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SpaMedica’s chief medical officer says that addressing the UK’s ophthalmic capacity crisis requires more than clearing cataract backlogs, it demands a long-term strategy for workforce development and health equity.
When the Royal College of Ophthalmologists said that SpaMedica was delivering three-quarters of all independent-sector cataract training placements in England, it marked a key moment in the evolution of NHS workforce delivery. What began as a temporary response to rising surgical backlogs has evolved into a vital pillar of clinical education, with SpaMedica now hosting trainees across every English NHS deanery.
But as chief medical officer Alex Silvester argues that expanding surgical capacity is only one part of a much larger equation. From tackling health inequalities in socioeconomically deprived regions to upskilling high-street optometrists and establishing the first independent-sector undergraduate training framework with NHS England, eye care requires systemic, long-term reform.
Here, he speaks to Healthcare Today about why training must follow patient choice, the myth of the independent sector’s over-reliance on cataract surgery, and how long-term NHS partnerships are key to safeguarding the future ophthalmic workforce.
You’re now delivering around 75% of independent-sector cataract training placements in England. What does that tell us about the state of ophthalmology training in Britain?
While I hope to see other independent providers stepping up to do more, SpaMedica has been pushing for years to bring trainees through our doors. We faced initial obstacles simply because it had never been done before, but we are now in a fantastic position, welcoming significant numbers of trainees with every new rotation.
Rather than indicating a failure in NHS training itself, I view this shift as a direct reflection of patient choice. Over the past four to five years, patients have increasingly exercised their right to choose where they receive care, leading to a noticeable shift from traditional NHS trusts to independent providers.
If that is where patients are choosing to go, it makes total sense for clinical training to follow. As healthcare providers, we have a clear duty to help train the next generation of ophthalmic surgeons. Trainee doctors should have ample learning opportunities across every environment where patient care is delivered, including the independent sector – especially if those are settings where they may ultimately choose to practice in the future.
How much of the pressure on ophthalmology is just being driven by demographics?
Demographics are certainly playing a major role. My sub-speciality interest is in public health, and the reality is that we are all living longer. Crucially, the conversation has now shifted toward living better. People today want to maintain their independence – whether that means driving in their 70s, pursuing hobbies, or staying active in the workforce. There was a time when people accepted fading eyesight as an inevitable consequence of ageing, but today there is far greater awareness that cataracts can be safely and effectively treated.
However, demographic growth is only part of the equation. We are still seeing patients present with highly complex, advanced cataracts, largely due to systemic bottlenecks in primary community care. In less affluent regions, there are fewer community optometrists available, making access to initial assessments significantly more difficult compared to wealthier areas where commercial optical practices thrive.
Addressing that health disparity is a major priority for us. Many of our hospitals – such as those in Liverpool, Birmingham and Bolton – are deliberately located in areas that face high levels of socioeconomic deprivation. Historically, patients in these communities presented late with hyper-mature cataracts, often because they simply did not realise treatment was an option.
Late presentations directly lead to poorer surgical outcomes. Operating on an advanced cataract requires significantly more energy inside the eye and takes longer to complete, which increases the risk of post-operative inflammation and complications. Modern clinical evidence – and official NICE guidance – strongly supports intervening as soon as a cataract begins to impair a patient’s quality of life, whether that is difficulty driving or caring for grandchildren. The old clinical ethos of waiting for a cataract to ripen is completely outdated; early, proactive treatment leads to vastly superior patient outcomes.
“While cataract surgery is the most frequently performed elective procedure in Europe, the doctor shortage impacts the entire field.”
Where is the shortage? Is it just that we need more ophthalmologists?
If you look at reports from the Royal College of Ophthalmologists, their clear message is that we need more ophthalmologists and a greater expansion of training places overall. I fully agree with that assessment.
While cataract surgery is the most frequently performed elective procedure in Europe – and serves as a foundational skill for any eye surgeon – the doctor shortage impacts the entire field. Conditions like glaucoma, for example, carry a real risk of irreversible blindness if clinic capacity and specialist availability fall short.
From a cataract training perspective, the primary hurdle was simply aligning training capacity with patient flow. Trainees need to be stationed wherever patients are receiving care, and the system is now catching up. The latest GMC national survey highlights that progress: three years ago, only 30% of year-three ophthalmic trainees were achieving their required cataract procedure targets, whereas today that figure stands at over 70%.
