Option 1: rationing based on visual acuity

Commissioners often use visual acuity (VA) of 6/12 as a threshold for cataract surgery rationing based on the WHO definition of visual impairment.¹¹ The National Ophthalmology Database audit Year 4 report found 34.6% of the patients with cataract have VAs 6/12 or better.¹² If we exclude these patients from the predicted pre-COVID-19 backlog, the 50% predicted recovery workload increase can be reduced to a 2% decrease (8291–8942 cases per week). While this approach seems to offer a straightforward solution that prioritises severe cataracts, it is neither patient-centred nor advocated by the National Institute for Health and Care Excellence (NICE) guidelines.¹³

VA alone is an incomplete measure of patient disability, as the full impact of a cataract on a patient’s quality of life depends on individuals’ overall visual requirements in different environmental or task settings. Therefore, to disqualify a patient with better than 6/12 vision without considering their individual circumstances would not maximise the intended cost-effectiveness of surgery.

Cataract surgery is the most commonly performed operation and the most cost-effective surgical intervention in improving quality of life, with an average expected welfare gain of £1110 in the year after, for a surgery cost of £672.^{14 15} Post-COVID19, services should refrain from using a VA threshold, instead redesign their currently existing patient surgery decision-making aides (PSDMA) to ensure the right patient is operated at the right time.

Getting It Right the First Time national report for Ophthalmology found units with well-established PSDMA tools can achieve an 80–85% cataract referral-to-surgery conversion rate.¹⁶ The post-COVID PSDMA tool should combine existing NICE recommendations with recently published RCOphth and United Kingdom and Ireland Society of Cataract and Refractive Surgeons (UKISCRS) post-COVID guidelines to aid waiting list validation and prioritisation in the recovery phase,¹⁷ and where possible use validated tools to glean quantifiable data (table 1). A digital-enabled tool should enable instant user feedback and education to refine and sustain its implementation.

Option 2: limit surgery to first or only seeing eyes

This maximises the number of patients served by limited theatre resources. However, it assumes improvement of the worse eye provides betterment in overall quality of outcome for all patients at a lower cost, which is not true.

Cost-utility analyses of second-eye surgery have shown that it represents good value. Cataract surgery also has indirect social and health-economic advantages in improving well-being, reducing isolation and premature need for care and road traffic accidents.^{6 20} Considering the mean age of patients undergoing cataract surgery in the NHS is 76, it is critical that these patients have early access to second-eye surgery. Research shows patients who have access to second-eye surgery may experience fewer falls (18% vs 25%) and fewer fractures (3% vs 12%).²¹ New evidence also suggests that rates of falling may increase after first-eye surgery, which is then offset by second-eye surgery.^{21 22} Increased risk of falls may cause significant injury that requires inpatient care in the elderly, which in the immediate post-COVID phase could be hazardous. Moreover, leaving a patient with significant anisometropia may negatively impact their ability to drive and work, and leave them functionally worse after surgery.

Therefore, other measures of visual function such as binocular vision and Real-Life Vision Test should be considered when deciding first- and/or second-eye surgery.^{23 24} These may also help to decide suitability for immediate sequential bilateral cataract surgery (table 1).

Option 3: postponing clinic and surgical dates according to RTT

For patients already listed for surgery and those awaiting first appointment for cataract assessment, postponing them according to their current position on the lists may appear as the simplest administrative solution. However, presently the order of cataract appointments and waiting list is organised as per the referral-to-treatment (RTT) requirements. This is an NHS pledge to patients to complete their treatment in hospital within 18 weeks of the referral being made from their primary care clinician. Thus, the lists are organised by referral dates rather than prioritising according to clinical, social and economic parameters of individual patients.

