National Assembly for Wales

Good morning, everybody, and welcome to the Health and Social Care Committee this morning. I'm a new face. I'm Peter Fox. I'm the new Chair of this committee, and it's a great pleasure to join you this morning. This meeting will be bilingual. There will be simultaneous translation from Welsh to English for everyone, if needed. Today, we do have apologies from Joyce Watson, and one of our Members will be leaving us halfway through the morning as well. So, those are the apologies.

Before we start, can I just place on record my thanks to the previous Chair of this committee, Russell George, for all the work he's done on the various inquiries over the last few years? We thank Russell for his work in this arena, and for the way he's chaired this committee over that period. We wish him well. I'll try to continue in the same vein. 

Could I just take—? Are there any declarations of interest this morning from anyone? No. Okay. If you find one as we move through the agenda, just please let us know.

Before I go on into our key part of the morning, I think it would remiss of me if I didn't reflect on the very sad news of Claire O'Shea, as we heard many tributes yesterday in the Chamber. I'd like to pay a tribute to Claire—Claire, who, sadly, passed away on Monday. She played an absolutely huge role, we know, in this committee’s inquiry into gynaecological cancers, and I know everyone involved in the inquiry found her evidence not only shocking, hard-hitting and incredibly emotional, but what really shone through was her determination to see changes made to the way that women's health is treated, and she continued this through her work with Claire's Campaign, as we know. And I just want to, on behalf of this committee, extend our heartfelt condolences to Claire's family and friends, and we wish them well.

So, good morning again, and good morning to our witnesses this morning for our next item, which is our evidence session on ophthalmology services in Wales. This will be our fifth evidence session, and we have two today. I'm pleased that we are joined this morning by Helen Thomas, chief executive of Digital Health and Care Wales; Sam Hall, director of primary, community and mental health digital services, Digital Health and Care Wales; Dr Emma Cooke, executive director of allied health professionals, health scientists and community services development at Cardiff and Vale University Health Board; and David Thomas, director of digital and health intelligence, Cardiff and Vale University Health Board.

We welcome you this morning for this really important session. Thank you so much for submitting your various written evidence. We do have, as you can imagine, quite a few questions for you this morning. We'll try to work through most of them, but we're scheduled to finish around 10:45, so we don't want to take too much of your valuable time, and, if we perhaps don't finish all of the questions, we might need to write to you, or ask you to write with some answers to, perhaps, any final questions we might have, if that's okay.

So, if you're all ready, I'd like to perhaps start and look at current digital infrastructure, if I could. The national clinical strategy for ophthalmology states that a lack of digital infrastructure is holding back improvement in eye care services. I just wondered how would you assess the current digital infrastructure for ophthalmology. Is it sufficient for modern healthcare needs? And can I direct that question to Digital Health and Care Wales, please?

Diolch. Thank you, Chair. I'll give you a general answer to that to begin with and then hand over to colleagues in Cardiff, who are looking after the current actual digital infrastructure that supports eye care services. But just to say that we know that there are many opportunities that digital and data services can support and underpin in terms of the challenges that eye care services face, and we believe that there is a way to go in terms of ensuring that they have the full digital infrastructure that is needed. But, in terms of the detail of where we are today, I wonder if I could ask David Thomas, my colleague in Cardiff, to give you more detail on that.

Yes, please come on in, David.

Thank you, Chair, and thank you, Helen. In terms of the deployment of the electronic patient record solution in Cardiff and Vale, that has been done utilising the existing infrastructure. There's recognition that, in the longer term, this needs to be deployed to the cloud, and we do have plans to move that to cloud. I think it's important to say that, within Cardiff and Vale, we have now deployed the EPR solution across all our ophthalmology sub-specialties. We've completed that in the last eight months, so the infrastructure that it sits on is currently fit for purpose, but recognising that, in terms of scaling it up, there is a requirement for us to move to cloud infrastructure, to a cloud model, and that is the plan, and we are in the process of doing precisely that. 

Okay. Thank you, David. Sam, would you like to contribute anything on this as well? 

Yes. Thank you, Chair. For me, the real opportunity of rolling out the new technology that we've been looking at would be to shift some of the pressure from our secondary care support for eye care into primary care, so that some of the more simple cases potentially can be handled in that primary care setting, so by our community optoms, the people on the high street, rather than having to potentially wait a longer time to be seen in that secondary care setting and at eye clinics. The technology required to do that, to allow that sharing of that information between primary and secondary care to allow it to happen, is where this programme is based. That's what this technology allows us to do, and so the benefits of that are myriad.

Thank you, Sam. Well, thank you for that. Nobody else wants to come in on that. I'll move on. Since June 2023, Digital Health and Care Wales has been responsible for implementing digital solutions for ophthalmology. Much time has been spent on contractual and administrative issues, but, despite this, the digital investment proposal to the Welsh Government was rejected due to insufficient information. I just wondered: can you explain why were there gaps in the proposal and whether this has now been approved, and what is the current road map, then, for ophthalmology? Who would like to come in on that? David and Helen. It should unmute for you, David. There we go. 

Okay, thank you, Chair. I was trying to unmute at the same time. So, I suppose the proposal that was submitted to Welsh Government during 2023-24 didn't include the full range of options, and that was resubmitted to include the tactical option that we are now pursuing, that tactical option being to have extended the existing contract for Open Eyes for a further two years, and for us to then implement that across the other health boards during 2025-26. A letter was issued to that effect from Judith Paget as NHS Wales chief exec some months ago. So, it has given us the mandate now to implement that tactical solution, and we are on track to do that by the end of March 2026.

Thank you, David. Helen.

Thank you. The investment proposal that we put into Government was majoring on the strategic solution that we needed to take forward, and we're still awaiting consideration of how we take that forward from Welsh Government. But, as David has confirmed, the approach that we all are behind, and had recommended, is the tactical roll-out, given the timeline left on the contract and the focus; that we need to, as the strategic organisation for digital, focus on the longer-term provision of those commercial arrangements.

Great. Thank you, Helen. Thanks for that update. So, DHCW is currently at—. Oh, sorry. Mabon, please come in.

If I can come in quickly on this. 

Yes, sorry. Thank you. So, with where we are in terms of the opportunity, in terms of the timescale that's left on the contract with Cardiff, tactical roll-out—and the funding available, I should say—is the optimum approach. The service sits with Cardiff, the contract sits with Cardiff, as it currently stands. So, the best approach to this in terms of the tactical roll-out for some of the other sub-specialties in some of the health boards is—. The agreement is that that would happen in that way. It wouldn't actually result in full national roll-out. That's why we, in agreement with Welsh Government, think that we should be focused on ensuring that we have a full roll-out embedded kind of system, following the end of the current contract, which ends in January 2027.

Okay, Mabon?

Yes, thank you.

Okay. Thank you, Helen. So, I was going to ask: DHCW is currently at escalation level 3 for performance on major programmes. Now, is the national eye care programme an area in need of more focus and attention and improvement, do you think? Helen.

Thank you. So, we're currently being placed in enhanced monitoring for major programmes. We're working through the de-escalation framework and criteria with Welsh Government. I think the tactical roll-out remains with Cardiff—so, the current provision remains with Cardiff. In the longer term, I would expect to see us moving that forward and would potentially form part of our plans, moving forward. As it stands, we're awaiting the confirmation from Welsh Government that they want us to move forward with that strategic plan and strategic solution.

Okay. Thank you. Anybody else want to add anything on that? Mabon.

Can Helen just explain what 'tactical roll-out' means?

Helen, did you get that? Could you explain a little bit more what technical roll-out is?

No, the 'tactical roll-out'. Sorry. So, in the answer to my previous question—. So, to roll out, where we can, in terms of the sub-specialty roll-out that Cardiff are taking forward.

Do you want to probe further?

Yes. Sorry, Helen. What does 'tactical roll-out' actually mean? Sorry, I—.

I wonder whether—. To be fair, probably David is best placed to answer that, because he's leading on that element of it.

Okay. Can I bring you in, David? You're still on mute. There we go.

Okay. Thank you, Chair. So, just to answer that question, then, tactical deployment means, essentially, we are rolling out the EPR component of the OpenEyes solution to all of the health boards across Wales, starting in the south-east region, where we're already live in one service—at Cwm Taf Morgannwg—and working with Aneurin Bevan to begin that within the next six to eight weeks, in all likelihood. And then the plan is to deploy the EPR then to the rest of Wales.

So, there are two components to the digital eye care solution. There's the electronic patient record, which is what we are rolling out, hosted through the Cardiff and Vale contract. And then there's the e-referral service, which is a separate component, that does have the option within the existing contract, but there are alternatives, which I think DHCW are looking at as well. So, I think it's important that we are working jointly and collaboratively, to look at getting the best value for money on this.

Okay. Thank you, David. Sam, you wanted to come in.

Thank you, Chair. So, just to pick up a little bit further on what David said, there were the three elements that DHCW were asked to look at as part of the transition. One, as David has just mentioned, is the EPR. That's the technical piece that allows that transfer of information between secondary and primary care, to allow multiple clinicians to actually be able to support the patient. So, that's a really important patient record, which gives you that holistic view of the patient.

Then there's a referral system. That was an original part of the programme, but hasn't yet been delivered. There are several ways to deliver that. We undertook a piece of work during the transition period to look at the market, and we've advised Welsh Government's optometric adviser on those options, and we took health boards through those options. So, there are clear potential ways forward for that.

