National Assembly for Wales

Bore da. Croeso, bawb. Welcome to the Health and Social Care Committee this morning. As always, we operate in Cymraeg and in English as well. We're operating a hybrid session this morning, so some Members are on the estate—and witnesses—and some are joining us virtually. So, just to note that as well. Moving to item 2, we have no apologies this morning, and if there are any declarations of interest, please say now. No, there are not. 

In that case, I move to item 3. Item 3 is our first evidence session to inform our short inquiry into ophthalmology services in Wales. We're very pleased to welcome this morning Rhianon Reynolds and William Oliver to committee to help us with our work. Would you just like to introduce yourselves, please, for the record?

I'm Rhianon Reynolds. I'm a consultant ophthalmologist in Aneurin Bevan University Health Board. I'm also the national clinical lead for ophthalmology within the NHS executive and llywydd of the Royal College of Ophthalmologists in Wales.  

Bore da. Good morning. I'm William Oliver. I'm assistant director in the strategic programme for planned care of the NHS Wales Executive, and I cover ophthalmology, amongst a couple of other things. 

Thank you both for joining us this morning. It's four years since the external review on eye care services in Wales. At that time, the situation was described as 'extremely serious and very fragile'. So, I suppose the question is what significant progress has been made in the four-year period since that report.

After the report, which was done by Andy Pyott back in 2021, we've been working on changing the way that ophthalmology is being delivered. We've developed the national clinical strategy for ophthalmology, which sets out the blueprint for the way that we would like ophthalmology services to be developed in Wales. We undertook a more detailed review of the way that ophthalmology was currently working within Wales. Andy Pyott's report was very much a high-level overview of what was happening, whereas we took a more in-depth approach to things. We looked at, amongst other things, demand and capacity data. We also had good clinical engagement, where we spoke to stakeholders involved with ophthalmology care and asked them about the barriers to them being able to deliver the care that's needed within Wales and what the potential solutions around that would be. 

Coming out of that, there was the process around developing the report, but there are four overarching themes that had come out of the report in terms of the principles for change. The main barrier that we came across was workforce, which is a significant limiter in Wales. We have problems in all aspects of our secondary care ophthalmology services. That includes medical, nursing; our hospital optometry departments are non-existent in lots of health boards. So, there's a huge workforce piece of work.

Our estates are very limited. Even if we wanted to do more work and we had greater workforce, our physical capacity in terms of estates is limited and it's often not fit for purpose, either to work in clinically or for our visually impaired patients to be able to access the services that they need. Digital infrastructure, again—ophthalmology is quite different from lots of other medical specialties. We need a bespoke ophthalmology digital solution, and that isn’t in place yet, which has, again, limited our capacity to work differently and work more closely with our primary care colleagues as well. So, that’s, again, one of our limiters.

Overarching solutions that we developed were things such as organisational reform, so working differently within ophthalmology, moving more towards a regional model of care, so breaking down health board barriers. Where we have an extremely limited resource in terms of our workforce—our highly skilled specialist workforce—pooling resource within regions would be a more effective way of using us, rather than having multiple specialties spread very thinly across different health boards, where trying to provide equity of care in different regions is difficult. So, pooling of resources in terms of regional working is one of the areas that was highlighted.

Clinical networks are also really important. Within the clinical implementation network within the NHS executive, we’re starting to build those clinical networks. We have an extremely effective multidisciplinary team that works under the CIN that has started developing all-Wales approaches to job descriptions for our support within ophthalmology, so our non-medical workforce, effectively—so, our optometrists, orthoptists and nursing teams—working with them to change how they work and making it an equal approach to the way they’re used in health boards across Wales.

Within the clinical networks, as a clinical group in terms of our medical consultant workforce, I think we're more united than we have been in many years, and it has taken probably four years to get to this point. At the point where Andy came in, we were quite disengaged—absolutely disengaged with services. We were change-fatigued, we’d had many years of not being listened to; there was a lot of disengagement. Over the last four years, we’ve done a lot with relationship building, and now a lot of our clinicians are back around the table, willing to work together and build those clinical networks. We have developed clinical reference groups within them as subspecialties and so on.

So, those are the sorts of things that we’ve been working towards. We’ve been building foundations to change, rather than being able to make signs on paper that are artificial indicators that might be used. But the foundations are certainly well under way to being able to provide a real sustainable change to the way we work.

Thank you, Rhianon. I'll come to you next, William, but what I'm taking away is that, following that review four years ago, it's the clinical strategy that you referred to that is addressing the issues in the review and setting the steps that are needed to move on in the correct direction, I suppose. But William, if I extend the question to you: on top of what Rhianon has said, what do you see as the top priorities when it comes to the national strategy that Rhianon referred to? What are the top strategies in that? And I'm not asking you to go into too much detail, because we'll dive into that later on, but in headline terms, what are the top priorities?

I think Rhianon’s already covered those four pillars that we’ve put the strategy in, but I think also, it’s not just the strategy. So, what we wanted to do was build on Dr Pyott’s report, and give it a bit more detail in terms of that blueprint for services to follow so that provider organisations will be able to build that into their own integrated medium term plans and then delivery.

The other element of the clinical implementation network, though, is about implementation, clearly, because it’s in the name. So, we’d want to have the strategy as the blueprint, but also then to try and deliver sustainable services, picking up those elements, which are infrastructure, digital, and we have to deliver digital services to transform and enable patients moving between secondary and primary and community care, which is obviously essential. There have been some issues with that, and we can probably pick that up later.

But I think more importantly, it's about making sure that estates are fit for purpose, for patients and for staff who work within them. Also, we've engaged and commissioned Getting It Right First Time to come in and do some specific reviews around glaucoma and cataracts, and then we've got now evidence-based models from inside Wales as well as outside Wales that we've started to share as learning opportunities with other health boards. So, there are a range of different aspects that we're taking forward.

And just finally from me: are you aware of RNIB Cymru's concerns about the underreporting of patient harm and system inefficiencies in ophthalmology services?

Absolutely, we're fully aware of it. This is something we have discussed. Within the Royal College of Ophthalmologists, we have definition of harm for eye care patients, because it's different to other medical specialties. Severe harm within ophthalmology is vision loss; it's rarely death. Where there is difficulty, I think, is with interpretation of those within health boards. The process of reporting harm is arduous, difficult and time-consuming. It's often reviewed by people who don't understand ophthalmology, and often patients coming to harm are downgraded in terms of harm when it reaches levels who don't understand ophthalmology. So, I do think there's absolutely underreporting of harm, but until we make those processes easier, and until there is proper recognition of what harm actually is in eye care, I think we're going to struggle to realise the true indicators of harm.

Can I add something to that as well? I think using the royal college guidance and definitions, we have seen health boards start to use quite a robust process, using ophthalmology nursing staff to actually do a retrospective, but more importantly, learning the lessons to try and avoid prospective harm. We've shared that process with other health boards, so they can adopt that model as well. So, I'm hoping that the identification of what's happened and then using that as lessons learned is going to be taken forward by our health boards.

Joyce.

Because we won't have time to go through the detail this now, could you send us a note explaining in more detail what you're telling us now about harm not being quantified and qualified in the way that you would hope, maybe? That would be helpful to us.

Yes.

I'll make a note, William, as well. We'll drop you a note afterwards as well to save you making a note of that. Mabon, you wanted to come in with a question as well.

Mabon, I'm so sorry; the translation was only working in Welsh on both channels for a moment. It's now been corrected. Let me just check with translation: can you say something, please? [TRANSLATION: 'Testing interpretation.'] That's correct, yes. 

It is. Thank you, Mabon.

I will take those off, because it is a bit strange. It's difficult to say, because we can put all these things in place within the implementation network, we can put the plans, we can put the pathways, we can say what best practice is going to be, and there are certain areas that have shown change—so, in small pockets, things such as diagnostic hubs for glaucoma services are being developed, high-flow cataract surgery is starting to be carried out, and so on—but all these things require investment, and whilst we can put the plans in place, change is not something that can be done for free.

We can make small changes, we can change the way that we work and so on—for example, in terms of using diagnostic hubs and high-flow surgery—but we need investment, we need technical staff to provide those services, we need instruments to be able to do it, and so on. So, we can put the blueprint in place, but without investment in making that change, it's going to be difficult to show significant change. We know what we can do, and there is evidence of how these things can work. For example in Exeter, the models that we're proposing in terms of cataract services, glaucoma and medical retina high-flow hubs and so on, they've reduced their waiting lists from the thousands down to very, very few, because they had the investment, both financial and time-based investment. So, it's difficult to say when they're going to be, because it depends very much on what investment is made on an individual health board basis.

Thank you, Rhianon. We've got the next set of questions from Lesley Griffiths—so, Lesley, another virtual Member as well. Just to say, I hope it's okay, Lesley, feel free to interrupt, if that's okay with you both, as well. Sometimes it can be a bit awkward in a virtual meeting, but, thank you, I appreciate that. Lesley Griffiths.

Thanks very much, Chair, and good morning to you both. I just wanted to talk a little bit about NHS waiting times both for in-patients and out-patients. I'll start on in-patients first. I represent Wrexham, and I recently visited a couple of optometrists in the city centre, and it was really good to hear from them about the integration between primary and secondary care, and how they were helping, particularly, I felt, to take a burden off Wrexham Maelor Hospital—this is what we were discussing at the time—and the waiting times there. You've spoken a bit, Rhianon, about the barriers to not being able to see more patients and the waiting times still remaining high, and I'm just focusing on in-patients at the moment. I was just wondering if you wanted to expand any more about why we are seeing waiting times so persistently high. I appreciate there's an ageing population, et cetera, but I just wonder if you could perhaps expand a bit more on the reasons why.

So, in terms of in-patients, I assume we're talking about day-case procedures, so surgical patients—

Sorry, I meant out-patients. Sorry.

Okay, fine. The problems that we have in terms of the out-patient waiting list is that ophthalmology is the biggest out-patient specialty in the NHS. However, we're often perceived as a small specialty because we don't have in-patients. So, within prioritisation, we are often not overly prioritised in terms of how we are funded within health boards' ideas and so on. So, that's one aspect of it.

Our workforce limitations are also in place. In terms of consultant ophthalmologists, we are woefully under-resourced in Wales right across the board. In some areas of Wales, they're like a desert for ophthalmologists. It's very important to understand the difference between ophthalmology and optometry. Ophthalmology can't do everything optometry does; optometry can't do everything ophthalmology does. We need both to be able to provide this care, and whilst I absolutely support the implementation of the Welsh general ophthalmic services pathways and so on, because of the nature, we need to train more optometrists. There's going to be more of a transition to using optometry than, I think, the wholesale shift of a third of our waiting lists straight out to primary care, anyway.

The other limitation that we have with out-patients is space. So, even if we had more secondary care clinicians, we don't have the space to put them. I'll give you the example of my own health board in that we are very fortunate to have made a new appointment for a consultant corneal surgeon in our health board. At the moment, we're trying to work out where we can physically put him, because we don't have enough rooms, we don't have enough theatres. I myself have not been able to carry out clinics because I don't have a clinic room. So, we don't have enough space in secondary care for our doctors to work, let alone, then, bringing optometry into secondary care to train them to be able to take that back out into community. So, that is a big problem we have.

Also, our waiting lists are quite historic, so understanding what's on them is also a problem. That's something that needs to be a natural evolution, in the way that our waiting lists are understood.

