In this issue, we present the initial results from the second national survey of cataract surgery, which was a collaborative endeavour supported by the Department of Health, the Royal College of Ophthalmologists, the College of Optometrists, and the Royal College of Nursing. Great credit is due to the authors for what was clearly an enormous task, but they rightly credit all the participating centres for the vital contribution of their own data. Together with the previous 1991 survey,1-3 we now have a detailed picture of what we are achieving in terms of the baseline characteristics of our patients and of the outcome, which is presented by Desai and colleagues in this issue of the BJO (p 893). A further paper will appear giving a fascinating modelling exercise on the national burden of visual impairment due to cataract and the levels of activity required to tackle it.4

Thus, epidemiologists have provided the evidence for an informed debate about what if anything should be done to meet the needs of the population and deal with the ever lengthening waiting lists. This is both a national and global issue. This year, in February, “Vision 2020, the right to sight”—the World Health Organisation’s global initiative for the elimination of avoidable blindness—was launched by the new director general with a commitment of high priority among the WHO’s numerous campaigns.5 Tackling cataract blindness is the first of four priority areas identified for the campaign. The issues from a global perspective were elegantly summarised by Allen Foster at last year’s Cambridge symposium.6 Armed with these insights, we are now in a position to debate our response to these challenges.

We are fortunate as ophthalmologists to own an intervention that is of undoubted effectiveness7 and which can achieve quality of life gains of an almost unequalled scale for a single surgical procedure.8 But it is clear that the extent of the gain is proportional to the severity of visual impairment which preceded the intervention. The rapid evolution of technology, first intraocular lenses and now phacoemulsification (5% in 1991 to 77% in 1997) which together offer rapid rehabilitation and precise aphakic correction, has encouraged us to intervene earlier. In 1997, just under a third of eyes operated on could still see 6/12 or better. While the indication for surgery in these cases could surely be justified in terms of an individual’s symptoms, there is an opportunity cost. This concern was well expressed in a recent leader in theBMJ.9 Those who demand more will tend to be operated on at the expense of those whose need may be greater. The authors of that leader implicitly accept that the volume of surgery nationally is fixed. It seems clear from the epidemiological evidence that volumes will have to increase if we are to avoid a rapidly growing backlog of visual impairment from cataract and an increasing number of our elderly dying visually impaired by a condition for which we have excellent treatment.

Foster’s model for the global scenario is quite clear about the required action when demand is high (as manifest by growing waiting lists). Output must be increased while costs are reduced and quality maintained or improved. Economy of scale should allow us to increase volume and decrease unit cost but this will still require an increased government investment. That quality can improve with increased output has also been shown to be the case although there is a threshold beyond which the pressures of quantity start to reduce quality.

Many ophthalmologists will be naturally concerned that cataract surgery is not devalued; it is after all our bread and butter. But we should be aware that we hold a monopoly and that if we wish to keep it, we should deal with it responsibly. One thing is certain, there is never going to be a shortage of work—even in the lifetime of our most junior trainees. Compared with almost all other industrialised nations, except perhaps New Zealand, there is comparative underservicing of our community. This is an enviable position because we have the opportunity to expand and develop to reach an optimal target of service provision. It is much harder to face reductions and constraints in our activity. The irony is that many of us do face such constraints owing to the shortage of resources in the NHS or perhaps the way they are distributed. But if we want to do more and attract more contracts, we will have to find ways of reducing the unit cost. It is much better that we find ways of doing this ourselves than have it thrust upon us.

Desai and colleagues flag three important questions relevant to this debate which their paper generates. These are the first; there are more to follow.