatments they deem to be of limited clinical value, despite being proven to be effective.

National clinical guidelines published by the National Institute for Health and Care Excellence (NICE) in 2017 cite the costeffectiveness of cataract surgery, stating that it has ‘a high success rate in improving visual function, with
low morbidity and mortality’.

And according to Anna Maino, consultant ophthalmologist at Manchester Royal Eye Hospital, the British press and social media coverage of this subject isn’t helping patients: “The headlines made people believe that cataract surgery is ineffective, when NICE guidelines say the opposite. CCGs are deliberately not following NICE guidelines and some CCGs use specific levels of visual acuity to select which patients are eligible. Visual acuity, however, does not tell the whole story. I have operated on a number of patients who might still retain relatively good visual acuity for distance but are greatly troubled by poor visual acuity for near, glare, loss of contrast and loss of stereopsis. These problems will adversely affect their quality of life, their ability to participate in pastimes and to avoid isolation (as many patients will stop driving).”

Also commenting exclusively to Ophthalmology Times Europe, Marianne Coleman and Jignasa Mehta from the British and Irish Orthoptic Society’s Public Health Clinical Advisory Group say that orthoptists are closely involved in the cataract surgery pathway in a number of capacities, such as IOL biometry and binocular vision assessment. They agree that cataract surgery is vital to patients and shouldn’t be denied: “Dense cataract can disrupt contrast sensitivity and binocular vision, both major risk factors in falls amongst older people1.

Timely cataract extraction before significant deterioration of monocular visual acuity is therefore important2.”

Use of any visual acuity threshold for surgical referral goes against NICE guidelines for cataract surgery3, which were constructed based on the evaluation of a number of tools/approaches to determine referral threshold, all of which were found wanting. Yet, under current rationing, use of binocular visual acuity thresholds by some CCGs for first-eye surgery referral allows for one eye to deteriorate to the point of meeting the requirements for monocular visual impairment (6/18), a major barrier to good quality binocular vision, they add.

“Time and again in practice, orthoptists are treating older people with binocular vision problems that have emerged as a consequence of cataract-related disruption to heterophoria control, be it due to visual acuity decline in both eyes, or a prolonged period of impaired vision in the unoperated eye while awaiting second eye surgery, which is even more heavily rationed by many CCGs,” says Marianne Coleman, whose research at the University of Surrey focuses on binocular vision problems experienced by older people with dementia, funded by Fight for Sight and the Royal Society of Medicine.

MTG research findings

Research by the Medical Technology Group (MTG), a coalition of patient groups, research charities and medical device manufacturers working to make medical technologies available to everyone who needs them, adds that 104 of the 195 CCGs in England restrict access to cataract surgery. These CCGs include it on lists of ‘Procedures of Limited Clinical Value’, normally reserved for complementary therapies or cosmetic procedures where there is little evidence to prove their cost effectiveness or clinical benefit.

The result of CCGs’ restrictions on cataract surgery is that patients across the country are being denied access to a procedure that they are entitled to, which could restore their eyesight and reduce risk of accidents, such as trips and falls. The research also suggests patients are being treated differently depending on where they live.

For example, London suburb’s Basildon and Brentwood CCG restricts access to cataract treatment while nearby London districts Barking and Dagenham CCG offers the procedure to all patients.

Concerned that the treatment patients receive is being determined by where they live, not what they need, the MTG is launching Ration Watch, a campaign to highlight variation in local commissioning and call for changes to eradicate the
postcode lottery.

Barbara Harpham, chair of the MTG, said: “It’s simply not fair that patients up and down the country are being denied access to vital treatments because of where they live. This indiscriminate rationing by local NHS organisations must stop now
and information about what treatments are or are not provided should be made freely available to patients. It should depend on your needs, not your postcode.”

Impact of visual impairment on falls

Jignasa Mehta is the lead for the British and Irish Orthoptic Society’s Public Health Clinical Advisory Group, and her research at the University of Liverpool focuses on the impact of visual impairment in falls and fear of falling, funded by the Dunhill
Medical Trust.

She says: “The existence of such inequalities in access to cataract surgery is a major public health issue affecting older people. Visual function and binocular vision assessment is absolutely vital within the cataract pathway as part of a multifactorial falls risk assessment, yet consideration of this factor within cataract referral guidance for both first and second eye surgery varies hugely between CCGs.”