Can I come in to add to that? I think, as well, the coding in the waiting lists is absolutely essential. We've got an ophthalmology total waiting list, but ophthalmology especially does not operate in that way. Obviously, we know that there are nine sub-specialties that are completely different, with different consultants that have got that specialism in terms of that sub-specialty, and we absolutely need to have waiting lists on that granular level so that we can understand the demand/capacity imbalance, rather than just seeing ophthalmology as a global problem. Absolutely, it's a fair comment that waiting lists and the volumes of patients waiting on those lists are far too high at the moment. Obviously, we're trying to do what we can to reduce that. But I think the other unique challenge that ophthalmology has is that it isn't just the growing prevalence, which we've put in the strategy, over the next 10 years and future demand that will increase, but, actually, patients aren't necessarily discharged, so it's an ongoing continuation of treatment or maintenance to try and maintain either sight loss or potentially prevent irreversible sight loss. So, I think that is the other element; it's not a normal surgical pathway.

Thanks, both, for that. You had the contract—the optometry contract was renewed in 2023, and I appreciate that we're only at the beginning of 2025, but do you think it's effective? Do you think it needs looking at again, or are you content with what—?

I think there are aspects of the contract reform that have been extremely effective and have been a great win for patients and eye care as a whole. So, for example, now we have patients with severe sight impairment in the community who can now be certified with sight impairment, with a specific condition. Age-related macular degeneration can now be certified in the community by low-vision optometrists, which means that these patients who wouldn't normally be within hospital eye care don't now need to come into hospital eye care to get that benefit. So, that's a huge win.

The use of the independent prescriber scheme in terms of urgent eye care has also been extremely effective in being able to support our urgent eye care services in terms of taking a bit of pressure off that front-door access. I think the WGOS for reforms as regards the more complex conditions, such as medical retina and glaucoma, these are the ones that will take a little bit of time to implement, because the training required and getting the balance right on using those, I think, is going to be a little bit more difficult and require a little bit more of a workaround. And I think there are aspects of it that need review. I work very closely with the national clinical leads for optometry and, as part of the process, the way that those work is deemed to be reviewed on an annual basis anyway. So, as issues arise, there is a process in place to be able to address them and change them.

I think, for me, that's a real positive, because we look at ophthalmology, and, obviously, I've got a focus on secondary care, hospital services, but, actually, we recognise that they have to work together. And the flow of patients between community and hospital services will be one that continually bounces back, so the patient can get the right expertise and input or support from the third sector, as well as just those services. I think the key enabler to try and make sure that this implements properly and we start to get the full benefit is that the focus is on digital transfer of information and clear information about that patient between community and secondary care, and that needs to build, I think.

Thank you.

Thank you. Just picking up on the point you made, Rhianon, I think you said that glaucoma and diabetic retinopathy, obviously, as you—

Medical retina.

Medical retina, okay. Obviously, with those more complex eye conditions that will need hospital eye services to treat them, is there anything that you think—? I mean, you've mentioned workforce, you've mentioned estate. I guess those two things in particular will have a massive impact on the work that you can do as ophthalmologists.

Yes, absolutely. Those two things will make a significant difference. I spoke earlier, as well, about the regionalisation of care and working more collaboratively within a region. So, we have centralised complex care for those really difficult cases that need highly specialised care, which can be centralised in one place. And then, we can start using a hub-and-spoke model. We can have more local care that's still hospital based, but can be provided closer to home, with a multidisciplinary team approach to that sort of care, so not necessarily needing to be delivered by a consultant ophthalmologist, but by other medical teams and MDT teams, and then we have our community on the outside, as well. So, if we adopted that way of working, it's likely that we would be able to increase the numbers coming through.

So, you think that regional model is the way forward?

Absolutely. I think it's essential.

Okay. So, on that basis, do you think there's more that the Welsh Government need to do to ensure that that happens, or do you think you can drive that yourself within the service?

I think it's extremely difficult to drive from within the service, because, at the moment, whilst there’s a nod to collaborative working in different regions of Wales, the way health boards are measured is still on a health board basis. So, whilst we’re asking, for example, in south-east Wales, where we have three different health boards working together, whilst we’re asking each of those health boards to provide performance details to question their own waiting lists and so on, they are always going to default to what they’re doing within their health board rather than working towards a regional way of working. Because we have this sort of measure on a year-by-year basis, and we have to get to a certain number by a certain number, done in a certain number, it doesn’t really let you build that sustainable regional way of working. There are all sorts of barriers in place. There is different governance in health boards, there are different job plans. There are all manner of different things where, unless you remove them completely, you’re not going to be able to provide proper regional care.

Did you have any other questions, Lesley, at all?

I do, sorry.

If you can just try and ask them all together, if you can, if you don't mind. Thank you.

Okay. That’s really interesting, and I absolutely understand what you’re saying, and we’re seeing in lots of public services that it’s okay to say, 'We’re going to collaborate', but you have perverse consequences, don’t you, really, of that?

Just as my final question, you referred to the Pyott report from Dr Pyott, and in there he refers to having these high-volume cataract surgery centres in Wales. I was just wondering if you could give us an update around the work being done. Certainly, in Wrexham, I haven’t seen weekend working, but we’ve seen cataract patients going to other hospitals, in fact, over the border, in Shrewsbury. So, clearly, there’s work being undertaken around wating time initiatives, but I’m very interested to know what’s being done about weekend working in particular. And that’s my last question. Thank you.

I'm sorry, Rhianon—try and answer as briefly as you can, just because we're a bit behind time.

Yes, okay. I'll be as quick as I can. I think the interpretation of Andy’s question about high flow is that high flow can only be provided by private providers, which is an absolute fallacy. There’s evidence of NHS providers in England who are doing that, and there are areas in Wales now where we are providing high-flow cataract surgery. Certainly, within Nevill Hall Hospital, we have high-flow surgery, which is done on a part-regional basis. So, there is potential to do it. What we need to do is stop thinking it’s only private providers that can provide that. It can be done in the NHS. There’s evidence to support it. We need the backing to be able to do it in the NHS.

I’ll very briefly add that health boards are using private capacity as well as a pressure-release valve. I think there are risks around training, about on-call provision, about then what’s left within the NHS if that started to expand. So, I’m really keen, and we are in the clinical implementation network, to make sure we invest in NHS Wales, but make sure it’s efficient and delivers what we know, a model we can deploy, and then use that as learning to try and get every health board to adopt that best practice.

Sure, thank you. James, you wanted to come in with a quick question.

Yes, please, on waiting lists. Data does show that between 10 per cent and 15 per cent of people who are waiting for cataract operations also are suffering with glaucoma. I know from conversations I’ve had with people, there’s actually a procedure that can be done, called a trabecular bypass, at the same time somebody’s waiting for a cataract operation. It’s basically the same thing. It’ll save time and people waiting on waiting lists. Why aren’t more of those operations being done at the same time, because, ultimately, it’ll save money and give a better outcome for patients? I’m just interested in why that’s not being driven across all health boards.

If people need combined cataract and glaucoma surgery, they get combined cataract and glaucoma surgery. That’s something that’s done in Wales.

But that doesn't happen in every health board—it doesn't happen in every health board.

It depends specifically on what you’d determine the—. I’m not a glaucoma consultant, so I am not able to answer the nuances of glaucoma surgery. However, what I do know is that not all glaucoma patients are equal. That surgery may not be appropriate for those patients. Just because they’re waiting for a cataract surgery doesn't mean that we should be doing glaucoma surgery at the same time. If they're being managed appropriately, actually, the NICE guidance for the management of glaucoma conditions is not to jump in with surgical intervention. So, I would say that it's the remit of the glaucoma consultant looking after that patient to determine whether that is appropriate or not for that particular patient. Patients are not all equal, and putting people together and saying we treat them all the same is absolutely not going to give us the right outcomes for these patients. Glaucoma is a spectrum of disease. There are patients who have very mild glaucoma who need minimal intervention. We have people who go blind because of glaucoma who need highly complex care by specialist glaucoma teams. And putting them all in one bunch is not helping patients with glaucoma.

I think something to add in response is that, underneath the clinical implementation network, we've got the clinical reference groups—so that's the glaucoma consultants, there are the medicines reconciliation consultants; it's that sub-specialty group looking at pathways of standardisation, which we’ll, hopefully, then be able to roll out to health boards and give that, ‘This is how you need to follow x’ pathway. So, if it is a potential trabeculectomy surgery at the same time as cataract, that should be in there as a pathway and therefore health boards are able to pick that up. So, I think that will start to give, hopefully, a way forward, but also reduce the variation, potentially, in clinical service delivery as well.

Can I just come back and say that part of the issue is that we're underutilised in terms of having glaucoma consultants in Wales? There are health boards that don't have glaucoma consultants, so we cannot provide that service in those health boards because we don't have glaucoma surgeons.

Okay. And in those health boards—

I know in Powys, for example, the consultant that comes across from Hereford into Brecon wants to do this, but isn't allowed to do it himself. The board won't allow him to do it. So, there we are.

That's a discussion we can have with health boards. There's absolutely no barrier to him being able to do that.

Okay, that's important. Thank you. So, just to give us some indication, we've got four subject areas we need to cover, and our session is due to finish at 10:30. So even if we go for 10 minutes on each section, we're still going to be well over. So, please keep that in mind, and keep questions pointed and answers as brief as you can. I hate to ask that, but—. Joyce Watson.

Good morning. I'm going on to the electronic patient record and digital transformation, and, basically, there was £8.5 million invested in the OpenEyes platform. It was led by Cardiff and Vale University Health Board in 2021. So, what's the status of it now?

We're not actually responsible for it. It's not a project that sits under us. It sits under Digital Health and Care Wales, so it's not something that we have any control over. We don't have it across all the health boards. It's available in Cardiff, it's potentially being rolled out across other health boards, but the fact is that we don't have it. We need it. And we, as the NHS exec, don't have any particular control over how it's being implemented.

So is it better for us to ask the question of those who do?

I think so. From my perspective, what I can definitely share is the fact that, as I alluded to earlier, it's absolutely essential to deliver modernised out-patient and potential surgical services in ophthalmology. Yes, it's in Cardiff and Vale, and I think across all sub-specialties; it's in Cwm Taf health board as well. I believe there is a plan to implement that roll-out, but, once again, as you've highlighted, it has been quite a long time coming, and I'd like to see it tomorrow to enable better care and better provision of information for patients.

So what's stopping you?

I suppose you'd have to ask the question to the relevant bodies.

So I'll ask the question—. Because if time is tight and you're not the right people to answer the question—.

It's certainly not clinical. It's not from a clinical perspective. 

We can certainly write to them and do so before we ask the Cabinet Secretary to come in to give evidence.

But I can ask you if you think it's being prioritised.

No, I don't think it is.

I think, from my perspective, I've done all I can to try and influence and raise the agenda of the fact that we need this system in place in Wales. As I said before, it will enable better provision of care and also quicker sharing of clinical information, which then clinicians like Rhianon can make a judgment on and then stream to the right, relevant area of support or intervention. So, we definitely highlighted it and escalated that we need this yesterday.

Sorry—. Rhianon said it's not being prioritised. Why do you think it's not being prioritised?

I don't think it's being prioritised because I think health boards are being asked to do individual things and within health boards there are limits within the IT departments. I don't think centrally there's been enough drive forward to be able to deliver it. I don't think that the central steer is there.

