“The Elective Recovery Taskforce was the first step in a journey to making change happen”

The Government’s Elective Recovery Taskforce published its recommendations for easing NHS waiting lists in August.

Amongst the recommendations were plans to expand independent sector provision, in an attempt to ease the current backlog of almost 700,000 people waiting for ophthalmology treatment.

Founder of Newmedica, Darshak Shah, was an appointed expert adviser on the taskforce. Here, he speaks to OT about waiting lists, expansion of training opportunities, and why he is passionate about patient choice.

How much will the planned expansion of eye care treatment in the independent sector increase capacity?

NHS ophthalmology patients have already benefited from more independent sector capacity. As Newmedica, we’ve been at the forefront of building new eye hospitals and increasing capacity for NHS patients. Over the 16 years that I’ve been involved in this space, hundreds of thousands of NHS patients have received their care from the sector, whether diagnostics, consultations, or surgery.

Newmedica delivers more than 235,000 patient interactions a year, and that covers all conditions, not just cataract surgery. We will see patients with glaucoma and macular conditions and those needing oculoplastic and other treatments. As we and others build more eye hospitals and work more closely with primary care optometry to share the care across all eye care professionals , NHS patients will continue to benefit from easier to access services. All of these services, remember, are free at the point of use, because they are NHS-funded.

How important is it to bring down the NHS ophthalmology waiting list in a timely manner?

This is a subject that is very close to my heart. As well as founding an ophthalmology provider, I’m also an NHS ophthalmology patient – I was diagnosed with keratoconus about 20 years ago.

It was the case 16 years ago, and it is still the case in 2023, that in England, we have avoidable sight loss. Patients are losing their sight because there’s not enough capacity to see them in time. Many organisations have flagged this over the years, whether it’s the Royal National Institute of Blind People, the Royal College of Ophthalmologists, or the AOP.

The Health Service Journal has reported that delayed follow ups are increasing risks and causing harm for ophthalmology patients in some parts of the country.

As a patient myself, I founded Newmedica to change the way that eye care is delivered. When we see this sort of thing happening, there’s a clear need for more capacity to see ophthalmology patients. One of our core redesign principles, when we look at services, is to see how we harness the skills of optometrists to work with ophthalmologists to increase capacity.

We do that within our own clinics, where we bring optometrists in to deliver part of the care. But we also have shared care schemes with community optometrists. Putting all of that together helps to increase capacity, see more patients, and aims to minimise cases where patients needlessly lose their sight.

It’s really important to bring down those waiting times. Remember the 7.6 million patients, across all conditions, are those who are either newly referred or waiting for surgery. That number doesn't include patients who are waiting for follow-up. So, if you’re a glaucoma patient, and your six-month follow-up has been delayed, you do not feature in that 7.6 million. That is on top, and it’s not particularly well measured.

There’s a clear need for more capacity to see ophthalmology patients

How important is the role of the optometrist in carrying out post-operative checks?

When I started Newmedica, there were about 1500 consultant ophthalmologists in the country and 20,000 optometrists.

Optometrists are trained to examine the eye, to pick up clinical conditions, to do tests and to use microscopes to look inside the eye. So, you have a highly skilled workforce, which has been trained to do many of the things that are needed for different parts of different pathways. It’s not just post-op checks: it’s glaucoma detection, it’s glaucoma monitoring, it’s potentially acute macular degeneration – a full range of eye conditions. Providers within each of those pathways can employ optometrists, whether in an ophthalmology clinic or in their practice, to deliver part of their care.

It’s clear that there are not enough ophthalmologists to deliver the quantity of care that the population needs, and so one has to harness the skills of optometry to increase the amount of care that’s delivered.

1500 ophthalmologists is not enough to deliver the quantity of care that the population needs, and so one has to harness the skills of optometry to increase the amount of care that’s delivered

What needs to happen to build the trust and the clinical relationships between High Street optometrists and ophthalmologists, either in or outside the independent hospital sector?

We invest a lot in training, and not just of Newmedica people – we seek to go beyond our own boundaries in terms of training.

We’ve worked with several trusts and universities over the past year to provide training to junior doctors, who are training to be ophthalmologists, as well as pre-reg optometrists. Delivering training for the next generation is one of the classic criticisms of the independent sector – that you do all the easy work, and then you don’t do any training. You’re not investing in the workforce that follows.

We at Newmedica believe that, as a responsible provider, who is firmly part of the system, we need to make our contribution to the next generation. Over the past year, we’ve delivered training to 30 junior doctors, who have come into our clinics, and either worked in outpatients or delivered surgery, and to 100 pre-reg optometrists, again, who have come into our clinics and worked with our teams to gain that experience. I’m really proud that we have started that programme. Next year we intend to do more and to exceed those numbers.

Training is one of the hot topics at the moment. Part of the taskforce implementation plan involves our healthcare trade body, the Independent Healthcare Provider Network, doing a survey each year to look at the uptake and experience of trainees. I think that’s a good thing. It shouldn't be a minority of providers who are delivering the training – everybody should be doing their part on this, because if we don’t have a workforce for the next generation, these problems are going to get worse. We’re very proud of the training we offer.

The second piece is forming strong relationships with local community optometrists. We do that through two mechanisms. Firstly, we run a programme of continuing professional development events, typically hosted in our clinics, where optometrists from the local area come in. Those are presented by our ophthalmologists and there will be a series of different case topics that are presented over the course of the year, that allow optometrists to get a flavour of how the clinic works and the different environments, as well as then receiving that training on a regular basis.

