Rationing cataracts gets worse. What about the other areas of covert rationing by exclusion?

Cataract surgery is increasingly rationed: Articles in the Telegraph, and in the BMJ confirm this.

Surely the public has a right to know what is to be excluded. If second cataracts are to be excluded then lets make this National. Citizens then know that they will have options to cover the deficit. Insurance, or simply a health savings (tax exempt) account would be options.

In the kingdom of the blind the one eyed man is king. Desiderius Erasmus‘s Adagia (1500).

Leading ophthalmologist vows to stamp out “unjustified” screening for cataract surgery BMJ 29th May 2019 (BMJ 2019;365:l2326 )

Mike Burdon, president of the Royal College of Ophthalmologists, who also chaired NICE’s guideline committee, said that it was his mission before he stepped down as president in a year’s time to convince clinical commissioning groups (CCGs) to stop rationing cataract surgery and not to label it a procedure of “limited clinical value.” He said that this approach was “unjustified whatever way you look at it.”

He added that it was a false economy for CCGs to apply criteria for cataract surgery as a way to control costs.

Rationing on the rise

Cataract surgery is the most common operation in the NHS, with more than 400 000 procedures performed every year in the UK.

Experts had hoped that NICE’s 2017 guideline would make it harder for NHS commissioners in England to ration treatment for financial reasons. But The BMJ’s analysis shows that rationing has actually risen in parts of the country since then, with patients increasingly having to meet strict criteria before they can be referred for surgery.

Among the 185 CCGs that provided data (95% response rate), the investigation found that almost 2900 prior approval requests or individual funding requests for cataract surgery were rejected last year, more than double the number two years ago. Although the proportion of prior requests for cataract surgery being rejected has fallen since 2016-17, the absolute number is rising (fig 2).

Fig 2

Rejected requests

The investigation follows recent research by the Medical Technology Group, a coalition of patients’ groups, research charities, and device manufacturers, that found that over half of CCGs in England included cataracts in lists of treatments they deemed to be of “limited clinical value.”3

The investigation is the latest by The BMJ to lift the lid on NHS rationing driven by financial pressures. In 2017 it revealed how CCGs were restricting access to a plethora of procedures, including cataract surgery,4 and a follow-up investigation last year found that increasing numbers of patients seeking knee or hip surgery were discovering that they couldn’t have the operations on the NHS.5

Burdon said that The BMJ’s latest findings showed that commissioners were ignoring National Institute for Health and Care Excellence (NICE) guidelines. He said, “Health economists spent 18 months reviewing the evidence for cataract surgery on both first eye and second eye, and they convincingly concluded that there was no justification to ration cataract surgery on the basis of acuity. This was independent of ophthalmologists, including myself.

“What is the point of NICE doing detailed evaluation if CCGs are just going to knowingly ignore that advice? The health service budget is limited, but you should make those spending decisions on the basis of the clinical evidence. Cataract surgery comes out as probably the most cost effective thing in the NHS.”

Graham Jackson, co-chair of NHS Clinical Commissioners, said, “Unfortunately the NHS does not have unlimited resources, and ensuring patients get the best possible care and outcomes against a backdrop of spiralling demands, competing priorities, and increasing financial pressures is one of the biggest issues CCGs face.

“Cataract surgery specifically is an area that is often subject to prior approval. Such clinical decisions are critical in deciding when a patient has reached the stage that an operation will be the best option. Performing surgery is not without risk; a clinical threshold is a good way of defining which patients would best be served by (in this case) cataract removal.”

A Department of Health and Social Care spokesperson said that clinicians were the right people to decide when or whether a patient should have a procedure. “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 spokesperson said.