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Glaring oversight

The Doctor
Issue 8 
April 2019

Cataract surgery, one of the safest procedures and with some of the best outcomes, has been deemed of ‘limited clinical value’ by commissioners in what’s seen as nothing more than a money-saving ruse. Tim Tonkin reports

Many things have been said about cataract surgery.

Life-changing, for sure. ‘Miraculous’ is not to everyone’s taste, but restoring sight has biblical connotations and it’s hard to underestimate going from near blindness to seeing the world through new prescription lenses.

It’s one of the safest procedures, with the best outcomes. What you don’t tend to hear is that it’s of ‘limited clinical value’.

‘Limited clinical value’ – are we talking about the same procedure? But that’s the reason given by large swathes of the NHS for restricting access to it.


People's decision

The BMA has always said that if the NHS is going to ration (or ‘prioritise’ – the word ‘ration’ is itself rationed) then it should be an open and honest debate, involving the public.

However, research by the MTG (Medical Technology Group) last month found that more than half of English CCGs (clinical commissioning groups) are restricting access to cataract surgery by listing it as a ‘procedure of limited clinical value’ or ‘procedure of prior approval’.

‘Patients are having to endure long delays before they can undergo cataract removal’

Under this designation, the surgery is classed alongside cosmetic treatments such as dermabrasion and tattoo removal.

The MTG, which is made up of patient groups, research charities and medical device manufacturers and lobbies for greater access to medical technologies and treatments, found that ‘just over half of English CCGs listed cataract removal in that way’.


Financial pressures

NHS Clinical Commissioners, the national body representing CCGs, has responded to the findings by describing the limitations on accessing treatment as a regrettable but often unavoidable consequence of the systemic financial pressures on the health service.

‘Wherever possible  they [CCGs] want to give them what they need,’ a spokesperson says.

‘It is unfair to place restrictions on such an important treatment’

‘Unfortunately, the NHS does not have unlimited resources and ensuring patients get the best possible care against a backdrop of spiralling demands, competing priorities and increasing financial pressures is one of the biggest issues CCGs face.’

Many CCGs are also choosing to make access to surgery contingent on patients scoring sufficiently low enough on a visual acuity assessment before they will be prioritised for treatment; in direct contradiction to NICE (National Institute for Health and Care Excellence) guidelines in 2017.


Unlimited value

East Midlands consultant ophthalmologist Amar Alwitry (pictured below) says that, while he understands the financial pressures faced by all parts of the NHS, it is unfair to place access restrictions on such an important and cost-effective treatment.

Mr Alwitry says that in his own professional experience he has encountered patients with cataracts whose visual acuity was above the threshold in one eye but below it in the other.

He says that by labelling cataract surgery as of limited clinical value, was effectively creating a situation whereby patients might be told that they could only receive treatment for one of their eyes.

‘Cataract surgery is one of the safest and most common procedures we undertake. We continually strive to improve and preserve our patients’ sight, and it is hard to turn patients away when you know they deserve and would benefit from second eye surgeries.

‘I appreciate the need to balance the books and as a nation we need to understand the necessity of using our finite resources wisely but refusing second eye cataract surgery does not save money. It simply delays the procedure and leaves our patients with poor vision for longer.’


Positive guidance

While there is no national policy on how to define medical procedures as being of limited clinical value, guidance published last November by NHS England identified 17 procedures that it felt should not be routinely commissioned owing to their limited clinical value. Cataract removal is not among them.

Royal College of Ophthalmologists president Mike Burdon (pictured right) insists that financial pressures provide insufficient reason to limit a patient’s access to treatment.

‘Cataract surgery is one of the most efficient procedures in the health service and the new guidelines will significantly improve the safety and quality of patient care, removing variation in treatment across the UK,’ he says.

‘There is no justification for CCGs restricting access  to cataract surgery. CCGs must take notice of the  NICE recommendations which reinforce the message that cataract surgery should be delivered at point of clinical need.’


'Simple and effective'

BMA council chair Chaand Nagpaul says: ‘The rationing and postcode lottery of such a simple and effective treatment as cataract surgery, is an indictment on the inadequate funding policies of successive governments towards the NHS.

‘The Government has a responsibility to ensure that the NHS provides consistent treatment to patients regardless of their postcode, and to provide the level of resourcing it requires so that patients do not have to endure the health inequalities that underfunding results in.’

Find out more about MTG's research



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