Preventable Sight Loss

Margaret Greenwood Excerpts

Tuesday 30th April 2024 Westminster Hall

[Margaret Greenwood (Wirral West) (Lab)]

I beg to move,

That this House has considered preventable sight loss.

It is a pleasure to serve under your chairmanship, Sir Mark. I would like to begin this debate by asking Members who have good eye health to consider these questions. How would you feel if you lost your sight? How would it affect your life and your ability to connect with family and friends or earn a living, travel independently, enjoy the place you live in, the hobbies you have or visit new places? If you were to lose your sight, how would it make you feel to subsequently find out that it actually could have been saved?

Sadly, hundreds of our constituents are going through this very experience. In England, over 600,000 patients are currently on NHS waiting lists to begin treatment for ophthalmology—the branch of medicine concerned with the diagnosis and treatment of disorders of the eye. A survey by the Royal College of Ophthalmologists from this year shows that only 25% of NHS ophthalmology departments feel able to meet patient need, and 70% of departments are more concerned about out-patient backlogs compared with 12 months ago. These are incredibly alarming statistics. Alarming, too, is the fact that it was reported last year that, in 551 confirmed instances, patients had lost their sight as a result of delayed appointments since 2019.

Alongside the problems with ophthalmology in the NHS, we have seen the growth of the independent or private sector. I ask Members to consider the impact that the increased use of private sector provision is having on eye care. Independent sector providers now deliver almost 60% of NHS-funded cataract procedures. That has more than doubled from around 25% before the coronavirus pandemic. Although it has helped to bring down cataract waiting lists, the Royal College of Ophthalmology has found that 67% of NHS ophthalmology departments reported that the impact of independent sector providers on patient care in their area is negative. Let us reflect on that: over two thirds of ophthalmology departments in the NHS believe that the impact of independent sector providers on patient care is negative. It is important that we understand why.

The three aspects those departments have said they are most worried about are training opportunities for junior doctors, funding for the NHS ophthalmology department in which they work, and the available workforce. They believe that these will hamper the long-term ability of their departments to deliver sight-saving care for patients. Every Member of this House should be concerned about that.

The Royal National Institute of Blind People has said that the role of the independent sector has been associated with significant challenges that pose an increasing risk to the sustainability of comprehensive eye care services in the NHS. I believe that the impact on many of our constituents could be, and is likely to be, devastating.

[Alex Sobel (Leeds North West) (Lab/Co-op)]

Does my hon. Friend agree that the use of the independent sector creates a postcode lottery as well? More affluent areas get to the front of the queue more quickly, and we see regional variations where the independent sector is stronger. That is a real concern for people waiting to have this treatment.

[Margaret Greenwood]

My hon. Friend makes an important point, and I will touch on regional variations later.

A paper published last month by the Centre for Health and the Public Interest reported that in the period 2018-19 to 2022-23, the NHS paid the private sector around £700 million for cataract treatments. While cataract operations are very important and can transform people’s lives, it is crucial that those responsible for health policy consider whether the increase in the number of them being delivered comes at the expense of other sight-saving treatments.

We must ensure that the NHS is comprehensive in the range of treatments that it provides. The Centre for Health and the Public Interest warns that the increase in the percentage of the NHS budget being spent on cataract operations is likely to mean that there are fewer resources available to treat other eye care conditions, such as glaucoma and macular degeneration, which are generally considered more serious and lead to irreversible sight loss. Ophthalmologists have also told me that it is impacting capacity for the treatment of conditions such as cancer care, urgent treatment and the treatment of newborn babies.

Data received by the charity from 13 NHS trusts has shown that waiting times for some irreversible conditions have increased between 2017-18 and 2022-23, including for glaucoma and diabetic retinopathy. Waiting times have also increased for cataract operations. The charity also reports that the rise in expenditure on cataract services has been accompanied by an increase in the number of private, for-profit clinics, which have been established to deliver NHS cataract services. Its paper states that 78 new private, for-profit clinics have opened over the past five years.

It is not surprising that some senior ophthalmologists have raised concerns that the increased expenditure on NHS cataract provision, carried out predominantly by the independent sector, is being driven not by patient need but by the commercial interests of the companies delivering it. Last December, Professor Ben Burton, president of the Royal College of Ophthalmologists, warned that the entire commissioning process needed looking at, with local integrated care systems unable to effectively control their use of resources, resulting in some patients with

“very mild cataracts getting surgery at the expense of other patients going blind”.

He added that the approach of unplanned commissioning means that

“the NHS is losing consultants, money and trainees to the private sector”

and that the profit margin is “too high”, meaning that

“companies can pay three times the NHS overtime rate...So, unsurprisingly, people are dropping sessions in the NHS and doing cataract surgery at private companies.”

Professor Burton further warned that:

“We are trying to train the next generation of cataract surgeons, but they’re not getting any straightforward cases to train them on, because the NHS is being left with the more complex cases, with the less complex ones being outsourced.”

