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Mike Burdon, President RCOphth strongly condemns failure to stop the continuing crisis in hospital eye services

11 June 2018

Ophthalmologists in the four home Nations are all too familiar with the current crisis in Hospital Eye Services and will welcome the opportunity provided by this APPG to bring the evidence before those responsible for our National Health Service. The Royal College of Ophthalmologists fully endorses the 16 recommendations made in the report. They can be summarised as a call for a strategically planned, fully integrated and appropriately funded eye health service that has the capacity to deliver timely, high quality care appropriate for the increasingly aging population of the United Kingdom.

To my mind, the only disappointing aspect of this report is that it has been necessary to produce it at all. The crisis in eye care is not new and has been discussed at a national level many times in the past.

In 2002 Robert Taylor, then lead Clinician in York, coined the term ‘bow wave of doom’ in an article predicting the increasing difficulty in delivering eye outpatient care. I am not sure that he envisaged at that time how deep a crisis we would be in by 2018.

Some of you will remember the publicity surrounding the capacity issues at the Bristol Eye Hospital in 2003 when it emerged that 25 patients had lost vision as a result of delayed follow-up in the previous two years, more than 1,000 appointments a month were being cancelled and some patients had waited 20 months longer than the planned date for their appointment. This was discussed before the Commons public administration committee and, at that time, it was felt that targets for new outpatient appointments had been achieved at the expense of cancellation and delay of follow-up appointments.

The then Shadow health secretary Dr Liam Fox said, ‘This is the clearest and most shocking example of how ministers’ obsession with targets is both immoral and unethical. The public will be astonished that doctors and nurses are unable to treat the sickest patients because ministers dictate to them who they should treat and when.’

In reply, the Department of Health responded, ‘We have been consistently clear with the NHS, that clinical priorities must come first, and that it is for doctors to decide what those priorities are.’

Perhaps one of the most depressing comments at the time was the statement released by Bristol Eye Hospital management to the effect that the hospital recognised the ‘inconvenience’ caused to patients and was taking steps to reduce the time patients facing cancelled appointments had to wait.

In retrospect, the focus on targets leading to the prioritising of new patients above follow-ups may have deflected opinion from the fundamental problem – a mismatch between demand and capacity that continues to grow.

Since then further evidence of the harm caused by delays in follow-up has been published at regular intervals.In 2009 the National Patient Safety Agency identified that it had received 44 reports of concerns about patient safety due to delays in appointments for glaucoma patients, of whom 13 went blind over a four-year period. In 2017 my College published the results of a British Ophthalmology Surveillance Unit study showing that up to 22 people per month are permanently losing sight as a result of delayed and cancelled hospital appointments, a study that we are in the process of repeating.

I think it is appropriate to reflect on why we have arrived at the current situation. Perhaps paradoxically, part of the problem reflects the success of the NHS.

  • Firstly, people are living longer for which we are all grateful but most blinding eye diseases are age related. Work done by The Royal College of Ophthalmologists predicts a 50% increase in demand for ophthalmology services over the next twenty years
  • Secondly, we have developed more, and more effective treatments for eye disorders. One example of the impact that such treatment is having is a reduction in blind registration for patients with diabetic retinopathy despite an increase in the diabetic population as a whole

However, the fundamental reason why we have arrived at the current huge mismatch between demand and capacity in Eye Care is a long-term lack of strategic planning of eye services at both local and national levels. There are, I am sure many reasons for this but, to my mind, the most disappointing one I have heard is that eye diseases are not high enough up the political agenda, a fact that I find surprising given that most, if not all of us in this room will require some form of eye care in our lifetime. Perhaps another reason is that most of our activity is directed at preventing blindness, and it is difficult for others to assess the true impact of our work.

This report includes personal testimony from people directly affected by the lack of capacity within eye care services, and it is entirely right that they are central to the message we are bringing before Parliament. However, I would like us to briefly consider the impact on healthcare professionals. I have personally experienced, on many occasions, my ability to deliver high quality care being compromised by follow-up delays causing potential or actual loss of vision, and I am not alone. This is devastating for patients and soul destroying for clinicians

Yesterday I received a text from an ophthalmologist saying that the Chief Executive of his Trust has cancelled all ophthalmologists study leave until the backlog of patients is sorted out. This is in a Department where clinicians are regularly running additional clinics in the evenings and weekends. I cannot think of a better illustration of poor quality NHS management than this. The Chief Executive is naïve in thinking that the backlog will be cleared in this way, and he is abrogating his responsibility to manage his ophthalmology service. Clinicians are expected to work to their safe capacity and I believe that the vast majority do so. Thereafter, any excess in demand has to be managed by hospital managers who need to provide appropriate additional resources. Fundamentally, most eye departments need more doctors, more staff, more equipment and more space in order to meet the demands of an increasing population.

Today is the 6th of June, a date that already lives in history as D Day, the day the Allies began the liberation of Europe. Hopefully, at some not too distant future time, it will also be remembered as the day that politicians and the Department of Health started taking action to protect the sight of the nation.

Mike Burdon
The Royal College of Ophthalmologists