And then, the third element was the roll-out of Microsoft 365 to all of our primary care optometrists, to allow them to have access to NHS Wales e-mail address and systems, to add a level of security for passing information and sharing. And that has been completed. So, it's those three elements altogether that provide—as you discussed at the beginning—that eye care infrastructure across Wales.

Thank you, Sam. That's clear. I'm going to move us on to the next section, because it will link in. Can I ask Lesley, please?

Thanks very much. Good morning, everyone. I just want to ask some questions about the OpenEyes digital project, so I suppose my questions are to Emma and David primarily. So, I remember it being launched, I think it was probably about four years ago, with significant funding; I know Welsh Government gave some funding. Perhaps you could explain, within that £8.5 million, was the funding from health boards, because I'm unsure about that. It had an agreed deadline to be rolled out by March 2023, but that didn't happen, so I wonder if you could explain. The second point is why it didn't happen, and thirdly, what the current status is, please.

Thank you. Shall I pick this up, Chair?

Yes, please.

Okay. So, in terms of the programme, yes, the programme was launched at the time that we were going into a pandemic, so there's obviously an impact there. I think that the specification, or the case, that was set out was understood by everyone, but the mechanism by which that was to be deployed was not necessarily understood by every health board. Therefore, I think that there is something around the clarity and the engagement, to ensure that everybody was on the same page in terms of what was being proposed, and I think that, probably in hindsight and in terms of lessons learned, the engagement could have worked a lot better with other health boards.

In terms of the money, there was a sum of money that Welsh Government invested by way of capital, and that capital really covered the kits that ophthalmology required within the health boards. So, that was deployed and, clearly, there's a full audit trail on what was procured for whom, when. The remainder of the money was health boards investing themselves into the programme, and clearly that hasn't happened in the way that was envisaged at the outset, partly because the other health boards hadn't seen the benefit and weren't realising the benefit in terms of the money that they were being asked to contribute. Apologies, the third point of your question there, Lesley? 

The current status, please.

So, the current status is that it's gone live fully as an EPR across Cardiff and Vale; it's live in one service at CTM, Cwm Taf Morgannwg. There are plans to implement to the other health boards, where ophthalmology services aren't provided, during the course of this year, and the letter that Judith Paget wrote out to all health boards about a month ago makes it quite clear that there's that expectation for that to happen. So, that will be implemented now.

Is this project run in any other parts of the UK?

So, the OpenEyes solution is run in many places, including Moorfields Eye Hospital. So, it's a tried-and-tested solution, and the feedback we're having from our consultants within Cardiff and Vale, who have now moved from another system to OpenEyes, is that it is realising the benefits that the original case set out. So, yes, I mean, it's a model system that is recognised probably internationally as a good system. So, yes, I think we are implementing something that will make a big difference.

So, obviously, as you say, it's fully live now, so that's two years beyond the date when it should have been. So, what impact—? I mean, patient-wise, I'm sure there will have been an impact. Any financial penalties for not meeting that deadline?

No. We've been able to extend the contract at a fraction of the cost by being able just to implement the additional two years that were in the original contract. And indeed, if we wish to extend it further, there is a procurement method whereby we can procure a support service, but that would need to be in conjunction with DHCW, because we're then talking about a strategic long-term solution here.

Okay. Thank you.

Okay.

Thank you, Lesley. If I move on, then, and invite Mabon.

Yes. So, there was money allocated by Welsh Government for all the capital, but then the human cost, if you like, the human resources associated with making this go live, there was an expectation that that would be funded from health boards. Indeed, a number of health boards did employ people in readiness for taking on the OpenEyes EPR, who had subsequently been doing other things. The conversation we've had with Welsh Government is to recognise that, given the financial constraints that each health board is facing, in order for this to now be implemented, there was a request that there be some additional funding made available to health boards in order to cover the local implementation costs. The support and the contract is covered through the central funding that was allocated to Cardiff and Vale on behalf of NHS Wales organisations.

I think the way that the programme was implemented and managed in the early days, there were a number of concerns that some of the health boards had. There were a number of issues in terms of how things would work; particularly, there were concerns from a cyber perspective, there were concerns about the change management processes, and it did take some time for those things to be resolved. I suppose almost two years of that was during a period of the pandemic, where things didn't really progress in the way that they should have, but I think we've now been able to re-engage with all the health boards and everybody's absolutely clear on what the plan is, what the expectation is, and what the benefits are that can be realised. And in the meantime, as I said earlier, within Cardiff and Vale, we've now been able to put the system across all our ophthalmology services, so people can actually see it now working, they can see the benefits. I think we do now have the buy-in from health boards to proceed, but we need to recognise that there was a period where things didn't progress as they should.

Can I bring Emma in on that point, Mabon? Emma.

So, I think David's made my point, but I think when we deployed in Cardiff, there was a bit of optionality around choice of adoption of the actual OpenEyes, which meant some clinicians adopted it quickly and others didn't. And I think because we didn't roll that out in that managed way, as David said, we weren't demonstrating its full value to the rest of Wales and that's the bit I think we should have picked up on quicker and learnt from. That's the learning here, that we needed to deploy quickly and in a tactical way, as in, more directly, and then that would have demonstrated to other health boards the benefits, as in, many other centres across the UK use this very effectively.

So, the request that has been actioned is a sum of circa £50,000 per health board in order to boost the implementation resource that will be needed for each health board to go live. So, that has been made available to each of the health boards. The central support and the contract and the licensing are all covered through the contract that Cardiff and Vale are hosting, and that has been funded for this year as well by Welsh Government.

So, a number of health boards had received or have employed people on a fixed-term/short-term basis at the outset of the programme, the majority of whom have now left. But those that were employed within the health boards were working to ensure that the infrastructure was of sufficient scale and purpose to be able to take on OpenEyes. So, I don't think that that resource has been wasted.

You're on mute, David. There we go.

Okay, diolch. I believe there were conversations, in terms of how other places had been able to implement, and a conversation had happened with Welsh Government in terms of learning some of the lessons from elsewhere. It was partly that the programme was paused at the time that it was transferred across from Cardiff and Vale to DHCW. But in conversation with DHCW, it was agreed that, actually, as Cardiff and Vale were already live on a couple of services, it would make sense for us to deploy OpenEyes across all our services, particularly as we were using another system that was coming to end of life anyway. We thought, by doing that, there would be lessons learned locally and that people across Wales would be able to see the success that had happened across Cardiff and Vale, and that would be used as a catalyst, if you like, to re-engage, regenerate the enthusiasm to take on OpenEyes in all the other health boards.

Okay?

For now, yes.

Okay. Thank you, David. I'll move on and invite James Evans to ask his question, please.

Diolch, Cadeirydd. Bore da, good morning. I want to talk about health board collaboration, if I may. I'd like to address a lot of my questions to Digital Health and Care Wales. One thing that is an issue we talk about is the structural variances amongst Wales's multiple health boards and the influence of the uniformity and efficiency of digital transformation and innovation in ophthalmology. So, I'm just interested on what sort of seismic reforms could mitigate the disparities that we do see across health boards to ensure there is equitable digital healthcare delivery across Wales, because sometimes we do see some health boards doing things and some health boards not doing things.

If I could answer that—

Yes, thanks, Helen.

Thank you for the question. I think we do see variation. We have a number of systems that are deployed in a once-for-Wales situation, and we've got a myriad of local systems and services. One of the things, I suppose, more globally for Wales, system-wide, is we have, as a top priority, been tasked by Government to develop the national target digital architecture for Wales. That's quite multifaceted. That's about the technology that's needed, it's about the data and the standards to exchange data that are needed, and it's about the kinds of systems that users will interact with.

So, there's some work that we're doing—a lot of work—in that space that sets out, if you like, what that blueprint looks like, and then you'd be able to cut through that. It's clearly quite a big endeavour, but you would look at that from a service perspective as well, and really understand what those capabilities are.

I think the advantage in ophthalmology is that there is consensus that OpenEyes is this system that clinicians want to use to access the eye care patient record, and all that goes with that. So, that’s why, in terms of our recommendation to Government around the strategic way forward, it’s to procure a delivery partner that allows OpenEyes to be used for the long term, in a continuous improvement cycle, which is kind of the modern industry way of doing it, as opposed to what we would have perhaps have seen in traditional IT project implementations previously.

And I believe there is that consensus in health boards. I think David is right—seeing the successful roll-out now in Cardiff goes a long way to alleviating, maybe, some of the concerns around the change and the impact of that change. I think having a single system means you can have—and underpinned by what the data standards need to be, so what are the common standards—the same configuration on the system, if you like, the same way of it working, so that it provides that level of consistency.

The next piece is around e-referrals, isn’t it, as Sam mentioned earlier. So, that’s about the seamless kind of transfer and communication that we need to go between primary and secondary care services. I believe there’s consensus in this space as well, in terms of us needing to move ahead that agenda pretty quickly. And the procurement for that, then, would provide an interface, an underpinning, and, actually, the procurement would ensure that a supplier who came in to provide that service would need to comply with the standards that we have in place, to connect into the digital architecture in Wales. So, it means that services plug in and they connect, and connect on a technical level, if you like, but the important thing is they connect on a clinician to clinician level, so that they’ve got the information they need, and the process for sharing that information.

So, I think eye care is in a—. Moving forward, I think, we’ll—. When we are able to move forward on those procurement activities that we have suggested, we’ll be in a good position in terms of health board engagement.

Okay. Because health boards do have their own autonomy, don’t they, to do what they want, really, in terms of some level of procurement. They’ve had a very good project in Cardiff, but even if Government and the NHS executive say, 'This is a great project, we’d like to see it rolled out everywhere', the individual autonomy of health boards doesn’t allow that to happen, does it, because they could easily turn around and say, 'Oh, I’m sorry, we don’t tend to agree with you, we’re not going to do that.' It’s one frustration I have with the system that we currently have.