Okay. Do you have another question, Joyce?

Well, we'll ask them elsewhere.

Thank you. That's helpful. Thank you, Rhianon. John Griffiths.

Diolch, Cadeirydd. If we move on to estates and infrastructure, Rhianon, you've already told us that the condition of ophthalmology estates in Wales is a real barrier to the delivery of services in the way that we would like to see. Are there any specific actions the Royal College is putting forward to make necessary progress?

I'm sorry, I don't really understand what Royal College—. In what respect would the Royal College make—

What we want to know, really, is what are the asks of Welsh Government in terms of the estates. You've identified that there are real problems, which we know about. So, what do you see as the solutions?

So, within the college, we do have guidance around things such as what an estate should look like in terms of things like cataract theatres and out-patient departments and so on. So, we already know the way that certain things should look. As well as the college, the third sector have recommendations about how healthcare access should be—so, how eye units should be to allow accessibility from visually impaired people. So, there are lots of ideas around how services should look. But I think that the problems we have are far more fundamental, in that they're not fit for purpose because ceilings are falling in, because we don't have enough space, because we have plants growing through walls, we have patients standing in corridors, where doctors have to squeeze past them, waiting for their appointments. So, rather than having an aspirational idea of what estates should look like, it's far more fundamental, the problems that we've got.

So, is it a matter then, Rhianon, of short-term measures being taken before substantial building work takes place to create a much better estate?

There is a certain amount of short-term changes that could be made. Ophthalmology needs bespoke space. So, we can't just slot in to other theatres; we need specific equipment. Our out-patients are specific to ophthalmology; we can't slot in to other out-patient spaces. So, unless space elsewhere within current estates is made ophthalmology-specific, we can't just slot in and around other specialties. So, whilst there are certainly estates within Wales that could be repurposed for ophthalmology, and regional services, again, that is going to take investment, because it needs to be changed into ophthalmology-suitable space.

I think I'd add as well that we in GIRFT, a couple of years ago, visited every hospital in Wales and then fed back elements around how the estate could probably be maximised. But that doesn't answer the question in terms of whether it's fit for purpose or not. And I think, with all the diagnostic equipment and imaging equipment that is required, you need multiple rooms to be able to allow that patient flow to happen. We've also been outside of Wales and seen the Exeter model, again, where the blueprint and the model of floor space and what needs to happen to really get some high-efficiency and high-quality services, but the throughput of patients through that to make it meaningful, is absolutely there. So, I think it's incumbent on us to try and look at those models, on a regional basis, if not on an each health board footprint, and start to follow those through.

Okay. Could I ask you, William? Welsh Government held an ophthalmology summit in October of last year, and we understand that health boards then agreed to create business cases for necessary investment for estates improvements. Do you have some idea of how much funding we're talking about in terms of ensuring the safety of eye care units, for both patients and staff?

No. 'No', in short. I'm not sighted on individual health board business cases. What I think the summit did do is allow Welsh Government to perhaps endorse the strategy, No. 1, and I think that's something to pick up with Welsh Government, in terms of the follow-up of that. I think, then, we're trying to support health boards to try and identify what the infrastructure and the estate looks like—so, how many rooms do they have available, are all nurse specialists able to work in there, for example. Rhianon's already highlighted the fact that there are clinic room shortages and issues with space. I'm hoping that, as an integrated medium-term plan process is due at the end of this month for health boards to submit their plans, that that level of information would be included within those—but to be determined.

Okay. I wonder as well if you could tell committee what measures are being taken to ensure that essential technology and equipment are available, particularly replacing items that are nearing the end of their useful life.

I'm smiling, because our microscope's just broken in Aneurin Bevan this morning, so we've had to shut down a theatre. I think that's it as well, that there isn't a process in place in most health boards to be able to replace equipment and so on, in terms of coming to the end of its life. These are all capital investments that need to be made, and we have to battle with other specialties within the health board to be able to get them. I think there's a lack of understanding that these are essential for us to be able to perform our services. They're not a 'nice to have', they are an absolute essential, and I'm not sure that that is always completely understood.

There have been instances where we've undertaken a hospital site visit and seen a single microscope or a single item of equipment, and then, if that did break, the service does fall over, and we've had to escalate that, and, obviously, feed that into the health board. Potentially, they should have already been sighted on that.

So, what needs to change or happen?

I think, within health board capital development programmes, that should be there in terms of an equipment replacement process. It would be for health boards to respond whether that's adequate and fit for purpose and working, I suppose.

Is that not happening? Does that not happen already in health boards?

It should do.

It should do.

But it doesn't.

It doesn't always, no. For example, in north Wales, when they were looking to replace their machine that measures and calculates lens power for cataract surgery, they struggled to get one. They even tried to get one through charitable funds and were still—. The challenge in getting these essential pieces of equipment often takes up a lot of clinical time and so on, which is quite difficult.

I think in terms of business cases—sorry, going back to that quickly—the people who are responsible for writing these business cases are quite often the operational teams. Whilst we're chasing targets and figures—referral-to-treatment targets of 104 weeks—and all these things, our entire teams are being transferred to doing that work. Building business cases and sustainable futures is—. It gets put on a backburner.

Can I just ask, John, have you got more questions? Mabon wanted to come in as well. Do you want to come back now or shall I bring Mabon in?

Bring Mabon in. I'm happy, Chair. Thank you.

Then I'll come back to you, John. Thank you. Mabon.

What are the consequences?

So, for us in Aneurin Bevan, we have two eye theatres, so 50 per cent of our capacity would be limited until we can get that microscope up and running. While it's not essential for all ophthalmology surgery, it means that cataracts can't be done, for example, any intraocular surgery can't be done, glaucoma surgery, corneal surgery and so on. So, we're at 50 per cent capacity until that is fixed. Hopefully, it'll be done very quickly, but this is the impact that these things have.

And what are the ongoing consequences, I suppose?

It extends waiting lists, it extends waiting times for patients.

Yes. Okay. John, did you want to come back in with any further questions, sorry?

Just finally, Chair, are there any areas of infrastructure investment that you would want to highlight in terms of dealing with the expected increase in demand and offering advanced care?

We have very good examples of the way we can build infrastructure to be able to create more capacity within the service. We keep talking about Exeter; there are other examples of things like diagnostic hubs and high-flow services that could be built, but they would require specialist infrastructure to be able to do that; not least, digital infrastructure is vitally important to be able to make those services work, as well as physical estate capacity and human resource to be able to carry out the examinations and assess the outcomes as well. So, we know what we need to do, we can do it, we want to be able to do it, but we can't do it unless we're given the support and the money to do it.

Thank you.

Okay, Chair.

Thank you, John. Mabon ap Gwynfor.

So, workforce is extremely limited, as I said. Within ophthalmology, we—. Within ophthalmologists—so, consultant ophthalmologists levels—we're well below what the royal college recommendations are. We're one of the lowest within the United Kingdom. So, royal college recommendations are 3.2—and this is generic ophthalmologists—per 100,000 head of capita, and we're running about 1.9, roughly, in Wales. So, in terms of consultant workforce, we're extremely under-resourced. The college is doing granular analysis around that as well, looking at sub-specialty work as well. So, as that's developed, we're likely to be well behind what we need on a sub-specialty level within Wales as well. So, we might have x number of ophthalmologists, but if they're all medical retina ophthalmologists, it means our sub-specialties work in glaucoma, cornea, paediatrics and oculoplastics doesn't get done. So, we're well under-resourced in terms of ophthalmologists, so, it's a precious resource that we need to look after and take care of.

Our training for ophthalmologists in Wales as well, the college again recognise that there is a gap in what there needs to be in Wales to be able to deliver the training requirements for the consultants of the future. We're limited in what we can do with that because we don't have the space or the people to train them at the moment, so that's something we're working on, although Health Education and Improvement Wales have recently appointed a head of school to be able to help us with those sorts of issues.

Optometry, I've touched on before. Whilst we have primary care optometry providing a service, secondary care optometry is an entirely different service to primary care provision. So, primary care optometry work very locally, secondary care optometry are—. They're complementary, but not the same. And within Wales, we have very, very limited secondary care optometry available to us. We have other healthcare professionals who work alongside us, such as orthoptists and nursing, and again, we have huge issues recruiting into those roles as well.

I think there's a couple of additions from me as well. So, if we're training consultants or clinicians in the future, we need to make sure they stay in Wales. So, it's actually about retention and making sure they bed in and don't go over the border elsewhere.

And I think, also, it's using a multidisciplinary workforce; I know you've mentioned ophthalmologists, but actually we're reliant on our nursing teams and our theatre teams just as much. The work, once again, of the clinical implementation network as our multidisciplinary team group has really started to have some focus and progress in that space in terms of consistent job plans—sorry, job descriptions—et cetera, potentially job plans as well, but also training across health board boundaries, so we can get standardised models of teams that work together ideally, based on the royal college blueprint of what an ideal team should look like. So, we're definitely taking steps forward, but it's definitely an area that's fragile at best and is a risk for us still, at the moment.

Yes. We need to try and stabilise it. We don't want destabilising forces coming in and changing what we have, because it is really fragile and it's something that really needs to be taken care of because it's a risk to lose it.

Sorry.

I don't know the figures, but what I can tell you is our training for ophthalmologists is not done within university, so it's done within the deanery, which is HEIW, who oversees the training of that. Ophthalmology recruitment into training is a national process, so it's done through the royal college for the entirety of the UK. I know that there's a disproportionate number of trainees who get training places who come from a very small number of postcodes within south-east England, and it's something we’ve raised previously. The college is supportive of us being able to develop our own recruitment programme for training. However, we don't currently have the support to be able to do that. I do know of trainees who are from Wales, who want to stay in Wales, who haven't got training places or have got training places and been placed outside of Wales. We don't have control over it, basically.

I think it will make a big difference. When I was recruited into ophthalmology, it was local recruitment, so I applied to the places I wanted to work, and I've been fortunate enough to do everything within Wales. I'm from Wales, I wanted to stay in Wales. We can no longer give our junior doctors that guarantee, and I think it's something that we would like to do. And I think that everyone would be in agreement with that. I don't think there's anything—. And I know other areas of the UK have similar issues. I know Scotland have an issue with the retention of trainees. I know Northern Ireland has a problem with the retention of trainees. So, it is an issue.

Again, unfortunately, we're beholden to HEIW, in terms of our training places and, at present, they don't feel they'd be able to provide that level of increase in training numbers. The number of 36 came from the college because that's what they think we need, in terms of being able to address our workforce shortages. But without being able to train them and having the infrastructure in place to be able to do that, then there has, as of yet, been no increase of our training coming through. It's a regular occurrence that people are placed within Wales and, at their first opportunity, they transfer back to where they came from, basically. Every year, we have gaps on our training rota from trainees who've transferred back to where they actually wanted to work.

I would add, though, that we're obviously having conversations, discussions with HEIW off the back of the strategy to make sure we can try and keep conversations live. So, I think that's an area. Obviously—

There is a head of school in post now, so, hopefully, they will be able to drive forward what needs to change for training.

I think another important aspect that we've picked up via the strategy, though, is our current workforce, their retirement profile or perhaps their stepping down in hours. Because, just as much as bringing new people in, we don't want to, obviously, have the risk of, in the next two to three to five years, having a retirement profile that puts us in further imbalance. So, we've got to look at both of those aspects: who's potentially leaving or dropping clinical time, as well as those coming in to the service as new.

