Cataract surgery is the commonest operation offered within the NHS. In January 2016 less than 20% of all NHS-funded cataract surgery was carried out by Independent Sector Providers (ISPs): by January 2024, this had tripled to 59%. (Fig. 1).

Since 2016 the proportion of NHS-funded cataract surgery delivered by independent sector providers has increased from less than 20% to more than 50%.

Not only has the proportion of ISP-delivered cataract surgery expanded; but the total number of cataract operations done in England post-COVID has increased far more than predicted. The Royal College of Ophthalmologists’ Way Forward Document anticipated a 50% increase in cataract numbers from 2015 to 2035, suggesting 400,000 operations in the UK in 2021/2022. However, this has been surpassed in England alone with 600 000 cataract operations in 2022/23, making that nation a significant outlier in the UK (Fig. 2).

The English commissioning system is more accessible for independent sector providers, which may explain this disparity.

Such a dramatic shift in the delivery of a common surgical procedure challenges equity of access, funding of traditional NHS Ophthalmology departments, and workforce planning for both surgeons and theatre staff; but perhaps the most significant question is how, when 60% of NHS-funded cataract operations have moved into the independent sector, will the future generation of UK cataract surgeons be trained?

The UK differs from other nations in that curricular defined competence in cataract surgery is required for all UK ophthalmology surgical trainees. Ophthalmology trainees must complete, at the very least, 350 independent cataract procedures during their training with an audit of both complications and outcomes. In 2016, when 80% of all cataract operations were performed at traditional NHS sites, trainees would have no difficulty in accessing the full range of routine to complex cases, in large numbers, facilitating robust training.

This traditional training model has been significantly disrupted by the huge shift to ISP-delivered care. Moreover, ISPs work from isolated cataract-specific sites, with limited access to medical support in the case of the acutely unwell patient. This inevitably results in risk-averse case selection, with referrals for patients with significant medical, physical, or cognitive needs being redirected to traditional NHS hospital providers.

Consequently, not only are the total case numbers in those NHS hospitals reduced; but the case-mix is significantly biased towards complex patients, and training opportunities - especially for newer trainees - are reduced.

This situation has been highlighted in the annual GMC National Training Survey every year since 2019. The 2023 Survey showed that a large proportion of trainees were struggling to achieve the required number of cataract operations, and that they were unable to access enough training opportunities in ISPs to mitigate this loss of opportunity [1].

This situation is now improving, with active engagement from several ISPs and - despite reports of significant variation in opportunity for ISP placements across providers and regions - where training is delivered in an ISP, the quality is reportedly high.

The Long Term Workforce Plan and the Elective Recovery Programme have consolidated the use of ISPs into future delivery of NHS services. Given that 60% of cataract surgery in England is already delivered at these sites it is imperative that appropriate and sufficient training is integrated into these care models. The inclusion of training requirements within commissioning contracts is a robust way of ensuring that we continue to train high-quality cataract surgeons, who are capable of delivering high-volume surgery as consultants, and this is now reflected in the 2021 NHSE Cataract Service Specification which states (“The Provider must agree to take a proportionate number of trainees at different levels from the Deanery […] 11% whole cases is expected for all providers of NHS funded cataract surgery”). This, if applied, will help to redress the imbalance.

There are potential advantages in utilising ISPs to deliver routine cataract training: the environment is optimised for cataract management, and is not burdened with the delivery of emergency eye care or other subspecialty services. This should allow investment in modern training tools such as virtual and augmented reality simulation, and video analysis of surgical technique. Such investment is almost impossible cohesively in the NHS.

A collaborative approach, where each site trains in what it does best, will maximise trainees’ exposure to both high volume routine cases and complex cases. At the same time, standardisation of training will augment its delivery regardless of site: trainees will experience cross-site learning, which should enhance training and not cause conflict. All training centres must have access to trainees’ portfolios and supervisor reports, and must contribute to trainees’ annual review of competence and progression (ARCP) [2].

The NHS has assumed standardisation of care across its delivery platforms and has similarly assumed standardisation of practice and training in cataract surgery. However, the reality is one of multiple ISPs, each with different investment structures, funding models and financial goals: they are, by their nature, profit-driven organisations. This diversity may create significantly different training experiences for trainees depending on which ISP the are allocated to. Clear expectations regarding the delivery of training could and should be included in commissioning documents so that not just the volume of training (11% of commissioned cases) but the quality of training (complication reporting, video review, simulation to re-train) is defined.

NHS England has created a paradigm shift in the way it delivers cataract surgery. It is desirable that those sites proven to deliver highly safe and efficient care, whether NHS or ISP, should be commissioned to deliver excellent and timely care for patients. Cataracts are a front runner in this paradigm shift, and can provide a blueprint for other specialties, such as orthopaedic procedures and abortions, which are now facing a similar change.

In order for this integration of ISP and NHS to work, NHS England must ensure that national commissioning not only guarantees the quality and safety of care, regardless of provider; but that it also has the requirements of training firmly embedded within it, to afford the next generation of cataract surgeons the opportunity to train to the standard which our ageing population will require.