Select Committee on Public Accounts Thirty-Second Report


CATARACT SURGERY IN SCOTLAND

ENSURING EQUALITY OF ACCESS TO CATARACT SURGERY ACROSS 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 each year.[20] 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.[21]

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.[22]

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.[23] 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.[24]

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.[25] 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 hospital.[26]

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.[27]

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.[28]

30. The National Audit Office reported significant variation in treatment rates for those over 65.[29] 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.[30] 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]

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.[32] They also said that extending the check to all those over 75 would be a policy decision for Ministers to take.[33]

32. The National Audit Office also reported that low rates of treatment of cataracts might be connected to social deprivation.[34] 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.[35] 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.[36]

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.[37]

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.[38]

  Conclusions

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 from cataracts.

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 2.38 Back

21  C&AG's report (HC 275 of Session 1997-98), figure 1 Back

22  Qs 11, 87-90, 142-143 Back

23  C&AG's report (HC 275 of Session 1997-98), para 2.36 (figure 11) and 2.41 (figure 12) Back

24  C&AG's report (HC 275 of Session 1997-98), para 2.48 (figure 14) Back

25  Qs 26 to 32, 71 Back

26  Q 35 Back

27  Qs 13, 15, 45-50  Back

28  Q 37 Back

29  C&AG's report (HC 275 of Session 1997-98), figure 13 Back

30  C&AG's report (HC 275 of Session 1997-98), para 2.45 Back

31  Q 56 Back

32  Qs 36, 56-61, and Evidence, Appendix 1, p (PAC 195) Back

33  Q 13 Back

34  C&AG's report (HC 275 of Session 1997-98), para 2.41 Back

35  Q 12 Back

36  Qs 62-65 and Evidence, Appendix 1, p (PAC 195) Back

37  Q 38-43 Back

38   Qs 41, 92-93 Back


 
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