- Slit lamp examination (including fundus) - Perform biometry and focimetry - Decide appropriateness for surgery - Perform auto-refraction - Discuss desired post-operative refractive status with the patient (including current type of spectacle correction) to enable the choice of lens implant - Perform ECG and blood tests - Identify 2nd eye surgery where appropriate Benefits - reduces duplication of tasks - reduces waiting time for patients - frees up nursing time for other duties - ensures all key tasks are completed in one visit - improves patient experience - reduces overall time in clinic 09 

1. Delivering Quality and Value
Focus on: Cataracts

2. DH INFORMATION READER BOX
Policy
Estates
HR/Workforce
Commissioning
Management
IM & T
Planning /
Finance
Clinical
Social Care / Partnership Working
Document Purpose
Best Practice Guidance
ROCR Ref:
Gateway Ref:
9873
Title
Focus on: Cataracts
Author
NHS Institute for Innovation and Improvement
Publication Date
14 May 2008
Target Audience
PCT CEs, NHS Trust CEs, SHA CEs, Foundation Trust CEs, Medical Directors,
Directors of Nursing, PCT PEC Chairs, NHS Trust Board Chairs, GPs,
Opthalmic clinicians
Circulation List
Description
This document is one of a series of documents produced by the NHS Institute
for Innovation and Improvement as part of our High Volume Care programme.
Produced by the Delivering Quality and Value Team, the aim of the Focus on
series is to help local health communities and organisations improve the quality
and value of the care they deliver.
Cross Ref
High Volume Care: Update
Superseded Docs
n/a
Action Required
n/a
Timing
n/a
Contact Details
NHS Institute for Innovation and Improvement
Coventry House
University of Warwick Campus
Coventry
CV4 7AL
www.institute.nhs.uk
For Recipient’s Use

3. Contents:
1. Introduction
2. Our approach
3. The recommended pathway
4. The key characteristics of high quality cataract care
5. Measures for improvement
6. Benefits of following the pathway
7. Next steps
8. Further information and resources
9. Acknowledgements
Appendices
01

4. 1. Introduction
‘Cataract surgery is now
the most common surgical
procedure undertaken in
England, with around
300,000 operations
performed annually in the
NHS.’
Cataract is a common condition
which causes gradual loss of
clarity in people’s vision. The
World Health Organisation has
estimated that over 18 million
people are blind due to cataract1,
representing 48 per cent of total
world blindness.
02
Mainly affecting elderly people,
cataract can have wider
consequences for individuals and
can affect people’s ability to go
about their normal lives, often
leading to social isolation.
Cataract surgery is now the most
common surgical procedure
undertaken in England, with
around 300,000 operations
performed annually in the NHS.
With increasing life expectancy
and an expanding elderly
population, the incidence of
cataract and, therefore the
demand for surgery continues to
rise.
modernisation. The Department
of Health’s Action on Cataracts2
publication and the Royal College
of Ophthalmologists’ Cataract
Surgery Guidelines3 have greatly
assisted ophthalmology units in
improving quality and standards
for cataract patients.
Following publication of these
resources, the day case rate for
cataract surgery has increased
from 88 per cent in 2000-01, to 96
per cent in 2006-07.
However, from our recent
observations, there is still a
marked variation in the way
cataract care is delivered across
the country, with many units
identifying potential areas for
improvement in their existing
pathway.
In developing Focus on: Cataracts
we have worked closely with NHS
ophthalmology units to identify
the key characteristics of high
quality and efficient care for
cataract patients.
What is care like now?
These key characteristics are
based on our observations of best
practice adopted by
ophthalmology teams across
England. It is intended to help
anyone involved in the cataract
pathway improve their service
and reduce variation in practice.
Cataract care in England has been
an excellent arena for service
We have also explored the extent
to which existing guidance has
1 World Health Organisation, ‘Prevention of blindness and visual Impairment’
www.who.int/blindness/causes/priority/en/index1.html
2 Department of Health, ‘Action On Cataracts: Good practice guidance’ (2000)
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4005637
3 Royal College of Ophthalmologists, ‘Cataract Surgery Guidelines’ (2004)
www.rcophth.ac.uk/docs/publications/CataractSurgeryGuidelinesMarch2005Updated.pdf
been applied in practice
(including Action on Cataracts
and the Cataract Surgery
Guidelines) and sought to identify
any issues or barriers that may be
hampering the implementation
of such improvements. In addition
to this, we also looked for further
opportunities for quality
developments in the delivery of
cataract care.
There are great challenges and
opportunities for all those
involved in opthalmic care. To
meet these challenges and take
advantage of the opportunities
will take focused and planned
effort. It will mean: looking
closely at your current cataract
pathway and taking time to
compare it not only with existing
guidelines, but with the
recommended pathway and key
characteristics explored later in
this document.
‘Due to the high volume
of cataract activity, any
improvements in quality
and efficiency will have
huge benefits to patients,
ophthalmology units and
acute trusts.’

5. Delivering quality and value in
cataract care
Payment by Results (the system of
paying hospitals according to the
number or complexity of cases
treated) is now firmly embedded
within the NHS and plays a major
role in financial planning within
NHS organisations.
The Payment by Results system is
based on a national tariff - a price
list for activity. The national tariff
is calculated using national
average costs (reference costs) as
reported annually by every NHS
trust. Reference costs are
collected on a full ‘absorption’
basis meaning that they include
all costs associated with providing
a treatment such as staff,
materials and equipment.
The national tariff is published
annually in December and
implemented from the following
April. In this way NHS trusts and
PCTs can use the tariff to inform
their local financial and service
planning.
Each procedure or treatment has
its own Healthcare Resource
Group (HRG) code and a national
tariff. There are three HRGs
assigned to cataracts: B13, B14
and B15 with the majority being
performed under B13. The table
below shows the annual volume
and the associated tariff for each
HRG.
Figure 1: Baseline tariff payments and activity for cataracts in NHS England
HRG code
Elective spell tariff
(2007/08)
HRG name
03
Annual volume
(2006/07)
B13
Phakoemulsification cataract
extraction and insertion of lens
£720
269,745
B14
Non-phakoemulsification
cataract surgery
£825
2,951
B15
Other lens surgery low
complexity
£665
16,848
Tariffs are also assigned to outpatient appointments as shown below:
Outpatient
speciality code
130
Outpatient
specialty name
Ophthalmology
outpatients
Adult first
attendance
tariff
(2007/08)
£103
Adult follow-up
Annual adult
attendance
first attendance
tariff
volume
(2007/08)
(2006/07)
£49
1,615,978
Adult
follow-up
attendance
volume
(2006/07)
4,621,097

6. The graph below (Figure 2) sets
out NHS organisations’ reference
costs against the national tariff
for the main cataract procedure,
B13.
‘This means that: 57 per
cent of organisations have
costs in excess of the
national tariff of £720 for
cataract procedure B13.’
These figures again highlight the
potential for improvement that
can be made by streamlining the
cataract pathway.
Figure 2: NHS organisations’ reference costs against the national tariff for cataract procedure B13 (elective)
HRG B13 - Phakoemulsification Cataract Extraction and Insertion of Lens
04
NB data does not include excess bed days and has been adjusted to account for market force
factors. Reference cost data is based on Finished Consultant Episodes (FCEs) and tariff data is
based on spells and therefore not directly comparable.
Questions to be answered within your Trust:
• How do your costs compare with the tariff?
• What reference costs were submitted by your trust for cataract surgery? (HRGs and outpatients)
• Are staff aware and involved with cost improvements?
• Do your local costs properly reflect resource usage across HRGs and services?
About the Focus on series
This document is one of a series published by the
NHS Institute for Innovation and Improvement as
part of our High Volume Care programme.
Produced by the Delivering Quality and Value
Team, the aim of the Focus on series is to help
local health communities and organisations
improve the quality and value of the care they
deliver.
The areas we are focusing on in the programme
have been selected because: they are high volume
(and therefore high consumers of NHS resources),
they show variability in their use of resources and
they represent a range of clinical areas.
To find out more about the programme and the
Focus on series see the Delivering Quality and
Value pages at: www.institute.nhs.uk

