Influential thinktank The Health Foundation has published a report which examines trends relating to independent sector provision of NHS ophthalmology services in England. RCOphth Policy Manager Jordan Marshall summarises the key findings, and how they link to existing work the College has led.
Recovery in ophthalmology backlogs but investment in NHS units and workforce the missing piece of the puzzle
Last week’s report from The Health Foundation (Waiting for NHS Hospital Care: the role of the independent sector in delivering orthopaedic and ophthalmic care) analyses recent trends in the delivery of NHS ophthalmology services by independent sector providers (ISPs). This is a subject that RCOphth has looked at in detail over the last 18 months, including in our analysis of cataract surgery trends and position statement on three steps to sustainable patient care – the latter of which is referenced in this report.
Health Foundation points to the rapid growth in ISPs delivering NHS cataract procedures – up from 13,069 in January 2020 to 30,676 in October 2022. With NHS providers delivering 27% fewer cataract procedures over the same period, this now means ISPs are delivering 59% of NHS cataracts – compared to 30% in January 2020.
The report notes that because of this rapid ISP growth, in ophthalmology ‘the overall number of treatments being delivered per month has recently risen above pre-pandemic levels’. This is good news for the many patients who have been waiting for a cataract operation. The report recognises that there are specific factors that have enabled this rapid increase in cataract activity in ISPs compared to other specialties – including referral pathways from optometry and amenability to scaling.
It also highlights the important point that more complex ophthalmology work is difficult to scale up in ISPs. It references inpatient vitreous retinal work, which has seen no increases in the ISP share of activity since 2020, while making the broader point that the volume of non-cataract ophthalmic procedures delivered in ISPs ‘stayed more or less stable’.
This analysis feeds into a crucial point RCOphth continues to make to policymakers, including in our response to the launch of the Elective Recovery Taskforce. While bringing down cataract surgery backlogs is important, we cannot afford to ignore those waiting for outpatient appointments which are crucial for diagnosis and ongoing disease management (for conditions like glaucoma, AMD and diabetic retinopathy), and therefore preventing avoidable irreversible sight loss.
Because these areas are more complex and less suitable for rapidly scaling up, the NHS will continue to deliver the vast majority of this care but needs better support to be able to do so in a timely way. That means addressing the chronic workforce shortages and underinvestment that NHS ophthalmology units are facing, as we outlined in our recent 2022 workforce census. Our President Bernie Chang made this point too at a recent event in Parliament.
Continuing to address training and sustainability concerns is key
As well as looking at statistical trends, Health Foundation also considers the knock-on impacts of growing ISP ophthalmology provision. Referencing RCOphth’s census findings and 2021 position statement, the report notes that ‘Possible downsides include workforce training if there are big reductions in the volume of simple cataract procedures delivered by the NHS…and other possible impacts on the sustainability of NHS services’.
RCOphth has worked with NHS England, ISPs and other stakeholders to develop constructive solutions to these issues. In late 2022, we updated you about groups we convened that led to the publication of a College blueprint for cataract training in the independent sector and further contracting guidance from NHS England, clarifying issues around non-contracted activity, conflicts of interest, how to enable patient choice and requirements for post-operative care.
Earlier in 2022, we supported NHS England to develop and publish a cataract service specification, which aimed to ensure all providers of cataract surgery in England met certain standards and requirements – including the delivery of training and the handling of post-surgical complications
The Health Foundation report also highlights potential concerns in access linked to deprivation and ethnicity. For example, it states that ‘in the poorest areas, treatment volumes in the latest 12 months were still around 1% lower than pre-pandemic levels, while in the richest areas they were 5% higher than pre-pandemic. This is largely being driven by the faster growth of the independent sector care in more affluent areas’. It also notes that ‘White patients have been consistently more likely to receive NHS-funded care from ISPs’.
It is essential that we create a policy environment that ensures equity of access for ophthalmic patients no matter their background or where they live. Part of this will undoubtedly be about ensuring we have sufficient workforce to deliver care in all parts of the country.
RCOphth will continue to build on the work with all parties outlined above, ensuring that surgical training opportunities are available for ophthalmologists in training, and that additional capacity is commissioned when it will support improved access to ophthalmic care for patients. We will continue to articulate the urgent need for investment in the NHS ophthalmic workforce and infrastructure so we can deliver the most timely care for all our patients and do all we can to prevent avoidable sight loss.
