Hundreds of thousands more NHS patients a year are having cataracts removed in England in a boom driven by private clinics – but funded by taxpayers.
Doctors say the trend, which now means nearly 60% of NHS cataract operations are outsourced to private providers – up from 24% five years ago – is piling pressure on already stretched NHS finances and sapping the funds needed for more serious conditions that can lead to blindness.
The surgery, a painless procedure to treat blurry vision by replacing the eye’s natural lens with an artificial one, usually takes 10 to 15 minutes and has become increasingly routine.
The Royal College of Ophthalmologists says the number of cataract treatments has jumped by nearly 40% from pre-pandemic levels, meaning an extra 200,000 people a year are having the procedure on the NHS. It claims the jump is down to outsourcing to the private sector.
But Ben Burton, the college’s president, says that while the independent sector helped reduce backlogs after the pandemic, it has “continued to expand to a level where there’s less and less benefit and more and more cost”.
The Royal National Institute of Blind People is also concerned that the use of private providers is having a “destabilising effect on NHS eye care services”. It said: “It is also important to take into consideration the unequitable nature of the expansion of the independent sector, which has shown significant regional variation and favoured affluent areas.”
NHS spending on cataracts has doubled in five years and there has been a jump in outsourcing, according to research published in March by the Centre for Health and the Public Interest (CHPI) thinktank.
Its analysis of data from 37 of 42 integrated care boards in England found that the NHS paid private clinics about £700m for cataracts from 2018-19 to 2022-23, which doubled its overall annual spending on cataract procedures in NHS hospitals and private clinics from £218m to £437m.
Over the five-year period, this helped push the share of the NHS eye care budget that is spent on cataracts up from 27% to 36%.
“Free NHS cataract surgery in four weeks.” This tempting offer appears on Google when you search for SpaMedica, the biggest private provider of cataract surgery to the health service. It advises patients to ask their optician or GP to refer them for treatment at a hospital of their choice and says they should hear back within two to three weeks.
The top five companies providing cataract surgery to the NHS have opened 101 new eye clinics between them over the past five years, taking the total to 126 in England. In 2022, they collectively made pretax profits of more than £100m, according to figures filed at Companies House, with SpaMedica earning £72m.
NHS waiting lists for eye treatment have also grown in Scotland, forcing some patients to go private. Christine McAleer, 76, a retired nurse who lives in Rutherglen, near Glasgow, said she decided to go private after an optician’s eye test showed two signs of glaucoma and was told the NHS waiting list for a diagnostic examination was 80 weeks.
“I’m totally against private care; I worked for the NHS for 35 years,” she said. “I didn’t want to go blind so I saw a private eye consultant. He said I didn’t have glaucoma but I needed cataract surgery.”
She paid £6,300 from her savings for cataract treatment in both eyes at Ross Hall hospital in Glasgow, which is run by the UK’s biggest private health provider, Circle Health Group.
Burton of the royal college said the outsourcing had been “a good thing immediately after Covid to get cataract waiting lists under control – but they’ve very rapidly come down to a sensible level in many areas of England.”
He worries about hospitals losing staff and funding to private cataract clinics, making it harder for the NHS to treat eye conditions such as wet macular degeneration, the most common cause of preventable blindness in the UK, and glaucoma.
“If you’ve reduced the number of the cataract waiting list considerably, that’s great,” said Burton. “But if you’ve got more people going blind from other conditions as a result of that policy, that isn’t desirable.”
The CHPI has received data from 13 NHS trusts showing that waiting times for some irreversible eye conditions have increased over the five years to April 2023.
NHS clinicians reported more than 200 cases of people losing some or all of their vision because of treatment delays since 2019, with hundreds more unreported cases suspected, according to data in a freedom of information request to NHS England made by the Association of Optometrists in March last year.
Last October, the thinktank Reform found a backlog of follow-up outpatient appointments not captured in government statistics – comprising almost 10,000 ophthalmology patients for each trust – who were typically those at highest risk of avoidable sight loss.
Cataracts, says Burton, do not need to be treated as quickly as more serious conditions. “A mild cataract is like having a dirty window in your house. For most patients, it’s not something that’s an emergency and if you leave it a few months longer, it doesn’t make any significant difference.”
The Independent Healthcare Providers Network (IHPN), which represents SpaMedica and the other companies, counters that ophthalmology is the only big specialism where the median waiting times are now lower than in 2019, before the pandemic.
Its chief executive, David Hare, said: “There are currently over 600,000 NHS patients waiting for ophthalmology treatment in England, and independent providers are helping to cut NHS waiting times and ensure as many patients as possible can be treated.”
Colin Hutchinson, a retired consultant ophthalmologist and member of campaigning organisation Doctors for the NHS, is concerned that some people have cataract surgery unnecessarily and that they are not informed of the risk of serious complications such as permanent sight loss – of which there is a one in 1,000 chance.
“Anyone over the age of 60 is going to have a little bit of cataract – that doesn’t mean you need to have a cataract operation,” he said. “There’s no great benefit in having surgery any sooner than you need it.”
NHS England has recently taken private contractors to task over a marked increase in “complex” cataract procedures, for which the charges were as much as £400 higher. Complex cases have risen 144% in five years and the CHPI estimates this has cost the NHS £29m extra over the last two years alone.