7. 2. Our Approach
At the NHS Institute we are
committed to co-producing our
products with frontline NHS staff.
We invite clinicians, managers
and patients from inside the NHS
to work with us as part of our
project teams. We also work
closely with a range of NHS staff
and organisations to ensure that
the people who we want to use
our products are able to influence
their design as much as possible.
Site selection phase: During the
course of this project we visited a
number of organisations
specifically to look at the cataract
pathway. We worked with nine
ophthalmology units across
England each with different
configurations and different
performance profiles and
including two private providers.
As well as spending time at each
unit observing the cataract
pathway (following patients
through their journey from
referral to aftercare) we
interviewed more than 100
staff and patients. The
Acknowledgements section at
the end of this document lists
and thanks the organisations
with which we worked.
Visit phase: Visits to the sites
were conducted over one or two
days. Our activities included a mix
of pathway observation and semistructured interviews. We also
considered how organisations
were using information to aid
clinical and non-clinical decision
making.
Our discussions involved a range
of professionals within the
cataract pathway including
ophthalmologists, optometrists,
orthoptists, pre-assessment
nurses, theatre staff,
anaesthetists, day case managers,
ophthalmology operational
managers, booking and
administrative staff as well as
patients themselves.
Post visit phase: Following our
visits we consolidated and
validated the knowledge we had
gathered. Working with frontline
staff at a co-production event, we
were able to review and agree
the recommended pathway for
patients with cataracts and start
to identify the fundamental
principles and characteristics that
units need to embrace in order to
deliver this pathway successfully.
In the course of this work we
also consulted numerous
professional bodies and voluntary
organisations about our findings.
Our aim:
This document aims to
help local health
communities and
organisations improve the
quality and value of care
for cataract patients. It
contains the key
characteristics for a high
performing, quality
cataract service along with
case studies and measures
for improvement.
The aim is for these
characteristics to be
widely adopted across the
NHS so that cataract
patients have a high
quality experience
irrespective of where they
receive their care.
05

8. 3. The recommended pathway
Undoubtedly the national day
case rate for cataract surgery has
improved significantly to an
average of 96 per cent ranging
from around 74 per cent in a few
units to as high as 100 per cent in
several others.
As a result units are still
combining aspects from the
traditional model of cataract care
and the recommended model,
resulting in:
• delays
• duplication
‘the national day case rate
for cataract surgery has
improved significantly to
an average of 96 per cent’
06
However, during our recent
observations we found significant
variation in how cataract care is
delivered between
ophthalmology units. For instance
some cataract patients spend only
one-and-a-half hours at the
ophthalmology unit on the day of
surgery, compared with up to six
hours in other units.
• and waste within their existing
pathways.
Many units appear to focus their
improvement efforts on only one
aspect of the patient pathway
(e.g. the pre-assessment stage),
meaning there is still scope for
further improvements across the
entire pathway.
However, as the highest volume
surgical procedure for most acute
trusts, any improvements made
towards the recommended
pathway would generate huge
benefits in both time and cost
savings, as well as providing a
more patient-focused service.
Our observations and discussions
during site visits, together with
extensive feedback from
stakeholders during coproduction, have enabled us to
identify the key characteristics of
the recommended care pathway
for cataract patients.
The following tables compare the
traditional and recommended
pathways for the management of
cataract patients across the whole
care pathway.
We do not expect that
units will be following the
traditional pathway in its
entirety but that they will
be able to identify one or
more areas within this
they could improve upon.

9. Referral:
Traditional (up to 2 weeks)
Recommended (immediate)
Step 1: Patient visits optometrist (including high
street opticians)
Step 1: Patient visits optometrist (including high
street opticians) and is referred directly to hospital
eye service
• No specific information as to whether the patient
has lifestyle problems due to cataract or whether
the patient understands the risks and benefits of
surgery and wishes to consider it
• Complete GOS18 generic referral form and send
to GP
• Discuss risks and benefits of surgery (provide
patient information leaflet and consent
information)
• Discuss patient lifestyle
• Ensure patient wishes to proceed with surgery
• Offer choice of provider
• Complete bespoke cataract referral form,
including refraction, and send to hospital eye
service with a copy to the patient, GP and PCT
Step 2: Patient visits GP and refers patient to hospital
eye service
• Send GOS18 form and details of past medical
history to hospital eye service or book
appointment via Choose and Book
Benefits
• saves unnecessary visit to GP
• saves administrative time of GP generating Choose and Book referral
• direct referral leads to shorter waiting time for surgery (appointment can be sooner as non-value
added steps are removed from the referral process)
• accurate bespoke referrals from optometry eliminates wasted visits to hospital eye service for the
patient and saves unnecessary worry – this may reduce cataract referrals by up to 40%
• higher percentage of correct referrals saves unnecessary clinic visits freeing up space for other
patients.
07

10. Booking:
Traditional (up to one week)
Recommended (immediate)
Step 1: Booking team
Step 1: Booking team
• Referrals allocated
• Direct booking into cataract clinic (no or limited
vetting)
Step 2: Consultants
• Referrals vetted by consultants
Step 3: Booking team
• Booking into general clinic
Benefits
• saves unnecessary administrative time
08
• speeds up time taken to generate appointment
• frees up clinicians’ time as no (or limited) vetting of referral letters is required
• reduces the number of patients booked into a general clinic and then returning for pre-assessment
on another date.

11. Pre-operative assessment:
Traditional (3 hours)
Recommended (1.5 hours)
Step 1: Patient sees nurse 1
Step 1: Patient sees either nurse, optometrist or
orthoptist
• Measure visual acuity, pupil reactions and
intraocular pressure & perform biometry and
focimetry
• Measure visual acuity, pupil reactions and
intraocular pressure & perform biometry and
focimetry
• Discuss past medical history
• Discuss current medications
• Complete observations
• Provide patient information leaflets (including
consent information for patients to review
before consent is signed)
• Agree day case
• Discuss anaesthetic options
• Dilate pupils
• Investigations only if indicated
Step 2: Patient sees nurse 2
Step 2: Patient sees ophthalmologist
• Discuss past medical history
• Slit lamp examination (including fundus)
• Complete observations
• Decide appropriateness for surgery
• Discuss current medications
• Discuss desired post-operative refractive status
with the patient (including current type of
spectacle correction) to enable the choice of lens
implant
• Identify 2nd eye surgery where appropriate
Step 3: Patient sees nurse 3
• Perform biometry and focimetry
• Perform auto-refraction
• Perform ECG and blood tests
Step 3: The following should be performed by the
ophthalmologist or a suitably trained nurse,
optometrist or orthoptist as seen in Step 1
• Complete bespoke cataract consent form
(patient reads consent information)
• Complete pre- and post-operative drug
prescriptions
• Complete admission documentation
• Arrange INR test for one week pre-operatively
09