There isn't a workforce plan. We don't have one across Wales. I think we need one, and it really depends on who is able to do that. I can't comment on leadership because I'm not entirely sure who would lead on it, to be able to do it, to be perfectly honest. I know HEIW have done workforce planning in other areas. They've done optometry and so on. But, yes, we need a workforce plan. We don’t have one.

I think HEIW, for me, have a role to play, and they are playing a role. I think health boards, obviously, have got their own workforce plans, but it comes back to our regional footprint model as well, because if a health board went off and said, ‘Oh right, we need x number of consultants’ is that required just within that footprint, or does it actually impact the wider regional footprint as well? So, I think we need to take things perhaps higher than just a health board footprint level, on certainly a regional, but potentially then an all-Wales basis.

It depends really on what we’re talking about, whether that’s within NHS services, or whether it’s within private providers. So, as Will said earlier, we are using private providers across the border as a pressure release valve, in terms of trying to reduce the waiting lists. That’s working to a certain extent, but there can be ways we could do it within Wales, and within the NHS specifically.

If we’re talking about specialist services that sit across the border, for example, Bristol Eye Hospital is a tertiary or quaternary referral centre, for example, so there’s extra specialist care that needs to be referred there. So, there are patients that still go there, and there will always be patients that go there, because there are certain services only they will be able to provide. But we are still dependent on them for things such as vitreoretinal surgery, which we should be able to do in Wales, but we just aren’t—partly workforce, partly estates, partly all of the other things that I’ve been talking about, things like—. I’m a uveitis—inflammatory eye disease—specialist, and there’s certain things I should be able to provide, but I don’t have the infrastructure within health boards to be able to do it, so I need to send the patients to Bristol. I would be happy to do it, but I don’t have that support and infrastructure to be able to do it. So, I don’t think there has been a change in terms of how much we send over the border, yet, in NHS care.

Thank you, Mabon. James Evans.

Diolch, Cadeirydd. I’ve got a question for Rhianon. The Industry Vision Group has said that ophthalmology is a lot more amenable to technological advances than other specialities. I’m just interested: does Wales have that academic support across the country to enable those technological advances to happen? And if it is happening, how many people across Wales are involved in clinical trials in ophthalmology services?

Clinical trials in Wales aren’t where they should be; they are developing. It’s something that I’ve been involved with myself. I am a clinical academic; I have a research and training post within Cardiff University, so it is something that I have done and am involved with. We are expanding our clinical trials within Wales. We are bringing more in.

In terms of advanced technologies, we have, within Cardiff, one of the highest rated vision science units within the UK, if not the world. We’re also about to develop, or we’ve had funding for, the centre for vision services research within Wales. It’s within Cardiff University, but it’s going to, hopefully, have a global impact.

So, actually, our research basis in terms of vision science in Wales is quite high. Translation into the NHS is more difficult. So, the academia is there, but how it’s delivered within health boards, and the relationship with health boards and academia, is still a work in progress. But it’s something I’m working very hard on.

Yes, what do you think those big barriers are? What could we recommend to actually help break down some of those barriers?

I think that having better access to academia for ophthalmologists would be important. So, having more joint roles like myself. I have a joint role within Cardiff University and Aneurin Bevan, so I work across both sites, and being able to take the research into health boards, I think, is important. Being able to—. I'm not sure how Government can really make the difference in terms of research, because unless health boards have different governance structures—. That's the biggest barrier, really. If I have a project that's running in Aneurin Bevan, we have to go through different governance in each health board and so on. So, it's quite complex—

Sorry to cut across. Do you think that there's a role for the NHS executive here, then, to try to—

Research is part of the national clinical strategy. Research is part of that. And I think that the NHS exec—everything we should be doing should be embedding research more into what we're doing. So, it's being able to understand the way that we're delivering services and so on. So, I think that the NHS exec is more about the implementation of services, rather than research as such. I don't know what you think, Will. 

I suppose that there is a role to play in terms of influencing and making sure that the right bodies are around the table. So, I think we've got life sciences and a range of other academic industry partners where we could probably up the agenda, and so can, probably, Welsh Government, to liaise and get those forums to work a little bit more as a network together. So, 'yes', I suppose, in short.

Okay. It's interesting. I'm just interested: how does that work, then, in England, with the structures there, with regard to academia and how it feeds in to the NHS structures there? Are there similar issues in England?

I don't think it's quite the same in England. I think that having—. I'll give you an example from within my health board. So, my money that I earn from the trials that I do and the research that I do doesn't necessarily come to me to be able to develop that further. So, I can't, for want of a better word, stockpile my income from my trials to be able to buy a piece of equipment I might want to be able to then allow me to do even more, because I have to spend all of that money within the space of a year. So, that limits how we can build that research capacity. And that's not just ophthalmology, that's all aspects of clinical research within the NHS. So, unless you're getting grant funding to be able to fund you to be able to buy these things, you can't resource a service in the same way that England has to be able to manage their own finance within the research pot. 

Okay. Lovely. Russ, I've got one quick question, if that's all right. 

Yes, go ahead. 

Just on health inequalities, if that's okay, as many more NHS services are being shifted down to community ophthalmology services, do you think that those have been seamlessly integrated within the NHS funding structures? What we don't want to see is patients paying more, do we, because we want to make sure that we have a fair health system that avoids disparity in the system to make sure that people get timely care and that people actually can get the care rather than the privilege of actually being able to afford to pay for it. So, I just wondered what your thoughts are on that. That's my final question, Cadeirydd.

So, I think you mean community optometry, rather than ophthalmology, because ophthalmology is a secondary care service. But community optometry services and the Welsh general ophthalmic services contract reforms, I think, are variable across health boards, because it depends very much on who is in the community to be able to provide those services. Where it's working, it's working very well. What it doesn't do is that—. All the patients who have that care are provided with that care from the NHS. It's not something that they would pay for normally. In terms of other care that they may look to private providers for, I absolutely agree, we do have inequalities in that respect, and that comes back to the inability currently of the structures that we have in place to be able to address the capacity needs that we have. So, until we change that, we won't be able to treat everyone in a timely manner.

I think I have a—

Sorry, Russ, can I have one more quick question? Sorry.

Go on, and then I'll bring William in. Go ahead, James. 

It's the link, isn't it, between community ophthalmology—community services—and health boards. Just slightly on a technological question, the same as Lesley, I've been visiting a lot of optometrists lately, and they've actually said to me that the systems they use don't integrate with health boards, so they are still sending faxes and letters everywhere, rather than having an integrated service. Is that an issue that you think needs to be addressed?

Absolutely, and that is part of the digitisation transformation that should be undertaken. Certainly, we are still receiving letters; our referrals are not digital. There are huge issues around that, and that is part of the digital transformation that needs to take place, that integration of primary and secondary care in terms of transfer of care—so, a shared electronic patient record to allow us to be able to give care across both, and also an electronic referral that feeds into that electronic record to make that referral between pathways more seamless than it currently is. I absolutely agree and we don't have it.

Why is it so slow?

I don't know. It's not me; it's not us doing it. It's a huge area of frustration for us and I don't know what the limiters are. There are limiters within health boards in terms of internal governance structures, which have put barriers in places. There are limits of central implementation, there are limits of funding. I'm not involved in that, so, it's difficult to know why it's so slow. I don't know why it's so slow; I really don't.

I think everyone in every organisation we spoke to, though, recognised the importance of it, so I once again question why we can't get that over the line, because we need to have it. I agree with you in terms of what we need for service delivery is a digital electronic referral in, but that isn't just the end of the journey, because they need to transfer that clinical information and make sure that the patient is going to the right clinician or team, because they may have multiple conditions on an eye care pathway or multiple eye care pathways as well. So, we need to make sure that we're coding those elements in terms of the glaucoma condition of that patient (1) going to the glaucoma clinic to get the care they need, but they may also have a couple of other conditions they're being managed for at the same time as well. So, that's why that digital information is absolutely critical to share, to enable them to get to the right place.

It needs to be very much a joint piece of working. I think there is an idea that the referral side is optometry, electronic patient record is ophthalmology—it's not. That entire pathway needs to be involved in every part of that process.

Thank you. We are over time. Last question: is there anything you want to impart to us for when we start to consider what our recommendations are to the Government? Is there anything else you want to impart to us? I'll come to you first, William, on that, but also I'll come to you Rhianon, because you're the lead for ophthalmology within the NHS executive. I was going to ask you: do you think you have all the levers and responsibilities that you need to do that job? I'll come to William first, and then I'll come to you. William.

I think I'd refer back to the national clinical strategy. We've put a lot of effort, work and time into that document to try and give the future vision to get sustainable service delivery. So, I think what we need is for all organisations, from Welsh Government to third sector partners, which we've worked with, to health boards and provider organisations to buy into and then take forward those elements. And we can obviously play a support role and a monitoring role within that, but I think that sets out what we need to deliver. 

I think also we've seen areas of good practice within Wales. We know that health boards are making choices in terms of their service delivery and we're trying to share that with other health boards, so, we need to see that roll out quicker.

Digital we've already covered, I think, and probably you want to get into a bit more depth with that, but I think those would be the top things for me.

Okay, thank you. Rhianon.

So, for me, you asked if I think I have the support that I need to be able to drive forward change—I don't necessarily think that I do. I don't think that within the NHS executive, but within eye care in Wales, there's a very complex governance structure, where there are multiple groups, multiple committees, multiple people, who often, although we may have a joint vision of what should happen, don’t always go about it in a joined-up and combined way. There are lots and lots of different people around the table, so it's almost a 'too many cooks spoil the broth' type of picture. I think there's a dilution of what ophthalmology is within understanding secondary care services. I think that, often, other voices in primary care—. There are very many more in primary care, and, although it is utterly essential to what we do, sometimes there's a lack of understanding that we're different and that we need different things. 

I also ask that any investment that is made to us is for us to become sustainable. So, the proverb, 'You give a man a fish, you feed him for a day. You each a man to fish, you feed him for life', is very, very pertinent in ophthalmology. You can clear the waiting lists, but unless you do something to stop those waiting lists building up again in a few years' time we're going to be in exactly the same situation we are in at the moment. So, that's really important; any investment that comes needs to be a sustainable investment in NHS services.

And the investment that does come now is sometimes not: is that what you're suggesting?

Yes, I do.

An example of which is what?

For example, in south-east Wales, we've had funding to outsource a large number of cataract services across the border. So, great, we've managed over the last three months to reach our targets in terms of waiting lists, but that financial investment that's been made in this hasn't actually changed what we do as a core service, so, whilst we may have moved 2,500 patients off the waiting list, we've got no way of actually providing a greater capacity, whereas the £7 million that was given to us by Welsh Government could have been invested in building better infrastructure of estates, employing more staff, doing these things that would have meant that, in two years' time, we're not in the same situation we are in at the moment.

Okay. You say you need more support. So, what more support do you need, and who from?

I think Government could give us more support in helping us work with health boards, so potentially mandating more regional ways of working, working with health boards to either take ophthalmology entirely out of health boards as an overall arching thing and allow us to work independently in the way that we absolutely can do—

Do you think that would be a good idea?

I think it would be a good idea.

Okay, that's really interesting, helpful. Okay. Sorry, I interrupted. Anything else to add?

No, no, no, that's fine. I think I've said enough.

