Demand for cataract surgery has increased substantially over the past decade, and the Covid-19 pandemic has led to a slowdown in activity, causing waiting lists to build further. While cataracts are debilitating, they are not considered life threatening and other types of surgery often take priority, in particular during a situation like Covid-19 when cases need to be prioritised to a greater extent.

However, some Trusts have taken positive action to ensure it would be able to continue with cataract surgery, despite stretched resources. The team at Stoke Mandeville Hospital, for example, have been able to quickly adapt to the new circumstances and now have fewer people on their waiting list than before Covid-19.

Demand is set to increase

The need for cataract surgery is expected to increase as more baby boomers reach the age of 65. In the recent paper ‘The Way Forward’, the Royal College of Ophthalmologists predicts demand will rise by as much as 25% over the next 10 years.

The demand drivers are many and include an ageing population, better surgical techniques, improved patient outcomes meaning surgery is more beneficial for the patient, and increasing availability of surgery.

Expectations are also rising as better vision is needed for everyday tasks. Older people are now more physically and socially active than any previous group of seniors and use electronic devices for entertainment,  for information and to keep in touch with friends and family. A higher proportion of older people also drive.

During lockdown, technology has become more important as a driver for demand as both professional and social interactions have moved online, and people are more aware of their vision problems than before. However, many people have put off seeing an optician or a GP, and this may lead to a surge in referrals once the restrictions start to ease and many older people have been vaccinated.

Although the number of cataract procedures performed have risen over the past decade, recent figures show that the rate of increase has slowed since 2016/17, leading to waiting times increasing in many areas. Patients in some parts of the country were waiting up to 7 months for cataract surgery prior to Covid-19.

Cataracts can be very distressing and can have a profound effect on a person’s quality of life. Everyday tasks such as working and driving can become difficult, if not impossible, with cataracts. But a 20-minute procedure can achieve an overwhelming improvement in sight and restore the ability to carry out normal daily tasks. The procedure has a very high success rate.

Better eyesight means fewer falls and broken bones, and patients who can see well are better equipped to look after their other medical problems, for example administer medicines, reducing the burden on other parts of the healthcare system. So, as well as being important for a patient’s physical and mental health, cataract surgery can also be considered a good investment for the NHS.

Reconfiguring the cataract service

Capacity can be released internally by improving effectiveness in existing theatres, fitting in more patients or working longer hours, but with staff shortages, Covid-19 and a need for social distancing, that has been difficult to achieve. But finding new ways of working can help manage demand in a better way while ensuring all patients get treated in a way that benefits them.

‘The Way Forward’ paper gives a number of recommendations, including maximising the utilisation of both theatre and surgeon’s time in order to improve throughput, and ensuring pre-op patients are kept close to the theatre to reduce delays. Having a stand-alone cataract theatre can help achieve both.

Stoke Mandeville hospital was one of the first NHS units in England to restart elective cataract surgery 6 weeks after the initial lockdown, and since then, over 3000 successful cataract operations have been performed.

Key to the team’s success has been; the wider efforts to reconfigure the delivery of cataract services across Buckinghamshire, which has involved assembling a multi-disciplinary team from across the hospital and the CCG; and the introduction of flexible healthcare infrastructure at the Stoke Mandeville site.

A dedicated space for cataract surgery

The Vanguard unit there provides a complete, stand-alone facility for cataract procedures, consisting of a mobile laminar flow theatre with a procedure preparation room and recovery bays, connected to a modular clinic with a reception and patient waiting area.

The first operation in the new facility took place in November 2020 with the Trust aiming to work through its current cataract surgery waiting list within a year; but already, waiting lists are lower than before Covid-19.

One of the main benefits of having a stand-alone theatre has been a substantial reduction in turnaround times. The Trust has been able to dramatically increase efficiency in the theatre and reduce the amount of downtime. And so far, patients and visitors have also reported a very high satisfaction level, while surgeons enjoy working in the new unit too.

“Our Trust is well known for delivering an excellent cataract service. The project has been a great success so far, and we have had conversations with other trusts who have asked us for advice so that they can start to implement the changes that we have,” says Sarah Maling, joint lead of the cataract service at Buckinghamshire Healthcare NHS Trust.

“Patients love the Vanguard unit, and we have even had requests directly from patients to be treated in the new theatre.”

The operating theatre was designed by Vanguard and Alcon, a provider of ophthalmic surgery equipment, in close collaboration with the Trust’s ophthalmology team.

Dealing with changes in demand

Buckinghamshire Healthcare NHS Trust is not the only Trust that has been able to continue with cataract surgery throughout the pandemic.

A bespoke ophthalmic hub was recently put into place at Royal Preston Hospital, where a dedicated unit was created from two Vanguard two laminar flow theatres and a modular facility. The modular building hosts a welcoming reception and waiting room, consulting rooms, as well as a two-bed ward area and staff facilities, and the unit forms a ‘one-stop’ facility for eye surgery at the Preston site.

Having a standalone facility separate from the hospital was a huge asset to the Trust during the early stages of Covid-19. It has enabled the team at Royal Preston to continue surgery outside of the main hospital theatres, and the flexible nature of the facility meant it could be adapted to accommodate more urgent surgery too.

A temporary visiting hospital also opened to patients at Ashford Hospital in Surrey in November 2020, with the aim of boosting ophthalmic capacity and reducing cataract surgery waiting lists. The facility consists of two mobile laminar flow theatres and a modular patient reception with a ward and staff welfare facility that are connected together to form a stand-alone visiting hospital.

The complex has its own entrance and exit providing patient access to the outside; and patients arrive directly onto the unit and are discharged from the unit after their procedure.

Meeting the expected raised demand in the longer term

Longer waiting times in combination with steadily growing demand for cataract operations has led to an increasing number of patients to be treated privately. In 2017/18 almost one in five NHS-funded cataract procedures in England were done in the private sector, and this figure has likely been even higher during the pandemic.

But while outsourcing to the private sector is an option, retaining the service within the NHS by bringing a dedicated ophthalmic theatre onto the hospital site means greater control and increased flexibility.

A combination of mobile operating theatres and modular buildings provides an ideal solution for increasing capacity in the short term – or for piloting the set-up of a dedicated ophthalmic hub or high volume cataract surgery centre to increase capacity in the longer term. The layout and fit-out can be bespoke to each site and the units can be moved between locations to test out different scenarios.