12. Traditional (3 hours)
Recommended (1.5 hours)
Step 4: Patient sees ophthalmologist
Step 4: Patient sees booking team
• Slit lamp examination
• Offer patient choice of dates for surgery and for
post-operative follow-up appointment
• Measure intraocular pressure and pupil reactions
• Agree type of admission
• Discuss anaesthetic options
• Dilate pupils
• Fundus examination
• Decide appropriateness for surgery
• Complete consent using standard trust consent
form (time is spent writing common risks on
form every time as there is no specific cataract
consent form)
• Discuss desired post-operative refraction
Step 5: Patient sees nurse 4 / booking team
10
• Complete admission documentation
• Fixed date for surgery
• Provide patient information leaflet
Benefits
• only one pre-operative assessment visit provides better service for patients and frees up clinic time
• reduces the number of steps and handovers a patient encounters during their pre-assessment visit
and therefore the amount of time the patient spends in hospital
• suitably trained professionals performing most tasks frees up ophthalmologist’s time
• pre-assessment visit ensures that everything is ready for the day of surgery (e.g. consent, choice of
lens, INR test, 2nd eye listing, post-op drugs and post-op appointment).

13. Day of surgery:
Traditional (6 hours)
Recommended (1.5 hours)
Day unit
Step 1: All patients arrive at the beginning of a list
(nil by mouth following trust policy)
Step 1: Patient arrives at staggered or semi block
times and meets ‘primary nurse’ who follows the
patient through the journey including theatres
(patient eats and drinks normally)
Step 2: Nurses dilate patient’s pupil in the day unit
Step 2: Patients dilate their pupil at home or on
arrival
Step 3: Review admission documentation
Step 3: Review admission documentation
Step 4: Examination of the eye by operating
ophthalmologist
Step 4: Recording of observations (blood pressure,
pulse)
Step 5: Complete consent form with operating
ophthalmologist
Step 5: Ophthalmologist or appropriately trained
nurse marks eye and confirms consent
11
Step 6: Operating ophthalmologist chooses lens
implant
Step 6: No undressing
Step 7: Operating ophthalmologist marks eye
Step 7: Patient walks to anaesthetic room
Step 8: Recording of observations (blood pressure,
pulse)
Step 9: Ophthalmologist completes post-operative
drug prescription and sends to pharmacy
Step 10: Total or partial undressing
Step 11: Trolley or wheelchair patient to
anaesthetic room
Ideally, the operating surgeon should be in the position to meet their patient at pre-operative
assessment to discuss refractive expectations and to choose lens implants for the patient ahead of the
day of surgery. This will minimise delays and reduce last minute patient cancellations on the day of
surgery.

14. Anaesthetic room
Step 1: Monitor patient with ECG, pulse oximetry
and blood pressure
Step 1: Patient gets onto operating chair / trolley
and is positioned comfortably for surgery
Step 2: Venous access
Step 2: Monitor patient with pulse oximetry
Step 3: Anaesthetic given
Step 3: Anaesthetic given
Step 4: Patient wheeled into theatre on trolley and
transferred onto operating table (using up to four
members of staff)
Step 4: Patient wheeled into theatre accompanied
by primary nurse
Theatre
Step 1: Position patient
12
Step 1: Monitor patient – pulse oximetry and with
hand holder
Step 2: Monitor patient – ECG, pulse oximetry,
blood pressure
Step 2: Perform operation
Step 3: Perform operation
Step 3: Patient walks from theatre to day unit (if
fit enough)
Step 4: Transfer patient using pat slide from table
to trolley (using four members of staff and risks
injury to staff)
Step 5: Trolley or chair patient to recovery area for
observations
Step 6: Operating ophthalmologist writes
prescription for post-operative medication
Traditional (30 minutes)
Recommended (0 minutes)
Recovery
Step 1: Wheel patient to recovery
Step 2: Monitor patient with observations (blood
pressure, pulse)
Step 3: Transfer patient by trolley or chair to day
unit
No stop in recovery

15. Traditional (1 hour plus)
Recommended (30 minutes)
Day unit
Step 1: Monitor patient with observations (pulse,
blood pressure)
Step 1: Monitor patient with observations (pulse,
blood pressure)
Step 2: Await drugs from pharmacy
Step 2: Reviewed by nurse for discharge
(post-operative patient information and postoperative appointment date already given at preassessment, and post-operative drops already
dispensed from pharmacy)
Step 3: Patient’s eye examined by ophthalmologist
/ nurse on slit lamp
Step 4: Post-operative information given to
patient by nurse
Step 5: Post-operative appointment arranged via
booking team
13
Benefits
• less observations needed
• no need for patients to go to general recovery – this can be unpleasant for patients and it reduces
staffing costs
• staff time freed up by omitting unnecessary moving and handling of patient
• shorter stay in day unit reduces pressure on nursing staff and helps them care for patients better.
After care
Traditional
Recommended
Step 1: 24-hour follow-up with ophthalmologist
Step 1: 2-4 week review by nurse, optometrist or
ophthalmologist
Step 2: 2-4 week review by ophthalmologist
Step 2: 4-6 weeks patient attends local
optometrist
Step 3: 4-6 weeks patient attends local
optometrist
Benefits
• avoids 24 hour post-operative visit for the ‘routine’ patient which is more convenient for the patient
and saves clinic time.

16. 4. The key characteristics of high quality
cataract care
Through our observations and
work with NHS partners we have
found the following
characteristics to be the key
features for delivering both
quality and value care for
patients undergoing cataract
surgery.
After the explanation of each
characteristic there are case
studies from frontline teams and
suggested improvement
measures.
These key characteristics are
grouped and presented in two
main categories:
• overarching characteristics
which are common to the
entire pathway
• pathway specific characteristics
relating to the main steps in the
recommended pathway:
• referral
• booking
• pre-operative assessment
• day of surgery
• after care.
14

17. Overarching characteristics of an ideal cataract care pathway
Key characteristic 1:
The pathway is ‘fit for
purpose’
The best performing units have
developed pathways which are
specifically designed for high
volume day case cataract surgery.
Examples of this include:
• developing bespoke cataract
consent forms
• developing protocols that are
specific to cataract surgery (such
as allowing patients to eat
before surgery).
‘We don’t treat cataracts
but treat people with
visual disability caused by
cataract – there’s an
important difference’
Case study
‘We treat people, not cataracts’
Worcester Cataract Clinic is part
of the Worcestershire Acute NHS
Trust and operates out of the
Worcester Royal Hospital and
Kidderminster Treatment Centre.
The centre won a Beacon Award
in 2000 for its friendly and
efficient cataract service. At that
time more than 100 consultants
and staff from the UK and
Ireland visited the department
for lectures and live surgery
sessions.
The clinic has run a four-visit
bilateral sequential cataract
surgery service for the past three
years resulting in significant
savings to the health economy in
Worcestershire. For every 1000
patients with bilateral cataracts
there is a potential saving of
1000 outpatient appointments
over the most efficient
conventional system.
The clinic believes, for instance,
that if a patient’s blood pressure
is acceptable at the pre-op clinic
10 weeks before it does not
need to be tested again.
‘We don’t treat cataracts
but treat people with
visual disability caused by
cataract – there’s an
important difference’
explains Paul Chell, Clinical
Director
‘We regard patients as
being well and we respect
their involvement in their
refractive outcome. For
example, if a patient is
accustomed to monovision
in contact lenses then we
feel that option should be
offered as an outcome for
their cataract surgery.’
The pathway also offers:
The service is patient focused
and based on a set of
fundamental principles which
includes the concept of treating
people from the point of view
of wellness not illness.
• one-stop cataract assessment
and diagnostic clinic
• one pre-operative
appointment for both eyes
• the creation of a refractive
plan for each patient
• a length of stay of 90 minutes
on the day of surgery
• improved privacy – with no
need for patients to undress
• one follow-up appointment
for both eyes
• open access to clinic for
patients post-operatively
• one opticians visit and one
pair of glasses for both eyes.
Results:
Audits show that the interoperative complication rate is
less than six per thousand for
the department as a whole. This
reduces the number of
outpatient clinic attendances as
intra-operative complications
not only increase the risk of a
poor visual outcome but also
doubles the number of patient
visits.
15