So, I’m just interested—. Do you think that, actually, perhaps a more centralised governance model around this sort of element, around ophthalmology, would actually help deliver this a lot quicker rather than, say, not taking away autonomy from health boards—actually bringing it all centralised, and saying, ‘Actually, we’re going to do this and have it standardised across the seven health boards across the country’?

There are two options. I think that is what the proposal is—that, in the interim, we don’t kind of lose any more time on this, and we do Cardiff, and we can support Cardiff in the tactical solution at the moment. And that may well be not for roll-out, it may be sub-specialty, and David’s team are working on the plans with health boards, to know what the art of the possible is to the end of the contract. What we’ve got to be clear of, as we procure a delivery partner, is that it is once for Wales, in terms of that contract for that delivery partner, for one system that is being provided. And there are—.

I suppose the other thing to say—and you may pick this up with colleagues from Government—is that we do now have—and we had the first meeting last week, actually—the new digital data and technology leadership board for NHS Wales. That was chaired by the Minister with the digital health responsibility in her portfolio. And there is a draft once-for-Wales definition, and an acknowledgement that, often, it is appropriate and the best kind of approach to do this in a single instance, in a single system way. Sometimes, actually, there’s got to be room for local innovation, and that’s where the innovation is going to actually grow from the ground up, isn’t it? it’s not going to be something that can be centrally dictated. You need services to kind of evolve, and to have some of that opportunity to take forward innovation. But I think that what we need to do is to find the balance between the two and to be clear on what is core and what should be once and central, and what then is able to be more locally defined. 

James, could I come in on a question there?

Yes, that's fine.

It's just a bit of a practical thing, really, as I like to know that everything is fit for purpose. Is every health board in the right physical place to roll this out? Have they got the capacity, the right people, to do what we have, or is there an imbalance that needs to be addressed? We talk about it holistically, but I'm just conscious from my past experience in organisations that they're in very different places. What's your assumption on that? Perhaps Helen or Sam.

Yes, I'll come in and Sam can follow that up and perhaps David specifically on the tactical roll-out. I think that, in fairness, there is variation in the capacity that is available in health boards. I think particularly at the moment there is quite a heavy order book, if you like, or programme work plan for digital teams to be supporting major programme implementations. So, I think that capacity is a real challenge for the health boards, and investment is a real challenge, given the current financial context as well. So, I think that that is a genuine concern, actually, from health board colleagues and for all of us in terms of that. So, that requires really clear prioritisation and it requires pragmatism and collaborative working, I think, and learning from each other. But it would be remiss of me to say, 'No, everything is fine', because it's not in terms of capacity; there does need to be recognition that there are competing priorities, particularly at the moment. It's a busy field at the moment.

Thanks, Helen. Briefly, Sam, do you want to add to that and I'll go back to James, then?

Yes, of course. So, I was just going to add that where we now have consensus over OpenEyes, for instance, as a piece of technology, that makes it much simpler to roll out nationally. However, it is a specialist piece of software, so making sure that health boards have access to the right people who are able to support it once it's live in their system is really important, and that's obviously where competing pressures come in. So, whilst everyone is signed up to that and they absolutely want this technology because it will help so many people, it's making sure that they have a stable footing on which to—. You wouldn't want to adopt something and then not be able to support it sustainably going forward. So, for me, that's the real bit where we need to make sure that they're set up to succeed. 

Yes. Thanks, both. James. 

Yes, really quickly, do you think that there's a role for the regional partnership boards here, in any way, in helping to deliver regional collaboration as well? I know that there are an awful lot of levels, aren't there—you've got the NHS executive, which are annoyed with the pace of delivery, you've got Welsh Government capacity issues, you've got capacity issues within Digital Health and Care Wales. I'm just interested, do you think that there's a role for the RPBs here as well to try to deliver some of this over a regional footing, just out of interest? Perhaps Helen's views on that.

Yes. I think that, yes, definitely the RPBs would have a role to play in getting some of that consensus and aligning strategically behind digital plans. So, definitely, I think. We're having a conversation today specifically about this one service, a really important service, but that is multiplied x number of times, isn't it, in terms of all of the services that we provide. So, there are some, I think, perhaps, opportunities for them to provide some insight and input into some of that strategic alignment more broadly around health and care services and those capabilities, if you like, that need to be available for us to manage pathways seamlessly across sectors, yes.

I have one final question, Peter, if that's okay. 

Could I bring Emma in on that point, your last point, please? 

Yes, that's fine.

I was just going to assure you that there are eye care collaboratives that are set up within each of the health boards, and that is a partnership collaborative. So, it brings third sector, primary and community care and secondary care together, and that is so that everyone is aware of what is happening and then working together. So, that's the assurance part that's happening. That doesn't report into the RPB at the moment, it reports through more of a planned care route for us, but it does bring that partnership bit that we would get from the RPB that way.

Thanks, Emma. Sorry, James, carry on.

That's fine. My final question is more around—. What we talked about is great, but it's around delivery, isn't it, and actually making sure it is delivered on the ground. Do you think that Digital Health and Care Wales have that sort of authority and resources to spearhead this transformation across—I know that Peter talked a little bit about resources earlier—to actually spearhead this across Wales? Or do you think, actually, that it needs more of an assertive intervention by Welsh Government Ministers to overcome some of the barriers and accelerate the implementation of these models across Wales? Because, as I say, it's all great talking about it, but it's actually about delivery and delivering for patients, isn't it? So I'm just interested: do you think you have the powers to do that, and if not, do you think it's a place for the Minister to come in and step in and actually make a more direct intervention in this space? And I'm done, diolch, Gadeirydd. 

Thank you, James. Who'd like to come in on that? Helen.

Thank you. I think, going back to my previous answer, I suppose, around clarity on the definition of 'once for Wales', if you like, and where it's important that we should be moving as one and whether that is about interoperable systems—systems that can easily connect together and share their data—or whether that's about buying single instances. I think that the work that we're doing on the national architecture will set the blueprint. So, it will give clarity for organisations to buy into, and I know that Welsh Government are also working on the options to develop the case for what does the electronic health record for look like.

So, I think there's some work to do in that space, and I think that if we have clarity through the governance that has now been set up by Government around roles and responsibilities in the system, and we have clarity around what we mean by 'once for Wales'—because I think it means different things to different people—then we will have a mechanism to be able to evidence the decisions that we're making in a very objective way so that we're clear on the opportunities and challenges. Because there are choices in all of this, aren't there, and it's not necessarily one size fits all. But I would be a real proponent, I suppose, of national systems to provide equitable access and availability and experience for citizens and our users across Wales.

Thank you, Helen. I'll move on to our last section, then, and invite John Griffiths in.

I had some questions for Digital Health and Care Wales relating to how we drive change. And first of all, regarding other digital initiatives that are part of the national digital eye care programme, I'd like to know how those are funded and what are the key challenges Digital Health and Care Wales face in making sure that those other initiatives are integrated into digital solutions for ophthalmology. 

Who would like to take that? Helen again, please. Thank you.

If I could just clarify, specifically the wider digital ecosystem you're describing there, John—is it in terms of how the eye care would benefit, if you like, and connecting to that?

Would anybody else like to add anything?

I guess if I pick up that, if that's the meaning of the question—

Yes, it would be useful if you just explained—. Obviously we have OpenEyes, but there are other digital initiatives as part of that national digital eye care programme, so, how does it all fit together and what are the funding issues and broader challenges, really?

If I start with this, and Sam will give a bit more detail. Sam ran through the three elements that were part of the eye care programme. We talked a lot about OpenEyes, which is where the record and all of the information around that, the patient interactions, would sit. Then there's the electronic referrals, and then there's the access for community optometrists into the NHS Wales systems, if you like, and then having that e-mail and user account to connect in.

We've fully rolled out to all optometrists the ability to connect into the NHS Wales system, and that is funded through Welsh Government and now available, so they all have licences and that is being used. In the interim, that means that there is secure e-mail available now between primary and community care in eye care, so all of that is in place.

In terms of e-referrals, there has been some pilot work in Cardiff as part of the eye care programme to move that forward. That is part of the strategic recommendation that we've put forward that would require circa—the procurement would need to work this through, clearly—£2 million additional investment over a seven-year period.

And then, I suppose, other things just to pick up on are clearly the focus now on ensuring that patients have access to their record, have access to interaction with health and care services through the NHS Wales app as the digital front door. So, there are huge opportunities, and we've also got the national data resource where we would expect the data to flow into the national data resource from the eye care system, which means that the opportunities for join-up of that data with other data that we hold actually provides opportunities for innovation and moving those services forward.

So, we do endeavour to ensure that we are strategically aligning all of the programmes of work that we are taking forward in Digital Health and Care Wales to ensure that those opportunities are exploited. Sam will have a bit more detail on where some of those opportunities could be.

There are some brilliant opportunities around this. As Helen mentioned, there are those three elements. The ability for our high-street optometrists to be able to see the record of the eye care that is happening for a patient allows them to make more decisions and to be able to do more work on the high street, thereby really being able to reduce our waiting lists for some of that care. That's really important that those linkages are there between that referral system and OpenEyes. All of the systems we're looking at talk to OpenEyes. We wouldn't buy something that didn't talk to another system; in the most basic of terms, they have to connect, which is part of the bigger picture Helen's talking about of this network of connected systems. It's hugely important as the national architecture.

