Waiting for NHS hospital care: the role of the independent sector in delivering orthopaedic and ophthalmic care
30 April 2023
Key points
- The waiting list for planned hospital care – which stood at 7.21 million in January 2023 – has grown by 58% since just before the start of the pandemic. To help expand capacity and address this backlog the NHS has been looking to independent sector providers (ISPs) to treat more NHS patients.
- The number of elective care treatments delivered each month has been increasing but has only just recovered to pre-pandemic levels. Small overall increases in the share of NHS-funded elective care delivered by ISPs (up from an average of 7.7% pre-pandemic to 8.7% more recently) hides significant variation across settings (inpatient vs outpatient) and specialties.
- In this piece we examine the role of ISPs in delivering elective care, focusing on two areas where the ISP share of care has grown significantly: ophthalmology and orthopaedics.
- The independent sector has rapidly scaled up its delivery of NHS-funded inpatient ophthalmic care, with 4 in 10 (38.6%) procedures conducted by ISPs in February 2022. This has helped overall activity return to pre-pandemic levels.
- The overall volume of NHS-funded inpatient orthopaedic care has not reached pre-pandemic levels, but the independent sector has recovered its activity levels. ISPs delivered 31.2% of NHS-funded orthopaedic care in February 2022, which represents a growth in their share of care.
- Much of the growth in ISP-delivered inpatient ophthalmic care comes from cataract procedures, which account for around 60–70% of all inpatient ophthalmic care. ISPs have consistently conducted more than 50% of cataract procedures since January 2022. This suggests the delivery of cataract procedures is both highly amenable to scaling, and attractive to ISPs – which isn’t true of other procedures we’ve explored through this analysis.
- There is evidence of inequality in receipt of ISP-delivered care related to patient characteristics (ethnicity, deprivation, age and region). White patients are more likely to be treated by the independent sector than any other ethnicity, as are patients living in more affluent areas.
- The NHS faces a significant challenge to deliver the scale of growth required to bring the waiting list down. The independent sector is showing it can contribute to addressing the elective care backlog in some areas of treatment, but it is likely to play a limited role in fully recovering services and won’t be a substitute for addressing the major problems facing the NHS.
Figure 1
Figure 2
The example of ophthalmology shows that the independent sector is capable of quite rapidly scaling activity to help deliver more elective care procedures – given the right conditions. But what has prevented the same scaling of ISP delivery in orthopaedics and other specialties? A range of factors might contribute to this. It is beyond the scope of this piece to fully explore these, but our analysis and discussions with stakeholders suggest that factors include:
- Referral pathways: Part of the reason for the scaling of ISP-delivered ophthalmology care is that referral pathways from high-street optometrists are working more smoothly with ISPs than with the NHS. For other specialties, where referrals are controlled by the NHS, it may be challenging for NHS commissioners to fund a substantial increase in ISP activity even where genuinely additional capacity to treat more patients is present.
- Amenability to scaling: Simpler procedures are easier to scale up. Cataract surgery – which represents the majority of inpatient ophthalmic elective care (between 60% and 70% since 2018) – is often carried out via day admission under local anaesthetic. Conversely, orthopaedic procedures include things like hip and knee replacements – while these are also relatively simple procedures, surgery is conducted under general anaesthetic and requires hospital stays of 3 days or more. This type of procedure is likely to be harder to scale at pace, particularly given the finite workforce available to deliver care across both the NHS and independent sector.
- Independent sector infrastructure: Some ISPs are set up to provide a narrow range of care – for example, 1 in 4 (23%) independent sector providers of NHS-funded care deliver only ophthalmic care. It may be cheaper for ISPs to provide high volumes of lower complexity care. Contracting arrangements and regulation may also make it easier for them to enter the market for certain types of care.
- Financial incentives: The ability to adequately cover costs, or indeed make a profit, when delivering procedures under the NHS tariff may be greater, or at least more consistent, for ophthalmology than for orthopaedics.
- Managing demand: ISPs need to manage demand for NHS-funded care alongside demand for privately funded care. The demand and income opportunities may be different for ophthalmology and orthopaedics.
Procedure-specific trends
We have also looked at a series of individual procedures to add to our understanding of trends. These procedures account for the majority of all procedures in the two specialties.
In ophthalmology we chose cataract (replacing the cloudy lens inside the eye with an artificial one) and vitreous retinal procedures (including eye injections or laser treatments for conditions such as macular degeneration or diabetic retinopathy) as the most common treatments by volume. However, they show very different patterns (Figure 3).
The number of cataract procedures delivered by ISPs has seen a sustained increase over the past 2 years, increasing from 32.0% in February 2020 to 51.4% in February 2022 and continuing to increase since. This represents a return to a long-term trend following the main period of COVID-related disruption.
For vitreous retinal procedures, while the independent sector share is at a slightly higher level than pre-pandemic (increasing from 12.3% in February 2020 to 14.0% in February 2022), the growth is much less pronounced than for cataracts, and more closely resembles the overall elective care trend.
Figure 3
Many of the possible reasons for the differences between ophthalmic and orthopaedic care delivery likely also help explain the differences at procedure level seen here. For example, inpatient vitreous retinal treatments include more varied and complex procedures, which would be more difficult to rapidly scale. The picture is different for outpatient care, where there has been considerable growth in the independent sector’s share of vitreous retinal work – largely comprised of diabetic retinopathy screening, a more straightforward, homogeneous procedure which is therefore easier to scale.