18. Key characteristic 2:
The service has a high
degree of autonomy
‘Ophthalmology units
benefit enormously from
being able to devise and
adopt policies and
procedures that reflect the
very different nature of
this extremely high
volume surgical specialty’
16
Ophthalmology is a unique
service and the best practice
pathway for cataracts has many
specific requirements which are
different to other surgical
pathways.
As a result ophthalmology units
benefit enormously from being
able to devise and adopt policies
and procedures that reflect the
very different nature of this
extremely high volume surgical
specialty.
For instance, many
ophthalmology units use a trustwide generic patient consent
form. But consent could be
obtained more appropriately and
more efficiently using the
bespoke cataract patient consent
form devised by the Royal College
of Ophthalmologists (see Section
8 - Further information and
resources).
Cataract surgery is the largest
volume surgical procedure in
many acute trusts and, therefore,
by giving ophthalmology units
increased autonomy will enable
them to implement
improvements more easily and
develop a pathway tailored
specifically to the requirements of
cataract patients.
We have observed that those
ophthalmology units with a high
degree of autonomy within a
trust find it easier to develop a
cataract pathway which delivers
high quality efficient care.
Key characteristic 3:
Data and information are
used effectively to
enhance decision making
Greater financial authority and
responsibility may enable eye
departments to develop new and
better services. Clinicians should
be aware of Healthcare Resource
Group (HRG) costs and tariffs
including the costs of instruments
and pre- and post-operative
drops. All staff can help in
identifying potential cost
improvements.
Thresholds on a variety of clinical
areas are being applied
nationally. For instance, during
our visits we observed thresholds
implemented by a PCT which led
to a considerable reduction on
the number of cataract
procedures listed. As this has
been a recent adjustment to the
service it is too early to judge the
merit of this new practice.
However, although there are no
nationally agreed guidelines,
ophthalmology units need to
understand the implications to
their service if thresholds are
imposed locally.
Audits should also take place on a
regular basis (e.g. rate of
optometrist referrals for cataract
that actually require surgery,
reasons for unplanned admissions
and cancellations).

19. Key characteristic 4:
Multidisciplinary
teamwork is key
Ophthalmologists, optometrists,
orthoptists, pre-assessment
nurses, theatre staff,
anaesthetists, day case managers,
ophthalmology operational
managers, booking and
administration staff all work
together to make improvements
to the cataract pathway. The
whole team should be aware of
the entire patient journey (ideally
having observed it firsthand) so
that a consistent message is given
to patients and carers.
The ‘do it once, do it well’
principle is useful here. Each part
of the pathway needs to be
completed by someone who is
appropriately trained.
‘Having confidence in
individual members of the
team opens up new
possibilities for the
expansion of roles’
Having confidence in individual
members of the team opens up
new possibilities for the
expansion of roles. For instance,
during our observations some
surgeons expressed a lack of
confidence in the pre-assessment
stage and felt ocular examination
necessary on the day of surgery.
This can lead to delays in starting
and finishing lists and can
prevent the unit from staggering
the arrival times for patients. This
can be avoided by:
• ensuring staff have the correct
training and support
• close working between preassessment staff and the
operating surgeon which helps
promote confidence in all steps
of the pathway leading up to,
and following surgery.
17

20. Case study
Flexible theatre cover; reduced waste
The problem caused by increased
demand for cataract surgery but
with no additional theatre time
or staffing has led to the
creation of a new and flexible
role within the Ophthalmic Unit
at Norfolk and Norwich
University Hospital NHS Trust.
18
Working closely with secretaries,
theatre managers, booking
clerks and the outpatient
manager the associate specialist
plays an important role in
helping the unit target areas of
need and minimise wasted
theatre time.
Results:
The role of associate specialist
was created by re-grading the
staff grade. The move has
significantly increased cataract
capacity and throughput in the
unit and has achieved this
entirely within the existing
theatre sessions and without the
need for extra staffing.
The associate specialist prioritises
their time by picking up theatre
lists in Norwich and Cromer first
and then booking in clinics for
the sessions they are not
required in theatre.
• overall an average of 1500
more cataract operations per
year are carried out
A database is kept of all the
annual leave booked by all the
medical staff in the unit and a
monthly timetable is produced.
This allows the associate
specialist to identify and pick up
theatre lists and clinics which
would otherwise be left vacant.
The system is particularly useful
during school holidays when
many theatre lists would
otherwise be unfilled due to
consultant absence.
The move has significantly
increased cataract capacity
and throughput in the
unit and has achieved this
entirely within the
existing theatre sessions
and without the need for
extra staffing
On theatre sessions there is no
case selection or cherry picking
of more straightforward cases,
and there is normally still time
for the associate specialist to
carry out some teaching of
junior doctors.
In the first year after
implementing the new role:
• wasted theatre slots were
reduced by 85 per cent and an
extra 1000 cases were carried
out
• a specialist registrar would
normally do over 100
outpatients sessions per year
(roughly 1800 outpatient
slots). The flexible associate
specialist is able to do that
number in addition to all the
extra cataract work. When
cataract numbers were
reduced in 2006-2007 due to
PCT restrictions on patient
eligibility for surgery the
number increased to 170 clinics
(over 3000 outpatient slots).

21. Key characteristic 5:
Patient flow is optimised
and waste and duplication
eliminated
The number of patient handovers
throughout the pathway needs to
be reduced. For instance, some
patients can see up to seven
different individuals (including
four different nurses) during their
pre-assessment visit while others
see only three professionals in
total.
To support high throughput lists,
the ideal set-up of an
ophthalmology unit would be as
a discrete (or self contained) unit
within the trust. A ‘cataract
centre’ containing its own
outpatient rooms, day unit and
theatres is an ideal way to
facilitate patient flow.
Careful thought should be given
to how patients flow through the
system with any steps that don’t
add value being eliminated
altogether. For instance, the day
unit should be close to theatres
making it easier for patients to
walk to and from surgery. Some
units have to trolley patients long
distances taking up time and
resources and often creating
delays.
Ophthalmology units will
undoubtedly have restrictions to
major layout changes so the basic
components would be a
dedicated day unit and theatre
close together. The one-stop preassessment team should also be
located in one area within
outpatients. Much can still be
achieved without the need to
have a completely self-contained
department.
Key characteristic 6:
Patient information is
consistent, timely and
accessible
Patient information should be
relevant and consistent
throughout the whole patient
journey. This should begin at the
start of referral and involve an
informed discussion between the
patient and optometrist of the
risks and benefits of cataract
surgery.
This allows a reduction in the
number of inappropriate referrals
and makes for a more efficient
pre-assessment clinic. But it does
require close links between
referring optometrists and
providers.
Information also needs to be
provided in an accessible format,
such as audio tapes that patients
can listen to at home before
surgery. See Section 8 - Further
information and resources for the
Royal National Institute for the
Blind’s ‘See it Right’ Guidelines.
19

