Evidence submitted by Robert Johnston
(ISTC 11)
I am the first author of the largest survey
of cataract surgery in the UK since 1997. The first paper was
published in the medical journal Eye in July 2005. [105]Previous
national surveys of cataract surgery have taken place in 1997
and 1991. This paper therefore documents the enormous quality
and quantitative improvements that have taken place since 1997.
I was an advisor to the winning Netcare bid
for the chain of ISTCs. This gave me an interesting incite into
the multiple changes of policy by the department of health and
their determination to have a particular model of healthcare delivery
(mobile units and foreign personnel). I turned down the medical
director job for Netcare (and a vast salary) because I do not
think that here today gone tomorrow surgeons are a good way of
practicing medicine. This model was adopted at the insistence
of the DoH.
1. FACTUAL CONCLUSIONS
OF MY
STUDIES AND
EXPERIENCE
At present government policy is based on inadequate
evidence (waiting times, waiting lists and percentage day case
or local anaesthetic only).
The government policy should be based on "need"
(how bad vision is before surgery) and quality of care data. It
is vital for you to understand that there is no absolute cut off
of patients that would benefit from cataract surgery, but each
time the threshold for surgery falls the potential pool of patients
increases enormously.
This data does exist for cataract surgery.
The evidence that I have collected shows that
the UK is now bordering on overprovision of cataract surgery,
for those that present with cataracts to their optometrists or
GPs. For example in the 1997 survey of cataract surgery in the
UK a visual outcome of 6/12 (approximately driving vision) was
used as a measure of a "good" outcome after cataract
surgery. In my study in 2003 almost 50% of patients had this level
of visual acuity before cataract surgery and reviewing data from
centres that use my software in January 2006 this has risen to
55-60%.
Good research has shown that there is still
significant visual impairment from cataracts in patients who do
not present to health professionals (those in nursing homes, deprived
communities, ethnic minorities etc).
Waits for cataract surgery have been eliminated
throughout England (not Wales) due to the increased productivity
of NHS departments. The contribution to the reduced waits by ISTCs
is insignificant in terms of numbers of cases performed and their
limited geographic spread.
At many locations where ISTCs operate the local
NHS departments no longer have enough cataract cases to perform.
As a result of the ISTC programme and the forced
recruitment of overseas surgeons the number of consultant ophthalmology
jobs in the UK has fallen very dramatically over the last few
years. There are now numerous highly qualified surgeons unable
to find a consultant job.
ISTCs are frequently being paid for operations
that they do not perform. You should confirm exactly what this
number is.
Patients are not really given the "choice"
of where to have their surgery. PCTs have been forced by the DoH
to pay for capacity at ISTCs regardless of whether the operations
are performed and therefore coerce patients to go there. There
are already examples of PCTs selling off this capacity to other
PCTs at a significant loss.
The tariff paid to ISTCs and the subsidies for
their start up costs makes surgery in these facilities more expensive
than in current NHS departments.
The tariff for cataract surgery in NHS departments
subsides other areas of healthcare (in ophthalmology and other
specialties) that are not the subject of government targets.
2. OPINION
A system that pays optometrists to refer patients
with cataracts and then pays private organisations to perform
surgery, regardless of real need, will have one result—MORE
SURGERY. The government has therefore set up a tread mill of ever
increasing expenditure on cataract surgery with ever more marginal
patient benefit.
There is no doubt that other areas of ophthalmology
are now more desperately in need of funding (eg the most common
blinding condition—age related macular degeneration) and
yet because this does not appear on waiting lists etc it is not
prioritised.
Demand limitation needs to be implemented now.
ISTC type facilities can be very efficient and
NHS departments have little or no incentive to be efficient.
In my view the most effective way to deliver
healthcare with incentives for efficiency and high quality is
an HMO model. Pay efficient private sector groups a capitation
fee to deliver comprehensive eye care for a population and define
the quality benchmarks that must be met. Groups of UK surgeons
would jump at the chance to show what dramatic improvements would
result. The organisations can have incentives by sharing any money
they do not spend.
Rob Johnston
Consultant Ophthalmologist
9 February 2006
105 Pilot National Electronic Cataract Surgery Survey:
I. Method, descriptive, and process features. R L Johnston, J
M Sparrow, C R Canning, D Tole and N C Price. Eye 19: 788-794. Back
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