Private eyes - impact of NHS outsourcing of eye care to the private sector

This winter has revealed to us all just how fragile our Accident & Emergency care services have become when faced with a perfect storm of simultaneous increased demand and cost, as well as changes in NHS structural management.

Different political parties will have different policies as to the nature of required reform. The role of the private sector in the NHS is being actively considered (perhaps now more than ever) as its inevitable saviour by many.

There are insidious examples of private sector involvement in UK healthcare already. For example Harmoni, the largest provider of NHS Out of Hours GP services which has contracts covering 8 million patients  across London and the South East whose former clinical lead, Dr Fred Kavalier, resigned owing to concerns about cost-saving measures potentially compromising patient safety.

Another example is the NHS patient outsourcing of eye care to the private sector. There has been a growing trend in this direction of late. Figures obtained from the Health and Social Care Information Centre by the Independent show that 35,329 cataract operations were carried out by the private providers for the NHS in 2012-13. This was double the number five years ago.

The sort of organisations that tender for this work include Vanguard Healthcare Solutions, a company that has beset by scandal after it was revealed that 37 out of 62 NHS cataracts patients seen by their subcontracted surgeons at a mobile unit in Musgrove Park Hospital, (part of Taunton & Somerset NHS Foundation Trust), had serious complications which then had to be treated back within the NHS by NHS employed ophthalmologists based inside Musgrove Hospital.

A damning internal report dated October 2014 revealed that amongst these patients, some suffered burns, others lost pigment in their irises, and some were left with microscopic shards of metal in their eyes. One patient was allegedly left completely blind as a result of sub-standard ophthalmic surgery.To put this in perspective, this is a complication rate that is ten times greater than what is normal.

Perhaps this was due to the fact that the sub-contracted surgeons were operating on 20 cataract patients a day, significantly more than their NHS counterparts?

1. Or perhaps this was because there was an unusual combination of staff (sub-contracted from another company, the Practice plc by Vanguard) 
2. equipment (also sub-contracted from another company, Kestrel by Vanguard) and
3. facilities that had never been brought together before?

Or perhaps this was due to the lack of on-site training before patients began arriving on the first day after the mobile unit had been set up?

Charities that represent the visually impaired have commented on these poor outcomes. Clara Eaglen, the RNIB’s Eye Health Campaigns Manager said “it is unacceptable that an operation with such low risk of serious complications has left these patients with a reduced quality of life”.

The potential problems with outsourcing cataract surgery to the private sector were identified by the Royal College of Ophthalmologists (RCO) who in 2004 (before the Vanguard scandal occurred) prepared an Outline of Good Practice document.

These included:

1. Problems for the patient (i.e. no prior opportunity for patient discussion of surgery, difficulties in arranging adequate follow up)
2. Problems for the provider (i.e. difficulties in obtaining patient previous medical history).
3. Problems for the local eye unit (i.e. ‘cherry picking’ of regional workload of simpler operations, leading to adverse effects on training, skill-retention, and recruitment).

Despite recommendations made by the RCO, including the importance of accreditation of private healthcare providers, outsourcing is still sometimes leading to poorer patient outcomes.

Clara Eaglen at the RNIB further commented that: ‘Following an increase in the number of NHS patients being referred to non-NHS providers, our key concern is that outsourcing does not compromise patient safety and reduce the quality of care received’.

The irony of course is that with poor patient outcomes, the aftercare (‘picking up the pieces’) becomes the role of the overburdened NHS. If ophthalmic injury has resulted from negligent surgery, the NHS may also be involved in litigation required to compensate the injured patient.

What is the cyclical end result of extracting money from the NHS in this way, and impoverishing it further? To quote Noam Chomsky:

“That’s the standard technique of privatization: defund, make sure things don’t work, people get angry, you hand it over to private capital."

Let’s not allow the cure to be the poison.