22. Referral: key characteristics
Key characteristic
Direct referral is used to
save patient and clinic
time
Bespoke cataract referral forms
can filter out patients who are
untroubled by cataract or do not
wish to proceed with surgery at
that time.
20
The form should trigger a
discussion with the patient about
the risks and benefits of having
surgery. It is through this
discussion that agreement with
the patient can be sought to
proceed with referral to
secondary care for treatment
options.
The referral form should cover:
• refraction
• visual acuity
• intraocular pressure
• significant symptoms (e.g. night
driving)
• co-morbidity of the eye
• relevant medical history from
opticians (e.g. mobility
problems, requirement for a
interpreter) in conjunction with
past medical history from the
GP if required.
Copies of the form need to be
given to the patient, GP, PCT and
hospital eye service.
An example of a bespoke cataract
referral form can be found in
Appendix 1 at the end of this
document.
Optometrists are the preferred
profession to provide this
information. Although a fee is
often incurred for direct referrals
there are potentially overall
savings as patients do not need to
see their GP and unnecessary
referrals to the hospital eye clinic
are reduced. However, many PCTs
do not currently have the funding
available for direct cataract
referral schemes.
Where it can be achieved the
direct referral pathway should be
implemented alongside an
education programme to
introduce optometrists to the
ophthalmic department criteria
for cataract surgery.
In addition:
Consistent information from all
healthcare professionals helps to
manage patient expectations
right throughout the pathway beginning with their visit to the
optometrists. A leaflet including
information about the risks and
benefits and the consent process
should be given to patients at this
first visit.
The optometrist should also have
information about all providers of
cataract surgery giving the
patient choice of provider for
their operation.
Regular audits of optometric
referrals should take place, and
feedback given to referring
optometrist to improve the
standard of the service.

23. Case study
Direct referral from optometrist to cataract service
Surrey PCT has developed a
pathway that is allowing
optometrists to refer patients
directly to the cataract clinic.
The scheme requires the
optometrist to undertake an
educational lecture with local
ophthalmic surgeons. This
involves explaining the criteria
for cataract extraction and the
risks of cataract surgery. The
optometrist is then able to
discuss in detail the option of
cataract surgery with patients
helping them decide whether or
not to proceed with the hospital
referral.
If, on visiting the optometrist,
cataract is found, referral is only
considered if the patient is
noticing an effect on their
lifestyle. Then:
• the patient is informed of the
risks of loss of vision from
cataract surgery
• if the patient wishes to
proceed the referral is made
• an assessment of angle closure
is made and documented
(enabling clinic staff to dilate
the patient’s pupils prior to
seeing the ophthalmologist)
• the patient is given an
information leaflet about
cataract and the operation
• the optometrist also has
information about the choice
of local providers for cataract
surgery – meaning the patient
can choose their provider
• the bespoke cataract form is
filled in and five copies are
made - one each for the
optometrist, patient, GP, the
hospital cataract clinic and the
PCT for remuneration.
The optometrist receives £25
from the PCT for each referral
regardless of whether the
patient progresses to surgery or
not. In cases where more than
10 per cent of an optometrist’s
referrals refuse surgery when
seen at the hospital eye service
the optometrist is required to reattend the training lecture.
Initially there were several
similar schemes across the health
community. These have now
been brought together in one
consistent system where the
documentation is all the same.
Results:
• audit information from one
cataract clinic found that
before the set up of the
bespoke cataract referral
scheme 50 per cent of
cataracts referred did not have
any indication to have surgery
• after the introduction of the
scheme the conversion rate to
cataract surgery in the cataract
clinic increased to 90 per cent.
21

24. Booking: key characteristics
Key characteristic
Direct booking is
supported by bespoke
referral systems
22
Alternatively, patients can be
given a choice of dates and times
for their outpatient appointment
through the Choose & Book
electronic referral system.
Direct booking into a cataract
clinic from the bespoke referral
form offers the most streamlined
solution. Using information from
the bespoke form booking staff
can book patients into the correct
one-stop pre-assessment clinic
without the need to involve other
professionals.
For optimal waiting list
management a robust policy for
DNAs (did not attends) needs to
be in place and followed.
This reduces the need for
clinicians to ‘vet’ referrals. Limited
vetting should only occur for
cases with co-morbidities.
‘Direct booking into a
cataract clinic from the
bespoke referral form
offers the most
streamlined solution’

25. Pre-operative assessment: key characteristics
Key characteristic
Pre-assessment is
streamlined,
comprehensive and avoids
handovers
From our observations, the time a
patient spends at pre-assessment
varies from one and a half hours
to three hours. The shortest time
was achieved in a one-stop clinic
(as outlined in Action On
Cataracts) where the patient only
has one visit prior to surgery.
It was achieved by the
professionals listed below
undertaking the following:
Nurse / optometrist /
orthoptist
The following steps should be
performed by the same individual
member of staff to avoid
handovers:
• measure visual acuity, pupil
reactions and intraocular
pressure & perform biometry
and focimetry
• observations
• past medical history
• discuss current medications
• patient information leaflets
(including consent information
for patients to review before
consent is signed)
• investigations (if required)
• agree day case - if patient
deviates from the ‘normal day
case’ pathway follow strict
inpatient criteria
• discuss anaesthetic options
• pupil dilation.
Note: auto refraction is
unnecessary at this point as the
information has already been
provided by the optometrist.
Undertaking this examination at
this stage is a duplication.
Although The Royal College of
Ophthalmologists Cataract
Surgery Guidelines clearly states
that there is no benefit in
performing ECGs or blood tests
there are still a small number of
units currently carrying out
unnecessary ECGs.
23

26. Case study
Biometry could be an extended role for Orthoptists
Biometry is a natural extended
role for orthoptists using many
of the skills they already have.
Recognising this the University
Hospitals of Leicester NHS Trust
is using orthoptists to carry out
biometry at its cataract clinics
saving time for both patients
and clinicians.
24
Orthoptic undergraduate
training already covers the
anatomy and physiology of the
eye in detail: ophthalmology
investigative techniques,
refractive error and, of course,
binocular vision. These are the
areas that need to be fully
understood in order to carry out
successful biometry and for
satisfactory post-op outcomes to
be achieved.
In addition, orthoptists routinely
take an ophthalmic and medical
history from patients - other key
skills needed in cataract clinics.
According to the trust the only
additional training orthoptists
require is in the use of the
equipment (the keratometer and
A scan, and, more recently, the
IOL Master).
Biometry is a natural
extended role for
orthoptists, using many of
the skills they already
have
At Leicester two senior
orthoptists were initially trained
by medical staff and cascaded
the knowledge to the rest of the
orthoptic team. Regular
competency assessments are
carried out to ensure standards
are maintained.
An added advantage of the
extended role is when binocular
vision problems are identified
for the first time during
biometry. With orthoptists
carrying out the test these can
obviously be addressed at the
same appointment.
The British and Irish Orthoptic
Society has produced a
document, Competency
Standards and Professional
Practice Guidelines for the
Extended Role of the Orthoptist
(2006). See Section 8 Further
information and resources.

