Private Healthcare Companies Face NHS Fraud Investigation Over Cataract Surgery Profits

Private clinics delivering NHS cataract surgery are under intense scrutiny amid allegations of artificially inflated costs, unnecessary operations, and questionable financial incentives offered to high-street optometrists. The Department of Health and Social Care has launched a comprehensive investigation following revelations of serious concerns among NHS England officials regarding financial practices and patient safety.

The NHS Counter Fraud Authority’s involvement marks a significant escalation in examining billing irregularities within the private cataract market, which has experienced a staggering 400% growth since 2019. With cataract surgery representing the most common surgical procedure in England, the NHS currently funds 650,000 operations annually, with costs doubling since 2019 across 131 newly established private clinics.

A confidential DHSC briefing has highlighted concerns about five major companies – SpaMedica, CHEC, Newmedica, Optegra and ACES – and their impact on existing NHS services. The document reveals that 76% of NHS departments lack sufficient consultants to provide comprehensive eyecare services, resulting in extended waiting times for patients with serious conditions.

Financial analysis by the Centre for Health and the Public Interest reveals these five companies received £536 million for NHS cataract surgery in 2023-24, generating profits of £169 million. The investigation has uncovered evidence of potential ‘upcoding’ practices, where treatment complexity is artificially elevated to secure higher payments from the NHS.

The regulatory framework’s weaknesses have enabled private providers to access substantial taxpayer revenues, with local NHS commissioners seemingly powerless to intervene. Of particular concern is the practice of guaranteed follow-up appointments with high-street optometrists, costing the NHS approximately £16 million for 235,000 appointments in the year to 2023.

NHS England has responded by reducing the amount companies can claim for complex operations as of March 2024, following unexplained growth in cataract surgery unrelated to demographic changes or waiting list pressures. While private providers maintain their compliance with NHS regulations, the ongoing investigation threatens to reshape the landscape of private healthcare provision within the NHS system.