Shared decision making for cataract surgery

Currently, cataract referral guidelines and processes are agreed locally between hospital ophthalmology services, general practitioners, and primary care eye service providers such as optometrists. There is a wide variation across England between the number of patients referred for surgery and those who undergo surgery, with rates ranging from 40-92%. Ideally, for patients, this conversion rate should be more than 80%, which can be achieved if following referral guidance as recommended by the Royal College of Ophthalmologists. Much of the improvement to patient experience and clinical outcome is due to shared decision making. This empowers the patient to be better informed and agreeable to treatment before they are referred to secondary care and protects patients who do not wish to consider surgery, once they are properly informed of the risks and benefits, from needing to go to hospital. This will naturally filter the number of referrals to secondary care to be only those who wish to have the procedure, reducing unnecessary referrals and saving clinician time. Therefore, all referral pathways for cataract surgery should include shared decision making tools.

This guidance applies to those 18 years and over.

Cataract referrals should not be accepted unless a formally documented shared decision making process has been performed by their referring primary care optometrist with the patient (and their family members or carers, as appropriate) as part of a referral. This includes but is not limited to:

• How the cataract affects the person’s vision and quality of life
• Whether one or both eyes are affected
• What cataract surgery involves, including possible risks and benefits
• How the person’s quality of life may be affected if they choose not to have cataract surgery
• Whether the person wants to have cataract surgery.

In line with NICE guidance, do not restrict access to cataract surgery on the basis of visual acuity.

Please note that this guidance is intended as a standard threshold for access. However, if you/ your patient falls outside of these criteria, the option to apply for an Individual Funding Request is still available to you.

Cataract surgery represents 6% of all surgery performed in the UK (over 400,000 procedures a year) with a pre-pandemic predicted growth of 25% in the next 10 years. Patients who are referred need to be reasonable candidates for surgery and have a desire to undergo the operative procedure. Current referral processes often refer patients who, when they have had an informed discussion, do not wish to undergo surgery, which has produced huge variability in conversion rates (from direct cataract referral to undergoing surgery) nationwide, with rates ranging from 40-92%. The reason for poor conversion rates can be due to many factors including commissioning of services, incomplete training, and lack of engagement of primary care staff on shared decision making. The ideal conversion rate to cataract surgery is not agreed, but rates of more than 80% can be achieved by referral guidelines and efficient forms, as recommended by the Royal College of Ophthalmologists.

Shared decision making tools have been proven to improve conversion rates and lead to better patient experience and clinical outcomes. Their use is endorsed by the Department of Health policy ‘Equity and Excellence: liberating the NHS’ highlighting the importance of the patient’s opinion and choice with regards to their care. This guidance uses evidence to propose that all referral pathways for cataract surgery should include shared decision making tools.

NICE guidance has clearly stated since 2017 that referrals for cataract surgery should not be restricted purely on the basis of a measure of visual acuity, and this is strongly endorsed by the Royal College of Ophthalmologists.

Cataracts are when the focusing lens inside your eye develops cloudy patches. Over time, these can cause blurriness, mistiness and deterioration of vision and, if untreated, cause blindness, although this is normally reversible with surgery. Cataract surgery replaces the lens in your eye with an artificial one. People who are referred for cataract surgery need to be fit enough to undergo the surgery, as well as understand the process and want to have it done. Currently, across England the number of people referred who go onto have the surgery varies between 40-92%: this is known as the conversion rate. It is thought this variation is because of how patients are identified, counselled and referred, with many patients who do not want surgery being referred. Conversely, in some areas NICE guidance is not being respected and access to surgery is being inappropriately restricted based on visual acuity.

To improve the conversion rate, and therefore reduce unnecessary referrals for patients who do not want cataract surgery, evidence suggests that clinicians should always use resources to help support patients in making an informed decision as to whether surgery is the best option for them. Decisions to refer for surgery should not be based on visual acuity alone, but instead on the effect the cataract is having on the patient’s visual function and quality of life, and their willingness to have surgery once they understand the risks and benefits.

The EBI programme recommends that the pathway for patients with cataracts to be referred for surgery is updated across England to include shared decision making and not restrict access based on visual acuity.

We recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.

Further information on patient involvement in EBI can be found on the EBI for patients section.

 

 

1. Royal College of Ophthalmologists. The Way Forward report summary. 2017
2. Royal College of Ophthalmologists. The Way Forward report: Cataract. 2017
3. Department of Health. Liberating the NHS: No decision about me, without me. 2012
4. NHS England. Getting it Right First Time: Ophthalmology Speciality Report. 2019
5. NHS England. Shared Decision Making
6. NICE. Cataracts in adults: management [NG77]. 2017
7. Royal College of Ophthalmologists. Workforce Guidance: Cataract Services and
   Workforce Calculator Tool. 2021
8. NHS England. Transforming elective eye care services. 2019
9. Gaskell A, McLaughlin A, Young E, McCristal K. Direct optometrist referral of cataract
   patients into a pilot ‘one-stop’ cataract surgery facility. J R Coll Surg Edinb. 2001
   Jun;46(3):133-7. PMID: 11478008
10. Academy of Medical Royal Colleges. Choosing Wisely. 2016
11. General Medical Council. Decision making and consent guidance. 2020
12. Local Optical Committee Support Unit. Clinical Pathways
13. NHS England and Improvement Eye Care Hub. National Eye Care Recovery and
    Transformation Programme guidance

Last revised - December 2023

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