27. Ophthalmologist
• slit lamp examination including
fundus examination – or,
alternatively, this can be carried
out by a suitably trained
professional (e.g. nurse,
optometrist, orthoptist)
• decide appropriateness of
surgery
• discussion with the patient of
the desired post-operative
refractive status - this avoids
complex discussion and decision
making immediately before
surgery which can be distressing
for the patient
• identify second eye surgery
where appropriate.
Note: Ideally, the operating
surgeon should examine the
patient. This is best performed
once at pre-assessment and not
left until the day of surgery or
duplicated. This is more practical
now that the time between preassessment and surgery is shorter.
member of staff (ideally the same
member of staff as in Step 1) to
avoid handovers:
• consent should be obtained
through a bespoke consent
form specifically for cataract
patients
• the consent form should clearly
state the risks and benefits
associated with cataract surgery
and should be pre-printed
• pre-operative drug prescriptions
should be completed during
this visit on a pre-printed form
– this helps minimise delays on
the day of surgery and could be
undertaken by the nurse acting
under Patient Group Directives
• standardised post-operative eye
drops should be prescribed in
the initial pre-assessment visit
and patients educated on how
to instil them
• patients unable to self medicate
should be identified and
contingencies put in place to
support them - this streamlines
processes on the day of surgery
Remember:
Do it once, do it well
• specific requirements (e.g.
translation, transport) on the
day of surgery are identified
and arranged in advance
Ophthalmologist or
suitably trained nurse /
optometrist / orthoptist
• admission documentation for
the day unit should be
completed at this point in the
process, in advance of the day
of surgery and reviewed on
arrival for surgery
The following should be
performed by the same individual
• the INR test should be arranged
in the community one week
before surgery - this avoids
waiting for results on the day
of surgery and the possible risk
of cancellation.
Information required at
assessment:
During our observations there
were many examples where trustwide policies produced large
amounts of unnecessary work.
These steps did not add value to
the process.
Patients in one trust, for example,
had to undergo a DVT risk
assessment, a nutritional level
assessment as well as a bed sore
risk assessment before cataract
surgery.
Far from adding quality to the
process these constraints may well
detract from it by reducing the
time staff have to discuss relevant
issues and concerns with the
patient.
Booking team
Patients are offered a choice of
dates and times for their
operation and follow-up
appointments.
25

28. Case study
‘Plan of care’ booklet supports the whole cataract pathway
As well as dealing with a vast
throughput of patients since it
opened in 1993 the Cataract
Treatment Centre at Sunderland
Eye Care Infirmary has also
taken positive steps to help
patients understand each stage
of their care journey.
26
The unit has introduced a simple
and informative plan of care
that patients can use when they
return home following preassessment, surgery and after
their post-operative
appointment.
Working together to devise the
booklet patients and staff
agreed that the information
should describe care from preassessment right through to post
operative clinics. Knowing what
will happen to them in advance
allows patients and carers to
make arrangements, for instance
with transport or organising
help with drops.
‘Knowing what will
happen to them in
advance allows patients
and carers to make
arrangements, for instance
with transport or
organising help with
drops’
The booklet also supports the
pre-assessment process by:
• giving patients and carers a
take-away resource so they
don’t have to retain all the
information given to them on
the day
• enabling staff to signpost
information in the booklet so
they don’t have to repeat
information and instructions.
Dates for surgery and all other
appointments are clearly
identified on the front of the
booklet thus giving patients a
useful ‘at-a-glance’ record. The
plan also gives contact numbers
in case the patient experiences
any problems or needs advice.
Care has also been taken over
the font size of the booklet,
setting it at N18 – a size which
most patients with visual
impairment are able to read.
The booklet’s yellow colour also
contrasts with the print to give
high definition and ensure easier
reading.
The booklet is professionally
printed and reviewed yearly
with patients.
Results:
As well as patients and carers
being better informed the
booklet has helped reduce
cancellations and forgotten
appointments leading to better
utilisation of clinics and theatre
lists.
See appendix 2 for the Plan of
Care booklet.

29. Case study
Nurse led consent
Newcastle Upon Tyne Hospitals
NHS Foundation Trust
introduced nurse led consent in
2002 following the Department
of Health’s ‘Consent Policy’
earlier that year. The Trust
already had a fully nurse led preassessment clinic – so expanding
the role to include taking
consent was seen as a natural
move and a good way to
support continuity of care for
patients.
With all nurses now leading the
consent process the consent
form is signed by the patient
and the nurse and remains in
the medical notes. This is then
readily available on the day of
surgery when the nurse obtains
the second signature.
Results:
• it provides a better patient
experience as the nursing and
consent aspects of treatment
and care can be discussed at
the same time
• patients are offered a choice
of dates and times for their
operation and follow up
appointment.
• the process frees up 10
minutes per patient of
consultant time
27

30. Day of surgery: key characteristics
There is wide variation across NHS
organisations in the total length
of time a patient is in hospital for
their cataract operation. In some
units this is done in an efficient
and timely manner and takes no
longer than one and a half hours.
In others a patient can stay for up
to six hours without any added
value.
28
• dilation is done at home or
directly on arrival
For operating lists to be efficient
it is important to have a member
of staff who is responsible for the
flow of patients through the list.
This role is best undertaken by an
anaesthetist or theatre sister who,
assisted by the use of a TV
monitor, can assess how the
operation is progressing and
prepare for the next patient
accordingly.
• warfarin levels are taken a
week prior to the day of
surgery
Key characteristic
Day of surgery processes
are streamlined
• the eye is marked by
ophthalmologist or nurse (who
will remain with patient in
theatre) – this allows the list to
flow with staggered arrival
times without removing the
surgeon from the theatre. (See
Section 8 Further information
and resources for the ‘Correct
Site Surgery’ Guidelines)
What this means in the day unit:
• a primary nurse remains with
the patient throughout the
surgical pathway from
admission to discharge thus
improving continuity of care
• arrival times are staggered patients prefer this and it helps
minimise pre-operative waiting.
However, semi-block arrival
times will also facilitate theatre
flow and reduce the number of
patients the nurses are looking
after at any one time
• admission documentation
already completed at preassessment is reviewed
• observations are recorded
(blood pressure, pulse)
• consent is confirmed with
ophthalmologist or nurse
• undressing is not necessary as
patients wear a cap and a
theatre gown over their clothes
and good draping techniques
are used to avoid iodine on
their clothes
• the majority of patients are
able and happy to walk to the
anaesthetic room thereby
avoiding the use of trolleys and
chairs - this reduces patient
handling and risk of back injury
and helps free up staff normally
involved in patient transport.