Can I add one more thing? I think what we've definitely got is really good relationships in links into health boards, the clinical teams, the operational teams, and that's really a solid foundation on which to work. So, I'm absolutely conscious that the situation of ophthalmology is not where we want it to be in any way, shape or form, but I think we've got a groundswell of consensus and people engaged to make a difference. So, I just want to thank them, really.

Okay, thank you so much. It's been a really helpful session this morning. Diolch yn fawr iawn. Thank you so much for your time, so thank you.

Thank you for letting us speak.

Thank you very much.

No, thank you. Thanks so much. Right, we'll take a 10-minute break. Back in just over 10 minutes.

Welcome back to the Health and Social Care Committee. I move to item 4. In this evidence session, we have Dr Pyott with us. Dr Pyott, I wonder if you could just introduce yourself for the record.

I'm a consultant ophthalmologist, based in Inverness for NHS Highland. I have experience of working overseas in Asia and have visited quite a number of countries there, looking at eye units. But within a UK context, I am responsible for doing peer-review visits around Scotland, and so am quite knowledgeable about the state of eye care services in my country. Four years ago, I was commissioned by the Royal College of Ophthalmologists to do a report on the state of eye care services in Wales, for which there is a report that I hope most of the Members are familiar with.

Yes, thank you so much. In regard to that report, I suppose the question is what influenced the development of the current eye care strategy in Wales, and I suppose, since your report that you were referring to, in 2021, what progress have you observed since the publication of that report. 

I suppose it's a little bit difficult for me to fully answer that, in that I've been observing very remotely. I'm aware of the most recent strategy document that has been published, and I'm encouraged that a lot of the right ideas are proposed there, particularly in terms of the urgent need for improvement in the estate, and also for the strategy of a combination of not only community-provided care, but also for the provision of efficient care provided by the hospital eye sector within larger purpose-designed buildings. I've also seen the aspiration for much more cross-border co-operation between the different units, and also for an upgrading of skills of non-medical personnel. All of this is to be encouraged. I suppose I'm still a little concerned that all of the suggestions about efficient electronic transfer of data and electronic records have not really come to full fruition.

I think I've also been encouraged to read of the moves that are taken to try and improve training and retention of staff. It's impressive to see that there's an excellent simulation centre being established in Cardiff, and also for an alternative training for staff who might not have achieved the national recruitment, which is a considerable problem. I am aware that we have the same issues in Scotland, where I am concerned that the current overemphasis on the larger training units, particularly in the south of England, may attract candidates to the detriment of those working in more remote regions. So, I think I'm encouraged that some progress has been made, but I'm concerned that there may be still some deficiencies.

Thank you, Dr Pyott. You made 10 recommendations in your report. I think you've spoken, in part, to some of those areas that haven't yet been progressed as, perhaps, you would have expected. Are there any other of those 10 recommendations—you've referred to some areas—that you'd want to also point to where you think progress is still lacking? 

I think what is often seen as a priority for many patients who are concerned about long waits is the provision of efficient cataract surgery, and also the provision of an efficient macular service, where treatment is going to be provided in a timely fashion. For the latter, there are some excellent examples, particularly what has been done for many years now with the provision of the service in the Newport area, through a Specsavers facility. That's to be really encouraged and it could be replicated elsewhere. But I think the biggest driver is for cataract services—that's what patients often see as a priority for them, many who are languishing on long waiting lists with an impact on their daily lives because they can no longer drive, or in some cases, can no longer keep down employment. Cataract services are extremely important, not only for the individual patients, but from a public health point of view, because of the impact that has on the potential prevention of dementia, and also for falls. There are now studies showing the impact on dementia and orthopaedic services because many patients being admitted with fractures have, in fact, got ophthalmic conditions, of which one of the more common will be cataract.

Thank you. Mabon, you wanted to come in.

This comes out of a very large study in the United States, where they followed patients over a number of years and saw that, in the group that had had early intervention with cataract surgery, their risk of dementia was down by 30 per cent and this was maintained over quite a number of years. Those working within hearing services would say the same thing—that where you have social isolation due to sensory impairment, this can have a significant impact on the patient's ability to maintain their memory.

This predated the pandemic. They were able to provide a service within the community where all you basically need is a clean room and you're able to inject these biologic agents into the eye to prevent macular disease and complications of diabetes and vein occlusions. It's extremely impressive, and for conditions like that where patients are going to require regular treatment, the closer it can be delivered to the patient's home, the better.

Thank you. Thank you, Mabon. Lesley Griffiths.

[Inaudible.]—apologies.

You're having a tennis match with pressing the mute button or not.

Thank you very much. Good morning, Doctor Pyott. I just want to concentrate a bit on waiting times. In Wales, we've got long waiting times, particularly for cataract surgery. I personally don't think it's any different to Scotland or England, but I was just wondering if you think that is the case. Also, we've put significant resources into ophthalmology, so why do you think we still have such long waiting lists? I appreciate we've an ageing population, but just your views on that, please.

This is quite a complicated issue. In fact, things are quite different in some parts of England. The situation in the larger country of the union is that they have a different funding model and over 50 per cent of cataract surgery is now being provided by the independent sector.

I know that the president of the college of ophthalmologists is actually quite concerned about this situation, because in some regions it actually almost amounts to prophylactic cataract surgery, by which I mean that patients are having surgery performed but they don’t particularly need it. If they’re seen in a facility and someone says, ‘Oh, you’ve got a bit of cataract there’, who are they to question whether that means that they require fairly prompt surgery?

In some parts of England, it’s reported actually that the waiting time is very low. I think my concern would be that, sadly, sometimes people are being regarded as a resource to be mined, rather than a patient who actually requires treatment. This can be what happens if you have an overprovision of service. It’s not something we’ve seen yet in Scotland, although there is growing influence of the private sector, particularly at weekends, providing sessions to perform cataract surgery.

The attraction for many of the health boards who want to go down this route is that they see larger numbers being performed on these independent lists, and there are complex reasons for that. There are incentives for this approach, not least a financial one, but also there can be quite a lot of cherry picking, and the least complicated cataracts are assigned to these providers. My concern is it can have a potentially very destabilising effect on the health service. Part of the reason that they are so efficient is that they will often be using very dedicated teams who are used to doing high-volume cataract surgery and nothing else.

Of course, the reality is that all these personnel within the teams have been almost always trained by the health service, and in many cases are then being lost from the health service, so that is a double jeopardy, not least the fact that the taxpayer is still paying for all this to be done. I can understand why people have an enthusiasm for doing that as a short-term fix, but I’m very concerned about the long term, destabilising effect.

Part of the reason they are able to achieve the sufficiency is because they have got teams that are used to working together. Both in Scotland and in Wales, frequently, I saw units where that was not the case, and that nurses were being pulled away to other duties. You’re still coming from an era when things were different and it was acceptable to have nurses working across different specialties. Things were less complicated. There was less reliance on non-medical staff. I've found very few units in Scotland where they had dedicated nursing teams, and I think the same would be true in Wales.

I’ve often said that if there are three things that would best equip units to be efficient, it’s have a dedicated nursing team, have a dedicated nursing team, and have a dedicated nursing team. Because frequently what will happen is that there’ll be perverse disincentives, so nurses may actually prefer to go a bit slow because the danger is, if they finish early, they’re going to be sent somewhere else. They may not want to go down the corridor to the colorectal team. They may prefer being in the eye department.

Lesley, are you happy for John to come in and I'll come back to you? John. 

Dr Pyott, I just wanted to ask you about the balance between NHS provision and use of the private sector. I represent part of Newport in the Senedd, and I'm familiar with Specsavers and the services you mentioned earlier. I've visited there, and they seem to be doing a very good job. But hearing what you've said about some of the dangers of overreliance on the private sector, I just wonder what you think about where the balance lies.

Yes, that's very difficult because, of course, both in Wales and Scotland, and I think now increasingly in England, we are very reliant on our colleagues working in community optometry, and they are essentially private providers, they're businessmen running a business. We've become very much dependent on them and I think that that often works really well. I don't really have a particular problem with that. I think where I'm more concerned is where you have direct competition. So, that would pertain to cataract services where there's a competition between those independent providers and those working within the normal NHS units, and that's quite different.

Lesley.

Thanks very much. I'll just come back to the independent sector, and I absolutely share the concerns you raised, and I think it also impacts on capacity within the NHS. I hear what you're saying about those people who have been trained by public money, and absolutely share all those concerns. I read somewhere that around 58 per cent, I think, of cataract operations in England are now done in the independent sector.

That's correct.

Just picking up on John's point about balance, I agree with you. I was also reflecting on what you were saying about the dedicated ophthalmic teams and on progress. So, I worked in an ophthalmology department 40 years ago, when we had dedicated nursing teams, but you were probably in hospital for about 10 days when you had a cataract operation. And so you reflect on progress, but don't throw the baby out with the bathwater, and I absolutely agree with you about what you're saying about dedicated nursing teams. So, you mentioned perverse disincentives—I think that was the phrase you used.

Yes.

So, again, how do you think health boards can make sure that they're getting the most efficient ways of working? Would it be by having those dedicated teams that are on that ward?

Yes, on the ward and particularly in theatre. And my other suggestion, which I've been trying to promote in Scotland with limited success, is having nurses who are able to move across different specialty areas so that you see this as being a career that's going to be developed within a department. So, you have nurses who are trained not only in theatre, but in out-patients, so that there is then a flexibility that you can move across the two sectors if there's pressure in one rather than the other. Because often we're now finding that, in our unit in Inverness where we've had this huge expansion in capacity, actually keeping all the theatres running to their maximum capacity is quite difficult, because we don't have enough nurses. We're not yet at the stage that we can move them across the two areas. Now, there was another point I was going to make that's just gone out of my head.

Don't worry. I was going to say—. Lesley, I'll come back to you.

So, am I getting it right? You think it's better for nurse teams to be a bit more general so they can do 'everything', in inverted commas, so they're within the unit, they're on the ward, in the theatre, in out-patients. Whereas would you say consultants now are far more specialised? So, again, when I worked in ophthalmology, the surgeon did everything—ptosis, squint, cataract, glaucoma, corneal graft. It seems to be that consultants are far more specialised now. So, we just took evidence from a consultant who said she didn't do glaucoma surgery at all.

Yes, that's absolutely correct. I found, within my career in ophthalmology, which is now well over 30 years, that the range of surgery that I did became more and more restricted, so that now all I'm doing is specialising in high-volume cataract surgery. And in fact, I even wonder whether that is the other way in which you can achieve real success in terms of efficiency—by having those small number of surgeons who are going to be able to crack through and do very large numbers of surgeries. One of the ways in which I would also suggest it's possible to achieve that is by adopting immediate sequential bilateral cataract surgery, so doing both operations on the one visit. And that was something that was viewed with a lot of suspicion for a long time, and it has been really quite difficult to persuade people that this is a new way of working. The pandemic actually did make it a bit easier because you could then very rightly argue that the risk of a serious complication was less than the risk of a hospital-acquired infection. And in fact, what I will often say to patients, which is particularly true in the area that I work, is that their risk of having a fatal car accident coming up for their second eye is greater than the risk of having a catastrophic bilateral infection. Because things have changed a lot, and now, because we work through very small incision cataract surgery, and because of pre-operative anti-sepsis and the use of intracameral antibiotics, cataract surgery has become extremely safe.

