CATARACT SURGERY IN SCOTLAND |
24. In 1993 the Scottish Forum for Public Health
Medicine published a Needs Assessment for cataract surgery in
which they estimated that there could be over 24,000 new cases
In practice, the number of cataract operations carried out by
the NHS in Scotland has increased from 10,000 in 1992 to around
16,000 in 1997.
25. We therefore asked whether the difference was
a reasonable estimate of unmet need. The Executive told us that
24,000 was a reasonable estimate of the number of new cataracts
arising each year, or estimated prevalence in the community. They
pointed out that the same report suggested that the number of
patients who would need treating each year would be 16,000 which
was the number now being achieved.
26. The National Audit Office reported that there
were significant variations in cataract surgery levels across
Scotland, with pockets of low treatment rates in some areas of
high social deprivation.
Moreover, clinical audits at two trusts pointed to a substantial
level of unmet need, with more than one third of patients having
visual acuity levels which meant that they were effectively blind
at the time they were listed for cataract surgery.
27. The Committee asked the Executive why there were
significant variations in treatment rates between individual general
practitioner practices. They could not explain this precisely.
They pointed out that it was the job of the local health board
to look at individual practices, different levels of need and
different levels of uptake.
However, they outlined a range of variables at play: the extent
to which patients came forward; whether they visited their general
practitioner or optician; whether they complained of a problem
with their eyes; whether the general practitioner routinely checked
for visual acuity; and what happened when a patient arrived at
28. We asked why a large number of patients were
effectively blind at the time they were referred for treatment.
The Executive told us that picking up morbidity in the community
depended on patients either coming forward to the optician or
to the general practitioner. Patients who might benefit from cataract
treatment would know that it would be appropriate for them to
come forward, usually because they were having trouble in bright
sunlight or their eyesight was deteriorating. However, the Executive
admitted that they had not issued specific advice or mounted specific
campaigns nationally to try to raise awareness of cataracts. They
did have a very active health education / promotion programme
in Scotland which was targeted towards the elderly and the priority
areas of coronary heart disease, cancer and mental health. But
cataracts had not been singled out as a particular priority.
29. We asked whether the Executive had considered
the possible effects on areas such as social services if people
were waiting or not being referred until they were effectively
blind and therefore disabled. They said that increasingly they
were looking at the effects on social work and on the wider community
in deciding where to put their resources.
30. The National Audit Office reported significant
variation in treatment rates for those over 65.
They also found that while some general practitioners look for
cataract as part of an annual check offered to all patients over
75 years old, not all did so.
We asked whether there was anything against the proposition that
general practitioners should actively search for cataracts with
certain risk groups, notably the elderly. The Executive had no
argument with the suggestion that, to get at the patients who
were not coming forward and pursuing actively the need for treatment,
they would have to rely on general education campaigns which would
include general practitioners seeking out patients more actively.
31. As regards health checks for those over 75 years
old, the Executive told us that the check required general practitioners
to look at sensory functioning, but it did not specify that there
had to be a check of visual acuity. In a note, they explained
that the resource consequences of including routine checks on
visual acuity for all people aged over 75 would be small. However,
the change would require a UK-wide re-negotiation of the standard
general practitioners' contract, and as it was most unlikely that
this would be restricted to testing for cataracts, the wider resource
implications could be very substantial.
They also said that extending the check to all those over 75 would
be a policy decision for Ministers to take.
32. The National Audit Office also reported that
low rates of treatment of cataracts might be connected to social
We asked about the efforts being made to ensure equality of access
to treatment for patients in social groups IV and V who were less
likely to go to their general practitioner. The Executive pointed
out that since the General Election, they had added to their list
of strategic priorities the addressing of inequalities in health,
including inequalities of access to health services.
And Ministers had urged all health boards in Scotland to make
sure in their planning that they targeted in particular deprived
communities. However, no specific action had been taken on the
treatment of cataracts, other than commending the C&AG's Report.
In a note, the Executive added that they had not estimated the
costs of targeting cataract treatment on the socially deprived
but they expected health boards to consider options for targeting
in the light of the needs assessments they carried out locally.
33. The Committee asked the Executive about waiting
times for cataract surgery. They assured us that more people were
being treated for cataracts within the waiting times specified
by Ministers: that patients must be treated within 12 months of
a cataract being diagnosed. The best figure the Executive had
was that about 83 per cent of all patients treated for a cataract
were treated within three months of being referred.
34. We asked what measures the Executive might take
in the future to help people to see for as long as possible. They
told us that they expected this question to be encapsulated by
the Royal Colleges in the detailed guidelines they would be producing.
The guidelines would recommend thresholds of visual impairment
for referral and for the operations to be carried out. The Management
Executive also fully expected the guidelines to address the question
of how long it was reasonable to expect patients to wait.
35. The Committee notes that the number of cataract
operations carried out by the NHS in Scotland has increased from
10,000 in 1992 to around 16,000 in 1997, and that waiting times
are within the target of 12 months set by Ministers. We are, nevertheless,
concerned that the Executive are unable to explain some of the
wide variations in treatment rates between different areas and
general practitioners, and about inequality of access to treatment.
We note that addressing health inequalities in Scotland has become
a priority which health boards should address in their strategic
plans, and we urge the Executive and health boards to undertake
more research into variations in treatment for cataracts, in order
to better inform priorities and the allocation of resources.
36. We were shocked that there are a large number
of patients who are effectively blind by the time they are referred
for cataract surgery. We are extremely concerned about the quality
of life of these patients, and about the "hidden" costs
on social services of their care while they await treatment.
37. We were also shocked at the variation in treatment
rates for those over 65, and that health education and promotion
campaigns for the elderly do not seek to increase the awareness
of the problems of cataracts and the availability of treatment
which could significantly enhance the quality of life of those
affected. We welcome and endorse the Executive's view that the
forthcoming clinical guidelines for cataract surgery should address
visual acuity levels for general practitioner referrals as well
as the reasonableness of waiting times for cataract surgery, and
we look to the Executive to ensure that health education and promotion
programmes cover cataracts in future.
38. We are surprised that checks of visual acuity
are not included automatically in health checks for people aged
over 75 years. According to the Executive, the cost of carrying
out these checks automatically would be small. We therefore urge
the Government to make the necessary policy change as quickly
as possible to improve the quality of life of those suffering
39. Implementation of our recommendations should
go some way towards tackling the substantial, and growing, level
of unmet need for the treatment of cataract which we fear may
exist in Scotland.
20 C&AG's report (HC 275 of Session 1997-98), para
report (HC 275 of Session 1997-98), figure 1 Back
11, 87-90, 142-143 Back
report (HC 275 of Session 1997-98), para 2.36 (figure 11) and
2.41 (figure 12) Back
report (HC 275 of Session 1997-98), para 2.48 (figure 14) Back
26 to 32, 71 Back
13, 15, 45-50 Back
report (HC 275 of Session 1997-98), figure 13 Back
report (HC 275 of Session 1997-98), para 2.45 Back
36, 56-61, and Evidence, Appendix 1, p (PAC 195) Back
report (HC 275 of Session 1997-98), para 2.41 Back
62-65 and Evidence, Appendix 1, p (PAC 195) Back
Qs 41, 92-93 Back