A commonly cited paper by CCGs identified an equivocal relationship between falls and delays to second eye surgery5, but stereopsis has been linked by the same research group to quality of life in older people with cataract6. As established decades ago, the patient’s quality of life is a far more informative metric than visual acuity when deciding on referral for cataract surgery7,8.


Yet these considerations are inconsistently applied by CCGs, with further arbitrary inequalities in access existing within some referral guidelines, such as prioritisation of drivers over non-drivers.

With all this in mind, Helen Lee, Eye Health Policy Manager for the RNIB, agrees that cataract removal is a crucial procedure that has a huge impact on the lives of patients and their families.

According to Lee: “We know that restrictions or delays to cataract surgery can severely impact people’s ability to lead independent lives, making them twice as likely to experience falls and significantly reducing quality of life. It’s shocking that access to this life-changing surgery is being unnecessarily restricted by so many CCGs. We firmly believe that all patients who will benefit from cataract removal should be entitled to it and we urge CCGs to ensure the NICE guidance is fully implemented. Eye health services should be prioritised, so patients get timely access to treatment, rather than waiting months−or even years−for sightsaving surgery.”

Other treatments that are rationed in an investigation by the MTG, conducted in October 2018, it was revealed that CCGs across the country are also rationing access to other proven treatments by including them on lists of restricted treatments or by applying high thresholds.

Often these treatments can make a significant difference to patients’ quality of life and deliver savings to the NHS in the long run.

The MTG’s campaign is also calling for a national body to scrutinise decisions by individual CCGs and ensure patient access to treatments is consistent across the country.

Both Marianne Coleman and Jignasa Mehta state that orthoptics is a profession devoted to maximizing binocular vision for all patients, to maintain their quality of life and confidence in mobility, and mitigate vision-related risk factors in falls, and eyecare professionals continue to be dismayed by and condemn the rationing practices employed by many CCGs.

Further, the designation of cataract surgery (particularly for the second eye) by many CCGs as a procedure of low clinical value fails to take into account the important role of good quality binocular vision and unimpeded stereopsis in the independent lives of older people.
Conclusions

With well over half a million people in England living with a cataract and advice from The Royal College of Ophthalmologists stating the import of treatment in both eyes, it is crucial CCGs support and help patients across England by adopting consistent and more holistic access criteria for vital cataract surgery that is proven to be effective.

The campaigns mentioned here, led by clinicians and patient-led groups, leading charities and optical organisations, continue to ensure this happens for better outcomes for all their England-based patients.

References:

1. Lord SR, Smith ST, Menant JC. Vision and falls in older people: Risk factors and intervention strategies. Clinics in Geriatric Medicine 2010;26:569-581.
2. Feng YR, Meuleners LB, Fraser ML, Brameld KJ, Agramunt S. The impact of first and second eye cataract surgeries on falls: A prospective cohort study. Clin Interv Aging 2018;13:1457-1464.
3. National Institute of Health and Care Excellence. [ng77] cataracts in adults: Management. London: National Institute of Health and Care Excellence,; 2017.
4. Meuleners LB, Fraser ML, Ng J, Morlet N. The impact of first- and second-eye cataract  surgery on injurious falls that require hospitalisation: A whole-population study. Age and Ageing 2013;43:341-346.
5. Foss AJ, Harwood RH, Osborn F, Gregson RM, Zaman A, Masud T. Falls and health status in elderly women following second eye cataract surgery: A randomised controlled trial. Age Ageing 2006;35:66-71.
6. Datta S, Foss AJE, Grainge MJ, et al. The importance of acuity, stereopsis, and contrast sensitivity for health-related quality of life in elderly women with cataracts. Investigative Ophthalmology & Visual Science 2008;49:1-6.
7. Mordue A, Parkin DW, Baxter C, Fawcett G, Stewart M. Thresholds for treatment in cataract surgery. J Public Health Med 1994;16:393-398.
8. Steinberg EP, Bass EB, Luthra R, et al. Variation in ophthalmic testing before cataract surgery. Results of a national survey of ophthalmologists. Arch Ophthalmol 1994;112:896-902.