New evidence has emerged that clinical commissioning groups (CCGs) in England are ignoring clinical guidelines by rationing access to cataract surgery due to financial pressures.
An investigation* published today in The BMJ found patients were increasingly forced to meet strict criteria before they were referred for surgery despite doctors saying that there is “no justification” to restrict this effective procedure.
Cataract surgery is a common operation in the NHS with more than 400,000 procedures performed every year in the UK. Guidance from the National Institute for Health and Care Excellence (NICE) says it is cost effective and should not be restricted to more severe cases.
However, The BMJ gathered new evidence that patients were being screened and those not meeting visual acuity thresholds were being denied surgery.
It asked all of England’s 195 CCGs about cases of prior approval or exceptional funding over the past three years for cataract surgery.
The analysis showed that rationing has increased in parts of the country since NICE’s guidelines were published, with patients increasingly having to meet strict criteria before they can be referred for surgery.
Among the 185 CCGs that provided data, the investigation found that 2,851 people were turned down for cataract surgery after being referred for it by their doctor in 2018-19 –more than double the number two years ago (1,301).
Figures from the 132 CCGs that provided comparable data revealed that 22% of the total number of cataract operations carried out in England in 2018-19 were screened beforehand – three times the number in 2016-17 (7%).
Mike Burdon, president of the Royal College of Ophthalmologists who also chaired NICE’s guideline committee, told the journal the criteria being applied for cataract surgery by some CCGs to control costs was a false economy.
“There's a cost to the patient and the cost to society from even minor visual loss, and that's what NICE identified,” he said.
Graham Jackson, co-chair of NHS Clinical Commissioners – the representative body for CCGs – said that performing surgery was not without risk, adding: “A clinical threshold is a good way of defining which patients would best be served by (in this case) cataract removal.”
However, a Department of Health and Social Care spokesperson told the journal: “Commissioners should take the latest NICE guidelines into account, to ensure fair and consistent access to the best possible treatment for all cataract patients.”
The journal’s investigation also found widespread local variation in how referrals for cataract surgery were processed.
Some CCGs required no prior approval or individual funding request to refer patients, but others processed and rejected hundreds of referrals in this way.
Nicholas Wilson-Holt, consultant ophthalmologist at Royal Cornwall Hospitals NHS Trust and a former member of the NICE guideline committee, said: “It [prior approval process] is acting as a barrier and it’s not in the spirit of the recommendations.
“It makes people question the value of having NICE guidance, if we take a ‘pick and mix’ approach to which areas we adopt.”
*Iacobucci G. Leading ophthalmologist vows to stamp out “unjustified” screening for cataract surgery. BMJ 2019;365:l2326. DOI: 10.1136/bmj.l2326