The other thing that is of real benefit is some work we're doing at the moment on our communications gateway. This is something that actually communicates lots of systems together. It's the bus—for want of a better word—that information can get on and be taken somewhere else. That piece of technology is currently being modernised, and that will allow information that is really critical that comes through in eye care—. Eye care is brilliant for actually identifying other illnesses and other complaints. The Welsh clinical portal is effectively the bible of medical information. Being able to get that information into that system as well, again, gives us a really complete picture of that patient, and things that may present through eye care that could then show something up that is potentially more severe or a different ailment, linking all those things together. A lot of what we do is about connections and about sharing, because that is the way to make sure that we have holistic patient care.

I see a hand raised, Chair.

Sorry, David. Yes, please come on in.

Thank you. Just to add, if I may: in terms of the lessons learned within  Cardiff and Vale, it's clear that it's not just a case of implementing a digital system; there's business and process change as well, so it's treating it as a transformational change and recognising that, and making sure that there's the support there that where clinical process changes as a result of an IT system, we allow adequate time and we provide the resources necessary to enable people to work differently. I think that's where we then begin to see the benefits being realised.

Diolch. Might there be a place for solutions such as telemedicine, artificial intelligence-powered screening, digital triage, perhaps, as part of the broader digital strategy for ophthalmology? 

Definitely, and those opportunities are available, aren't they? But they're only available if we've got the digital systems in place that are supporting that process of treatment and the exchange of that information, as Sam has explained, because you can't have the data that you need for AI unless you've got the digital systems that are capturing that data and supporting the pathway of care. But, absolutely, I think those opportunities around telemedicine and AI really are another impetus as they are here and now, but not unless you've got the systems in place and the services that are using digital technologies to generate the data needed. 

Just to add to that, there's also some fantastic emerging technology around the visualisation for eye care as well. That's something that wasn't within the programme, it wasn't part of the original, because it didn't exist then. Now, it's part of our research, we've identified organisations out there that can produce fantastic eye care images that show the eye over a passage of time. That is going to add so much. If we're able to tap into this technology in Wales, that will give us real opportunities for that research around how do these things develop, how can you stop them early, what are the other symptoms that you might see.

All the time, because we're in this digital world, from back when the programme was initiated things have moved on. Actually, the OpenEyes system has got better, it's several versions down the the road now since when we first started, as I'm sure David can tell you. But there are more systems that are kind of associate systems to give that really holistic view of eye care going forward.

As we know, to lose your sight is huge. You can't imagine a much more—. It's damaging to a family and an individual, losing one's sight, so we know the importance of this. We absolutely do. David and I talk about this a lot, we know the importance of delivering this system, but the world has moved on now, and we have more opportunities in this space, for sure. 

Can I just ask a little bit more about data in ophthalmology and how it's used to track patient outcomes and improve planning? Who's in charge of that, and how is data used to better allocate resources and reduce waiting times? 

I wonder if David wants to come in on that one in terms of his experience in this space. 

Having an electronic patient record has completely transformed the way that our clinicians are able to interact with patients. Just being able to manage the care that's provided by relying on a digital solution where previously it was paper in most cases has really transformed things. But I think we've got a bit further to go, and I think it's when we get the e-referral system in that that will really transform the big challenge around waiting lists and being able to share the information with community optoms who are able to do a lot of the things that currently are referred into hospital. So, there's more to go at here, but there's clearly some lessons learned, and these are things that we want to share, obviously, with DHCW, but with the other health boards in terms of why it's important to implement this EPR and why it's important to get on to this digital eye care journey.

I'll bring Emma in quickly. I'm conscious we're running out of time. Emma, would you like to briefly add to that?

Yes. I was also going to say now that it is implemented in Cardiff, we've been able to go through the list and actually make decisions on who could be managed in primary care, so we can move patients who are on waiting lists into primary care to be seen more timely. Obviously, in future, people won't be sitting on secondary care lists because they'll come through the primary care pathway, and only those with complex care will be seen in the secondary care space. But in the short, now we're going through our list and looking at how we can transfer those, which is making much more timely care in working in partnership, and then they can escalate care easily through the OpenEyes system.

Thank you, Emma. John, do you want to ask a final question?

Yes, perhaps I could ask a final question, Cadeirydd. We know that there's strong support from clinicians in both primary and secondary care for these digital solutions. How could that support be used, do you think, to accelerate the implementation of these digital systems?

David.

Yes, thank you. I think there's recognition from the professional bodies as well as the clinicians themselves that they are very keen to see the OpenEyes implementation happen, particularly in the health boards that I've been talking to recently—CTM, AB and Swansea Bay in particular. I think they are pleased to understand that there is a directive now to ask that health boards implement the EPR, this tactical solution, as quickly as possible. I think health boards themselves will have no difficulty in persuading their clinicians there, because I think that's really where the demand is coming from. It's being able to marry all of that up and have a fairly fast but safe implementation plan so that we can get the EPR into all health boards as quickly as we possibly can.

Thank you, David.

Just following up on that, David, are you suggesting, then, that clinicians need to be persuaded of the case, because, as I said, we understand that there is strong support from clinicians in primary and secondary care?

No, I think it's making sure that the health boards prioritise this as an urgent programme of work, really. I think the clinicians have made the case, and it's making sure that it lands with the right people in each of the health boards. Part of the issue has been resourcing, and the pause that was implemented was quite frustrating to some clinicians, I know that, but now that we've got the green light, I don't think there's going to be any issue. In fact, I know that the clinicians will be clamouring to want to be first to deploy the EPR solution.

Okay. Thank you.

Thank you. Mabon, I'll bring you in. We're just going to stretch over, if you're okay to give us a couple more minutes with just a couple of final questions. Mabon would like to come in on this one, though.

Diolch. I think the expectation that we are working to is that OpenEyes as an EPR will be implemented across all the health boards during this current financial year. What we haven't agreed with individual health boards is whether that will include all specialties by the end of March. So, they're the discussions we need to have with each health board, but the intention is to roll it out during this year, which I know is only 10 months or so now. But that is the plan, certainly, yes.

Okay. Thank you, David. I've got a couple of final questions, so bear with me. We've heard about digitalising eye care in the context of recent cyber attacks on organisations. Do we believe that the system is secure and it wouldn't be disrupted, for instance, if there was a cyber attack in the future? Can you give some assurances around that, perhaps, first?

Shall I answer that?

Please. Yes, please.

I think the current locally hosted solution of OpenEyes sits on the Cardiff and Vale infrastructure. We are doing lots of work in conjunction with DHCW and the cyber resilience units to make sure that our infrastructure is as resilient as possible. It would be remiss of me to give a 100 per cent guarantee given the ever-evolving threats that we face. Nonetheless, we are working with the cyber resilience unit and with the auditors to ensure that our cyber plans are fit for purpose and that we can demonstrate a level of resilience. What we are wanting to do is to move this to a cloud-hosted environment as quickly as possible. That will ensure that there is no local risk and the risk of, then, transfers to a much larger company that will have the necessary accreditations in terms of cyber and information security arrangements.

Thank you for that assurance, David. I've got a final question, and perhaps you can reflect on it. You might be able to give us some feedback now, but we'd welcome anything further in writing if we run out of time. We wouldn't mind having some more information about the e-referral system. It hasn't been delivered yet and I just wondered what else needed to be done to make that deliverable and what sort of time frame would we see that in. Thank you—David, yes, please. And Sam.

There's a current e-referral system available within the existing contract. That has been demonstrated to the Welsh Government. They have also been in conversation with DHCW around looking at the strategic solution, which may be one and the same or may be another. So, I think those conversations are ongoing, but they are being led by DHCW. It's probably Sam who's better to come in on that.

Thanks, David. Sam, would you like to come in, and we'll finish, then, on that?

We did a piece of work, with engagement from the health boards, to actually almost demo a number of these e-referral systems, so they could work out which ones were the most suitable and actually hit the most of the requirements that were needed by the clinicians, because that's obviously the most important part. There is a small list of those. That list and the pricing associated with them is now with the Welsh Government.

Thank you, Sam. That was helpful, just to know where we were with that. Can I thank you all very much for your time this morning, bearing with us and going over and giving us a bit more of your time? I really do appreciate that. There will be a transcript. You will receive a transcript of the meeting for you to have a look over. We're really pleased you found the time to join us and look forward to meeting with you again in the future. So, thank you once again.

Can we now call a break for 10 minutes? And if I could ask colleagues—well, eight minutes, if you could—if you could be back here around 10:45, that would be very much appreciated. Thank you very much.

Good morning everybody, and welcome back to the Health and Social Care Committee this morning, where we're taking evidence on ophthalmology. We're now going to go into evidence session 6 with our health board representatives, and I'm pleased to welcome this morning Carol Shillabeer, chief executive of Betsi Cadwaladr University Health Board; Catherine Wood, director of operations for planned care, Cardiff and Vale University Health Board; Michael Stechman, clinical director for ophthalmology and consultant general surgeon at Cardiff and Vale University Health Board; and Andrew Carruthers, chief operating officer, Hywel Dda University Health Board. Welcome to you all. Thank you for making some time for us this morning. We have a few questions. We'll try and get through them all. If we can't, we'll perhaps have to ask you to respond in writing to some, but we will certainly try.

So, I'll kick off, if I may, and we're looking at current capacity and waits. Given the serious consequences of sight loss, including its contributions to dementia, falls and other health issues, how do health boards prioritise funding for ophthalmology services compared to other specialists? Do you give greater priority to ophthalmology due to the significant consequences of people not getting the treatment they need in the appropriate time? By the way, I'm conscious everybody might have a view on everything here, and if you think your point's been covered enough by somebody, we'll move on so we can get through as many questions as possible. Who would, perhaps, like to kick off with that? Carol.

