Direction of NHS raises concerns among U.K. ophthalmologists

Controversy over changes in the NHS has been reignited with the announcement of a second round of funding for independent providers.

The newly appointed secretary of state for health in the United Kingdom, Patricia Hewitt, has recently reignited debate over the direction of the National Health Service with the announcement of a second round of funding for high volume independent surgical treatment centers to deliver routine operations.

The funding, which will amount to £3 billion (about US$5.26 billion) over the next 5 years, is part of a second wave of contracting with independent providers with the aim of offering patients more choices and decreasing waiting times for surgery. The funding will aim to allow private contractors to carry out 15% of all NHS operations and help the NHS reach a 2008 target waiting time of 18 weeks from the point of referral to the operating table.

The announcement has lit a new fire in the debate over the government’s race to shorten surgical waiting lists, such as those for cataract surgery. Some observers fear they are witnessing the NHS being “dismantled,” as a commentary piece in The Guardian newspaper warned. Other commentators have been more sanguine.

“These changes are not going to ruin the NHS. What it will do is fundamentally change the way [surgical services are] delivered,” said Richard Packard, MD, FRCS, a member of the Ocular Surgery News Europe/Asia-Pacific Edition Editorial Board and a consultant surgeon in Berkshire.

Some ophthalmologists have expressed concern about the impact these changes will have on the training of young ophthalmologists and about the burden that will be placed on the NHS to deal with more complex and chronic cases such as glaucoma and retinal diseases, as more cataract care moves into the hands of the independent contractors.

The president of the Royal College of Ophthalmologists, Nick Astbury, FRCOphth, released a statement asserting the College’s stance on the changes in response to a radio interview with Ms. Hewitt.

“The Royal College of Ophthalmologists is opposed to a target-driven culture that emphasizes one single condition at the expense of chronic eye conditions such as glaucoma, diabetic eye disease and age-related macular degeneration,” Mr. Astbury wrote. “The transfer of large numbers of patients with a single condition, such as cataract, significantly alters the residual case-mix, leaving a larger proportion of difficult cases suitable only for experienced consultants. Training must be a priority if we are to have eye surgeons for the future.”

Mobile cataract units

One of the features of the NHS changes is the mobile cataract units that have been brought in by a South Africa-based health provider, Netcare, a company that was awarded a contract to perform about 44,500 cataract operations across England.

Netcare has been working with Britain’s Department of Health for the past 3 years on the waiting-list initiatives, bringing in clinical teams of consultants, specialists, health care workers and nurses to reduce the waiting lists.

According to the Department of Health, Netcare has treated 12,500 cataract patients since February 2004.

“It’s probably one of the largest cataract contracts of its kind in the world,” Netcare’s chief executive officer, Richard Friedland, MD, told Ocular Surgery News in an interview.

U.K. Health Minister Lord Warner of Brockley said waits for surgery have been reduced from 9 months to 12 weeks, and this has a carry-over effect to other surgeries as well.

“Nobody in the NHS is waiting more than 12 weeks for cataract surgery now,” Lord Warner said. “This has a knock-on effect, in that those patients who are waiting for glaucoma operations and other operations will benefit from not having those cataract patients on the list as well.”

But according to Mr. Packard, while this solution helps reduce waiting lists, it overburdens NHS hospitals with patients that require extensive treatment and funding to support their care. Meanwhile, the surgical volume and money that would normally flow to the NHS hospitals are lost to the cataract units.

“You need to have a recognition that being an efficient cataract provider and getting the volume of patients is needed in order that you would be able to subsidize the other parts of the service,” such as care for more complex diseases, he said.

Lord Warner disputed this argument, stating that the NHS facilities will be rewarded appropriately for providing the more complex care and that the NHS is taking these issues into consideration in implementing the program.

“Saying we are not doing this for the other operations is actually missing the bigger picture, which is, we are doing it, we are just starting with cataracts. It is a program in movement at the moment. We are just sorting out how to approach the 2008 18-week maximum wait target for all treatments, covering the whole period from general practitioner referral to specialist treatment including all diagnosis,” Lord Warner said.

Mr. Friedland of Netcare said, however, that while it is possible that complex cases can be outsourced, these are not cases that could be currently handled by Netcare’s mobile units.

“Certainly within a mobile cataract unit, I wouldn’t think that much more than simple, routine day-casework could be attempted,” he said.