31. Case study
Primary nurse stays with patient across whole journey
In the Cataract Treatment Centre
at Sunderland Eye Infirmary
patients benefit from knowing
that the nurse who does their
pre-assessment will be the same
individual who accompanies
them right throughout the
surgical pathway.
During assessment the named
nurse involves the patients in
making decisions about their
care, offering them choices of
dates and helping them think
about other issues such as home
circumstances, transport
arrangements and anaesthesia.
The nurse then places the
patient on the operating list and
ensures that they will be present
on the day of surgery to look
after their patient.
On the day of the operation the
nurse positions the patient for
surgery and holds the patient’s
hand throughout.
Being this close means the nurse
can keep talking to the patient
and quickly deal with any
problems, whether this is just
reassuring them or something
more practical such as adjusting
air flow so the patient does not
get breathless or start to panic.
This has several benefits:
‘The one-to-one care
makes the patient feel
they are the only one that
matters – they are less
anxious and often
presume they are the only
patient on the list’
• a trust builds up between the
nurse and patient with the
nurse becoming more sensitive
to the patients needs and able
to detect when the patient is
anxious and needs increased
reassurance
• there is less repetition which
makes the patient feel they
are being listened to and not
handed from one member of
staff to the next.
Results:
• the patient knows who will be
looking after them during
surgery and they are confident
that they will see a familiar
face - this is very important to
patients who are elderly as
they are often anxious about
how they will cope during the
operation, whether they will
be able to lie still during
surgery and whether they will
feel any pain
• the one-to-one care makes the
patient feel they are the only
one that matters – they are
less anxious and often
presume they are the only
patient on the list
• there are no handovers
thereby reducing the chances
of mistakes
• patients cope well with
surgery and are quickly ready
for discharge
• nursing staff have increased
job satisfaction - staff
motivation is high with
reduced sickness levels and
reduced staff turnover in the
unit.
29

32. What this means in the
anaesthetic room / pre-operative
area:
The anaesthetic room is essential
for the smooth running of a
cataract list. This enables more
time to be spent getting the
patient comfortable and ready
for theatre without wasting time
during the theatre slot.
Specifically:
30
• the patient is positioned
comfortably on operating
trolley / chair
• saturation monitoring is the
only monitoring required
• anaesthetic is given:
• with sharp needle anaesthetic
techniques - an anaesthetist
should be present at all times
(refer to The Royal College of
Ophthalmologists Cataract
Surgery Guidelines)
• with topical anaesthesia and
blunt cannula techniques – an
anaesthetist presence is not
essential as long as at least
one member of the theatre
team is qualified in Advanced
Life Support.
Notes:
• The Royal Colleges of
Ophthalmologists and
Anaesthetists do not
recommend routine blood
pressure checks or ECGs in
theatre
• venous access is not
recommended by the Royal
College of Anaesthetists in
patients undergoing topical or
sub-tenons anaesthesia.4
What this means in theatres:
Dedicated cataract lists can lead
to greater efficiency and
throughput. A minimum of six or
seven operations can be
performed on a list including
training lists. High volume lists
are regularly achieving at least
nine.
High volume lists are regularly
achieving up to nine or ten
operations a list. It is important
that the complexity and the
length of surgery are taken into
account when deciding on the
number of cases on a list.
However, standardisation of the
entire pathway can help efficient
running of lists.
Other specific things to consider
include:
• saturation monitoring is all that
is required during surgery
• the ‘hand holder’ is an excellent
way to monitor patient
experience and wellbeing as
well as helping reduce anxiety
levels - in some units this role is
undertaken by volunteers
• standardisation in types of
instruments surgeons use will
help the scrub nurses know
which instruments the surgeon
will need and will make setting
up between cases easier
• some units find it efficient to
train the scrub nurse to drape
the patient and to fold or load
the intra-ocular lens prior to
insertion
• peri-operative drugs and postoperative drops should be preprinted to save surgeon time
during the theatre list - ideally
these should be prescribed at
pre-assessment to save patients
waiting for drops to be
dispensed on the day of surgery
4 The Royal College of Anaesthetists and The Royal College of Ophthalmologists, 2001. Local Anaesthesia for Intraocular Surgery.
www.rcoa.ac.uk/docs/rcarcoguidelines.pdf

33. • units are moving towards the
Electronic Patient Record (EPR)
but in practice most units
continue to use a combination
of electronic and paper records
- a rational approach to this
may help reduce duplication. In
units where the process is
nearly all paperless there may
be great benefits from making
the final push and becoming
completely paperless.
• the level of nursing staff in
theatres and the day unit varies
- the most efficient model we
observed was:
• 3 staff in theatres
s
2 scrub nurses and 1 runner
• 3 staff in the day unit
3 primary nurses / unit staff
rotating through theatres and
day unit.
s
What this means in the day unit:
After the operation, if the layout
permits, the patient should walk
to the day unit thus avoiding
further unnecessary patient
handling. If needed, consider
using a wheelchair.
A single set of post-operative
observations (blood pressure,
pulse) can also be performed,
avoiding a stop in recovery.
Other specific things to consider
include:
• standardise post-operative
medication between surgeons
ordered at pre-assessment - this
enables pre-packed, postoperative drugs to be available
immediately ready for discharge
• providing two bottles of postoperative eye drops avoids an
unnecessary visit to the GP for
patients needing another bottle
• some units are no longer using
eye shields after surgery, or for
patients at night, without an
apparent increase in postoperative complications
• in many eye units the patients
are reviewed post-operatively
by trained nurses for discharge
• unless a patient had
complicated surgery or is in
pain a slit lamp examination is
not required and adds little
value - this enables patients to
leave the day unit sooner by
reducing unnecessary waiting
and time spent in the hospital
• ideally a patient should be
discharged within 30 minutes
post-operatively - the same
nurse discharging the patient
should ensure patient
education is given including
emergency 24-hour contact
details
• date and time of post-operative
appointment (agreed at preassessment) should be
confirmed.
31

34. After care: key characteristics
It is usual to arrange a single
post-operative visit at two to four
weeks. This can be done in a
number of ways. The majority of
patients are reviewed in hospital
clinics and in some units nurses or
optometrists perform this role for
routine cases.
32
However, some patients are still
being routinely reviewed 24
hours post-operatively regardless
of whether there has been
complicated surgery. This is
unnecessary and means another
visit for the patient. Other
alternatives to hospital review
have successfully been set up
using local optometry services.
Important features of the postoperative review include:
• visual acuity measurement
• auto-refraction to screen for
refractive surprise
• eye examination
• discussion of post-operative
results
• management of post-operative
refractive error
• collection of outcome data
• listing of second eye
• refraction by optometrist - this
should occur four to six weeks
after surgery when the patient
has stopped using their eye
drops and has been discharged
from the eye clinic. In cases of
second eye operation refraction
follows the second operation.
Note: Most surgeons and patients
prefer to ensure that the first eye
has fully recovered before
advising for second eye surgery.
In line with the 18-weeks policy
the clock officially starts when a
patient is fit and ready for the
second of a bilateral procedure.
To keep up to date with 18-week
requirements visit:
www.18weeks.nhs.uk
The second eye pre-assessment
can be performed over the
telephone by a nurse (and a
choice of date offered for
surgery) for uncomplicated cases.
Some units proceed to second eye
surgery without a post-operative
visit for the first eye.

35. Case study
2nd eye telephone pre-assessment
Newcastle Upon Tyne Hospitals
NHS Foundation Trust has
introduced telephone preassessments for second eye
patients.
As well as placing a burden on
staff time and resources this was
an unnecessary step for the
patient and inconvenient if they
had to travel long distances.
Originally every patient would
have to come back for another
pre-assessment appointment at
the hospital before their second
eye operation even if it was only
a few months since their first
eye surgery.
Now patients book their second
eye operation date at their postoperative visit and nurses phone
patients to check their details
have not changed since their last
operation.
Results:
• considerable time and resource
savings for the department
• an improved experience for
patients.
33

36. 5. Measures for improvement
Through our observations we
identified a need and desire in
frontline staff and managerial
teams to understand current
performance in their cataract
services and compare this
performance to local and national
benchmarks.
Data to help identify potential
improvement opportunities in
cataract pathways was also
highlighted as a key need. Wellperforming organisations that we
visited had a good understanding
of their own performance and
routinely used data to drive
quality and safety in their local
34
services as well as to assess the
impact of any changes they
made.
They should also be used in
conjunction with 18-weeks
measures.
The measures offered here are
not in any way prescriptive. The
aim of using these metrics is to:
Local services will want to
prioritise the use of these
measures to reflect their own
local circumstances. Agreement
will also need to be reached on
how frequently this information
is collected and what level of
detail is sought.
• improve the quality and
effectiveness of care and the
patient experience
• decrease the variation in
cataract pathways
• stimulate thinking and help
local organisations consider
their own position in terms of
specific cataract processes.