For the post-COVID-19 world, it is vital that lists take into account which patient is able to wait; who has conditions that will worsen if delayed; whose eye, sight or general health (eg, fall risk) will be irretrievably harmed; and whose surgical risk may increase due to increased surgical difficulty from a maturing cataract. The latest guidelines published by RCOphth/UKISCRS also recommend reassessing and prioritising surgery based on clinical need.²⁵ New Zealand already applies these principles in their Clinical Priority Assessment Criteria; its cataract module includes detailed scoring for driving and independent living and risk of mature cataracts; however, it does not contain assessment on future risk of surgery as a criterion.^{26 27} Units should invest to develop digitally enabled prioritising software locally using the aforementioned criteria.

Patient streams: the integrated practice units

Various risk stratification methods are in use in the UK. Examples include the Cat-12 tool, the cataract complexity score^{6 18} and the built-in posterior capsule rupture (PCR) complication risk score in the Medisoft system.³² These methods correlate PCR risk with patient factors, surgical factors and surgeon experience. For example, a trainee will have a higher predicted complication rate for a white cataract compared to a consultant. These risk assessment tools were originally designed for balancing service provision, training and allocating the cases to the correct level of surgeon for patient safety. NICE guidelines also recommend its use for predicting cataract surgical risk from delay.¹³ However, it is commonly used as a tool for designing high volume lists. These systems can make unmeasured assumptions and equate low surgical risk to a shorter theatre throughput duration for a low cost, which can be misleading in some cases; for example, a claustrophobic patient with low surgical risk cataract may take a longer time than a patient with white cataract operated by a senior surgeon, and end up being more expensive due to sedation cost.

Instead, cataract services should be designed as integrated practice units (IPU). This is the core of value-based healthcare where complete care pathways would include education, engagement, treatment and follow-up all the way to patient-reported outcome measures.^{33 34} Cases can be first defined by patient- and surgery-specific characteristics (table 3), then organised into complex or routine IPUs (figure 1)

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Figure 1

Complex and routine IPUs designed around the characteristics of patients and their cataracts.

All patients present and future can be categorised now during the suspension of elective work using telemedicine, incorporating all aspects of the care cycle. The agile surgical database developed should produce specific patient lists, capable of adapting to last-minute requirement changes. Using improvement tools provided by NHS Improvement, the new system should be modified and adjusted according to measured outcomes, to ensure quality and sustainability for the future.³⁶

Telemedicine for virtual cataract service

COVID-19 pandemic has seen an exponential growth in the utilisation of telemedicine to provide service, for example, telephone follow-ups and the video consultation platform NHS AttendAnywhere.³⁷

We propose a ‘Virtual-Plus’ model for the future cataract service, akin to the well-established virtual glaucoma clinic.^{38 39} A PSDMA enabled e-referral from an optometrist to a cataract service marks the start. Accepted patients are sent tailored cataract-related e-resources prior to their first video consultation with clinicians to clarify the diagnosis and the surgery. The patient-specific information collected throughout can be fed into a patient streaming database. Patients listed for surgery then subsequently progress into a face-to-face diagnostic clinic where patient’s physical parameters such as intraocular pressures, biometry, and anterior and posterior segment photographs will be performed by technicians in hospital or by community optometrists.⁴⁰ Surgeons can then remotely review the acquired diagnostic data and finalise surgical plans with the patient with a second video consultation discussing refractive outcome and complete e-consenting, followed by nurse-led pre-assessment in the same session. Remote pre-assessment has been shown to be safe and cost-effective.⁴¹ Subsequent postoperative reviews with community optometrists or by allied health professionals can bring care to the patient, and both have demonstrated safety and efficiency.^{6 42}

We anticipate this model may not suit all due factors such as lack of digital capability within the unit or the users, unsuitable patients or complex cataracts, for example, dense cataracts or learning disability; patient choice or clinician preference. Ophthalmic units should endeavour to use NHS digital transformation resources to enhance telemedicine development, update electronic medical records and update workforce digital capabilities to enable a stepwise implementation. Adapting the Virtual-Plus model will provide a COVID-safe approach and release clinic capacity for unavoidable face-to-face appointments.