That's really interesting, because I think you would have quite a lot of difficulty persuading patients to have bilateral—

Well, actually, that is not so. My own personal experience is that, as you start to offer this as a technique, although in the beginning patients are a little bit concerned, when the word gets out and they start talking about it, they're the best adverts, and soon you will have patients knocking on your door, saying, 'Why can't I have bilateral?'

And I would imagine, from an efficiency point of view, that would be very good.

Yes. From the hospital point of view, it's very efficient. From the patient's point of view, there is less travel involved, and particularly when there are very long surgical waits, to be told, 'Well, you'll have one eye done now, and it may be 12 months before you get your second eye done, or we can do both now'—. Particularly if they're going to be unbalanced because they've got a difference in refractive requirement between the two eyes, it's very attractive to have both done at the same time. So, for patients travelling long distances, this becomes very attractive.

Now, the other argument that people often make is that this distorts the waiting time, and that you're concentrating on doing the second eye before doing the first eye of many patients waiting a long time. I've got a colleague in Tayside who now does more bilateral cataract surgery than anyone else in the country. I used to think that I was doing quite well at about 175 patients per year; he's now doing over 800. So, he is almost exclusively a bilateral cataract surgeon. He's got the mathematical modelling to prove that, although in the short-term you create a bit of a bow wave—. And it really depends on the numbers. You can have a computer programme that you can now feed in how many surgeries you're doing, what is your waiting time, and you'll be able to predict when you reach the crossover point and the numbers start coming down, because of that increased efficiency. Because if you go from offering, say, eight surgeries on a list to offering 10 or more, then, before too long, you're starting to really see the waiting time come down.

Can I ask just one final question, please, Russ?

Yes, absolutely.

You mentioned about a lack of progress in one of your answers to the Chair, around electronic data, electronic record sharing et cetera. I think we all recognise, right across public services, that that's very challenging. I was just wondering if you had any ideas about what we should be doing—whether Government should be driving this with the health boards, or whether it's up to the health boards to ensure that—. I represent Wrexham, which is right on the border with England, and it's a—. We've had waiting time initiatives over the border in Shropshire, and it's a real issue about lack of capacity to exchange records between Wales and England. So, I was just wondering if you had any ideas around that.

Well, certainly in Scotland, it's being seen as a national policy to drive out the provision of OpenEyes to every health board. So, Greater Glasgow and Clyde have now gone completely paper-free. They had a significant data-mining exercise, where they were able to transfer data from previous programmes on to OpenEyes. That has been a real success. So, slowly other health boards are picking this up. Some of us would like to see it happening a bit quicker than it is, but it's certainly something that is being seen as a very necessary national directive that needs to be followed.

Thank you.

Thank you. Joyce, did you want to come in at all?

I did. I wanted to come in about the earlier statement you made about nurses being more general in what they do, and moving from one job to another, maybe, within a specialism. We're aware of the retention of nurses, as they find it more difficult to do the heavy lifting, and the opportunities for them to transfer into work that would not require them to do any heavy lifting, and that there are barriers in the way. But we also know that there are barriers in the way when you talk about general nursing posts. So, how do you think that we could square off those two competing challenges to achieve that end?

Well, yes, there are two ways of looking at this general nursing, and I'd say the bigger problem at the moment, particularly within theatres, is that nurses are not dedicated to ophthalmology, but they're used to provide services throughout the different surgical specialties. Part of the reason that there's often a reluctance to break up that and allow the nursing team to become fully dedicated is often because of the necessity of keeping on-call rotas active, and the senior nursing managers get very twitchy when you start saying, 'We're going to take off some of the nurses who are going to be dedicated only to ophthalmology', because that can make things within the rest of the hospital more difficult to manage.

So, in general, throughout my travels around the world, I'd say that the most efficient eye departments are those that have a semi-autonomous governance and that are not impacted too much by other departments trying to influence the way they work. So, that's not fully answering your question, which was how you square that circle of having nurses who are being trained to a very high level to deliver services—whether that be in the interpretation of optical coherence tomography or the delivery of intravitreal therapy—against what I'm now suggesting, that some of them might be interested also in developing those skills, which would allow them to work in an operating theatre.

Now, of course, the other thing that I did see in Wales that was highly commendable, which was the training of non-nursing personnel to be able to assist in cataract surgery, and I was delighted to see that that was happening, and we'd applaud that. You can't push that too far, and you have to have some trained nurses to supervise what is going on, especially when it comes to the drawing up and potential administration of medications.

Thank you. Dr Pyott, I'm just going to ask as well if you mind if Members interrupt you as you're talking, because we've got more questions that we're going to get through, so—

Not at all. I realise that I'm pouring out an awful lot of information and that this may require some clarification.

No, no. Much appreciated. We've got less than 10 minutes for each section, so Mabon ap Gwynfor.

Thank you. I'm not sure I'd use the word 'disagreement'; that may have been something that got lost in translation. I think my report looked at anomalies that had arisen because of different governance restructuring of the way particular services were provided, and that looked at all sorts of difficulty in terms of individual patient journeys.

So, I get the impression that there is still some of that historic inefficiency that is remaining and that, because you've created different health boards coming out of different structures, historically, people were used to behaving in one way, and it's very difficult to change that kind of culture. When people have been used to one particular degree of practice, they can continue with it.

And, you know, we're not immune from these sort of difficulties in Scotland, in that I work for NHS Highland, but provide services to other health boards, and often we see that whenever things start getting difficult then people will start to pull back their services to the larger unit and allow those on the periphery to become less well provided, shall we say.

So, I think these conflicts are almost inevitable, although I saw that, in your most recent blueprint for Wales, there was the suggestion of having someone with overriding oversight to the distribution of what resources you have, and I think that is to be applauded. I think that there are almost certainly built-in inefficiencies that will lead to longer waiting times, and the more that those can be helped, the better.

Because I'm not working on the ground in Wales, it would be very difficult for me to pass comment on that.

Well, as regards the latter point, I think I've already stressed that I do see that there can be dangers with that. As regards recruitment and retention, yes, I'd say that we have the same sorts of issues in Scotland, but we have had some innovative ideas to try and make some of the hard-to-fill posts more attractive—particularly the global citizenship post that I mentioned in my report. Now, in some ways, that's a very expensive way of providing a service, and the only way it becomes justifiable is with a reduction in the extremely large costs that there are for providing locum care. Certainly, the islands boards end up having to spend a huge amount of money, and, you know, that's why these particular posts have been quite attractive to them, and we've had considerable success with that. Our most recent appointee to that position has really done a power of work and enabled the service to continue when otherwise it might not have been possible.

But I think I would also commend what I've seen in your blueprint of having alternative means of training ophthalmologists outwith the standard number training scheme, because I think, almost certainly, you do need to have more trainees, particularly those who've got a desire to stay within Wales. I'm always concerned, in my own country, when we train up people who then disappear south. That, again, is a loss to the Scottish health service in the same way it would be to the Welsh health service.

Well, I certainly was impressed with the fact that you've got an excellent school of optometry in Wales and, historically, you've got good schemes that are involved in keeping patients within the community.

As regards how much has changed since my report, again, I have to apologise that, whilst I'm able to give good information on the situation in Scotland, given that it's been four years since I've been able to visit units in Wales, I'm really not able to answer that.

Thank you. John Griffiths.

Yes, I'd like to ask some questions on integration of services. Your report suggested reducing reliance on service level agreements with English health boards for eye care services. Could you tell us why you believe it's necessary to do that, to decrease those cross-border surgeries and transfers?

Well, I think the simple answer is that, without that, you're seeing money going outside of Wales to other health authorities. It's much better to keep the money to develop your own services within the country. As I mentioned in my report, frequently, particularly when it comes to vitreoretinal surgery, the bulk of the treatment will be given by surgeons in training, once they've been trained up to a certain degree of competence that they can be allowed to be the first port of call to deliver that service. At the moment, I would say that Bristol is very happily having its training programme subsidised by the Welsh taxpayer, and it would be much better for the Welsh taxpayer to be preparing the next generation of VR surgeons for your country.

Okay, I don’t know if you'd be in a position to tell us anything about this, but we'd like to know, as a committee, whether there have been significant changes in the number of patients transferred to Bristol or Liverpool. No, you wouldn't.

I'm afraid I don't have that much—.

No, okay. You also say that managing long-term conditions like macular disease and glaucoma will rely on efficient imaging and information gathering, and this could be done either in community settings or high-volume ophthalmic diagnostic treatment centres. Would you have a preference? Would you say that one of those two is better than the other?

Well, in terms of the high-volume treatment centres, for the surgical specialties, they would be essential. The model is that you bring the patients in for those interventions that are going to require a handful of visits. So, if you're ultra efficient, you may be able to do everything in one day, and certainly there are units in the UK that would offer that service, so that they get their biometry and both eyes operated on in one visit. It's truly a one stop. But, even if you don't do that, even if you get it down to two or three visits, patients would be prepared to travel quite long distances for that to happen, because it is such a life-transforming procedure. However, for long-term conditions such as glaucoma and macular disease that are going to require frequent visits, that is better delivered in the community. And so I know that, in London, they have imaging centres set up in shopping malls, because, once you’ve got a good, efficient data transfer, then those images and the patient records can be read anywhere, and so you’re able to provide that service with no medical personnel there at all.

Within our own unit, we have quite a lot of virtual imaging going on, so that patients will come in and they'll have all the images and the data taken by nurses or non-nursing staff, and their visit will be over in 30 minutes. And then, later on, the doctor can look at all the information and make a decision as to what is required to be done.

So, you can have a bit of a mix and match. If you’re going to have a purpose-built regional centre, with easy transport links, then it may be more sensible to put everything together. But, in other parts of the country, where geography is important, then it may be better to have your imaging centres based in the community.

Do you have any further questions, John?

No, that's fine, thank you, Chair. 

Thank you. Joyce, do you have any questions at all?

Yes. I’m going to ask—. We’ve talked about the electronic patient record system, but I also want to ask about the main areas in technology, where we need to invest in infrastructure to ensure the availability of essential technology and equipment, in replacing items, for example, that are nearing the end of their operational life and to handle the expected increase in demand and offer advanced care. Because we had evidence this morning that was actually saying that, without due diligence in looking at this aspect of care, if something breaks down—and the example was given this morning—the whole clinic gets cancelled to carry out that particular piece of clinical need because of the failure to think ahead.

Yes. Well, certain pieces of equipment, such as a reliable OCT, are absolutely essential for the running of the macular service. And if that breaks down and there’s no back-up then you’re in very serious trouble, because you just cannot provide a modern service without it.

So, who should be responsible, and how should it work, to ensure that those things are certainly dealt with and known about?

Well, I suppose that would often come down to the commissioning of this equipment. Some of these imaging devices can be leased rather than bought outright, and, in that circumstance, it’s back to the manufacturer, the distributor of that equipment, who’s responsible for ensuring that they’re going to be maintained properly. Alternatively, within the financing of the health board, you would have to make sure that you’re setting aside an appropriate part of your budget to replace essential equipment in a timely fashion.

Thank you. 

James Evans. 

I wasn’t quite sure whether to hit the button then, actually, to take my microphone off; I didn’t want to get into ping-pong with it.

Thank you very much, Doctor, for your evidence today; it’s been very insightful. Thank you very much. I want to talk about health inequalities, if that’s okay. I’m just wondering: in the redesigning of eye care provision and eye care services across Wales and the UK, do you think enough focus is being given to addressing health inequalities in those redesigns?