That enables a relationship to form between optometrists in the community and ophthalmologists in clinic. We then see that developing into relationships, where if an optometrist has got a difficult case or something they’re not sure about, they will feel confident to reach out to our ophthalmologists to ask for some advice. Previously, maybe they would have just referred everybody in. Through that mechanism of partnering in care with community optometry, we hope that those patients who don’t necessarily need to come into a secondary care environment can have their care maintained in the community.

We at Newmedica believe that, as a responsible provider, who is firmly part of the system, we need to make our contribution to the next generation

Can you talk about the importance of patient choice?

Patient choice for me is one of the three levers for system change across electives. This is not just to do with ophthalmology. I think ophthalmology is probably ahead of the curve in terms of patient choice. One of the reasons I was asked to sit on the Elective Recovery Taskforce was to bring the ophthalmology experience, with respect to building new hospitals and patient choice.

If you look across specialties, patient choice is a real paradox. Patients have had the right to choose since 2008. For a right that people have had for 15 years, it is estimated that maybe 10% of patients across specialties are actually offered choice, which seems like an opportunity to me.

Patient choice remains a minority sport. You’ve got to know about it. You’ve got to feel confident enough to ask for it when you go to your GP or optometrist, and then your GP or optometrist needs to be willing to offer it. The outcome is that very few people actually get a choice.

I advocate a choice by default approach. Rather than people asking to be given their right to choose, everybody should be given choice as default, and if they don’t want to make the choice themselves they should ask the referrer to help them with that choice. This, along with a public awareness campaign, will start to drive the uptake of choice.

This right of choice, if it’s implemented and it becomes more than 10%, will start to match patients who need certain types of care with the capacity that exists in the system. It might be another NHS hospital – it doesn’t have to be an independent sector provider. Choice is universal.

I think one of the biggest issues at the moment is where you have capacity and it’s not being used, when there are so many patients waiting. The choice is a real matching mechanism. I was really pleased to see the Prime Minister’s announcements on choice, which covered choice by default – the five options that people will be given. There will be a public awareness campaign starting, which was in the in the taskforce implementation plan. I hope those actions will start to drive up the use of patient choice, which will then start to help those who are waiting for care.

You were an appointed expert adviser on the Elective Recovery Taskforce – as part of your discussions, were there any challenges to the idea of increasing the amount of NHS work providers could take on?

The taskforce was set up to reduce elective waiting lists. The experience of ophthalmology is quite instructive, in that way. I think there was a genuine shared objective of matching existing capacity, as I just mentioned, with patients who were waiting. As well as that, looking at how one could increase the amount of capacity that is made available to NHS patients. The objective was shared, and clearly in these sorts of working groups, many ideas are discussed and then some are piloted, and then those that you’ve read about in the implementation plan are the ones that made the cut.

In the broader healthcare space, there are a number of divergent views around how these services should be delivered, by which organisations, and in what way. I would always go back to the sad fact that, in 2023, in England, we have people who are losing sight, and that sight loss could be avoided. So, I’d simply ask those who object to independent sector providers providing new capacity, especially when we’re building capacity at risk with no guarantees, whether they would prefer patients losing their sight to this capacity being created.

What would you say to those who criticise optometrists for referring patients to private providers?

GPs have referral rights, optometrists have referral rights, dentists have referral rights. But all clinical professionals have an obligation to do the right thing by their patients. I think it’s quite difficult to criticise a clinical professional who is seeking to refer a patient for a clinical consultation or surgery that they need, and choosing the most appropriate place for that patient to go. I think it would be a brave person who would criticise a primary care clinician for doing the right thing by their patient.

Any thoughts on why patients might be keen to attend for surgery with private providers, even if the travel time is increased?

I think about choice much more broadly than just travel time. In all other areas of our life, we have a choice. We choose which supermarket to shop in. We choose which airline to fly with. When we go shopping, we choose which brand of biscuits to buy. So, it seems odd to me that we're not offered choice for something which is even more important.

Once you are offered that choice, I think any rational person would look at the different dimensions of that choice: how long do I have to wait versus, for example, how far do I have to travel? If the wait at the closest unit to you, whether it’s NHS or private, is long, and you can travel half an hour and get a shorter wait, you may be willing to make that choice.

It’s just normal, rational thinking, that each of us do about every other decision in our life. I don’t see why this is any different. We treat healthcare as something which is almost removed from normal life, but actually, it’s just another aspect of what everybody does every day.

What do you see as the most positive recommendations to come out of the Elective Recovery Taskforce?

The implementation plan that has been published is clearly the start of a process. We finished the taskforce in March. The plan has been worked up, and that work will start in earnest now, in terms of making it happen. The Elective Recovery Taskforce was the first step in a journey to making change happen.

The other aspects of the taskforce, which I think was by design, was to bring together people from all parts of the system. This wasn’t just an independent sector elective taskforce. The majority of people were from the Department of Health, NHS England, Integrated Care Boards, and trusts, and then there was a handful of us from the independent sector.

The pilots that were initiated during the course of the taskforce and will be implemented now came from multiple bodies. That was the most valuable part for me: that you had representation from the whole system. Hopefully that allows everyone to coalesce around an implementation plan that puts patients first. For Newmedica, that means working together with optometrists to change lives through better sight.