Bore da, pawb. Good morning, everyone. Thanks very much for the invitation to the committee. Just a couple of opening comments on prioritisation for eye care more generally. The first thing to say about Betsi Cadwaladr is clearly we're in level 5 special measures, and one of the reasons for us being in there is issues in relation to access, and timely access, to healthcare services and particularly planned care. So, we have a major programme in place in relation to improving planned care, and eye care is a key part of that. It is what we've classified as a challenged specialty, and that's because it requires that additionality that you were just alluding to in terms of prioritisation.

We do have a planned care fund that is particularly earmarked by the Welsh Government to deploy in relation to planned care specialties, of which eye care is one, and we've added some additionality into that in terms of the priority of increasing the capacity—so, appointments and interventions for people with eye care conditions. So, it is a priority in our integrated medium term plan, and it's an area that the board itself and the board committee—the performance, finance and information governance committee—keep an oversight on. Hopefully that helps to outline the prioritisation of eye care in north Wales.

Thank you, Carol. Andrew, would you like to come in?

Yes, please, Chair. Bore da. Thank you. I apologise if I've got a slightly red-eyed appearance. My hay fever has kicked in; it's not because I've been too upset before coming on this session. Just to add to what Carol has said, obviously we get the money from Welsh Government to help deliver on some of the referral-to-treatment sub-specialty areas, and that's very welcome and very helpful. Certainly, from a Hywel Dda perspective, that enabled us to achieve the 104-week target at the end of March across ophthalmology, and the 52-week maximum wait for out-patients. So, that was extremely positive. And within our plan for the coming year, we're committing to try and hold that position through the next 12 months.

I think, in terms of prioritisation, an added aspect I wanted to add is we're aware in west Wales that ophthalmology is an area for us as well. Like Carol has identified, it's a challenge service, as much for workforce reasons as anything else. The challenge is not having that resource in being able to deliver the requisite level of capacity, but we have, within our plan this year, in particular, committed as an organisation to invest £1.5 million in our IVT service; that's the intravitreal injection service. In terms of clinical urgency and clinical priority, we're concerned about the challenges we've got there, and we wanted to make sure, through the course of this year, we were able to address that. That will be reflected through the course of the next 12 months in our R1 ophthalmology performance. So, I just wanted to add that, in terms of our local prioritisation.

Thank you, Andrew. Catherine, from the Vale. 

Thank you. Yes, similar to colleagues, really, I think eye care is identified within Cardiff and Vale as absolutely one of our priority areas that we need to address. We categorise our waiting times and urgency as per the Royal College of Ophthalmologists guidelines, and map ourselves very carefully against that. We have made some inroads into reducing waiting times in Cardiff and Vale over the last couple of months, but it remains a real area of focus for us, and we do have a mismatch at present between demand and capacity, which we are working through workforce plans to try and resolve. We're also very grateful for the support from Welsh Government we've had in terms of investments into the services that are helping us to do that.

Thank you, Catherine. Is there anything you want to add, Michael, to Catherine's position?

Yes. Really, just from a clinical point of view, it's worth emphasising that, in Wales, we have a deficit nationally in terms of the number of consultant ophthalmologists per 100,000 of population; it's about 1.8, versus three in other parts of the UK. Particular to Cardiff and Vale, we have issues in that a lot of very complex services have been centralised into this health board, and this has led to challenges around allocation of theatre space. So, we have major trauma, neurosurgery, vascular surgery, and that's all competing for space within our estate to actually undertake eye care surgery as well.

Thank you, Michael. Okay, I'll move on to a question specifically for Andrew. You've already covered some of the work that you are doing and some of your views around targets and things. So, the health board has successfully ensured no patients wait more than a year for an ophthalmology appointment, and that's great. The performance in providing timely care for high-risk patients is one I know you're going to be focusing on, but it's currently only 34.6 per cent. What specific measures are being implemented to improve the timely care of these high-risk patients? And how do you plan to address the significant gap in meeting the clinical prioritisation target? Thank you. Andrew.

Thank you. I think we've got quite a significant variation in waiting time in that particular specialty area across our health board area. So, we've got a longer wait in Carmarthenshire than we have in Ceredigion. We try and manage that as a health board at the moment, and have done for the last 12 months, by always trying to offer the shortest possible waiting time to the next patient on the list in order of clinical priority, so that we're mitigating, as far as we can, the number of patients that are delayed.

Within our integrated medium-term plan for this year that the board approved—or approved for submission, anyway—to Welsh Government at the end of March, we signalled that we would be investing or looking to invest £1.5 million. We're prioritising that towards supporting that IVT service, and, in particular, improving that 35 per cent to the 65 per cent target that's there. And we're confident that, with the investment and the additional capacity that will give us, in terms of nurse injectors, medical support, and therefore additional clinical capacity, we will be able to achieve that target within the next 12 months.

Great. Thank you, Andrew. I wish you well with getting there. Can I move on then to a question to Carol and Betsi Cadwaladr? Performance in providing timely care for high-risk patients, R1, is under half—it's about 45.5 per cent, I think. The health board has the highest demand for ophthalmology out-patient appointments, with some 41,500 patients waiting. I just wondered, given these figures, what specific actions are you taking to improve the timely care of high-risk patients, and how are you addressing the concerns of patients who are worried about the long waiting times and the potential risk to their vision as a result? Because we know that, when somebody has a condition, sometimes there's no way back for them.

Thank you very much for the question. So, there are a couple of component parts to the answer to that. If I start with primary and community services, I think it's probably fair to say that the health board has not made as much progress over the last four or five years as other areas, and so it's something for us to learn from. We have though, over the last two years or so, taken a very proactive approach around 'Teach and treat', which is a new service that we have in north Wales, and that really focuses on the role of community optometry. Community optometry, we want to make sure that we're really utilising the skills and expertise so that the right patients can be seen in the right place, so that care closer to home, which means that patients who then come into the secondary eye care service have shorter waits. So, progressively, we have been shifting those pathways. There is a lot more for us to do and that's absolutely core in our plan.

If I just give you an example of the primary care optometry diagnostic treatment centres, we really think that regular screening, the regular review and assessment, will mean that secondary care clinicians and teams will have more capacity to see those patients they really need to focus on. I was talking with consultant ophthalmologists just the other day, and we were talking about the tracking of patients who are in that R1 category and ensuring that those appointments, from an administrative basis, are not lost. So, whilst we talk about clinical services, we've got to talk as well about the administrative and support services as well.

We have got a position where we do need to be more effective and efficient as a health board. Colleagues, members of the committee, may know that we have a very large geographical area in north Wales, and the services have been geographically provided. Actually, we're moving much more into that regional working, that regional thinking, so that we can move capacity around the system, so that we can better meet the needs of local people. And then we have the harm review and harm reduction process that we have been focusing a lot more on over the last few months and making sure that we're being open and transparent about the level of risk we've got in our services and the progress we are making in reducing that risk. So, I hope that helps; happy to give any more detail.

Thank you, Carol. That was helpful, and we'll be exploring a lot more questions, which might pick up further—. If I could then address my last question to Cardiff and Vale—both Michael and Catherine, as you see fit—Cardiff and Vale health board is seeing 65 per cent of high-risk patients within the clinically recommended time frame. Fair play, that's the highest of all health boards, but your target is actually 95 per cent. Could you explain your strategy for improving care for those at greatest risk? Is it feasible to achieve both these clinical prioritisation targets and waiting-time recovery targets simultaneously? Catherine, do you want to start?

I can start with that, yes. I think we are where we are, really, in terms of the 65 per cent, because we have been quite focused on making sure that we implement the WGOS 4 pathways—so, ensuring that our patients who can be sent out to our colleagues in community optometry are sent out expediently. I think, over the last three months, we've sent out over 1,000 patients to the community, which means that that commensurate shift allows us to free up our secondary care capacity to support the patients that can only be supported in secondary care. I think there is a little bit further we can go to push that service further and send more patients out to community optom.

In parallel with that, we are developing, in secondary care, what we're calling our glaucoma tech clinic. So, that is an investment that the health board has made in their consultant optometrists and healthcare support worker model, to undertake some of the diagnostics and help to expediate care for these patients. We're in the phase of recruitment for that service at the moment. It'll be in a dedicated space at Llandough hospital. The capital and the enabling works for the actual clinic space is all complete. So, once our recruitment is completed, which I anticipate will be within the next two to three months, all being well, that service will go live, which will also support.

In terms of your question around prioritisation of the clinically urgent patients, as well as the backlog, I think we do have to recognise the point Michael made earlier around the workforce that we have in Wales. That's going to be fundamental to balance in the competing demands for eye care, as we move forward. And I think, nationally, we need a strategic workforce plan for Wales that we can draw on—you know, great support from HEIW colleagues—to enable, to make sure, that the workforce that we grow in Wales stays in Wales and is fit to meet both our community demand and also the demand that will still necessarily remain within secondary care in terms of the waiting times. 

Thank you, Catherine. Michael, is there anything you want to add?

Yes. I echo everything that's been said already. I would just add, really, that there's a really important strand of work in terms of regional working that will help with this as well, trying to—as Rhianon Reynolds has said previously, I think, to the committee—unify waiting lists, so that we can spread demand across health boards and work collaboratively, and allow capacity to be used across all health boards in south and north Wales, rather than just working in silos. I think that's a really important part of this effort to try and deliver equitable care to patients in as timely a fashion as possible.

