It’s well known that the rising number of private ophthalmology providers in the UK have continued to increase their market share in providing various services. Referrals from NHS trusts have continued to increase with nearly 60% of cataract operations being outsourced to independent sector providers (ISPs) as of June 2024 [1]. By comparison, only 11% of cataracts were outsourced in 2016, which had increased to 46% in 2021 [2].
In addition to the rising number of operations being outsourced, private providers have also been able to successfully employ NHS staff, worsening the staff crisis [2]. It comes as no surprise – NHS staff have had their pay cut relative to inflation over decades and the private sector are able to offer a more compelling wage [3].
In order to maintain a high patient turnaround and reduce the likelihood of complications and litigation, private providers generally choose patients who are on balance – on the healthier side of the spectrum [4]. However, some providers are also now dealing with more complex cases as they’ve invested in infrastructure and workforce to deal with increased complexities. Over the past five years, private equity firms have set up over 100 low-cost eyecare clinics in England and enticed increasing numbers of NHS staff [5]. This has seen their income from the NHS increase by over 300% in five years [6]. As simpler cases are outsourced to private providers, it has led to increasing anxiety within trainees overachieving the required case numbers and variety to be competent and confident as consultants.
The RCOphth require that trainees must complete a minimum of 350 cases to be deemed competent in cataract surgery in order to apply for a consultant post. This can be increasingly challenging for trainees as the share of outsourced cataracts continues to increase [7]. Senior leaders have urged private providers to increase access to training in cataract surgery lists as concerns grow over a generation of ophthalmologists who lack exposure [2].
Spamedica, a national provider of eye health services, have recently extended cataract training provision to 60 NHS registrars to create more training opportunities [8]. Furthermore, investment into dry labs has enabled the NHS to make use of extra training services for ophthalmic trainees [8]. Invariably though, as ISPs run theatre lists at great expense, there is a time pressure for theatre turn around. With theatre staff in private hospitals often paid by case, there is an incentive to ensure patients are turned around effectively with minimal delay to ensure targets are met.
For a training ophthalmologist and for the consultant, this environment may not be ideal as the continued time pressure may require the lead consultant to take over cases to minimise delays. SpaMedica does use dedicated training lists with lower patient numbers aiming to reduce the burden on trainees and the consultants supervising, but unfortunately these training lists are not present in the numbers required to meet national training requirements.
"To prevent the erosion of training standards, the College and ophthalmic trainees must continue to push for greater allocation and access to training lists in the private sector"
In addition to training numbers, trainees also require experience in a variety of complex cases to build confidence and competence as they approach consultancy. While independent providers may add some extra capacity with training lists, not all providers have the structures in place to allow registrars to train and deal with complex cases. To maintain the high standard of British ophthalmology training, NHS leaders need to work with experienced ophthalmology educators and ISPs to build local agreements to ensure training standards are maintained.
The RCOphth has previously laid out a blueprint for how trusts and ISPs can work together to meet NHS criteria, where ophthalmic trainees must be able to train on 11% of outsourced NHS cases in the independent sector [9]. A trainee survey conducted by the college in July 2024 revealed that access to cataract training in the independent sector has improved in regions where ISPs operate [10]. However, despite this progress, trainees continue to report they require additional training opportunities in ISPs [10].
Furthermore, there continues to be a large variation amongst ISPs in the quality and number of training placements offered. While SpaMedica and Newmedica currently provide training placements in most of their operating regions, Optegra and CHEC do not, impacting trainees’ experience [10]. Eleven percent is a small target required of the ISPs who offer NHS-funded cataract surgery and as the ISPs are forecast to play a larger role in the provision of cataract surgery in the UK, more pressure will be required from trainees, the college and NHS leadership to maintain training standards. Trainees may have to take a more active role in lobbying healthcare leaders to protect their training opportunities as growing pressure to cut national waiting lists is resulting in training requirements for resident doctors becoming less of a priority.
The private sector could take on more training lists at the request from the NHS but no doubt this would be a great cost as naturally private providers wouldn’t be keen to see reduced profits for training purposes. The NHS may have to subsidise or cover any losses which will likely not nearly be as cost effective as protecting training lists for ophthalmology trainees within the NHS in the first place.
If greater outsourcing to the private sector continues to take place to reduce waiting lists in the short term at the cost of poor training for UK ophthalmology trainees, a growing number of ophthalmology trainees may have to extend their training or not feel confident to perform more complex cataract surgeries. This could worsen the shortage of consultants capable of performing a wide array of procedures in the future; further exacerbating the crisis in a specialty where consultant numbers are at 2.5 per 100,000 population instead of the 3.5 required [11]. To prevent the erosion of training standards, the college and ophthalmic trainees must continue to push for greater allocation and access to training lists in the private sector on a local, regional and national level.
Bibliography
1. Kollewe J. Boom in cataract surgery in England as private clinics eye huge profits. The Guardian 2024:
https://www.theguardian.com/society/article/
2024/jun/16/boom-in-cataract-surgery-in-england
-as-private-clinics-eye-huge-profits
2. Iacobucci G. Private providers must increase access to training in cataract surgery, ophthalmologists say. BMJ 2021;375:n2763.
3. https://www.rcn.org.uk/news-and-events/
Press-Releases/half-of-englands-nursing-staff-could
-quit-as-new-analysis-reveals-decade-long-attack-on-pay
4. Kollewe J. Eye doctors say private cataract operations have hurt the NHS. The Guardian 2024:
https://www.theguardian.com/society/
article/2024/jul/10/eye-doctors-say-private
-cataract-operations-have-hurt-the-nhs
5. Rowland D. The dangers of outsourcing NHS eye care to private companies. LSE British Politics and Policy blog 2024:
https://blogs.lse.ac.uk/politicsandpolicy/
the-dangers-of-outsourcing-nhs
-eye-care-to-private-companies/
6. Rowland D. Growing the private sector is no way to prevent the NHS becoming a poor service for poor people. CHPI 2024:
https://chpi.org.uk/blog/growing-the-private
-sector-is-no-way-to-prevent-the-nhs
-becoming-a-poor-service-for-poor-people/
7. https://www.rcophth.ac.uk/news-views/
rcophth-guidance-on-cataract-surgery
-training-in-high-volume-settings/
8. https://www.eyenews.uk.com/news/
post/spamedica-extends-its-ophthalmic-training
-programme-creating-vital-placements-for-nhs-registrars
9. https://www.rcophth.ac.uk/
wp-content/uploads/2022/10/Blueprint-for
-cataract-training-2022_v2.pdf
10. https://www.rcophth.ac.uk/wp-content/
uploads/2024/11/Research-summary-OTG
-Summer-2024-cataract-training-survey.pdf
11. Greenaway J. Coming Up Short: The State Of Ophthalmology in the UK. The Ophthalmologist 2023:
https://theophthalmologist.com/business-profession/coming-up-short
[All links last accessed April 2025]
Declaration of competing interests: None declared.