37. Pathway Step
Measure
Aim
Referral
percentage of optometrist
referrals for cataract that
actually require surgery
> 90%
Booking
percentage of referrals directly
booked into cataract clinic
without being vetted
> 80%
Pre-assessment
percentage of patients not preassessed on day of initial
consultation
< 10%
Pre-assessment
length of time at pre-assessment
visit
target 1 1/2 hours
35
Day of surgery
length of stay from admission to
discharge
target 1 1/2 hours
Day of surgery
utilisation figures for cataract
theatres
> 90%
Day of surgery
number of cases per week
70 per theatre (if 10 operating
lists per week)
After care
patient satisfaction surveys
quarterly
After care
percentage of patients using 24hour helpline vs patients
attending eye casualty
locally agreed

38. 6. Benefits of following the pathway
There are fewer visits to hospital
and pre-operative and day of
surgery visits are shorter:
• patient flow is improved
• variability in the process is
reduced. This results in:
• increased activity
• better use of capacity
(resources for inpatient
operations and emergency
care are freed up)
• patients being treated faster
• shorter waiting times.
36
Patient expectations are
managed and satisfaction is
improved:
• consistent information is
provided about the medical
condition, the options for
management and what to
expect from treatment
• patients have choice and
certainty over dates for hospital
appointments and over the
operation date
• patients are not referred
unnecessarily to the pathway
• access to well designed facilities
improves the patient experience
• well trained staff provide
consistency of care
• patients are able to return to
their own homes sooner
• risks of hospitalisation, e.g.
through hospital-acquired
infection, are reduced
• effective pre-assessment and
booking processes reduce
cancellations.
There are significant financial
benefits:
• reductions in the length of stay
and standardisation of
procedures and equipment all
reduce costs
• productivity is increased
through reducing variations in
the process
• waste is reduced and resources
are freed up e.g. fewer last
minute cancellations.
Surgical reputation is enhanced
through improvements in quality:
• opportunities for marketing are
created in the new, competitive
NHS environment
• staff and patient satisfaction
increase.
Team working and the working
environment improves:
• the multidisciplinary care
pathway achieves a shared
vision and purpose
• a high quality mindset is
developed in staff.

39. 7. Next steps
The advice and ideas offered in
this report are based on our
observations of practice within
ophthalmology units. Although
these practices are delivering high
quality care and value for money
it should be recognised that they
may not be the only way of
achieving these. However, we
believe they will offer useful
guidance and direction to anyone
seeking this goal.
To improve services we advise
organisations to use this guidance
and take the following steps:
• map your current pathway
against the recommended
pathway for cataracts and
existing guidelines
• identify areas of delays, waste,
duplication and savings in your
current pathway
• generate a local plan for
improvement.
While this document offers
suggestions to care providers and
commissioners on how they can
optimise their own provision of
care it is only a first step. We
know units will need practical,
relevant tools that will help them
make these improvements
happen.
We want to hear from you...
We genuinely welcome and value
your contribution to our work. If
you have comments or would like
to be involved in any way please
get in touch with us at:
Delivering Quality and Value
Team at:
cataracts@institute.nhs.uk
37

40. 8. Further information and resources
This is just a small selection of
some of the best links and
resources to help you improve
your cataract pathway:
Action on Cataracts: good
practice guidance (2000),
Department of Health:
http://www.dh.gov.uk/en/Publicati
onsandstatistics/Publications/Publi
cationsPolicyAndGuidance/DH_40
05637
38
Cataract Consent Form Template,
The Royal College of
Ophthalmologists:
http://www.rcophth.ac.uk/docs/pu
blications/publishedguidelines/consentform04.pdf
Cataract Surgery Guidelines (2007
- updated), The Royal College of
Ophthalmologists:
http://www.rcophth.ac.uk/docs/pu
blications/CataractSurgeryGuideli
nesMarch2005Updated.pdf
Commissioning Cataract Surgery
– an outline of good practice
(2004), The Royal College of
Ophthalmologists:
http://www.rcophth.ac.uk/docs/pu
blications/publishedguidelines/CommissioningCataract
Surgery-April2004.pdf
Competency Standards and
Professional Practice Guidelines
for the Extended Role of the
Orthoptist (2006). The British and
Irish Orthoptic Society:
www.orthoptics.org.uk/BIOS_Com
petencies_Standards__Extended_Roles__Master_Handbook.pdf
Correct Site Surgery, National
Patient Safety Agency & The
Royal College of Surgeons (2005):
http://www.npsa.nhs.uk/patientsaf
ety/alerts-anddirectives/alerts/correct-sitesurgery/
Local Anaesthesia for Intracular
Surgery, Royal College of
Anaesthetists and Royal College
of Ophthalmologists (2001):
www.rcoa.ac.uk/docs/rcarcoguidel
ines.pdf
‘See it Right’ guidelines (2006),
The Royal National Institute for
the Blind’:
www.rnib.org.uk/xpedio/groups/p
ublic/documents/PublicWebsite/pu
blic_seeitright.hcsp
Understanding Cataracts (patient
information leaflet), The Royal
College of Ophthalmologists:
http://www.rcophth.ac.uk/docs/pu
blications/patient-infobooklets/UnderstandingCataracts.
pdf
Association of Ophthalmologists:
www.aoo.org.uk
British Medical Association (BMA)
Ophthalmic Group Committee:
www.bma.org.uk
Eye Care Services (Department of
Health):
www.dh.gov.uk/en/Healthcare/Pri
marycare/Optical
Royal National Institute of Blind
People (RNIB):
www.rnib.org.uk
The College of Optometrists:
www.college-optometrists.org
The Royal College of
Ophthalmologists:
www.rcophth.ac.uk
United Kingdom and Ireland
Society of Cataract and Refractive
Surgeons:
www.ukiscrs.org.uk

41. 9. Acknowledgements
We wish to offer our sincere thanks to everyone who has contributed
to this project. In particular, we would like to thank the patients and
staff who gave us an invaluable insight into their work and practice.
The trusts we visited were:
Buckinghamshire Hospitals NHS Trust
Capio Healthcare UK
City Hospitals Sunderland NHS Foundation Trust
Leeds Teaching Hospitals NHS Trust
Moorfields Eye Hospital NHS Foundation Trust
Netcare Healthcare UK
Newcastle Upon Tyne Hospitals NHS Foundation Trust
Norfolk and Norwich University Hospital NHS Trust
University Hospitals of Leicester NHS Trust
Worcestershire Acute NHS Trust
We would also like to thank the following organisations for their
valued contribution to this work:
Association of Ophthalmologists
British Medical Association (BMA) Ophthalmic Group Committee
Eye Care Services (Department of Health)
Royal College of Nursing
Royal National Institute of Blind People (RNIB)
The College of Optometrists
The Royal College of Ophthalmologists
United Kingdom and Ireland Society of Cataract and Refractive Surgeons
39

42. Appendix 1 - Example of a Bespoke Cataract
Referral Form
40

43. Appendix 2 - Sunderland Eye Care Plan
41

44. 42

45. 43

46. 44

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