Thank you, Michael. Thank you, all, for those questions. I'll move on to Lesley Griffiths, please.

Good morning, everyone. I want to ask some questions around patient harm incidents. The questions are to all of you, but I've got specific questions for Andrew and Catherine.

I met with the Royal National Institute of Blind People probably about 18 months ago, and they were particularly concerned around underreporting of patient harm, particularly around wet age-related macular degeneration. I was wondering, firstly, if you're all aware of their concerns—because I think they've done some research that was reported on just a couple of months ago as well—whether you follow the Royal College of Ophthalmologists' guidelines in relation to reporting, and how many patient harm incidents you've had relating to ophthalmology services over, let's go for, last year, if that's easier—you know, the calendar year—but whatever figures you can give me. Again, I think RNIB were concerned about the robustness of the data being given. And the reason I've got a specific question for Catherine and Andrew is because I know, Carol, Betsi do report, and I was just wondering why—. Sorry, what's the word I'm trying to think of? You provide the figures for the harm incidents, and I can't see that it's the same with Cardiff and Vale and Hywel Dda. So, that was the question I have for Catherine and Andrew, as to why you don't do it, if indeed you don't, and it's just not that we've seen. So, I don't know if you want to start, Carol.

Yes, I'm happy to start. Just to say that, as, I think, in my previous answer, we're focused on harm and the transparency of that as part of our quality suite. We have been taking a bit of a stock-take review of our harm review processes, and we think we can certainly strengthen them and that transparency. I met—actually, quite a few months ago now—with the Royal College of Ophthalmologists, with the chair of the safety and governance committee, just to explore what tools and techniques that they would support us with, and that work is coming forward in our specific programme.

We look at harm across a number of planned care specialties, but given the emphasis and the clarity with which the RNIB have reported those concerns, they are very clearly life-changing levels of harm. So, that is work that is under way and will continue to develop here.

The important thing as well is that we learn from other organisations, so we try not to operate in a bubble, and I know that our clinical leads in ophthalmology are very well connected into the royal college guidance and practice, bringing that back through. So, hopefully, that helps. As always, happy to follow up on any specific data, et cetera, to the committee.

Sorry, I thought I'd muted myself. I mentioned that you had given your figures for 2024. There were 17 complaints of harm, 96 reported incidents and six claims of clinical negligence. Are those the figures that you have?

They are the figures that we have. What we want to expand upon is that proactive harm review where we have patients who have waited beyond the time period that they should have waited in the scheduling of their appointments. So, I want to increasingly move from the reactive response to the proactive response, and that's the area of development that we've got as part of our work in the health board.

So, we—. You know, we're pretty good at that sort of data, I want us to be more proactive and find those cases rather than wait for them to present to us, if you like, either in the form of complaints or clinical negligence claims.

Okay. Thank you. Shall I go to you, Andrew, next?

Sorry, I think I muted myself as I was being unmuted. So, apologies. Yes, I realise that that was an oversight from our evidence. Just to say, we take, obviously, patient harm really seriously as well, and it is something that we monitor and report on a regular basis. We have a weekly review of our incidents and those that are open within the service. We've had 33 incidents over the course of the last year, of which 16 remain open and nine of those are new incidences that have been reported in the last three months. Within there, there are three cases of moderate or severe harm—two of which have had the duty of candour applied to them, and for one of those cases, we're pleased to say, the treatment seems to be improving the situation and the recovering, so that's positive for that individual. And obviously we're working through, now, further appointments with that.

I think there is a—. I think this is something I've been trying to get us to improve over the course of the last year. I think, when I've had conversations with our local wet age-related macular degeneration society and the RNIB myself around levels of reporting, I think one of the main concerns has always been that our numbers have seemed quite low. So, I think what I'm trying to get us to do is to be, like Carol's just articulated, far more proactive in trying to identify these cases at an earlier point, or potential cases at an earlier point, and hopefully mitigate or prevent them ever becoming or getting to that stage of needing to be—. You know, becoming an issue that needs to be reported, because that feeds into the work that we're all trying to do to manage clinical risk and treat in order of clinical priority and urgency. So, it is something we take seriously. I'd be happy to submit the data we've got on harms as a follow-up to the session if that would be helpful to complete the evidence as well.

So, just two questions: are those figures available publicly? And secondly: you mentioned that you do a weekly review of the incidents—is that just in ophthalmology or is that in other services where you have harm incidents reported?

So, the weekly review—. We specifically review the ophthalmology ones weekly because we're aware of the—. Obviously, because of the enhanced clinical risk. But we do have a regular process of reviewing and monitoring incidents across the organisation as part of our quality and safety governance arrangements, and it's something that we as an executive team and as a board take a very close look at, and it features as part of our internal performance escalation arrangements with my clinical care groups and services.

And are those figures available?

Yes, they're reported. Our incidents are reported—

The 33—and they're available on your website or—[Inaudible.]

Yes, they're available through our public reports, board reporting, committee reporting, and they're available on our website, yes.

Thanks, Andrew. Should I go to Catherine or Michael? Whoever—.

I think you've got to unmute yourselves, haven't you? Here we go. That's it.

Sorry. I'll start and then hand to Michael for a little bit more of the detail. The review and reporting and escalation of harm is an absolute priority for Cardiff and Vale. We did submit, in some of our supporting evidence, some numbers and incidents of harm that we've been working through. All of our harm reviews are reported again through the corporate governance processes up to public board and are available. I think we have recognised there's been an under-reporting of harm within Cardiff and Vale, and have proactively sought to do something about that in terms of employing a dedicated harm-review team. Their sole function is working through these patients, detail and learning, to see what we can do differently in the future.

Similarly, we invited a review of the Royal College of Ophthalmologists to come and look at our AMD services to understand, from their perspective, what we could learn and what we could do better in the future. That report is anticipated shortly. So, I think, not only are we doing very robust retrospective harm reviews, we're looking at what we can—[Inaudible.]—in the future, and I'm sure Michael will talk a bit more about that.

Yes, thank you, Catherine. I think you've covered most of what I wanted to say. Just to add really that, as well as being proactive in the future and looking at patient waiting lists and making sure that they're validated and that patients that we want to see are seen and have appointments, we're also looking to appoint fail-safe officers in our really challenged specialty, so wet AMD, obviously, and glaucoma. We hope that having those individuals in place will actually give us better governance around what is actually really, really a terrible thing for the patients that it happens to.

Thank you all for that. So, a question again for all of you: we've talked about age-related macular degeneration, and if you look at the patient-harm incidents, that probably is the most common condition, along with glaucoma, I think for obvious reasons. But I don't know if you want to say a bit more about other eye conditions and whether they are patient-harm incidents—probably less common, so cataract, for instance, et cetera. But Carol, you referred to making sure that patients are seen in a timely manner. So, again, I don't know if you want to say a bit more about other eye conditions, or what are the most common? But I think the most common are glaucoma and macular degeneration, as I say, for obvious reasons. Do you want to start?

Yes, excellent, thank you. You're absolutely right, those two conditions are the highest by volume. And, of course, for north Wales, we've got a very large population, so for us the volumes are significant. I want to just tie a couple of things together on the response of the other specialties, and that's that, increasingly—and I know we may well come on to health board collaboration and regional working—we've got some smaller sub-specialties within eye care more generally and across the health board, they are separated by geography, and we need to do a lot more pulling of those together. I think Michael referenced that in an earlier response. I know it's the same for south Wales as north Wales, really.

Our harm review process should be an overarching process for the organisation, so that being focused on where there are delays to access to treatment, and that we review the impacts of those delays. On the whole, we know what the issues are where harm has come about, and that's been a capacity constraint to see people. So, if we address the core issue of capacity constraints through being more efficient, productive, changing those pathways, we should see the reduction. I say that because the review process, in and of itself, is a means to the end—it’s not the end. So, it is about, ‘Well, what are we doing about reducing the length of wait for people to have that follow-up review?’ We may well talk about technology and imaging—I think Catherine’s just talked about that, and Michael has just talked about fail-safe officers. They’re the conversations that we’re having as well—what other tools can we bring to bear to reduce the harm, not just measure the harm?

So, all of the specialties are part of harm review, but you’re absolutely right, the bigger volumes are glaucoma, wet AMD, and, in a way, our bigger focus on the change of the pathways sits there, and we’ve got a lot going on on that.

Thank you. Over to you, Andrew. 

Yes, there’s probably—. I’m just thinking, there’s probably not much that I can add to what Carol’s just said. I think it’s the same—. For us, it’s the same position. Obviously, glaucoma and wet AMD are the two areas that are probably the ones I would be most concerned about, and most worried about, and feature most highly in our reporting. But our harm review processes apply across the specialty, to all aspects of the service. But most of the incidents that do get raised relate to delays in either accessing the service to start with, or to treatment, then, once they’re within the service. So, I’m not sure—. I think, apart from that, I’d probably be repeating Carol.

Okay, thank you. I can see Catherine nodding away as well. I don't know if there's anything you all might want to add. 

I’ll just add, really, that we include diabetics, which is another quite high volume, very common disorder in Wales. We include them in the harm review process that we’ve done for wet AMD, and they are obviously filtered with the same urgency as well.

Thank you. Catherine, did you want to add anything?

No, I think it’s all been covered. I guess it’s worth just assuring, though, that the harm review process that we’ve got, as everyone else has said, is focused on the large volumes of AMD and glaucoma. But it is a process that runs across all of the sub-specialties, not only in ophthalmology, but across the organisation.