Modification to face-to-face encounters

The current practice of pre-entry screening of temperature, symptoms and contact checks may continue.¹⁷ As SAGE continues to review evidence and announce new guidelines, units must remain versatile to adapt to different protocols quickly. Contact tracing apps,⁴³ vaccinations, swab-test-and trace, future lockdowns and personal protective equipment (PPE) guideline modification will continue to influence practice. Units can facilitate correct practice by addressing infection control, environmental and administrative modifications. These include, but are not limited to, floor markings to ensure correct social distancing is followed, hand hygiene facilities and implementing slit-lamp breath guards. But more importantly, units should adapt educational resources to ensure that both patients and members of staff are constantly updated and reminded of the correct practices of safety measures (eg, short videos and posts on social media, posters in clinical areas and text alerts).

The conventional admission process for surgery day where all patients arrive at the same time, the surgeon performing a 30–90 min preoperative ward round, the patient then waiting between 30 min and 5 hours for their turn in surgery depending on the order of the list and patient load, followed by 30–45 min discharge process, should cease. As this causes 1 hour surgical theatre time loss at the beginning of the list, and up to 5 hours of waiting time for the patients, instead, patients should be staggered by time, and according to the available space capacity respecting social distancing measures. Patients can be given dilating drops to self-prepare for surgery, further reducing admission time. These measures will enable units to use staff time efficiently, reduce patient journey time in hospital, respect social distancing, deploy infection control measures and conserve PPE supply.

Facility and pathway assessment, process map modelling and mock clinic/theatre list simulations should be conducted and reviewed according to the NHS quality improvement Plan–Do–Study–Act cycle to identify potential problems, for example, local outbreak of COVID-19. This will ensure adequate time, facility and contingency measures are in place and rehearsed before reopening any face-to-face services.⁴⁴

Theatre organisation

Operation lists will need to balance efficiency and safety for both patient and staff for the recovery phase and for future. In general, theatre lists can also be segregated according to complex and routine IPUs then modified according to the phase of recovery required. See table 4.

RCOphth/UKISCRS recommend that surgeons and theatre staff use filtering facepiece respirators and eye protection where possible when performing cataract surgery in compliance with the PHE guidance for aerosol-generating procedures.¹⁷ Due to existing uncertainties during various recovery phases, it may be safest to start with a reduced routine list staffed by senior surgeons to maximise theatre operation time and mitigate exposure.¹⁷ Local and PHE infection control measures for elective surgery should be incorporated, simulated and tested to ensure patients and staff safety.

Theatre availability

Cataract surgery may face competition for precious theatre resources with other ophthalmology subspecialities or other surgical specialities for procedures deemed more urgent. It may be hard to argue cataract surgery against cancer surgery. Several methods of enhancing throughput in the cataract service already exist. Post-COVID-19 demand may propel these into wider implementation.

Constraints against change

It is important to remember tariff and staff are usually the main constraints against service remodelling. Take ISBCS for example, it may demonstrate more efficiency, but the second-eye surgery does not automatically equate to increased payment.⁴⁸ Trusts all moved onto blocked contracts from 1 April to 31 July 2020, suspending payment-by-result architecture.² This may or may not continue post-COVID recovery to every trust. Change to service models is inevitable; thus, trusts need to engage and collaborate with commissioners early so that innovative pathways are supported to ensure sustainability.

COVID-19 has demonstrated incredible NHS staff mobilisation and adaptation capabilities when the goal is clear and well communicated: to increase capacity, to save lives. Therefore, units should extend from this experience to build a collaborative working culture that promotes teamwork and user-centric service designs.

Training

Suspension of elective surgery will have hampered cataract surgery training for at least 14 weeks. The recovery plan to clear surgical backlog and mitigate exposure risk will certainly further delay the training of junior non-independent surgeons. Trainees should therefore have access to EyeSi simulator during this period to maintain and practice their skills, enabling them to maximise their training opportunity in theatre when available.⁵² Units with clearly categorised patients within an agile surgical database will be able to design intensive cataract training lists, which has demonstrated to produce safer surgeons.⁵³