Out of Sight – the hidden impact of cataract outsourcing on NHS eye care departments

This report examines the impact that the impact of the outsourcing of NHS funded cataract care to the private sector has had on NHS patients facing irreversible sight loss, staff training and the financial viability of NHS eye care departments.

It is based on data from 50 NHS Trusts received through Freedom of Information requests and a survey of 198 ophthalmologists carried out in December 2023.

It finds the following:

The impact out outsourcing on training the next generation of ophthalmologists

NHS England estimates that in order to train the next generation of ophthalmologists, there is a need to set aside around 47,000 routine cataract operations in NHS eye care departments for trainees to develop their skills and competences. Our research shows the NHS is now providing 37,000 fewer operations due to outsourcing than it did 5 years ago.

On average NHS hospitals are now providing around 20% fewer cataract operations than they did 5 years ago with some Trusts performing more than 40% fewer surgeries.

This loss of activity is having a significant impact on training within a profession where there is a shortfall of ophthalmology consultants. Our survey found that 62% of respondents said that outsourcing to the private sector had resulted in a large (56%) or small (6%) negative impact on opportunities for staff training within their NHS eye care departments.

The impact of outsourcing on the financial viability of NHS eye care departments.

Income from cataract operations is key to maintaining the financial viability of many NHS eye care departments, as it cross-subsidises care for more complex conditions such as glaucoma and macular degeneration which can lead to irreversible sight loss. Income from cataracts also supports emergency care and care for children in the NHS.

Our research shows that total income from cataracts across NHS Trusts has declined marginally, but half of our sample saw a 21% drop in income over a 5 year period.

The impact of outsourcing on the resources to treat patients facing irreversible sight loss.

Across the NHS the amount spent on ophthalmology services has increased by 52% over 5 years but large amounts of this increase have been spent in the private sector on cataract care. For NHS Trusts as a whole, their overall ophthalmology budget has only increased by 15% over 5 years mainly because of the outsourcing of cataract care.

Because the private sector uses NHS ophthalmologists to carry out cataract surgery, this has meant a reduction in the availability of staff to work in NHS hospitals. Our survey of ophthalmologists found that 37% of respondents said that they had seen a large negative impact of outsourcing on staffing in NHS eye care departments and a further 21% said that they had seen a small negative impact on staff.

This reduction in the overall ophthalmology budgets as well as a loss of ophthalmology staff undertaking work in NHS Trusts is likely to have had an impact on treating care for more complex patients – our previous research showed that for conditions other than cataract care waiting times have increased for these patients.

Recommendations

Despite the evidence showing a negative impact of the outsourcing of cataract care to the private sector on both patients and staff training, it is concerning that NHS England has not carried out any analysis of this issue. This is concerning because some Integrated Care Boards (ICBs) are now exploring outsourcing other areas of eye care to private companies.

On the basis of this research we recommend the following:

• NHS England should undertake a whole sale review of the use of the private sector to deliver NHS cataract care to determine the impact that it is having on a) waiting times b) staffing c) health inequalities d) available resources to treat more serious diseases which can lead to irreversible sight loss.

• When developing their commissioning arrangements for ophthalmology services, Integrated Care Boards (ICBs) should take into account the impact of the use of the private sector to deliver cataract care on NHS eye care departments in particular their financial viability, their ability to treat more complex patients and the training of the workforce. They should limit, and if necessary, reverse the outsourcing of the cataract care to the private sector if this means that NHS eye care departments and staff training are being negatively impacted.

• NHS England should conduct a review of the overall ophthalmology budget to identify whether disproportionate amounts are being spent on cataract care for people with comparatively lower healthcare needs and whether other more complex conditions are being under-funded.

• NHS England and Integrated Care Boards should pause any further outsourcing of eye care services to the private sector – such as treatment for glaucoma and macular degeneration– until it has carried out a comprehensive assessment of the impact of the recent experience of outsourcing on health inequalities and the sustainability of a comprehensive eye care services for all NHS patients.