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U.K. surgeons: Program to reduce waiting lists introduces other problems
Centers contracted by the U.K. Department of Health are handling much of the routine cataracts without expanding the system’s capacity.
Recent efforts by the government of the United Kingdom to reduce cataract surgery waiting times and expand the capacity of the U.K. National Health System are instead creating concerns for NHS hospitals, according to two U.K. surgeons.
Private cataract treatment centers began performing operations at sites around the U.K. in February, after contracts made by the U.K. Department of Health (DOH) with mainly foreign health care management companies went into effect.
The private centers include both stationary facilities that remain at a location for an extended period as well as centers that relocate periodically, performing operations for a few days at a time. These traveling centers include several mobile cataract treatment centers managed by the South African company NetCare and are essentially trucks that open to form complete surgical centers.
According to press releases by the DOH, these private treatment centers are primarily intended to perform additional operations to reduce waiting times for cataract surgery. They are also meant to be cost-effective alternatives to building new operating theaters to expand capacity at existing NHS hospitals. At the same time, they are meant to provide patients with a choice of where to undergo care.
Although the DOH is understood to have had good intentions, Paul Rosen, FRCOphth, an ophthalmologist in the U.K. National Health System (NHS) in Oxford told Ocular Surgery News that many ophthalmologists in the U.K. do not see the programs as necessarily beneficial.
“I think it is potentially a good idea if it provides additional capacity where it is needed,” he said. “But I think one of the problems is with the implementation. Where the contracts have been made with the local purchasers of health care, it has not always been where [the services] are actually required, where there is underprovision of cataract surgery.”
He explained that some areas of England are under capacity in both surgeons and available operating rooms. In such areas the mobile cataract centers are potentially helpful. However, in some areas the centers are not actually taking on additional cases, but instead existing cases at NHS hospitals are being transferred to the private centers.
“The big problem is that it is transfer of work, not additional work. In many areas we do not need any additional capacity; we could do more cataracts if there was appropriate additional funding,” he said. “Patients, therefore money, are transferred from the NHS hospitals to private contractors with the risk of destabilizing established eye departments,” Dr. Rosen said.
Despite repeated attempts, OSN was unable to contact anyone at the Department of Health for comment.
Financial concerns
According to Somdutt Prasad, FRCSEd, an NHS ophthalmologist at Arrowe Park Hospital in Upton, England, the private centers are contracted to perform only routine, uncomplicated cataract surgeries. This leaves the complex and more expensive cases to be handled by the NHS.
But by transferring many of the uncomplicated cataract surgeries, the programs are financially hurting the NHS hospitals, he said.
Dr. Prasad explained that all surgeries are remunerated at a similar rate. Normally, the simpler cases offset the costs of performing more complicated procedures, helping the hospitals to maintain profitability. Shifting that surgical workload to a private organization removes revenue from the hospital’s budget that less complicated procedures would have generated.
“Essentially, the way NHS units are funded, [routine cataracts] subsidize chronic disease care,” he said, citing as examples surgery for glaucoma, diabetic retinopathy and retinal detachment.
“Sitting down to do a vitrectomy will cost the hospital more and take much more time to do. But on the figures it appears as just one case, when I could have done seven cataracts in that time. It is envisaged that in the future remuneration will take into account the complexity of the procedure, but at present a per-case payment system is only being instituted for cataract surgery (in ophthalmology),” Dr. Prasad said.
“For a multispecialty unit that is providing multispecialty service ... it can make things difficult. They say ‘You are doing less cases than you did last year, (because you are doing less cataracts), then you can make do with a little less money,’” he said.
Complications, teaching concerns
Another concern is about follow-up. Patients will have a standard follow-up protocol, but if they have problems when the mobile unit has left, they will have to seek help in the NHS. The mobile centers provide patients with a telephone number to call if they experience problems. But if there is anything serious, the patients have to be transferred to an NHS facility “because their doctors are no longer there,” Dr. Prasad said. The centers also are not equipped to deal with certain intraoperative complications, such as dropped nuclear fragments. These cases would then be transferred back to the NHS.
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“If you have endophthalmitis or a dropped nucleus, then you need a vitrectomy, and you need a retinal surgeon, which they have no access to,” he said.
In addition to concerns over patient follow-up and complications management, Dr. Rosen and Dr. Prasad both noted that all NHS hospitals are also teaching facilities, which require routine cataract surgeries. Diverting many of the routine cases outside the NHS raises issues regarding training.
“We have to train ophthalmologists, which reduces surgical throughput, increasing costs. Furthermore, we may not have enough cases to train surgeons appropriately,” Dr. Rosen said.
Additionally, Dr. Prasad said, the centers are not permitted to employ anyone who is in the service of the NHS, effectively prohibiting the centers from being used as training facilities.
“I cannot teach [trainees] on cases that I would allow only a senior surgeon to do,” Dr. Prasad said. “By definition you need routine cases for training.”
Dr. Prasad said that not all of the routine cases are being redirected from the NHS, but it is a large number that varies by region. In some areas, he said, “[It] would probably mean that almost all the routine cases would be going [to the private centers].”
No increased capacity
Dr. Rosen noted that one of the aims of the programs was to increase the capacity of the NHS. However, the programs risk creating huge overcapacity. Since there is a limit on the number of procedures that will be bought, it is likely that they will transfer of work out of the NHS, he said.
“I think potentially it was a good idea, but perhaps it was not thought through as thoroughly as it should have,” he said. “I think what a lot of people feel is that there should be investment in the NHS hospitals and engagement with the existing surgeons.”
Dr. Rosen noted that often hospitals overall have insufficient numbers of operating rooms, leading to longer waiting times for other surgical specialties, such as urology. To try to reduce those other waiting times, hospitals take operating rooms from ophthalmology instead of building additional operating theaters.
Dr. Prasad said, “Essentially, what it really boils down to is that on the one hand we have a publicly funded health service that is delivered to everyone free. If you are going to continue with that, then it is really best to invest in your standing infrastructure.”
“We as ophthalmologists somehow have failed. We have not been able to convince policy makers that ophthalmology is not just cataracts. ... But there are other aspects to the ophthalmology practice that are as important — or more important — that have been brushed under the carpet,” Dr. Prasad said.
“The way ophthalmology is today, cataracts might be a lot of the elective surgery, but in time and effort cataracts are the minority of the job. Surgically, things like retinal surgery take much more time and much more effort,” he said.
For Your Information:
- Paul Rosen, FRCOphth, can be reached at Oxford Eye Hospital, Walton St., Oxford, England OX2 6HE, United Kingdom; 44-1865-224-739; fax: 44-1865-510-238; e-mail: paul.rosen@eye.ox.ac.uk.
- Somdutt Prasad, FRCSEd, can be reached at Arrowe Park Hospital, Upton, Wirral CH49 5PE, England, United Kingdom; 44-151-604-7193; fax: 44-151-604-7152; e-mail: sprasad@rcsed.ac.uk.
- The Department of Health can be reached via its Customer Service Center at Richmond House, 79 Whitehall, London SW1A 2NL, England, United Kingdom; 44-20-7-210-4850; e-mail: dhmail@doh.gsi.gov.uk.
- Michael Piechocki is an OSN Staff Writer who covers all aspects of ophthalmology, specializing in oculoplastics. He focuses geographically on Europe and the Asia-Pacific region.