The Anglo Saxon Chronicle tells of how Gwrtheyrn, the High King of the Britons (Vortigern in English) invited the Germanic brothers Hengist and Horsa to settle with their clan on the Isle of Thanet in modern day Kent who in return would then act as perpetual mercenaries to the king in his fight against the Picts and Gaels. These Germanic incomers found the living pleasant and the fighting easy and it was only a few short years before they turned against their Celtic masters in an event known as the Treason of the Long Knives and expanded their holdings to cover Kent, then the rest of England, Britain, and eventually much of the world. This story was repeated with the Visigoths inviting the Umayyads to fight for them in Hispania and more recently with the Sudanese Armed Forces losing control of Khartoum to their own hired mercenaries the Janjaweed.

Why waste time with these stories? The same is happening to our own NHS ophthalmic services and we as a profession are complicit in signing over our services to any qualified providers, deny there is a problem while the enemy masses around us, don’t know the extent of the danger hidden in our bubbles or have fought and lost battles and may already have come to the conclusion that the war is lost. I say to you now; the hour is late but if we act now we can prevent the loss of our core services to private corporations. I write here to wake you up from your slumber and alert you to the danger.

In the name of patient choice cataract waiting lists were solved in the short term in England by farming out our bread and butter operation to private providers who built up their own capacity and stole our trained staff as the NHS in turn started to atrophy. Many of you were tempted to either work part time or full time in the independent treatment centres as the remuneration was very much better. Many justify the decision as it means patient waiting times are less, but at present this is a false economy that is propped up by stealing the resources of hospital eye services and these resources are finite. We are borrowing from tomorrow to deal with today. Training to perform cataract surgery is almost exclusively undertaken in a withering NHS and although, reluctantly, some training has now started in the independent sector it is nowhere near the amount that is needed, or is fair. Training is suffering, our trainees tell us every day, because of the devastating impact of the independent sector and the answer to this is not to better incorporate training in these centres although it might in a very limited fashion reduce the impact of the plague that has been dealt cataract training by their very existence.

What may be a good choice for patients or ophthalmologists now is not a good choice for future patients and future ophthalmologists. Reduction of waiting lists for cataract surgery is pushing other specialties into the independent fold; medical retina, glaucoma and oculoplastics while the NHS will then consist of a failing rump service consisting of emergency eye care, neurophthalmology, paediatrics and odds and ends such as uveitis. This trend is already happening and there will be inevitable impact on our ability as a country to perform research as medical retina and glaucoma studies are the mainstay of commercial and non-commercial studies in the United Kingdom. Although it may seem obvious to many I say this now so there is no doubt; as with training our future ophthalmologists clinical research will not be anywhere nearly as effectively performed by the independent sector as it is by the NHS at present.

The supporters of any qualified providers state their care is quicker, more efficient and cheaper and therefore they play an important role. Their care is indeed quicker though efficiency comes at a price and there are plenty of examples of independent sector complications ending up burdening already stretched NHS services with vitreoretinal surgeons in some areas of the country attempting to stem the flow of variably declared and managed cataract disasters by shutting down outsourcing although they face a very steep uphill battle. The independent sector is not cheaper. A veritable eye watering amount of money has been spent to reduce the waiting lists but commissioning groups in England are already squealing at the cost and this is not a viable long term solution. Reigning in costs will occur via reducing surgeon remuneration or requiting patients to pay some sort of supplement that will be the beginning of the end in our NHS being free at the point of delivery.

There is an answer. The NHS has functioned admirably over the past 75 years and the model is sound. Wales is undertaking work to fix these problems via regional centres of excellence, integration of pathways with optometry via EPR systems and funding the changes needed via the National Clinical Strategy for Ophthalmology. It remains within the gift of our profession to fix our problems and solve the crisis facing ophthalmology by rescuing our NHS and putting the brakes on our slide toward the private sector but time is indeed running out. We need to collectively recognise the extreme risks involved of continued collusion with private providers and that short term benefits in our remuneration is sowing the seeds for the erosion of our professional standing for the future, the collapse of training and research and the end of the NHS as we know it with all the negative consequences that entails for our patients.

We have fallen victim as a profession to the hubris of Vortigern in inviting allied mercenaries from a completely different culture to help us out in a time of trouble. If we are not careful we will lose not only cataracts but much of the metaphorical fruitful lowlands of our profession to the independent sector and be left with only the hilly mountainous land and be divided and broken as a profession. It is not too late. If we recognise the danger and act together and act now we can save ourselves by throwing the invader back into the seas from whence they came.