Ophthalmologist and patient

Patient choice in ophthalmology treatments

NHS and private ophthalmology care – what should optometrists and patients know?

Tim Manners MRCGP, FRCOphth.

In England, more than 20 years ago, NHS-funded surgical eye care was generally in the local general hospital. This meant sharing space with all the other hospital services, but at least the patient knew where to go. Many of the much-loved eye hospitals up and down the country had closed decades earlier (with some notable survivals, including Sunderland and Moorfields).

What drove centralisation was the need for beds and safe anaesthetics. Recent decentralisation has been driven by several factors: a move to day surgery under local anaesthetic, the investment in NHS infrastructure not matching eye care demand, a belated realisation that elective care is disrupted by acute care when it is on the same site, and a comprehension that sometimes, care closer to a patient’s home is better for all.

This has led to growing private sector investment in NHS-funded care. This, together with patient choice, has pushed up standards of service and improved the physical clinic environment. Patients need a helping hand in understanding provider choice in their area, and optometry practices acting as the primary care referrer need to know what ophthalmology services are available locally. I’ve found these factors influence patient choice:

  1. Quality. An oft-overlooked factor but the most important. There is under-recognised variation in quality of outcome both by facility and surgeon. Both organisational and individual surgeons’ skill are relevant. Anecdotal feedback from local experience is still sadly the commonest way, but data is slowly catching up. Look at the Care Quality Commision ratings and reports as well as surgeon complication rates on the National Ophthalmology Database. Not all surgeons are on that database but if not, ask why. Outcome measures are getting better all the time, for example complexity of case mix is now taken into account. Patients need help in judging quality measures, and historically still attend NHS services given dreadful judgements, possibly out of misplaced loyalty to their local service.
  2. Accessibility. How quickly and easily can the patient be seen, and provided with follow up care and emergency care if needed? Waiting times have been massively disrupted by Covid in most NHS Hospitals. Information on next available appointments is available on eRS, which most optometrists can’t access. NHS.uk publishes wait times (three months in arrears) for ophthalmology services as a whole.
  3. Restrictions. The majority of NHS commissioners attempt to restrict access to cataract surgery in the first or second eye. In doing so they are disregarding NICE guidance which states “Do not restrict access to cataract surgery on the basis of visual acuity”. NICE also states the second eye is to be treated under the same criteria as the first eye. Challenging commissioners is outside the capacity of most patients, although relatives with power to challenge are sometimes useful!
  4. Expectations. The NHS provides cataract surgery with a standard monofocal lens. Though a good refractive outcome is possible, for example with mini-monovision, careful planning beyond a basic spherical aim is often overlooked, and at this time patients are not allowed to “top up” the basic NHS Lens.
  5. Chronic care. For chronic patients will get used to seeing a new clinician every time they attend, but they never like it. Also, the experience of waiting in NHS eye departments can vary.

These points are amplified for people able to pay for private care. The General Medical Council obliges doctors to explain all treatments available for a patient’s condition, even if it is not NHS-funded. This puts doctors in a difficult situation, having to explain that if the patient pays they can get a different level of service and very advantageous outcomes are possible with new premium lenses – while at the same time being able to profit from that choice if they offer private work. It’s an ethical minefield which is made much easier if the patient has some understanding of the choice before they are referred – from the optometrist. If the patient does decide to “go private”, the quality call is even more important as private data is harder to come by, and some patients feel that private is always better. This feeling should have been tempered by recent criminal cases, but many erroneously believe money buys better care.

Here are my pointers to a good private service:

  1. A good NHS locally reputation is a driver to good private work – but this is not always the case now.
  2. Is the clinic an acknowledged expert by peers? Do check the reputation isn’t historic.
  3. Is data on private outcomes externally monitored or self-reported? Is it easy to find?
  4. Does the surgeon work alone or in a team? Colleagues provide control, oversight and collaboration. A group may be CQC registered. If so look it up.
  5. Does the surgeon promise a tightly controlled scope of expert practice? This is a good sign if they do.
  6. If the surgeon is working solo in a private hospital then that hospital takes responsibility for the care, and should be able to evidence quality of care.
  7. Look at the Private Healthcare Information Network. This is still in its infancy but may get better.
  8. Await the government response to the Paterson report. Better governance of the fringes of private sector work should ensue.

Whichever service patients choose, optometrists are a prime information source and integral to a referral process which now largely excludes the GP.

Tim Manners is Medical Director of Newmedica.

This article first appeared in Optician magazine.

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