For orthopaedic procedures (we looked at hip, knee and hand procedures, again because of the volumes) there is very little variation and trends largely mirror the overall picture for orthopaedics – and indeed the overall trend for elective care.
The combination of the lack of variation between orthopaedic procedures, and the difference between cataract and vitreous retinal procedures (the number of NHS-funded cataract procedures delivered by ISPs increased by 1.7 times between February 2020 and February 2022 while the volume of non-cataract ophthalmic procedures stayed more or less stable) reinforces a conclusion that cataract procedures are outliers, rather than true indicators of the potential to scale independent sector delivery.
Figure 4
Differences in the share of care delivered by ISPs could have implications for equality of access. If independent sector care expands more than NHS-provided care, access to care for people in more affluent areas could improve more than for those in poorer areas. Figure 5 shows the recovery in ophthalmology inpatient care (pre- to post-pandemic) by level of deprivation, both in absolute terms and as a percentage. This shows that in the poorest areas, treatment volumes in the latest 12 months were still around 1% lower than pre-pandemic levels, while in the richest areas they were 5% higher than pre-pandemic. This is largely being driven by the faster growth of the independent sector care in more affluent areas.
Figure 5
The situation is different for orthopaedics where there no significant differences in inpatient recovery by level of deprivation – all volumes are down by around 30% compared to pre-pandemic.
Despite uncertainty about causes, given previous research has highlighted socioeconomic inequalities in access to NHS-funded elective care (using hip replacements as a case study), any potential exacerbation of these inequalities by the growing role of the independent sector is worth exploring further. Such inequalities would be of particular concern if it meant there were differences in the speed of access to care, or the quality, safety or outcomes of this care – which is beyond the scope of this analysis.
Ethnicity
For ophthalmic care, inequalities exist in care delivered by ISPs. White patients have been consistently more likely to receive NHS-funded care from ISPs, although the rate of increase for the share of care delivered by ISPs (since the main period of pandemic-related disruption) is similar across ethnic groups.
When we look at orthopaedic care, we see a similar pattern. Patients from a white background have been consistently more likely to receive NHS-funded ISP-delivered care. Changes across ethnic groups are fairly similar to the overall trend for orthopaedics. The notable exception is patients from black or black British backgrounds: throughout 2022 the proportion of these patients receiving NHS-funded orthopaedic care from ISPs fell. The reasons for this are unknown.
Previous research has found wide variation in rates for all NHS elective care between ethnic groups, with white patients seeing higher rates of elective treatment than black, mixed and Asian groups prior to the pandemic, and further variations in falls and recovery in elective activity for each ethnic group. The NHS has committed to putting reducing inequalities at the core of recovery plans and the findings of this report underscore the importance of collective action across all providers and local leaders underpinned by more reliable recording of ethnicity data.
Age
Independent sector provision of NHS-funded ophthalmic care is focused on patients aged 60 and older, and it is also among this age group that the rate of increase since the pandemic has been most pronounced – likely a function of the volume of cataract operations that the independent sector delivers, and how this has changed over time.
The share of NHS orthopaedic care provided by the independent sector increases gradually with age, peaking in the 60–79 age group. Compared to ophthalmic care, the differences between each age group are less pronounced.
Of course, these factors are not completely unrelated. Between the two specialties we see varying drivers of differences in access. In orthopaedics we see increases in independent sector provision with increased affluence across all ethnicities. In ophthalmology, affluence seems to result in less of an increase in access, and ethnicity is perhaps playing a greater role. For example, if we take black and mixed ethnicity populations, we see very little variation within ethnic groups between deprivation quintiles 1–4.
Regional variation
We know from previous analysis that geography is important. The backlog of patients waiting for elective care is not evenly distributed across England, and nor is ISP capacity evenly spread.
Our analysis shows there are regional differences in the share of patients receiving ISP-delivered care (Figure 6). These regional differences may also explain some of the variations in the types of patients more likely to receive ISP-delivered elective care.
The share of patients receiving ISP-delivered inpatient ophthalmic care has increased across all regions, compared with the pre-pandemic period. In four regions (the north east and Yorkshire, the north west, the Midlands and the south west) more than 50% of inpatient ophthalmic patients were treated by ISPs in October 2022. Patients in London are the least likely to be treated by ISPs. There is also substantial regional variation in the scale of the increase in the number of ophthalmic treatments carried out by ISPs between February 2020 and February 2022 (ranging from 1.3 to 2.6 times the number carried out in February 2020). This doesn’t seem to result in significant variation in the overall number of treatments delivered in each region – which ranges from 0.9 to 1.1 times the number carried out in February 2020. This suggests that even big differences in the share of care delivered by ISPs, and the rate at which this has changed, is unlikely to be helping some regions address their backlog of elective care more quickly.
The pattern with inpatient orthopaedic care is different. While there have been some increases across the country, particularly towards the end of the time period we look at, the difference is not as marked. The exception is the south west, where more than 50% of patients treated in October 2022 received ISP-delivered care.
Figure 6
Figure 7
One interpretation of this analysis is that while ISPs might be supporting activity levels, the waiting times observed suggest that – much like NHS providers – they are struggling to deliver care quickly and based on current evidence are unlikely to help bring down overall waiting lists.
We are grateful to Steve Wyatt and Alex Lawless at the Strategy Unit who undertook the analysis of Secondary Uses Service (SUS) data and contributed to the interpretation of findings.
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