Well, it’s very interesting that you ask that question, because, only very recently, I was involved in a meeting in Scotland looking at the map of inequality within the services that we provide, and I was really quite shocked to discover that, within our own region, we're probably one of the worst in terms of that inequality and that we are not providing adequate services to some of our most deprived patients. And ironically, the reason I think that is an issue is because of the lack of private healthcare in the highlands, and those who would otherwise be going for private care are most likely to be the squeaky wheel that gets the oil, and they are better equipped to be able to phone up the hospital and say, 'I've got a problem. I need to have my surgery now.' I'm not aware whether you have the same atlas of variation in Wales, but certainly this is something that is available to us in Scotland to be able to look and drill down and try to analyse why we have got health inequality. It's something that does need to be looked at. I've a real concern about patients who are needlessly languishing with occular conditions. 

Do you think that that's because we push more NHS treatments down to community optometrists as well, and obviously people are worried about the cost implement—I can't get my words out today—impact on people? Do you think that there is a two-tier system coming there, with those people who can afford to pay to go and get their eyes seen and tested, while others may experience delays because they can't afford it?

This, of course, is the benefit in Scotland, where that issue doesn't arise because the sight test is free. That, I think, has been a huge advantage for us. 

I think that's really important. One thing I do want to talk about is research and development. We've been told that optometry is actually an area that's very keen to learn about new advances in technology and investments into the area. Do you think that more could be done across universities, in collaboration between Governments and universities, to drive innovation within this field?

That's a slightly difficult one. The problem that you sometimes can face is that the optometrists get very attracted by lots of new imaging equipment, which they can purchase. And then—even in Scotland, this is an issue—patients will be offered an enhanced examination. So, they'll have to pay for that OCT examination. And then the difficulty with that is that the optometrist might not fully understand what they're looking at, and then refer the patient needlessly for an opinion from the hospital eye service. So, I think you've got to be a little bit cautious what you wish for. But there's no going back. Because of the numbers of patients that we're having to deal with, we are utterly dependent on our colleagues in community optometry. We cannot work without them. And in Scotland, we're now training up more to be familiar with the use of technology, such as OCT, so that they can be more directly involved in the management of long-term conditions. So, I think, if you're going to use technology, you have to recognise that you are going to have to put in the training to give practitioners the knowledge of how to do that, and that is something that has its own burden.

One final question, Cadeirydd, if that's okay. In Wales, what we're hearing a lot from community optometrists is that, when they're referring in to secondary care, a lot of those referrals are done via letters, and back to the old fax machines. They can't even really send e-mails. Is that something that happens in Scotland, or have you got a more seamless system for how community optometrists work with secondary care in terms of referrals?

It's much easier for us in that referral is all electronic, and optometrists are given an NHS e-mail account. That means that there are no concerns about breaches of patient confidentiality. Because that's always the big concern with the transfer of data, and we've been able to cross that particular problem.

Just very quickly, how easy was that to implement? Because it's one thing that ophthalmologists have been asking for a long time in Wales, but actually it seems to be a very slow pace. I'm just interested in how quickly the Scottish Government was able to embed that into the system.

Nothing is fast, particularly when you’re trying to implement electronic referral, but we’ve been doing it now for longer than I can really remember—it must be eight or 10 years, I’d have said.

Okay, that's fine. Thank you. I think Mabon wanted to come in.

Yes. Mabon ap Gwynfor.

We're still waiting to see the full benefit when it's rolled out completely nationwide. Once it is there, it will be possible to pull up the entire patient record. If they visit another region of the country and they have a particular issue, you’ll be able to see the full details that pertain. And that’s quite important for us in the highlands, where we have a lot of visitors. So, at the moment, we don’t have that.

An electronic record within a department does away with the paper notes. I can certainly remember visiting some of the units in Wales and seeing, still, huge stacks of notes, where it’s very difficult to actually retrieve the information that you want. With an electronic record, you will have immediate plotting of what is happening to a patient’s vision. This is particularly true in glaucoma and macular, where you’re having to manage long-term conditions. And so it’s much easier and quicker to be able to come up with the appropriate diagnosis and management for an individual patient. It’s really becoming, I would say, utterly essential in modern healthcare, but the implementation is difficult.

As I speak, for the last probably six years, we’ve had full transfer of data between the western isles and the highlands, so we’re now able to run virtual clinics. The doctor can sit near his home in Inverness and make a decision about a patient who is across the water in Stornoway. These kinds of things make it easier to provide your more remote treatments. And again, this will be of implication in those hard-to-serve parts of Wales, where you are underprovided with ophthalmologists.

Thank you. Dr Pyott, we're just a little bit over time, but just a couple of quick questions, and perhaps if you can just give short answers on these. I just want to understand the current uptake of eye tests, particularly in groups of the population more likely to skip a regular eye test.

Are you asking about Scotland?

I was looking for a Welsh perspective, but perhaps you don't know the answer to that.

I'm sorry, it's very difficult for me to answer that, but alas, generally you see that what is often a problem is that, because—. This harks back to the interface between the public and the private, in that you tend not to find optician shops in the poorer parts of cities—they tend to be on the high street and in the more affluent areas. So, you are always going to have a battle against this problem, where there will be commercial demands that mean that it is more difficult for the more disadvantaged to access services.

From that perspective, what can Government—whether it's the Scottish or the Welsh Government—do more to raise awareness in order to encourage people to take up regular eye tests?

I suppose that comes down to public health messaging about the importance of having an eye test, and, as I mentioned earlier, not to have a barrier of cost to be able to go and get your vision tested.

In one of our earlier sessions, one of our witnesses suggested that responsibility for ophthalmology services could be lifted out of health boards, so ophthalmology could make its own arrangements, I suppose, directly, if that's more responsive to patients' needs. Is that something that you have a view on?

That sounds very similar to what has happened to dental services, and I'm not sure we'd want to go down that route, because then that really would lead to health inequalities. This is harking back to some of my earlier comments that when you start trying to have more of the private sector involved in eye care, then inevitably there's going to be cherry-picking of those bits that are profitable. That is the other hazard with cataract services being seen as the only important issue, because they can develop their services to the detriment particularly of long-term conditions. This is where it's become a real issue in England, where they've hollowed out many of the departments because they've not been able to get the contracts for providing cataract services, and that has implications for their general budget as to how they provide the rest of what they have to do.

I appreciate that. I think that's all our questions, Dr Pyott, but is there anything that you think you want to add, perhaps that's not been drawn out in questions today, but you think might help our work?

No, I think we've probably covered the most important things there. Thank you very much for giving me the opportunity of revisiting the report that I wrote a number of years ago.

Thank you for your report and for attending today's session, and advance papers as well. Thank you very much. Diolch yn fawr iawn. We appreciate your time today.

That brings this session to an end. We'll be back just before 12:30 for our next panel.

Welcome back to the Health and Social Care Committee. We move to item 5 today. This is continuing our evidence into ophthalmology services in Wales, and we have a panel of three people providing us with evidence in this session. So, I'd be very grateful if you could just introduce yourselves for the public record.

My name's Owain Mealing; I'm the chairman of Optometry Wales.

Dan McGhee, a director at FODO, which is the Federation of Optometrists and Dispensing Opticians, here representing larger providers in Wales.

Peter Hampson, clinical and policy director of the Association of Optometrists.

Lovely, thank you. Just for technical purposes, I think your mike is controlled remotely, Peter, as well, so you shouldn't have to touch the buttons at all. I'm correct with that, aren't I? Yes, there we are. Right. Okay. Lovely. Thank you for being with us today. Perhaps if I could ask: how well integrated are community optometrists with NHS services in Wales?

What do you mean by 'NHS services in Wales'?

So, I suppose, the link between hospital services and other health professionals, other bodies, in Wales—how well are the services integrated in terms of ophthalmologists?

In terms of how the service works, we are, essentially, the gatekeepers for ophthalmology. So, most primary eye conditions are first identified in primary care optometry and then referred onwards to ophthalmology. Currently, that requires paper, fax, or, more recently, e-mail referrals. Information back from ophthalmology is usually in the form of paper; in some health boards, it will be in the form of an electronic communication, but it's usually a paper transmission. Similarly for GPs, as well, it's usually a paper transfer of information from optometry to GPs. But we work closely; the systems are designed so that we can receive referrals from GPs, pharmacy, dentistry if needed but seldom, and ophthalmology. So, the integration is there, we work together, but it's not smooth always.

Some of those aspects around digital we're going to come on to, because we've got some specific questions. I'm very interested that you mentioned fax machines—you did say 'fax machines', didn't you?

I did say 'fax machines', yes.

Yes. We have to double check on that. And there are some specific questions around that, which we'll come on to. But I suppose the wider question, as well, is: what can be done to reduce the burden, from your perspective, on people entering hospital?

The recent contract reform that we've had is the biggest generational change in eye care in Wales—

When I say 'hospital', I mean hospital eye care services.

Eye care services, yes. So, the WGOS levels 1, 2 and 3 are existing services that have been tweaked to move forward, and then WGOS levels 4 and 5 are the biggest game changers for patients entering hospitals. For example, WGOS 5, which is the independent prescribing service, the acute treatment of eye conditions within primary care by independent prescribing optometrists, results in—. In some health boards, there has been the redeployment of doctors from eye casualty into clinical roles. In other health boards, you end up with registrars not working until 9.30 at night to see excess patients, and some patients are kept within primary care.

The second part of that is WGOS 4, which is two modalities, which is the filtering of patients to stop unnecessary referrals into ophthalmology, and that's deployed mostly in health boards in Wales, and that's on the inflow of patients into secondary care, and that's reducing numbers. The second part of that is outflow of patients into WGOS 4 from hospital to reduce the burden. That requires a little bit more time to reach full effect, because these patients have to be identified in departments that are running at more than capacity, and then there needs to be a safe transfer of care from ophthalmology into primary care, which, if we're going to talk about IT later on, that sort of links in.

Sure. So, despite that we've had the contract reforms, waiting times remain high. So, I suppose, what evidence exists to show a reduction in hospital eye care referrals due to the reforms?

So, everything is very new in terms of WGOS 4 and 5. So, WGOS 5 has shown a reduction in referrals into eye casualty, so these patients are being managed in the community, closer to home. For example, there are constituencies where, if you were to get an eye problem, you’d have to go cross-border previously to be treated, whereas with WGOS 5 you could be managed much closer to home by somebody you know.

In terms of WGOS 4, time is required to show that. There are counts and audits built into WGOS 4 to look at what’s been filtered and maintained in primary care, and that evidence is there in terms of the outcomes that are submitted to the shared services partnership on a monthly basis. But these are new. Contract reform has come in in stages. So, we’ve had 1, 2 and 3 change, WGOS 4 is implemented health board by health board, and those are relatively new.

The other thing is that there are surgical conditions that can’t be managed in primary care, and, with unmet need being identified, better access to care, there are more patients that require surgical intervention and waiting lists are high. Similarly, ophthalmology, if there’s only one theatre, it doesn’t matter if we’re freeing up the time of ophthalmologists; if there’s only one eye theatre in a hospital, they can only operate with a fixed amount of capacity, which has an impact on waiting times as well.

Okay, thank you. If Dan McGhee or Dr Hampson want to come in at all on those points it's absolutely fine, but no pressure, because we've got lots of questions. Did you want to come in at all? No need to.

