fast-track surgery

Published: 31/10/2002, Volume II2, No. 5829 Page 28 29

A fast access service for cataract surgery has reduced waiting times and the number of visits required. Christopher Kerr and Sue Kavanagh explain

Croydon, in line with many other parts of the country, is keen to improve access to cataract operations. Action on Cataracts, published by the NHS Executive in February 2000, showed that, nationally, the average patient wait was eight to 10 weeks for an initial outpatient consultant and then a further seven months for surgery. At that time, the waiting time in Croydon for a cataract operation was from nine months to a year and a cataract operation involved seven visits to health service providers.

Action on Cataracts called for long waiting times to be reduced and for services to be redesigned from the patients' point of view. It pointed out that in some areas patients had three visits to eye health services to have their cataract diagnosed and treated, while in others seven or eight visits were required.

Following the publication of this report, Croydon primary care trust and Croydon local optometric committee established a fast-track cataract service to increase the number of operations. Funding was provided by the PCT, which provided£10,000 in start-up costs for the first year and has continued to meet the running costs. The scheme, which went live in July 2000, allows local optometrists to refer patients directly to the eye unit at Mayday University Hospital, Croydon. Consultation with local GPs found they were happy for patients to be referred in this way without their involvement.

Previously, the process consisted of a visit to an optometrist, followed by a visit to the GP, a hospital visit for an initial assessment, another hospital visit for pre-operative tests, the operation itself and then a follow-up visit to the optometrist.

Nineteen of the 52 optometry practices in the area are now taking part. Those agreeing to participate were required to sign a service-level agreement before using the service.

Patients seen by an optometrist and felt to require a cataract operation were referred to the fast-track cataract service using the appropriate locally developed form.We have now audited the first year of the scheme.

All patients in this audit were seen by a consultant ophthalmologist at Mayday Hospital eye unit. An initial pre-operative consultation took place with all pre-operative tests. Once it was agreed that an operation was appropriate and the patient was willing to proceed, the patient was given a date for the surgery to be carried out.

This process resulted in one fewer visit to the hospital for the patient, and no visit to the GP.

Following the operation, it was agreed that patients were to return to their primary care optometrist for a postoperative examination. At this visit, they would bring a post-operative report issued by the eye unit.

Optometric practices were paid£15 for each pre-operative referral and£15 for each post-operative examination.

The service was established to maximise useful information available to patients while minimising the overall patient journey by reducing patient visits from seven to four.

The revised pathway was expected to cut the waiting time for day-case cataract surgery substantially - to approximately two to three months from a year - with overall length of time between referral and operation reduced to six months and outpatient appointment waiting time reduced by 50 per cent. It was hoped this would help to develop Mayday's cataract service from a unit performing approximately 1,500 cases a year towards a service that would treat 3,000-4,500 cases.

This would make a significant contribution of 28 per cent towards the required 94 per cent target in the Action on Cataracts guidelines.

By introducing an optometric booked admissions service to Mayday in the future and integrating all hospital ophthalmologists into the service, it was hoped to further reduce waiting times.

Appointments were to be offered within 10 weeks of receiving the referral letter. A surgery date of not more than four months from appointment and between six and eight cases per list were to be operated on at one time, while sustaining day-case rules and all other clinical outcomes.

The audit was carried out using pre-operative referral claims received from practices. It showed a total of 318 referrals being made to the service during its pilot year. Of these referrals:

there were 243 made directly by optometric practices;

75 were from the hospital (second-eye operations);

two were from GPs.

Of the 318 referrals, a total of 262 operations took place. The Mayday eye unit record system showed:

there were 262 operations;

five patients were treated elsewhere;

four patients decided against the operation;

two patients were logged but offered no appointment;

three patients failed to attend the first appointment;

42 patients had no hospital or cataract records on the eye-unit system.

The operations carried out consisted of 187 firsteye operations and 75 second-eye operations.

Following completion of the initial information using the claim forms received and access to the Mayday records system, questionnaires were sent to 224 patients. There were 128 replies (57 per cent). Seventy-nine patients gave a score of up to 10 on their overall satisfaction of the service, and of those 79 patients:

56 gave a score of 10 (70 per cent);

nine a score of nine (11 per cent);

eight a score of eight (10 per cent);

three a score of seven (4 per cent);

one a score of six (2 per cent);

two a score of five (3 per cent).

The questionnaires also showed that 109 (85 per cent) of the patients returned to their optometrist for their post-operative follow-up examination and 74 received a post-operative report from the hospital following the examination.

The results showed:

the longest waiting time between referral and operation was 13 months, and the shortest time one month;

an average waiting time of 6.74 months;

there were 124 patients (47 per cent) waiting six months (either first or second eye) from the date of referral to the date of operation.

Recommendations included in the good practice guidance state that 'a second-eye cataract should be removed 'fairly soon', preferably within two to three months'.The longest waiting time for a second-eye operation was 10 months and the shortest was one day, with the average at 4.9 months.

Many of the hospital standards and monitoring protocols were unable to be included in this audit and much of the information was unavailable.

But we can determine that patients had an average of seven weeks'waiting time between referral and pre-operative assessment, which fell within the 10 weeks standard set. The longest wait was 40 weeks, and the shortest was one day.

The average waiting time between pre-operative examination and operation did not achieve its target of no more than four months.And the audit shows a greater length of waiting time for patients being referred to the service in the second half of its pilot year, compared to the first half.Waiting times need to be reduced in order for this service to continue to be fast track. It has been proposed to involve two other consultant ophthalmologists in order to achieve this.

Of the 128 patients who replied, 109 (85 per cent) returned to their primary care optometrist for a post-operative eye examination.

This equates to 41 per cent of those who had had an operation.Of these 109, only 74 had been given a post-operative form by the hospital.

These forms were not issued to patients at the beginning of the pilot - the process only started in the ninth month.

This needs to be monitored further to ensure the necessary information is being taken back to practices. The rate of patients returning to their optometrist is a concern. It is uncertain whether or not a post-operative examination is taking place for all patients who have undergone an operation.

From the replies received, it appears that patients thought the service was excellent.We would like to see it extended to include all the optometrists in the area.

Key points

A fast-track cataract service funded by a primary care trust has reduced waiting times and cut the number of visits required from seven to four.

Patients are given a date for surgery during their first hospital appointment.

The average waiting time is now just under seven months.

Patients are very satisfied with the service.More than half gave the highest satisfaction rating.

Christopher Kerr is chair and Sue Kavanagh is support worker, Croydon local optometric committee.