The report and the research that RNIB did, particularly this year, sort of led us to believe that they were very concerned about it. Have any of you had any discussions directly with RNIB Cymru about it, or any of your staff that you know of? Andrew. 

Yes, certainly, I know that—. I have met with RNIB Cymru in the last year around some of this matter, and discussed some of it, and heard their concerns, and tried to provide them assurance with the steps we were taking to improve our reporting and how we were mitigating harm in these services. I’m also conscious that they are members of our eye care collaboration group locally, which is where we pull together community and secondary care services with patient representatives and colleagues across the system involved in the delivery of eye care services. And they provide an update there to us on a quarterly basis, because it’s a quarterly meeting, so are obviously involved, then, in the conversations we have around the actions we’re taking and the reporting of some of these issues they see first-hand, as well, through that, with us.

So, we have mechanisms to engage with them, and I’ve met personally with members of the wet AMD society in west Wales, for example, and have a commitment to go back to provide them an update this year as well, in terms of the progress we’re making on some of the concerns they raised with me, which centre on the issues we’ve talked about so far, and where the majority of our incidents arise.

Thank you. Catherine. 

I haven’t met with the RNIB personally, as I’ve only been doing this role since February, but, again, the same as Andrew, we’ve got the eye care collaborative group within Cardiff and the Vale that’s got that RNIB representation and patient representatives. And I know that the harm review process has been on the agenda and discussed in that forum.

Thank you. 

Okay, thank you, Lesley. Can I hand over to Mabon, please?

Who would like to kick off with that one? Carol.

Diolch yn fawr. Thanks very much for the question. I'll just give a north Wales perspective. As a health board, we're really keen on digital solutions. You may know from wider work that we are currently procuring and will be implementing a mental health electronic health record, and we are just in the concluding phase of developing our outline business case for the more general acute and community electronic health record.

The commitment from the board is high in terms of digital solutions. The reason for that is that we believe it will add significant benefit to clinicians who provide care, and it will help to streamline, standardise and support care across the region so that patients or clinicians can move across the region to access care, and their care record will be available wherever they go.

In terms of the commitment on that, we have been increasing the amount of funding that we put in to digital provision over the last few years. That is also a very important thing for us to say. Whilst the money is not bottomless—we can be very clear about that, and we could do with lots more money into the digital agenda—we have been increasing that. 

In terms of the specifics of OpenEyes, we did some early work in terms of the preparation. When we think about implementing a digital system, we have to think that it's about 50 per cent about people and how people work, it's 25 per cent about the systems and processes of operating the business pathways and things like that, and then it's 25 per cent the digital solution itself.

We don't just go and buy these things off the shelf and plug them in, I think that's what I'm trying to say. It does take quite a bit of change work. For Betsi Cadwaladr, we have three geographical services, so we need to make sure that we're doing the work to systematise and streamline the pathways in order to then implement the new system.

I was pleased to hear from one of the clinical leads the enthusiasm for the system. We have put in an interim arrangement whilst the OpenEyes issue is being dealt with by DHCW and Cardiff colleagues, and we'll be restarting that active preparation with the intention that, as those issues get resolved, we are ready to take this as soon as we possibly can. We know that it's a big enabler for care across the pathway, so it is a priority for us in our specialty plan for this year. 

Would Andrew, Catherine or Michael want to come in on Mabon's question as well? Michael.

Thank you for the question. It goes without saying that we are absolutely committed to the electronic patient record and OpenEyes roll-out in Cardiff and Vale. This is echoed by the comments in Rhianon Reynolds's national clinical strategy as well—that this is going to be a huge enabler, certainly for regional working and for working within health boards. Just in Cardiff and Vale, I think we've had somewhere around 14,000 to 15,000 new patient entries entered into OpenEyes since January this year. So, we are well and truly on the road to implementation.

Yes, as Carol says, there are lots of things to iron out. You can't just take it out of the box and use it without a lot of optimisation and engagement with clinical staff to make it work for them. So, that's been a process that we've gone through. It predates me managing the service with Cath, but certainly we are absolutely committed to it in Cardiff and Vale. I know that colleagues working in digital in our health board are now rolling it out in the neighbouring health boards, and that's already started, that work. So, it's an exciting time, because I think that it will make a massive difference to patient treatment, and it will help with a lot of the work that's been going on around WGOS 4 for things like glaucoma, because it will allow direct triage of those patients and much more efficient workflows.

Andrew, do you want to give an update on where you are?

Yes, I'm happy to, Chair. I suppose just to add from a Hywel Dda perspective, we're very much committed to the need for an electronic referral pathway and patient record within Hywel Dda. We've recently, in the last six months, established the regional eye care programme board, which is working in partnership with Swansea Bay under our regional joint committee that we've set up towards the second half of the last calendar year. Within that, one of our key deliverables for this year is to progress towards the introduction and implementation of OpenEyes through the course of the next 12 months.

That's certainly an area that we are prioritising within our regional work plan because we recognise it's important that we've got a single system across our regional footprint, given the way our pathways work. I think we're at a point currently where we're just waiting to understand where we are in terms of the national roll-out programme and how we engage with that, and how we then support some of the business change requirements that Carol very well articulated.

Excellent question. Who would like to come in? Michael, please.

That's a really excellent question. In Cardiff and Vale, I think we demonstrated a phenomenal degree of collaborative working when we had the Vanguard theatres here during 2022 to 2024. We treated approximately 4,000 people with cataracts, around 40 per cent of those being Cardiff and Vale patients, and 60 per cent being patients from neighbouring health boards. So, we know that it can be done if we have the right infrastructure in terms of facilities to carry out that work.

Something that we're looking at in terms of cross-health-board working in the near future will be bolstering the vitreoretinal emergency service. We know that quite a lot of patients have to go to England for treatment at weekends. We would much prefer that the money that is spent on that is spent on patients in Wales and us being able to provide a sustainable 24/7 service across south-east and south Wales, and I'm sure north Wales as well, so that we can have the appropriate staffing levels for that, but also attract and train the consultant VR surgeons of the future.

The other example I'd like to give is around paediatrics. It's a matter of some consternation that we only have one full-time paediatric ophthalmologist in Cardiff and Vale for such an important specialty. We very much want to work with colleagues in neighbouring health boards to improve that and share the expertise so that we can provide a more sustainable service.

The final thing in the question was could we do more. Yes, we could, and I think that's laid out in the national clinical strategy, which I've mentioned already. I think the important thing will be that there has to be a proper well-thought-out governance structure, and the money, the resource, will need to, obviously, be able to be accounted for across health boards as well. That's probably all I can say.

It's a good question. I think from a south-west Wales perspective, the principle of regional working across a wide range of services going forward is something that both ourselves in Hywel Dda and our colleagues in Swansea Bay are fully committed to developing across the south-west Wales region.

As I mentioned earlier, we have recently established a regional eye care programme board. We've got a clinical lead for that and a senior responsible officer who's my counterpart in Swansea, and we've identified four priority sub-specialties that we want to focus on within that.

You won't be surprised to hear that's glaucoma, cataracts, medical retina and vitreoretinal services. We'll be establishing sub-specialty working groups to develop regional pathways and regional solutions to some of the service challenges both organisations share in terms of facilities and workforce.

Within that, we've also committed to progress some regional consultant appointments. There are two vacancies that we've currently got in Hywel Dda that we'll be looking to recruit jointly with our colleagues in Swansea Bay so that those posts work completely across the south-west region.

We're looking this year at how we can progress opportunities around regional training and development programmes to help us develop our workforce and retain and attract new colleagues into the region. And I mentioned earlier around the commitment to wanting that single digital system and OpenEyes across both health boards as well.

Our long-term vision—and the work on that will start this year as well in terms of scoping that—is that we would like to develop a fully integrated south-west Wales regional eye care service with joint governance, workforce, a single operational structure. But there's obviously a lot of detail to work through in terms of what that looks like and how that works, I think a little bit as Michael was saying, because I wouldn't underestimate the complexity of asking multiple health boards to work together in terms of those governance arrangements and making that happen.

I can try, Chair. As I say, we've looked at a number of services regionally, and one of the areas we were making greater progress on quicker was around pathology. I think to some extent, the governance arrangement depends very much on what you're trying to achieve. We at that point landed on an organisational delivery network. There are various different ways we can do this, but that was certainly the way our legal teams advised us to set the governance up to take forward pathology, so that you could have that joint management structure, a pooled workforce and budget whilst those services are still being delivered within the individual health boards, but that senior leadership team being accountable to a committee, effectively, of both health boards and organisations that commission the services and held them to account for delivery of those.

I think it'll be interesting as we work through some of the regional service issues and think about governance, the more services you add to that, the more complex that potentially comes in terms of some of the support functions you need as well around finance workforce to enable those to work. So, there are solutions to it, and obviously I think the first point, though, is the commitment of organisations to work together and want to do that and utilise resources in that way. It gets you a significant chunk of the way there; it's just about how you then legally cover that in terms of liability and various other issues in terms of those services. I think there's a way to do it, but as I say, it's quite complex to work through the detail in that space, from experience.

Can I move on and bring Carol in to the first part of your question, as well, then, Mabon?

Diolch yn fawr. Thanks very much. You may wonder why I want to come in on a question that is about health board collaboration, but I know north Wales members of the committee will know the geographical splits that the health board has had, actually for most of its existence, so 15, 16 years. This provides a real challenge for us in delivering sustainable services to the whole of the population, and we were talking about equitable services earlier on. We have to operate more as a single health board. That is really clear. We are a region in our own right, so we're trying to get the right balance between local and then people perhaps needing to travel for some of those more specialist secondary care and specialist-type services, although, of course, the north Wales population have been used to travelling across to the north-west for a whole host of things for decades. We're trying to get all of that balance right and to maximise the benefit of the size that our health board is. It is a large health board, large geographically, a large staff base, et cetera.