An NHS England consultation raised concerns about the rise in December 2022, saying it could not be explained by changes in patient complexity. In an official response to the consultation the following month, the royal college suggested the increase could be down to a practice known as “upcoding”.
All treatments have payment codes and upcoding means providers charge for a more expensive one than they performed.
The opportunity to do this is there, according to Simon Peck, who worked for the insurer Axa for nearly 25 years as head of audit and investigations, because the NHS coding system allows providers to claim additional payment where a case is more complicated or the patient is older or has comorbidities. “This choice is offered for good reasons; however, it also opens the door to potential abuse, particularly if there are not sufficient controls and procedures in place.”
Hare of the IHPN said: “Robust checks, including external audits, are in place and local NHS integrated care systems, who commission healthcare activity, work closely with providers to ensure that coding is accurate.”
NHS England changed the tariffs in April this year so there is only a £30 difference between routine and complex cataract treatments – £868 for a routine operation and £898 for a complex cataract.
NHS England has not yet done an analysis of the impact of private eye clinics on waiting times for cataract surgery and more serious eye diseases. A spokesperson said: “Thanks to the hard work of staff, the NHS has increased the number of cataract operations for patients and brought down the backlogs which inevitably built up during the pandemic.
“This has been achieved through a range of measures, including using the independent sector where needed to help deliver treatments, with prices constantly reviewed to ensure they are at a fair price for taxpayers.”
Among the critics of private sector involvement is David Hinchliffe, an ex-Labour MP and former chair of the health select committee. He was referred for a cataract removal by his GP to a local NHS eye clinic within the Calderdale and Huddersfield NHS foundation trust.
However, the trust referred him “without my knowledge”, he said, to a private company based in Sheffield, Pioneer Healthcare, which was sold in 2022 to the healthcare provider Totally.
The appointment was declined by Hinchliffe, whose GP did not know about his referral to Pioneer Healthcare and later referred him to Barnsley hospital NHS trust. It found that he did not need cataract surgery, but he is being monitored for loss of vision in his right eye caused by a hole in his retina.
Hinchliffe wrote to his NHS trust, saying: “I’m not prepared to go to this company because I don’t want to be treated by the private sector. I object in principle to the fact that the people who are working for this private company also work part-time in the NHS and if they worked full-time in the NHS there would be no need to use the private sector.”
Totally said: “We do not provide treatment to private patients and all our care is delivered on behalf of NHS, free at the point of treatment to our patients. Waiting lists continue to grow, which means new ways need to be identified to create more capacity.”
The NHS spends years training doctors and nurses who go off to work privately, some leaving their NHS work behind entirely, while independent providers train far fewer people.
There is also a huge shortage of consultant ophthalmologists in the UK. The royal college says there are just under 1,700 consultants, about 380 short of the number needed.
Under NHS regulations, optometrists should offer a list of five different providers for cataract surgery for patients to choose from. Optometrists can advise, however, on the best choice, and have sometimes been indirectly incentivised to refer patients to private clinics because they get a fee, typically about £50, for a follow-up appointment, which they would not get from an NHS hospital.
Addressing an NHS conference recently, the former Axa audit chief Peck warned about the risks of private sector use. Now working as chief medical adviser at Kirontech, a company that provides software and analyses healthcare billing data to detect fraud and poor practice, he has found that “misbilling is endemic in every health system I have worked in”. He says that the NHS “needs to protect itself against financial exploitation”.
Peck also says the NHS should follow in the footsteps of insurers and set up auditing teams that scrutinise billings, spot unusual trends and reclaim money where necessary from private healthcare providers.
“With both Labour and Conservatives, they [the NHS] are going to use private providers and they need a degree of awareness that I just don’t think they have of the risks they are running,” he said.
Top private providers of cataract treatments to NHS
The largest provider of is SpaMedica. Founded in 2008 by Anil Pitalia, a trained eye surgeon turned businessman, as an eye and skin treatment centre in Manchester, it now runs 55 hospitals in England.
Its UK parent is part of a German company that is in turn owned by French private equity firm PAI Partners and the Ontario Teachers’ Pensions Plan board. Pitalia heads an eponymous private family office that has invested in warehouses, the Granary office building in Leeds and Aeroworks in Manchester.
Another leading chain of eye clinics is Newmedica, which as of March last year provided services for 19 NHS contracts at 28 sites. It was founded in 2007 by Darshak Shah, an entrepreneur, and Jeremy Diamond, a glaucoma specialist who was an NHS consultant at the Bristol Eye hospital and now works privately. They sold Newmedica to Specsavers in 2020.
London-based Optegra, a chain of 18 UK clinics, is owned by the private equity firm MidEuropa and also operates in Poland, the Czech Republic and Slovakia. It has been run by chief executive Peter Byloos since 2018.
Preston-based Community Health and Eyecare Limited is a chain of more than 25 hospitals. It was founded and is run by Imran Rahman, a former NHS consultant ophthalmologist at Blackpool Victoria hospital.
Anglia Community Eye Care Service was acquired by Optical Express founder and chief executive David Moulsdale in January 2021, and folded into his Glasgow-based laser eye surgery firm.
Moulsdale made it into the Sunday Times rich list for the first time this year, with an estimated fortune of £374m.
