Amrit Hayre’s article raises a huge number of very important and interesting issues in a concise efficient manner, highlighting the multiple differences between NHS based cataract care and those found in an Eye Camp in Punjab [1]. These differences are stark; a huge difference in numbers of cases on lists, achieved by economies of scale, a production line mentality and the paring back of consent and communication right back to the bone. Right through the bone in fact.

Regarding efficiency the phenomenal work of the Getting It Right First Time (GIRFT) team is dedicated to ironing out kinks in cataract theatre flow for the maximisation of limited NHS resources to the betterment of patient care and reduction of ballooning waiting lists. Indeed, the GIRFT team under the stalwart leadership of Melanie Hingorani recently completed a review of surgical practices in Wales that highlighted many pressing changes that are needed to make publicly provided cataract care sustainable and affordable for the future. These changes, which include efficient high-volume lists in regional centres of excellence, are urgently needed or we risk tumbling down the slippery slope toward privatisation. We change or we fail. We adapt or we die. And what comes afterwards might be similar to the Indian experience described and for multiple reasons that might not be so very good after all.

There is a lot of emphasis placed in our training on communication skills and most complaints have at their root some sort of breakdown in communication rather than an isolated medical error alone. There are whole courses dedicated to breaking bad news. I am confident that educationalists the nation over would have conniptions on reading that these skills are dispensed with altogether in the name of blunt efficiency and that the art that is taking a medical history is replaced with bare veterinarianism. Indeed, it seems that patients learn that to get the treatment they need symptoms need to be exaggerated and potentially complicating aspects of their past medical history are actively suppressed. This goes against everything that we are taught in medical school.

In Aldous Huxley’s Brave New World efficiency is worshipped to such an extent that the whole of society is utterly reorganised along conveyer belt lines. Henry Ford, the inventor of the production line, is worshipped as a God with the numbering of the year (After Ford - AF) based on when the first Model T rolled off the line in 1908. The new ethos, termed Fordism, is meant to be good for society as all possible needs are catered for in an extremely efficient manner, though it comes at the expense of any and all forms of individualism.

People are odd. When our department moved over from an inefficient PRN regime for age related macular degeneration to the conveyer belt treat and extend protocol we could deliver many more injections much more efficiently, patients needed less visits and more sight was saved overall. But patient complaints rose. The cause it seemed was that patients liked the theatre of the old-fashioned visit and their view of what was important was not perfectly aligned with those of the clinicians. Similarly slit lamp examinations of the fundus in the age of OCT are a bit of an anachronism but some patients feel short-changed without one. Quite a few in fact. Many famous and not so famous doctors have commented over the years about how medicine is part art part science, and even though we may convince ourselves while reading Eye in our sitting rooms at night with a cup of tea that we as ophthalmologists are the creme de la creme of clinician scientists we secretly know the truth. That communication is critical to being a successful clinician as much if not more so than a thorough knowledge of all the latest published papers.

So, is it the case that an über efficient but communication lite cataract service is good for those in the Punjab but not for us? No. The people of Punjab perhaps have no other option and when faced with ophthalmic surgeons lacking what we in Britain might consider good communication and consenting skills have to play the game as they see it or risk not being selected for sight saving surgery. Our eye casualty gets a fair few phonecalls from patients worried about various things after cataract surgery. People worry about their eyesight the world over. It’s not that people nowadays abroad or here in the past were made of some sort of stronger moral fibre and cared less for the niceties of civilised discussion about their healthcare needs; surgeons practising couching famously had to make sure they constantly moved on lest their complications catch up with them. It’s just that in some situations and some places there is no choice that allows for both surgery and adequate communication.

We are undoubtedly less efficient than we should be here in Britain at performing cataract surgery. There are changes we can make, large and small, that will increase our efficiency and allow us to do more work whilst holding on to hard won principles of informed consent and good communication. Wales needs regionalisation and Centres of Excellence to achieve this, as detailed in the National Clinical Strategy for Ophthalmology. We can do this without flogging our surgical workforce to death in a conveyer belt system of operating that would be the very epitome of Fordism. We can do this without subjecting our patients to dehumanising medical encounters where core medical tenets are surrendered in the name of efficiency and without which the population’s ophthalmic needs would not be met. We must indeed adapt or the system will fail as we will simply be too inefficient to survive. An ophthalmic dodo ripe for extinction. That is why GIRFT and its recommendations are so important to us all; they offer us a middle way between the crippling inefficiencies of the past and the Brave New World of tomorrow with all its dehumanising streamlining. The price of failure is us having to sacrifice either surgical numbers or honest communication, where we are doomed without a proper balance of the two. I don’t fancy my children having to stand in line to be seen in a huge tent and lie about their health needs, if they are even asked at all, in order to qualify for cataract surgery in the rump NHS of a dystopian tomorrow.