A study into cataract rationing is an astonishing insight into all that is unfair and unethical about today’s cut-price NHS.
You’re 76 years old. You live by yourself, but you’re mobile and like to get out. One day, you start to notice a cloudiness in your vision, first in one eye then, after a few months, in the other. The blurriness gets worse. Alarmed, you visit your GP.
He thinks it is age-related cataracts in both eyes, and says surgery is the only effective treatment.
So you visit the ophthalmologist. She says you need surgery, that it won’t clear up by itself. But last year your local NHS raised the vision-loss threshold on treatment, so now you must wait until your eyes deteriorate further.
Meanwhile, your friend in a neighbouring town undergoes surgery for the same complaint with the same severity, because her area has a different policy.
A year passes. Your cataracts grow but not quickly enough. One day, you miss the last step on your stairs. You lie on the floor for three hours. You are admitted to hospital with a fractured wrist.
Having heard this news, your PCT gets in touch: you now have a history of falls and so qualify for surgery. But only in one eye – again, you must wait for the second to worsen.
This picture is being played out, in all its various permutations, across the country in today’s NHS.
The issue is not one of clinical evidence (the benefits are clear) nor cost effectiveness evidence (there is plenty). To me, it seems nothing else but a straightforward case of rationing to save cash.
The research from Imperial College London paints a stark picture of how the NHS is failing the elderly.
Cataract surgery is a good use of public money – if you can show a benefit from improve visual functioning on quality of life, such as the risk of falls. A hip operation is pricey.
Unfortunately, the way by which PCTs assess this varies enormously, and rarely follows national guidance or scientific evidence.
The team found a four-fold difference in the thresholds for vision loss employed by PCTs.
A third of trusts made no allowance for cataracts in a second eye. Some PCTs, such as the above example, will consider surgery where visual acuity is above the 50% threshold score only when there is a history of falls, or when the person has lost their independence as a result of cataracts.
Even then, only one PCT has a maximum waiting time on treatment (despite guidelines saying patients should never wait more than two months). A patient could be left, stranded in their home and at risk of falling, for many months or even years while sitting on the waiting list.
More alarmingly, even though there is no conclusive evidence whatsoever to suggest smokers have poorer outcomes after cataract surgery, three PCTs demand patients to quit for 8-12 weeks before surgery. In one policy, if they cannot prove they have stopped they’re shunted to the back of the queue. The Imperial team said this raised ‘ethical concerns’.
Perhaps there will be a time when politicians, finally, hold up their hands and admit the NHS simply cannot afford to offer every procedure recommended in clinical guidance from bodies such as NICE. I’m not banking on that one.
Perhaps, instead, the Coalition will recognise they are the root of these problems by ruinously underfunding the health service into the ground. Again, unlikely.
Meanwhile, you must sit tight, and wait for the sight in the other eye to worsen, worrying each day whether you are slowly going blind.
Cost of NHS reorganisation: £1.3bn (or about 1.4m cataract operations).