We will need to make some changes on workforce and how we take the workforce with us around that more flexible regional working without people being in their cars all day, every day. So, some of our work is focused on the workforce planning, particularly for those smaller sub-specialties that are within the eye care family. You will have seen from our evidence that we're in the process of appointing a regional clinical lead to help us to systematise and standardise some of the work and to develop our regional strategy and strategic plan, moving forward. So, it is as much an issue—. We don't perhaps have quite as much on the financial flows or the wider organisational governance as the other health boards, but we do have some of those other issues that relate to staff and where services can be provided for a population over such a large geographical area. Diolch.

Thank you, Mabon. We're running short of time, so if we could have three succinct answers, that would be great. Carol, can I start with you?

Yes, you can. It would take some persuading, I must be honest, to support a case where you further fragment the care of patients based on a single condition. We know it's a high-volume specialty and it's a high-priority specialty to us, but we are trying to ensure that we see the whole person, and people will have multiple conditions. Michael talked about diabetes earlier, for example—we've got to connect to those services. So, at this stage, it wouldn't be something that I would feel is worth pursuing in any significant way unless a much stronger case was put forward.

Catherine, would you like to—? Yes, come on in, Catherine; you have to unmute yourself, I think. There you go.

Thanks. I hope I've done that. Yes, I think, similar to Carol, we've got to be careful in terms of looking at care just as conditions and forgetting about the whole person in that setting. Clearly, our patients require support from a whole number of services, not just for ophthalmology. There are the diagnostics, some of those patients might need ITU facilities, HDU facilities, all of the things that we could provide onsite at the moment. I think disaggregating those in the way that's being suggested without a lot of careful thought might result in the treating of a condition rather than the treating of a person and all of their holistic needs, which I'm not sure is the direction we would want to head in at this point in time.

Thank you, Catherine. Andrew, any final views on that?

I think I would share some of those reservations, just around seeing the patient as a whole and some of the challenges that might pose. I think there's another question for us as health boards where we're working with multiple health boards, and it's a question I know we've posed ourselves in south-west Wales, which is, when you're working between two organisations, say, and you start putting a number of services into a joint regional single service arrangement, at what point have I, effectively, with my colleague, established a separate delivery organisation or delivery function where we would need to think about how we tied that back into our governance arrangements, which would be quite complex in itself. So, I think I would agree with what others have said.

Thank you, all. Okay, I'm going to move us on to John Griffiths, who would like to talk about facilities and equipment, I believe.

Diolch, Cadeirydd. Yes, we heard from Dr Andy Pyott that there is an urgent need to improve the estate, and Lowri Bartrum from Vision Support highlighted accessibility issues that are causing harm to visually impaired patients. So, we'd be interested to know whether there are any immediate steps you feel you could take or you're about to take to make eye care services more accessible to prevent accidents and ensure safe care.

Who would like to start? Yes, Carol, please.

Thanks very much for the question. I'm sure we could use the whole of the committee time to talk about estates and facilities, for sure. The NHS has got a lot of estate, but it's also got a lot of estate that is not in a good state, and we're no different in north Wales. We've got, as part of our plan for this year, a specific estates review. We have had a number of reviews over the years that have talked about estates as being a component part, but we want to put all of that together to get a more comprehensive estates plan for eye care services in north Wales. So, that's the aim of that, and to actually examine the opportunities for some earlier intervention. And we've just talked, as one example, about modular opportunities, et cetera. For those who know north Wales well, they'll know that Abergele is a site on which we provide eye care. I have had a walk around Abergele; it's a wonderful site, a lovely place, but the building itself is in a very poor state. It has actually got a very nice eye unit provided there; it's just that the rest of the provision that is associated to that eye unit needs a lot of work.

So, we want to be very clear about where we should put the very limited capital investment that does come our way. I think there is opportunity linking estate with the clinical services plan. We're working on a clinical services plan currently, and the eye care service will be part of that, and I'm really pleased that our new director of environment and estate has started here about six or eight weeks or so ago; he's going to be very busy indeed. We know that it's a big risk to the delivery of safe and effective care, and it's therefore on our organisational risk register as well as receiving a particular priority in our integrated medium-term plan.

Thank you, Carol. Catherine.

Thank you. Can you hear me?

Yes. Yes, you're live.

Okay, great. I didn't know if I was live or not. I think there are a couple of things that we've got in progress. I guess the question is in two parts for me, really, in terms of how we can improve accessibility for our patients within the estate that we've got. So, we're working very closely with the clinical implementation network at the moment in terms of reviewing all of our patient literature and accessibility from that perspective to make sure that it's as accessible to our patient population as it possibly can be, and also looking at accessibility parameters for the physical footprint that we've got, for which we are awaiting advice from the clinical implementation networks so that we can look to implement things that will make our estate as accessible as possible.

But I think it would be remiss of me not to reference the fact that our estate, as it currently stands, is not fit for purpose for delivery of modern eye care services. And I think it does require significant investment in terms of our theatres and out-patient facilities in order to right-size that in terms of the actual footprint and the accessibility from a patient experience perspective that we've got, and that's a point I don't think I can emphasise strongly enough to this committee, in terms of the impact that our infrastructure has on our ability to deliver our services in the way we would like to.

Thank you, Catherine. Andrew, do you want to add?

Yes. From a west Wales perspective, like colleagues have shared, we have many estates challenges and facilities challenges here as well. Certainly, I wouldn't describe our facilities as being fit for purpose for a modern-day ophthalmology service. We, obviously, a bit like Carol, have had a clinical service plan programme running for the last 18 months, and one of our additional challenges is the number of sites that we provide these services from across our geography. We believe that if we can consolidate onto slightly fewer sites, which means we're not stretching our resources thinly generally in terms of workforce, and also then the number of sites that we would need to bring up to standard, that would give us a far better opportunity over the next two to four years to really make inroads into improving the environments and facilities in which we're providing these services from.

Thank you, Andrew. Would you like to go on and have another question, John?

Yes, I wonder if any of you have plans to invest in modern, purpose-built facilities designed specifically for eye care in your area? Is that in the offing, or are you some way away from that?

Andrew, would you like to go first? We're running out of time, but we'll give you all a bash at it.

Certainly, I think, as I say, from a west Wales perspective, a lot of our estates and facilities are a challenge. We would certainly love to be in a position whereby we could invest in new facilities that are fit for purpose across a range of services, not just eye care. So, our process for that within eye care would be: we've got the clinical service plan, we'll be out to consultation over the summer, there'll be a decision taken by the board, and then we'll start looking through, with specific reference to eye care, what we might need to do in the capital new facility space to support the development of services within Hywel Dda. But, also, there'll be a regional lens on that as well, because we'll need to look at where Swansea are and what opportunities there are for us to collaborate in that regional service space as well, and that might throw up opportunities.

Catherine, and then I'll come to Carol.

Thank you. I think I spoke earlier about the development of our glaucoma tech clinic, which I think is a step in the right direction. As a health board, we're in the process of actively working up plans to progress a dual theatre cataract development, which I think, if we can do that, would be of significant benefit to our patients. We've proven that we can deliver on a regional basis—we've got that blueprint and proof of concept from the comments that Michael made earlier with regard to Vanguard. I would just urge that we recognise in Wales there's limited capital available to fund such cases, but I think the dual cataract theatres that we are seeking to employ in Cardiff over the next couple of years will be really fundamental to how we deliver and develop, moving forward.

Thank you, Catherine. Carol, I'll let you have the final word.

Thank you. We don't have a plan at the moment, but it is a very attractive idea to have a dedicated eye care facility for north Wales. Of course, the geography is a challenge as to what would go on there and how people would feel about that. But that formation of any sort of commitment or plan would need to fall out of the clinical services plan—what are we going to provide, and where are we going to provide it? Ideally, we want as much care close to the individual's home as possible—so, making sure we're maximising the use of primary community facilities, as well as perhaps the more secondary and specialist. But it is one of the things that I'd be very keen to be discussing with the clinical community here in north Wales. We are in the middle of developing a planned care hub in Llandudno, and that's separate from district general hospital. So, we'll be learning a lot of lessons through the development and implementation of different services there as well. Thanks.

Thank you, Carol. I'm afraid we won't be able to fit in any more questions. I thank you so much for your contributions this morning. We have still quite a lot of questions. We'll prioritise those and, if you don't mind, if we could write to you and if you could, perhaps, turn that around as quickly as you possibly could, that would be very helpful for us. There will be a transcript available for you of today's meeting that will be sent to you, so that you can check it over as well. We all appreciate your time today for such an important evidence session, and we wish you well in all you're trying to do to improve things around this area. So, thank you.

Diolch yn fawr. 

Thank you.

Diolch yn fawr. Thank you for the invitation. 

Thank you for the invitation. Thank you.

I'm going to leave now, Peter, if that's okay. 

Thank you, Lesley.

See you later. 

Okay, we'll move through to papers to note, item 4. You'll see in the pack, Members, there's quite a lot of papers. Are you content to note those letters or are there any issues you want to bring to the fore at the moment? Happy to note. Okay, thank you very much. 

If that's the case, we need to—. I propose in accordance with Standing Order 17.42 that the committee resolves to exclude the public from the remainder of today's meeting. Are Members content to do so? Thank you.