That very much chimes with the arguments raised by the Centre for Health and the Public Interest. In other words, the independent sector is cherry-picking the less complex work.

When he responds on behalf of the Government, will the Minister set out what discussions they have had with NHS England about sorting out the perverse outcomes caused by the unplanned commissioning that Professor Burton has highlighted? Unless we see a change of course by policymakers as a matter of urgency, there are real concerns that we will see the breadth of eye care provided within the NHS diminished to the point where some complex sight-saving treatments are no longer available on the NHS. They might be things such as the treatment people need when they are in urgent care after a road traffic accident, the treatment needed for newborn babies or treatment for cancer.

[Jim Shannon (Strangford) (DUP)]

I commend the hon. Lady for bringing forward this debate. First, this is a terrific subject. She will know that this morning I had a debate on optometry care, which is a similar topic, and the issue is clear. In that debate, I said that 22 people weekly lose their sight to preventable loss. The hon. Lady knows that. Does she agree that the annual eye test should be pushed as forcibly as a dental check-up, and that the message should start in schools and resound right through the community? I think she will agree that optometrists and opticians want to be part of that move forward. If that is the case, we need the Minister and his Department to work alongside them to push for appointments from an early age.

[Margaret Greenwood]

I thank the hon. Gentleman for his intervention; it was characteristically appropriate. I particularly welcome his call for the message to start when children are in school because it is massively important.

In the not too distant future, we may face eye care deserts in some parts of the country, in much the same way as has happened with dentistry, with some people missing out on crucial treatment. That is exactly what Professor Burton has warned could happen. He said:

“There is a risk that the NHS loses ophthalmology completely, like it has dentistry, in terms of it being a service which is available free at the point of delivery.”

It is not difficult to see how such a conclusion has been arrived at. The great tragedy we face if that happens is that some people will lose their sight from treatable conditions.

The use of the independent sector for ophthalmology has tended to be more prevalent in some parts of the country than in others, so Members representing constituencies in those areas may be particularly concerned. A regional analysis of trends published by the Royal College of Ophthalmologists in 2022 found that in 2021 the north-west of England had the highest proportion of NHS-funded cataract procedures delivered by independent sector providers, at 61%. The midlands, the north-east, Yorkshire and the south-west of England also had figures over 50%. Those figures have increased greatly since 2016. Although there is regional variation, we should be concerned about that right across the United Kingdom.

NHS staffing levels for ophthalmology are also a matter of extreme concern. As I said earlier, NHS ophthalmology departments are worried about training opportunities for junior doctors and the available workforce. In response to a recent written parliamentary question, the Under-Secretary of State for Health and Social Care, the right hon. Member for South Northamptonshire (Dame Andrea Leadsom), failed to provide clear information about the Government’s plans for specialty training places for ophthalmology. She said:

“A decision regarding which specialties these places will be allocated to will be made nearer the time that the places are required for the expanded workforce. NHS England will work with stakeholders to ensure this growth is sustainable and focused in the service areas where need is greatest.”

Will the Minister clarify that? When Under-Secretary of State for Health and Social Care spoke of stakeholders in that context, was she talking about the independent sector as well as the NHS? If so, will the Minister ask NHS England what progress it is making towards meeting its commitment, set out in the 2023 elective recovery taskforce implementation plan, to

“track, monitor and evaluate independent sector’s impact on the long-term NHS capacity landscape”?

That is an incredibly important matter, and if the Minister is not able to reply today, I would welcome it if he can write to me on that point.

How confident is the Minister that the full breadth of ophthalmology expertise will be there in the NHS for any one of us in five or 10 years? Data from the most recent workforce census from the Royal College of Ophthalmologists shows that there is real cause for concern, given that 76% of NHS ophthalmology departments report not having enough consultants to meet patient need. In reality, NHS ophthalmology departments are increasingly relying on costly locums to cover workforce gaps, and nearly two thirds—65%—use locums to fill consultant vacancies.

Typically, UK-trained ophthalmologists will have undertaken the vast majority of their training in the NHS, including those now working for independent sector providers. There are concerns that the increase in NHS staff working in the independent sector on cataract provision is reducing the availability of training opportunities that enable NHS staff to train in more complex areas. That is potentially a time bomb for the future, and could mean that we will not have anywhere near enough staff trained to carry out work on treatment for conditions such as glaucoma and wet macular degeneration.

It is clear that we are facing a sight loss health emergency, and there is an urgent need for a national eye health strategy. The RNIB has suggested that the goal of such a strategy should be to establish eye health as a public health priority, and it should aim to prevent irreversible sight loss.

As the Royal College of Ophthalmologists pointed out, it is imperative that NHS ophthalmology departments across the UK are supported to deliver high-quality and timely care for all patients, regardless of their condition and where they live. Among other things, it is calling on policymakers to support the development of a multi-disciplinary eye care workforce fit for the future. That should include delivering an additional 285 ophthalmology training places in England by 2031 and boosting investment in the ophthalmic practitioner training programme so that more eye care professionals can work to the top of their licence.