There is still more to be done, but I am exceptionally proud that 160 trainees joined SpaMedica this August for six-month rotations. We now host trainees across every single NHS deanery in England, including London, which was the final region to integrate independent sector placements into its rotations.
Our focus is now shifting toward the devolved nations, where some of the most acute pressures exist.
Is there a risk that we focus on producing more surgeons without addressing the other bottlenecks – theatres, nurses, equipment, consultants and follow-up capacity – that determine how many cataract operations can actually be delivered?
There is certainly a risk if you take a narrow view. A few years ago, there was a heavy spotlight on doctor training and surgical procedure numbers – a focus reflected in GMC reporting – and I am delighted to see progress on that front. But surgical capacity relies on far more than just doctors.
There is often an underlying fear that when an independent provider opens a facility, we simply poach staff from local NHS trusts, failing to create genuine net-new capacity. We actively avoid that model. A clear example of this is our hospital located down the road from Moorfields Eye Hospital, where not a single member of our nursing team was recruited from Moorfields. Instead, we hire clinicians from non-ophthalmic specialities or recruit high-street optometrists and upskill them in-house to perform intravitreal injections, laser procedures and complex diagnostic clinics.
That approach builds true, additive capacity rather than merely redistributing existing NHS staff.
Beyond our own workforce, we invest heavily in upskilling community optometrists through regional training and outreach initiatives, even if they never work directly for SpaMedica. Primary care discussions in Parliament often focus on GPs and community pharmacies – such as the Pharmacy First scheme – while overlooking the vital role of optometrists. As the frontline of eye care, optometrists are uniquely positioned to detect broader systemic conditions like hypertension and diabetes through routine ocular exams. Upskilling and empowering community optometry is essential if we are to relieve pressure across the broader healthcare ecosystem.
There is much criticism of independent providers that they have an over-focus on cataract surgery. Is that a myth?
It is a complete myth, and I think people simply aren’t fully aware of the breadth of services we deliver across the independent sector.
At 25 of our hospitals, we deliver age-related macular degeneration (AMD) treatments within 48 hours of referral – well within the national guidelines. AMD is a condition where delay means permanent vision loss, yet official Royal College reports show that in many parts of the country, patients are still not being seen within the target two-week window. We are actively stepping in to fill those critical NHS capacity gaps, stabilising patients’ sight and expanding provision wherever we can.
Our work extends into specialised tertiary screening as well. A prime example is our hydroxychloroquine screening service. Hydroxychloroquine – a drug commonly prescribed in rheumatology and dermatology – requires specialised ocular monitoring to detect early retinal toxicity. High-street optometrists lack the specialised equipment to perform these checks, while NHS hospital trusts lack the capacity to screen otherwise healthy, asymptomatic patients.
“Independent sector partnership within the NHS is hardly unprecedented – high-street optometrists and GP surgeries are private entities delivering NHS-funded care, and no one suggests dismantling those models.”
Is independent sector involvement in surgical training a permanent shift in NHS workforce delivery or is it a temporary relief for backlog?
We are unequivocally a long-term solution, not a temporary fix. Independent sector partnership within the NHS is hardly unprecedented – high-street optometrists and GP surgeries are private entities delivering NHS-funded care, and no one suggests dismantling those models. Independent providers add durable, high-quality capacity to the health service.
We bring private capital to build state-of-the-art facilities in underserved communities that have lacked local access for years.
Beyond official registrar rotations, we support under-recognised groups of clinicians, such as specialist, associate specialist, and speciality (SAS) doctors. Many of these overseas-trained doctors require high-volume surgical exposure to complete their portfolio pathway (formerly CESR) to attain full consultant status.
Training is precisely what transforms a contractual relationship into a true, long-term partnership. If we were merely cherry-picking simple cases, critics might have a point. Instead, we manage complex cataracts through specialised pathways I have developed over the past five years, while actively training the next generation of surgeons.
If you could change one thing about the way ophthalmologists are trained in England, what would it be?
If I could change one thing, it would be moving away from the transactional nature of current surgical placements. At present, trainees often attend our facilities one day a week solely to operate. While building up procedure numbers is vital for surgical confidence, becoming an exceptional surgeon requires far more than technical proficiency in the operating theatre.
I would like to see training rotations evolve so that trainees manage the entire patient pathway, including pre-operative consultations and post-operative follow-ups. Although cataract complication rates are exceptionally low, learning how to assess patients beforehand and manage any post-operative issues is essential for holistic clinical development.
