More sight-saving surgery possible, says national report

A national report into ophthalmology services recommends all trusts perform routine cataract surgery in 30 minutes or less, allowing even more patients to have vision-restoring treatment.

Making the best use of hospital theatre time allocated for routine cataract surgery will enable more patients to be treated, and more quickly, according the latest national report from the Getting It Right First Time (GIRFT) programme.

Cataract patients without complications could also receive their follow-up care closer to home via optometrists in the community, without the need to return to hospital.

Around 400,000 cataract operations were carried out in 2018, making it the most common surgical procedure in the NHS. If all trusts were able to treat eight cataract patients on a four-hour theatre list it could ‘create’ an additional 26,500 hours of theatre time (53,000 more operations a year).

The latest GIRFT report – the 10th from the programme – seeks to address the widely-acknowledged challenge of rising demand for ophthalmology services due to an ageing population. Ophthalmology is already one of the busiest specialties in the NHS, carrying out 6% of all operations and booking more than 7.5m outpatient appointments across 120 trusts. Demand is predicted to increase by more than 50% over the next 20 years.

Overall, recommendations and actions in the report focus on how units treating the major sight-threatening conditions – cataract, glaucoma, wet age-related macular degeneration (wet AMD) and diabetic retinopathy – can:

  • Optimise hospital theatre time for routine cataract surgery to enable more patients to be treated, more quickly;
  • Offer more care for age-related macular degeneration (AMD) in settings outside of hospital and closer to patients’ homes, such as mobile units and community eye clinics;
  • Improve the referral process for patients with cataracts, glaucoma and diabetic eye disease, to reduce the number of people attending hospital unnecessarily and ensure those who need treatment are seen more quickly; and
  • Arrange for some post-surgical care to be carried out by optometrists in the community, offering greater convenience for patients and freeing up outpatient time.

These and other recommendations in the GIRFT report have the potential to deliver cost efficiencies of up to £64m.

The report’s three authors look at how existing referral and discharge processes can be streamlined to ensure patients seen in hospitals are those most in need of treatment. Measures include introducing consistent referral criteria for suspected cataract or glaucoma patients, discharging glaucoma patients no longer in need of treatment to allow others to be seen more quickly, and using a 3D imaging technique called optical coherence tomography (OCT) to screen for diabetic maculopathy to help keep unnecessary referrals to a minimum.

The report also suggests measures to ensure patients are seen at the most appropriate time, by the most appropriate professional. This could be achieved by using more primary care optometrists to carry out post-cataract surgery reviews on patients with no complications, establishing more virtual clinics for diagnosing glaucoma, and through the provision of additional clean rooms for administering intravitreal injections to patients with wet AMD.

Improvements can also be made by using ophthalmology resources in the best way – for example, developing high-volume lists for cataract surgery to allow more patients to have their operations, training more members of the non-medical team to give intravitreal injections to patients with wet AMD, and adopting multidisciplinary team working in glaucoma diagnosis and management.

The report is authored by Alison Davis, consultant paediatric ophthalmologist at Moorfields Eye Hospital; Professor Carrie MacEwen, a consultant ophthalmologist at Ninewells Hospital in Dundee; and Lydia Chang, consultant ophthalmologist at Hinchingbrooke Hospital.

Ms Davis said: “Our discussions during this review process have shown that there is an appetite for change in ophthalmology, and we are excited by the opportunities offered by the recommendations in this report.

“During our many visits, it has been fantastic to hear staff talk about the introduction of new practices and that they are already learning from their peers. We hope we can build on their good work as we bring together our findings and make a range of recommendations where we think we can make a difference.”

Professor MacEwen said: “Even very small changes to practice have the potential to make a big difference to capacity in ophthalmology, not to mention to large numbers of patients with the three most common sight-threatening conditions.

“We know there are some very real challenges for teams working in the specialty, not least those posed by demand from an ageing population, and these recommendations offer the opportunity for easing some of the pressure at the same time as benefiting patients and providers.”

And Ms Chang added:

“In 120 visits to ophthalmology units, and in conversations with dedicated ophthalmology teams, we have heard of countless innovative solutions and successful practices which we are now pleased to share more widely in this report. Our thanks to everyone who has assisted in the production of this report – we are looking forward to seeing the recommendations being put into practice.”

The GIRFT ophthalmology report is welcomed by The Royal College of Ophthalmologists. President Michael Burdon said; “The principle value of this GIRFT report is that it provides an in-depth assessment of what is good practice and what could be improved.

 “The clinicians and managers working in ophthalmology services, and those that commission these services, have a duty to reflect on its recommendations. It is vital we adopt efficient models of care, and the reporting and auditing of that care, to ensure we are able to deliver the quality of services that all patients have a right to expect.”

13 December 2019