NHS Eye Care Outsourcing: What Independent Optometrists Need to Know

The NHS is outsourcing more than half of all cataract surgery to private companies. Those companies are making £1 in profit for every £3 the NHS pays them. And there is evidence that high street optometrists are being offered financial incentives to refer patients to them. This is not a future risk. It is happening now, and the independent optical practice sits at its centre.

A series of reports published in 2024 and 2025 by the Centre for Health and the Public Interest (CHPI) — an independent, non-partisan health policy think tank — has laid out in forensic detail what is happening to NHS eye care services in England. The findings are significant for every independent optical practice in the country. The full overview of their investigation is available here.

The headline numbers are stark. The proportion of NHS cataract operations carried out by for-profit private companies rose from 24% in 2018/19 to 55% in 2022/23. Over that same period, the NHS paid the private sector around £700 million. Half of NHS Trusts recorded a 21% drop in cataract income. And ophthalmology now accounts for almost 10% of the entire NHS waiting list in England.

Where the money is going — and who is keeping it.

In April 2025, CHPI published its third report in the series: Out of Sight — the hidden profits and conflicts of interest behind the outsourcing of NHS cataract care. The numbers it contains are worth sitting with.

Just five private eye care companies received £536 million from the NHS in 2023/24. Their average profit margin (EBITDA) across those NHS-funded services was 32%. That means for every £3 the NHS spent on a cataract operation at one of these clinics, £1 left as profit. In a year where NHS Trusts across England are cutting services, closing departments, and warning of financial collapse, that profit margin deserves scrutiny.

In one year alone, those same five companies extracted an estimated £90 million from the NHS in the form of interest payments on debt and dividend payments to shareholders. That £90 million did not fund a single cataract operation, train a single junior doctor, or treat a single glaucoma patient. It went to lenders and investors.

There is more. CHPI's analysis found that private operators provided 84,000 cataract operations over three years without a contract in place. The NHS Counter Fraud Authority, NHS England, the National Audit Office, and the Department of Health and Social Care have all been called on by CHPI to examine whether public money is being properly spent.

The conflict of interest the NHS is not talking about.

CHPI also identified 113 ophthalmic consultants who are primarily employed by the NHS and who simultaneously hold shares or ownership stakes in private clinics providing NHS-funded cataract care. Over four years, 50 of those consultants — 45 of whom are NHS employees — received £18 million in dividends from those arrangements. Very few of these conflicts appear on the websites of the NHS Trusts where they work.

The pattern CHPI found is consistent: the private clinics in which these consultants hold financial stakes have seen large increases in NHS cataract income. In contrast, the NHS hospitals where those same consultants are mainly employed have seen the number of cataract operations fall sharply. CHPI notes that further research is needed to establish direct causation. But the structural incentive is impossible to ignore.

What does this mean for independent optometrists on the high street?

Here is the part that matters most to independent optical practice. The CHPI Out of Sight report found evidence that high street optometrists are being offered financial incentives to refer NHS patients to particular private cataract providers rather than to NHS hospitals. The estimated total value of those potential incentive payments to all high street optometrists is between £17 million and £21 million per year.

CHPI is recommending that using financial incentives to induce referrals from optometrists or other healthcare professionals be made explicitly illegal, and that the relevant authorities examine whether existing rules and guidance have already been breached.

For an independent practice, the implications are serious. Clinical independence — the freedom to refer based on what is best for the patient, not what generates income — is the foundation of independent practice. It is the single most important thing that separates an independent optometrist from a corporate referral machine. The moment that a financial incentive arrangement undermines the foundation, the independence is gone. It does not matter how you frame it. A referral decision shaped by a payment is not an independent clinical decision.

The Royal College of Ophthalmologists' 2024 survey of clinical leads found that 67% believed independent sector provision had negatively affected patient care. Seventy per cent were more concerned about outpatient backlogs in their departments than they had been twelve months earlier. Glaucoma and medical retina — the complex, chronic conditions that, left undertreated, cause permanent and irreversible sight loss — were the areas of greatest concern.

The training collapse nobody is talking about enough.

Cataract surgery is the foundational training procedure for junior ophthalmologists. Trainees need to complete at least 350 cataract procedures before they can competently manage more complex surgical work. As private providers take over the bulk of straightforward cataract operations, NHS training departments are left with fewer routine cases and more complex patients. The result: 30% of ST2 ophthalmology trainees are currently on course to miss their surgical training targets.

CHPI's survey found that 62% of ophthalmologists reported that outsourcing had caused a large negative impact on staff training. This is not a workforce story from a distant future. The ophthalmologists currently being trained will not be available to treat glaucoma, AMD, and diabetic retinopathy patients in five years.

Meanwhile, 37% of ophthalmologists said outsourcing had had a significant negative impact on staffing in NHS eye care departments, and 46% said it had affected their NHS department's ability to treat more complex patients. For reference, the NHS ophthalmology waiting list in England currently stands at around 608,000 people. The queue for the conditions that can actually leave patients blind is getting longer, not shorter.

What independent practice should do with this information?

None of this means independent optometrists should turn away from cataract detection or co-management. Quite the opposite. What it means is that independent practitioners need to be deliberate and transparent about where they refer, and why.

The case for referring to NHS ophthalmology departments — where consultants train the next generation, treat complex disease, and do not extract profits — is a clinical and ethical one. Independent practices that build transparent, evidence-based referral pathways and can clearly articulate to patients why they refer where they do are doing something the corporate multiples will not bother to do. That is a clinical governance standard and a patient trust asset.

If any private provider approaches you about referral incentive arrangements, the CHPI report and RCOphth's published position make the landscape clear. The professional and regulatory risk of accepting financially incentivised referral arrangements in the current environment is significant. The Optical Voice will continue to follow the regulatory response.

The May 2025 CHPI briefing note on the local and national impact of profit leakage in NHS eye care goes further still in mapping the financial damage at an ICB level. If you want to understand the specific impact on your local NHS eye care department, this is where to start.

If you want to stay ahead of what is changing in independent optical practice — including how NHS commissioning decisions affect your referral pathways and your practice — the newsletter is the right place to start.

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