No, fine. I agree with what Owain's been saying on that, so it's fine.

Yes, no problem. John Griffiths.

Diolch, Cadeirydd. Just a couple of questions on community optometrists. Firstly, your views on how Welsh Government is supporting the transition of eye care services from hospitals to primary care through funding initiatives.

Who would perhaps like to address that point? Anyone?

What do you mean by 'funding initiatives', sorry? Perhaps that's a—.

Well, anything that Welsh Government is doing to support that transition of eye care services out of the acute sector into the primary care setting. So, are you aware of any funding initiatives?

Well, the whole of contract reform, I suppose, is a funding initiative to move patients out from secondary care into primary care. There’s also been the allowance, I think, of money from primary care to be spent within secondary care to try and identify these patients to move out. So, if you’ve got an ophthalmology department that may be under-resourced and struggling, identifying these patients is difficult. So, I know that there have been some funds released to be spent within secondary care. However, secondary care is not necessarily as agile and responsive as primary care in deploying these funds, and I think we’re still waiting on some co-ordinators to be employed within health boards to identify these patients and move them out into primary care.

I think it’s important to note as well that—[Interruption.] Sorry. As much as about getting the acute patients out of the hospital eye service, it’s preventing them going in. I think the new contract is certainly supporting more and more practices to be able to offer that service and ultimately help customers and patients that would be in a rural area that may not have (a) an opportunity or find it difficult to attend a hospital, or (b), even if they could attend a hospital, it’s not necessarily the right place for them to be initially.

If I can come in on that as well, in addition, the allowance of domiciliary provision of WGOS level 5, so mobile WP10 prescription pads, to allow patients who would otherwise require hospital transport maybe to get it, or just not be able to access services, to be able to have treatment at home is beneficial. So, these conditions end up being less severe, and so can be managed successfully within primary care.

Okay. John, you ask your next question, and then I'll bring in Dr Hampson.

Yes, okay. Just in terms of that new optometry contract, it’s said that it’s created a positive cultural change within optometry and primary eye health. I just wonder, taking that that is the case, what further improvements are needed to enhance patients’ access to eye health services and support professionals in primary care. It really is one of the main challenges community optometrists face in carrying out their services.

Workforce—so, we've been trying to chip away at workforce planning for as long as I've been in optometry. We have an agreement from Welsh Government that there is a workforce strategy to be developed with us. We are now, as of last month, reporting our workforce on a month-by-month basis, but identifying need—and pockets of lack of provision can be identified through this—and then targeting further training and support grants, as have been introduced of late in the most recent sort of negotiations between the profession and Welsh Government.

Dr Hampson, on this point or any other points that you want to respond to as well.

Thank you. I know I'm going to talk about it shortly, but I think IT connectivity is one of the biggest enablers to enabling both professions to work as well as possible. So, at the moment we've got a really helpful contract reform process that, talking to the funding, has permitted people to use the skills that they are trained in at university, and it's given them the opportunity to use that more fully in a way that, around most of the UK, not just in Wales, has often been problematic. It's been challenging. So it's a really positive step in that regard. But the ongoing piece is the connectivity to enable that safe transfer of patients, that sort of collaboration between different parts of the eye care professions, and to ensure that we actually get the best for the patients that we can. That missing piece will be connectivity, but we know that that's going to feature on the committee agenda to follow, but also as a wider plan for the whole of Wales's eye care.

Thank you. Any further questions, John? 

No, that's fine thanks, Chair.

Thank you. Joyce—no, sorry, Dan. Yes. 

,[Inaudible.]—if that's okay. There's a two-factor challenge with that. I think there's the initial education of individuals who have become optometrists and also remain in Wales, certainly away from south Wales, west, north, and I think central is particularly challenging. Then you can educate in independent prescribing, which the Welsh Government have been providing funds for increasingly, which is a great step forward. But we need that volume of practitioners to then educate further. So I think there are a few challenges within that.

And how does that happen?

It's a good challenge. It's somehow incentivising individuals to remain in Wales, I think, beyond their undergraduate degree.

How do we do that?

I think making it attractive in terms of—. We represent practices everywhere, and the further north of the M4 corridor you go, the harder it is to recruit. Targeting, for example, smaller practices in mid Wales with some of the time for training is massively onerous. And whilst you're reimbursed for the cost of the training, you're not reimbursed for the cost of not being in practice for a huge amount of time. But in the last round of contract negotiations, it was agreed that there would be a grant for some of the more onerous aspects of training to be at least partially covered, which, again, can help to get people into the position where they can afford to take time off the practice to train. But then how do you recruit and retain people and make it attractive for people? I don't know.

How do you make it attractive? That’s the question.

Well, I think it's an entire-nation issue, isn't it, in terms of economy, education and everything, to make it attractive to live and work here.

Sure. Absolutely. Joyce Watson.

And before I ask, and I am going to ask, about digital transformation or not, we did hear evidence early on about the new equipment that is available and understanding how to use it and how to read necessarily what it's showing you. Admittedly, that was in ophthal—. I can never say that. But anyway, not in your field. But is it a problem for optometrists that the upgrade in equipment presents another level of training that's needed to understand?

If I may, I'm 20 years in practice this year, and everything has changed many times. The CPD—continuous professional development—grants are there in primary care to support training and retraining, and development of professionals, so that we can keep up to date with changes in equipment. Everything in my practice has changed in 20 years, and it will change in another 20 years. And supporting professionals to keep up to date with the demands of changes, through continuous professional development grants, targeted funding for new qualifications, is the way of quality-assuring that professionals are up to date on new advances in equipment.

And, of course, the other side of that is the equipment itself—the capital investment. Whilst we recognise that optometrists sit outside, and it's a private business, is there any help and support? There's a greater reliance on you to deliver—is there any help and support for upgrades in the equipment?

No. There's nothing so far in the estates. If you look at most practices in Wales, they're in Victorian building stock. I was asked once about e-car charging and I said, 'We don't even have car parks a lot of the time because we're in Victorian stock.' And there is no alternative. So, looking at how we can improve the infrastructure of practices, as has been done in other contracted professions, would be helpful. But also, the cost of equipment now is dauntingly expensive, and requires risk and appetite for risk on the part of practice owners to take it on. And it's unaffordable in some practices. So, how we look to support that I think is key, moving forward.

I think one challenge I've seen, when services are being commissioned, is the request that a specific piece of equipment is used for that service when the majority of practices will have a different piece of equipment already. So, I think, sometimes, can there be consideration of whether a different piece of equipment—? My particular comments around visual fields plots: typically, practices will have type A, if you like, but then there's a request for type B. So, can it be more pragmatic, to find out what's in the sector already when services are being commissioned?

It's to make sure that service specification is in line with National Institute for Health and Care Excellence guidance on what is the minimum standard required, rather than particular pieces of equipment, so things don't become out of date—the manuals that we work from are not out of date then almost as soon as they're published.

I ask that because I went to see an optometrist in Haverfordwest, newly opened, and I knew that the equipment was hugely expensive. So, is there not a risk—and I'm just going to pursue this a little bit further—that some areas won't be served at all, because of this particular issue?

Yes. I think, once we are able to identify—. And this is where clusters are very helpful, to find out if services are being provided in each cluster. How we then identify what the barriers are, and target those barriers, to try and break them down, I think is quite key. But it is a risk, without capital investment in equipment, in areas that have low footfall, small practices, part-time practices. There have been practice closures in the last few years that were unexpected because of a variety of different financial constraints on them, and purchasing the equipment to make sure that you are of the minimum standard is part of that.

Thank you. Now, we are going on to digital transformation—or not, as you're going to tell us. So, what are the current processes—you started saying—for referring patients from community optometrists to hospital eye services? And what needs to happen to streamline, to reduce the waiting times?

So, currently we have three referral priorities. We have a routine referral, which would be a paper-based letter into secondary care. It doesn't quite fit with the green agenda, printing things off and then sending them in for them to be scanned. We have an urgent referral, which, in some health boards, is now an e-mail, but again it's a scan of a letter, sent by e-mail, printed off, reviewed, and rather clunky. And then you have the emergency referral, which is usually a telephone referral, and you speak to somebody directly, and then accompany that with an e-mail. The biggest change that we're genuinely very thankful for is having access to NHS e-mails as of last year. A contracted professional without access to NHS e-mails—it's impossible, really. But now we have that, that's going to make a big difference. But we need to change the pathways to make that useful. What needs to change with it is we need—. All of our development of contract reform was based on the assumption that there would be an electronic patient record for co-managing patients with secondary care, and an electronic referral system. That's what we need to get things going.

Just before you go on, Joyce, just to say, Dr Hampson, if you want to come in at any point, please just wave at the screen and I'll bring you in. Joyce, Mabon wanted to come in. Do you want to continue with your questions or shall I bring Mabon in?

No, I'll continue.

And I'll come to you after Joyce has finished, Mabon.

We've heard about the EPR—we know that it's an issue. In your view, are there steps to accelerate that?

I am yet to see anything that is accelerating it.

Who should be doing it, then?

I think the profession is quite clear on what we want: we want a system that works with practice management software to avoid the double-keying of information. Whether that's through application programming interfaces or what, I'm not entirely clear on that, but I assume it can be APIs, but I guess it sits with Digital Health and Care Wales—

What needs to happen and who needs to do it, I suppose?

What needs to happen is somebody needs to make a decision on what we're going to have, and deploy it, and make sure that health boards are on board with using it.

So, who's the 'somebody'?

DHCW it sits with at the moment, I believe.

Okay. Because we have heard—I'm going to move on into this space—about investment in advanced digital tools like optical coherence tomography, and that's a non-invasive imaging test, which you obviously know, and that it will improve patient outcomes in primay eye care. How is the investment in that going?

There isn't. So, optical coherence tomography is equipment that we privately fund. There are problems in terms of transmitting those images, because not every manufacturer has—. They're quite guarded over the ability to use the information that they generate on their scanner with other information. But there are tools available to pull those together. So, something around that needs to be looked at, so we can transmit that scan information from primary care into secondary care. But that doesn't cover the whole thing. There's a huge amount of other information that needs to be pulled out of the management system that I use in my practice, for the patient, that then is transferrable into secondary care, then, as well. OpenEyes was—. We were told that OpenEyes was going to do that. We have partial deployment in some health boards, we have no deployment of it in other health boards, and we've got full deployment in other health boards, but no API to link it with our practice management software. So, we've got optometrists—. I see the patient, I write up everything on my notes, and then I need to go onto a different bit of software to write it all again, and there needs to be something to join that up, and I believe that sits with DHCW. But OCT is part of it, but not the whole story.

Just on OCT, there are several manufacturers, and they don't all produce in the same format. So, it's how that's brought together to then go into the OpenEyes or the electronic referral system.

Right. I don't—. So, if you were going to try and solve that problem, it would have to be everybody using the same equipment, or not?

Peter might be able to help us on this one, but I believe there are bits of software that will pull things together.

There are, yes. It can be created in a DICOM format; it's typically what industry standards are moving forward to, but that's just another layer within that. So, it's not about the equipment, it can be converted at a later point.

Okay. So, we've also heard—and I guess this is what Mabon wanted to come in on, on the EPR, or lack of some of it—that you're still getting faxes. Is that the case?

I'm not sure if all fax machines have now been switched off.

Okay.