Moreover, Mr. Packard added, it is unlikely that providers like Netcare would want to get involved with more complex procedures because cataract operations are the easiest and most profitable to perform.

“They want to have the easy and straightforward cases where they can do four an hour without raising a sweat,” Mr. Packard said.

Compromised training

In a commentary piece in The Guardian, Robert Lane, the president of the Association of Surgeons of Great Britain and Ireland, wrote that 20% of training opportunities have been lost in ophthalmology and orthopedics because of the introduction of the independent sector treatment centers (ISTCs).

Some ophthalmologists have noted that in taking cataract business away from NHS hospitals, the caseload for trainees is depleted.

“Trainees require in NHS departments a mix of clinical material, as it were, or patients who have got a variety of conditions, so that you have got a good training substrate, ie, straightforward cataract operations,” Mr. Astbury said.

According to some news reports, Ms. Hewitt said that the government would be discussing with the British Medical Association the role that independent providers might be able to play in training students and junior doctors. Mr. Astbury dismissed this idea as unrealistic.

“The fact is, if you are doing huge numbers of cataract operations and making money doing that, it is not the best environment for a junior person to be practicing on patients who are, one, fee paying, and two, part of a volume service,” he explained.

Patient choice

According to Department of Health information, the department is evolving toward a patient-centered NHS that will give patients the choice of at least two providers for cataract operations, with a level playing field for the ISTCs and the NHS hospitals.

But some commentators have raised concerns about the lack of treatment continuity in such cataract units. According to Netcare’s Mr. Friedland, that company employs about half of its doctors on a rotating basis.

“Some of [the surgeons] are in their own private practice or in practice elsewhere, and so they will come three or four times a year, and some of them come more frequently,” Mr. Friedland said.

Mr. Packard says that this model raises concerns about instances in which secondary care or management of complications might be needed.

“[The Department of Health] recognized that the people like Netcare were not actually able to provide a regular source of good quality doctors because most of the people that are coming over are only coming for 3 weeks at a time, so there was no continuity of care, and if there were problems, they all went back into the NHS,” he said.

The patient-choice system being implemented by the NHS involves use of new computer software, called Choose and Book, through which patients will make their choice of location for surgery. It will allow patients to decide whether they want to go to an ISTC or to a hospital. But homogenizing the information technology of the entire British health system poses huge logistical problems, critics have noted.

“What’s envisaged is that there will be a nationwide system for the whole of the NHS, whereby everything communicates with everybody else, but all of the hospitals have already got systems in place, usually rather ancient, and none of them talk to each other because they are all written in different software on different operating systems,” Mr. Packard said.

According to Department of Health plans, the Choose and Book program is to be initiated in a small number of “early adopter” sites throughout the country in order to refine the system before incorporating it into the entire NHS.

What is to come

With so much up in the air, physicians and surgeons are left wondering what the state of the NHS will be when all is said and done.

“I think over the next 18 months to 2 years, things will start to fall into place,” Mr. Packard said.

Mr. Astbury suggested two possible outcomes.

“If the training hospitals are unaffected by the treatment centers and if waiting lists come down, then I don’t think we really have too much to complain about. But if they do affect the local health economy so that hospitals start to go under because they can’t compete and they do affect the case mix of the throughput in hospitals so that trainees simply do not have the straightforward patients to operate on, then I think that does become an issue,” he said.

For Your Information:

• Richard Packard, MD, FRCS, can be reached at Arnott Eye Associates, 22a Harley St., London W1G 9BP, England; +44-20-7580-1974; e-mail: eyequack@vossnet.co.uk.
• Nick Astbury, FRCOphth, can be reached at The Royal College of Ophthalmologists, 17 Cornwall Terrace, London NW1 4QW, England; +44-0-20-7935-0702.
• Richard Friedland, MD, chief executive officer of Netcare, can be reached at Netcare Healthcare UK Ltd., 2nd Floor, 3 Tenterden St., Hanover Square, London W1S 1TD, England; +44-0-20-7154-7839; fax: +44-0-20-7154-7801; e-mail: richardf@netcareuk.com.
• The U.K. Department of Health can be reached at Richmond House, 79 Whitehall, London SW1A 2NL, England; +44-0207-210-4850; e-mail: dhmail@dh.gsi.gov.uk; Web site: www.dh.gov.uk.

• Jared Schultz is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses geographically on Europe and the Asia-Pacific region.