In his editorial, Gwyn Williams has eloquently articulated the thoughts of many ophthalmologists in the National Health Service (NHS). Most believe that the patient choice agenda is being used to promote independent sector providers (ISPs). As a result, ISPs make huge and unreasonable profits from tax payers by absorbing all the easy work and ignoring the more complex or less profitable work.

Whilst some patients have the choice of 6 cataract providers, little information is made available for them to decide which of these providers are best for them. Other patients have to choose between risking blindness on a glaucoma waiting list or paying to be seen privately.

Over expansion of cataract services in Independent Sectors (IS) has undoubtedly increased the waiting lists in other areas by recruiting NHS hospital trained staff, and now increasingly threatening the budgets of NHS hospitals. The spending on ISPs is out of control with local eye units at risk of collapse, leaving limited staff to do the complex or unprofitable work in the NHS. This process is now being accelerated as ISPs are moving to take on more ‘easy’ services. Conflicts of interest are ignored and training is failing. Toothless ICB contracts, fear of legal disputes and external politically driven pressures will inevitably lead to disaster of ophthalmology services in the NHS unless there is a change of direction. We must prioritise those most at risk of permanent, preventable, irreversible blindness and cancers ahead of surgery for very early cataracts. We need to train, run comprehensive emergency services, do research, manage rare conditions, maintain equality and ensure remote areas as well as large cities are served by our NHS. We must consider the service as a whole. We need to understand that ISPs are not here to fix the NHS.

We have all seen what has happened to the provision of NHS dental care, which is now almost completely unavailable in many poorer areas. We cannot let the same thing happen to ophthalmology.

We need to invest in the NHS model and address the workforce challenges. The significant sums going to ISP investors need redirecting to a sustainable holistic solution. Ophthalmology has undergone huge changes in the last 10 years and continues to evolve but this process is now being hampered by fragmentation of services compounded by inadequate Information Technology (IT) communication systems between providers. We have the solutions but they require a long-term view, clinical engagement, adequate funding and commissioning free from political interference.