Britain’s national health service is outsourcing more eye, hip and knee operations than ever before as it struggles to respond to record waiting lists for surgery.
The number of these routine operations carried out by the NHS in its own hospitals increased until 2014 but has barely risen in the past decade as the private sector takes on a bigger role, according to data from the National Joint Registry and the Royal College of Opthalmologists.
The figures underscore a slow but steady shift by the taxpayer-funded NHS towards paying private providers for medical treatment, which health leaders say threatens the long-term financial viability of the health service.
Michelle Tempest, partner at healthcare consultancy Candesic, said the NHS was “having to rely on the private sector to carry out more planned, routine surgeries for a wider range of both surgical and medical procedures”. The trend was “likely to expand to other operations”, she added.
Although outsourcing speeds treatment and helps reduce some waiting lists, most operations in private hospitals are carried out by NHS employees in their spare time, potentially reducing their availability to state services. In addition, medical experts warn that a lack of cross-disciplinary expertise and a fragmented approach to handling post-surgical complications could harm patient health.
Both the governing Conservative and opposition Labour parties have committed to greater use of the private sector in the NHS, with outsourcing expected to continue to underpin national policy.
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“No one should be waiting in pain while hospital beds that could be used lie empty”, shadow health secretary Wes Streeting told the Financial Times. “Labour will use spare capacity in the private sector to get patients seen faster.”
More than a third of NHS-funded hip and knee cases are carried out by private hospitals, such as Circle Health Group and Spire Healthcare, according to the National Joint Registry, which collects and reports data on operations in England, Wales and Northern Ireland.
However, the high number of self-paying and insured patients means that the private sector carries out more than half of hip and knee replacements overall. Timothy Wilton, NJR medical director, said the increase in people paying for private healthcare themselves was “an indication of a failing system as waiting lists had increased so dramatically”.
“Hip and knee replacements may be ‘planned’ rather than ‘emergency’ but this doesn’t mean that people’s quality of life hasn’t deteriorated sharply,” he added.
Waiting times for routine hospital treatment in England hit record levels in September, with patients waiting for almost 7.8mn appointments, according to the latest NHS data.
A straightforward hip operation will cost the NHS about £7,000, which is lower than the £12,000 to £15,000 that independent hospitals charge private patients. For this reason private hospitals, particularly in the wealthy London market, prefer insured or self-paying patients.
Although NHS England, the commissioning body, pays private and state hospitals the same fee per operation, the tariffs do not always fully reflect the complexity of an operation.
Most private hospitals were not equipped with intensive care facilities or multidisciplinary medical back-up, said Wilton, leading them to take the easier cases, which left more difficult and expensive patients who needed to stay longer with the NHS.
In addition, if an operation needs redoing, the patient can be sent back to NHS. “NHS hospitals are continually financially overstretched as they are left with the highly complicated cases, who need access to multiple clinical experts and have long inpatient stays so the full cost of care is never fully met,” said Tempest of Candesic.
NHS England said it was “absolutely right” that the health service made use of all available capacity, including in the independent sector “to reduce the backlogs and provide the best possible service for patients”.
The problems are compounded by the sharp fall in the number of NHS hospital beds in England. These more than halved in the 30 years to 2019-20 to just 141,000 even though the number of patients increased rapidly, according to the Kings Fund, a think-tank.
Although beds were reduced in the belief that many operations can be carried out as day cases, the wards are often full of more urgent patients meaning hip and knee surgeons struggle to find beds. In some instances, the long wait for a vacancy resulted in surgeons being paid but unable to carry out operations, Wilton said.
The government said it was on “track to create an additional 5,000 permanent staffed hospital beds this winter.”
In ophthalmology, there has been an even sharper increase in outsourcing to private operators such as Spamedica, Newmedica and Optegra as well as the large private hospitals.
Jordan Marshall, policy manager at the Royal College of Opthalmologists, said the “huge shift” towards outsourcing surgery in the past five years was particularly noticeable in cataract operations, which are relatively simple and straightforward.
About 60 per cent of all NHS funded cataract procedures in England are carried out by the private sector, up from 30 per cent before the pandemic, according to the college’s data. NHS England pays around £841 for a simple cataract operation.
Although the use of the private sector had been “essential to bringing down waiting lists for cataract surgery”, Marshall said there were concerns over patient aftercare, which often falls back on the NHS. More difficult operations for higher risk patients such as those with glaucoma and age-related macular degeneration also risk being sidelined, Marshall said.
Most treatment in private hospitals and clinics is performed by NHS employees working in their spare time. Tim Gardner, policy expert at the Health Foundation think-tank, said this came with a price to the NHS in terms of the “opportunity cost of staff time”.
“While the private sector can support the NHS in addressing the backlog in elective care, it won’t be a substitute for addressing the major problems facing the health service”, said Gardner.