The royal college is also calling for better integrated eye care through investment in digital solutions such as interoperable electronic patient records between optometry and ophthalmology, and a further development of integrated pathways for optometry so that patients receive the most appropriate and accessible care and are prioritised based on clinical need. It is calling for the reform of commissioning, tariff and data reporting systems, which it believes will ultimately help the NHS ophthalmology services. All those things should be part of a national eye health strategy.

The strategy must be inclusive and must address the needs of everybody. The charity SeeAbility has pointed out that people with learning difficulties are 10 times more likely to have a serious sight problem than other people, but are far less likely to have a sight test. What is happening to ophthalmology services in the NHS is clearly a matter of extreme concern and is one example of just how damaging the privatisation of NHS services is to the delivery of a universal and comprehensive national health service.

The increasing use of the independent sector to treat NHS patients leaves us vulnerable to the vagaries of the market. Under this Government, the use of private-sector companies in health has increased. Indeed, the Health Service Journal reported last December that the amount spent by NHS trusts on outsourcing activities to other providers has almost doubled from £2.4 billion in 2019-20 to £4.7 billion in 2022-23. The HSJ stated that independent providers are

“likely to make up the bulk of the spend”.

The Minister will say that the Government are not privatising the NHS, but that is smoke and mirrors. The World Health Organisation defines privatisation as

“a process in which non-government actors become increasingly involved in the financing and/or provision of health care services”.

We have seen that in ophthalmology, with the commercial interests of private companies driving the increased expenditure on NHS cataract provision. That is the view of ophthalmologists. No doubt the Minister will say that the Government are providing the national health service with record levels of funding—again, smoke and mirrors. The fact is that, as pointed out in the 2023 report “The Rational Policy-Maker’s Guide to the NHS”, NHS spending has not been enough to keep pace with need when we factor in and combine the effects of inflation, population growth, population ageing and increased morbidity.

I ask Members to think about the questions I raised at the beginning of the debate. How would you feel if you lost your sight, how would it impact your life, and how would you feel if you then found out that the loss of your eyesight could have been prevented? How would you feel if you found that you could not get the treatment you need because less serious conditions were being treated as a priority in the independent sector by specialists who were lured there, away from the NHS, due to how commissioning works and because the market is increasingly influencing what is and is not treated?

RNIB figures show that every day, 250 people in the UK start to lose their sight. We need the national eye health strategy, the goal of which should be to preserve vision and prevent irreversible sight loss. I call on the Government to address those issues as a matter of urgency. The Government must invest in the national health service and strengthen it as a public service to ensure that it is universal and comprehensive. For that, they must build the capacity of expertise within the NHS so that we can be confident that the service is there to treat all eye conditions. In the words of Professor Ben Burton, the chief executive of the Royal College of Ophthalmologists,

“the key to ensuring long term capacity to deliver patient care is to invest in comprehensive NHS services, workforce and infrastructure.”

--- Later in debate ---

[Margaret Greenwood]

The Minister said that he is never going to agree with me on the use of the independent sector. Will he look back over this debate and consider the points I have made—and not just my views but those of the Royal College of Ophthalmologists and the RNIB—and the outcomes that are arising as a result of the increased use of the independent sector? He takes an ideological position, but what I am asking him to do is look at the practical outcomes of what is going on.

I thank all Members who contributed to the debate, including my hon. Friend the Member for Leeds North West (Alex Sobel) and the hon. Member for Strangford (Jim Shannon), and in particular my right hon. Friend the Member for Hayes and Harlington (John McDonnell) for his work on behalf of those who have had their eyesight damaged through laser surgery. I hope the Minister will pick up on his call for further regulation and for a meeting with the victims of that treatment. I also thank the many organisations that contacted me in advance of the debate with their thoughts and briefings. It is vital that we do all we can to ensure the provision of comprehensive and universal eye care in the national health service.

The growth of the independent sector in delivering almost 60% of NHS-funded cataract procedures is having a negative impact on patient care, as more than two thirds of NHS ophthalmology departments have said. As a result, treatment for other eye care conditions in the NHS—such as glaucoma and macular degeneration, which are generally considered to be more serious and which lead to irreversible sight loss—are being adversely impacted. We must also consider the potential impact of the availability of treatment for people in urgent care after, for example, a road traffic accident; the treatment needed for newborn babies; and the treatment of cancer both now and importantly for future generations.

Currently, the market is influencing what is and is not treated, and private companies are cherry-picking the treatment that they want to deliver. This is no way to protect and strengthen the national health service. We need a national eye health strategy to preserve vision and prevent sight loss as a matter of urgency. We need a comprehensive and universal national health service that is there for us all when we need it for eye care and all other areas of health. I thank everybody who contributed to the debate.

Question put and agreed to.

Resolved,

That this House has considered preventable sight loss.