UK ophthalmology struggles to maintain high standards in economic downturn

Government cutbacks impose strict limitations on treatments, timing and eligibility for surgery, expert says.

Harminder Dua

In an era of economic crisis and health care cutbacks, ophthalmology in the United Kingdom is struggling to maintain a high standard of care.

“Our daily commitment and challenge [in the U.K.] is to continue delivering high quality care with reduced forces and resources, sticking to the fundamental premise that health care should be free at the point of use,” Harminder Dua, MD, president of the Royal College of Ophthalmologists, said.

With increasing costs related to diagnosis and treatment, a growing number of patients, rising patient expectations, and the government’s need to adopt cost-saving policies to address the country’s £900 billion deficit, eye specialists are seeing their workload increase while struggling to offer their patients the best available standard of care.

“The options are there, the technology is there, but with the low finances, we can’t afford them,” Dr. Dua said.

Changes

In 1990, National Health Service (NHS) legislation in the U.K. reorganized the management and funding of public hospitals on the principle of separating providers, namely hospitals and community services, from the purchasers of health care (ie, the general practitioners). Purchasers are allocated a budget from which they can buy the services of providers, according to patients’ needs and the principles of cost-effectiveness.

“Purchasers establish priorities and criteria for ‘cost-effective care,’ and in recent times we have been imposed heavy limitations on referrals and interventions,” Dr. Dua said.

Ptosis and minor lid lesions such as chalazia can no longer be treated within the NHS because they are considered cosmetic, non-sight-threatening conditions. The criteria for cataract surgery eligibility have been revised, and only patients with visual acuity of 20/40 or less can undergo operations, unless an exception is made on the basis of the patient’s occupation. Cataract surgery in the fellow eye is subject to even stricter limitations.

“We had never been imposed such restrictions before. Although we are making a huge effort to find the best possible compromise between patients’ requirements and official regulations, there is an effect on patients’ care, not in terms of quality, but definitely in terms of timing,” Dr. Dua said.

The Royal College of Ophthalmologists has officially expressed its concern that this rationing or denial of care can put patients’ sight at risk.

An analogous controversy involving the National Institute for Health and Clinical Excellence (NICE) was recently resolved. The initial limitation of intravitreal injections of Lucentis (ranibizumab, Genentech) to selected cases in which both eyes were affected and only in the better-seeing eye caused public outrage.

“Amendments to this first provision made Lucentis largely available in the NHS. This is in fact an area of ophthalmology in which services are good, and lots of new job opportunities have been created for consultants and retinal specialists to meet the increasing demand,” Dr. Dua said.

Work overload

U.K. ophthalmologists complete their full training 7 years after graduation, when they become qualified as consultant ophthalmologists. According to membership data of the Royal College of Ophthalmologists, there are 1,131 consultant ophthalmologists in the U.K. Almost all of them have a contract with the NHS, and 70% to 80% undertake some private practice. Less than 5% work only in the private sector, which is mostly dedicated to refractive surgery.

Consultants are team leaders and work closely with junior doctors and associate staff such as optometrists, orthoptists, dispensing opticians and specialized nurses.

“We have a well-established optometry service in the country. Optometrists work in tandem with ophthalmologists, do all the testing for glasses and contact lenses, are involved in primary care and public health work such as glaucoma or diabetic screening. They can also prescribe a few drugs,” Dr. Dua said.

This historical partnership limits conflict between the two professions, although some controversy has been created by the increasing demand by optometrists to be involved in surgical procedures.

The usual referral route for patients who seek ophthalmic care begins with a general practitioner, who can treat mild ocular conditions such as conjunctivitis. If more specific eye care is needed, the patient is referred to an optometrist, who makes a broad diagnosis and decides whether to handle the case or to refer the patient to an ophthalmologist. Patients can bypass visits to the optometrist and general practitioner and go directly to an eye specialist only when paying out of pocket.

The NHS was established in the U.K. in 1948. It provides universal health coverage to all U.K. residents and is funded by general taxation. About 10% of the population obtain additional health coverage through private insurance companies.

“People go for private insurance to avoid NHS waiting lists, to have the freedom to choose their own doctor or specialist, and to have access to treatments and drugs that are not available on NHS,” Dr. Dua said.

There is a wide variety of private insurance policies, but refractive and cosmetic treatments are not considered. Premium implants are “a very gray area,” where some companies offer coverage and some do not, according to Dr. Dua.

Ophthalmology is well-represented throughout the country. Because the NHS is centrally organized, an even distribution of services is guaranteed. However, the ratio of ophthalmologists to the population is one of the lowest in Europe.

“New treatments are becoming available and the demand for them is growing. In spite of this, we have managed to shorten waiting lists, which are now less than 3 months for most surgical procedures. The exception is corneal transplantation, because of the limited availability of tissues,” Dr. Dua said.

Nonetheless, the increasing pressure on eye consultants is raising concern among ophthalmologists.

“We are expected to do more and more in the same amount of time, and a lot of us work long hours, far beyond what the contract asks us to do. We are coping, but the impression is that we are close to breaking point, where we will no longer be able to provide the same quality,” Dr. Dua said. – by Michela Cimberle

• Harminder Dua, MD, PhD, FRCS, FRCOphth, can be reached at the Division of Ophthalmology, University of Nottingham, University Park, Nottingham, NG7 2RD, U.K.; +44-115-9709796; fax: +44-115-9709963; email: harminder.dua@nottingham.ac.uk.
• Disclosure: No products or companies are mentioned that would require financial disclosure.