Health and Social Care Committee

Good morning, everyone. I'm Helen Baker. I'm the director of secondary care at HEIW.

Anton.

Good morning, everybody. Bore da. My name is Anton Saayman. I'm the interim postgraduate medical dean at HEIW.

Bore da, bawb. My name is Nik Sheen. I'm the head of optometry in HEIW.

Well, thank you so much for joining us, and welcome. We have a few questions, as you're aware, for you, because, as I've said, this is a very interesting area and there are lots of different facets of it that we're trying to understand and get to grips with. The workforce is a big issue. So, I'll start, if I may, with a couple of questions around general workforce planning, if that's okay. So, in 2022, Audit Wales highlighted workforce gaps in ophthalmology. I just wondered: has HEIW conducted a subsequent review of the ophthalmology workforce, and, if so, what improvements have been made in that time? I'm not sure who'd like to start.

Do you mean the ophthalmology and the eye workforce in terms of eye care, or the ophthalmology in terms of the medical piece?

Well, I think it'd be useful to get, perhaps, a perspective on the both then, if I could.

Okay. From a medical perspective, HEIW has information around the medical workforce from a variety of sources. We would usually get workforce information from external sources, for example, reviews from colleges or the Getting It Right First Time programme or things like that. We'd have our priorities that we get set, often from Welsh Government and others. We'll have feedback from the specialities and associated professions themselves, and we'll have feedback on workforce requirements from health boards, trusts, et cetera. Through a combination of the information that we gather over time, we would then, from a medical point of view, look at what we are going to do for training for the future, usually aligned to both our own education and training plan and integrated medium-term plan going forward. There are a lot of different factors involved in planning for training for the future, and we will probably talk about some of those later. Nik will be good to talk about planning for optometry and the other professions.

Thank you. Would you like to come in, Nik?

Yes, certainly. So, in terms of optometry, it's fair to say that it's an evolving picture due to the changes that are happening with the new eye care contract for optometry. We did put forward a strategic workforce plan a couple of years ago, and we've largely met the objectives that we put forward there. But what we are doing at the moment is we're in the process of gathering the evidence from the new contract. So, in terms of workforce, we've just started in March, for example, asking every single optometry practice to put forward their workforce on a monthly basis, and that data is collected from the shared services partnership. They're a couple of weeks away from finishing their data cleanse, so that they can send us information there. Recently, health boards have done an eye health needs assessment, which identifies their population's needs. So, what we are in the process of doing is waiting for evidence, gathering that evidence, so that we can then do a gap analysis, understanding what we need to do in the future to meet our workforce needs and our patient requirements for the services that we have in Wales.

In terms of what evidence we have currently and what we utilise, we've done various surveys, we've contacted practices and we have data from the service that's currently operating—a little bit of it. So, we use that as well, and have used that to look at what the current situation is. So, giving you some examples, we have contacted practices to find out waiting lists for routine appointments and then looked at those, but, as I said at the start, it's an evolving picture, because at the moment we are literally a couple of weeks away from getting our first look at the shape of the workforce, exactly what our full-time equivalents are in practice, exactly where everybody is with what qualifications. We do know a little bit already, but that will give us our first kind of full mapping.

So, in a couple of weeks’ time, you'll be in a better position to put a strategy together, you'll identify the gaps and what you might need to do to start filling some of those positions. Am I—?

Yes. We already plan in terms of the way that we commission higher qualifications for different regions of Wales. We look at population statistics to do that, we liaise with health boards on their needs. So, we already do quite a lot, but, in terms of getting the most robust data, we are in the process of having that first iteration of the workforce shape, if you like.

Okay, great. Anything you want to add, Helen?

No, not at this time.

Okay. I'll move on, then, a little. Could you give us a flavour of perhaps what the main challenge is that you're facing in ensuring a well-trained and adequately resourced ophthalmology workforce, to achieve that workforce? What sorts of things are you facing? And do you think HEIW has struck the right balance between investing in the training of existing staff and recruiting new staff?

Let me start with training in ophthalmology. Medical ophthalmology, I think, is where I'll start. As a medical deanery, what we do is we recruit to training programmes and we are then responsible for quality managing those training programmes so that the residents who are in those programmes can get all the experience that they require to come out the end of that programme—which in ophthalmology is long, and also has many, many special interest areas—to come out the other end of that programme, to get a certificate of completion of training, so that they can—what we hope—look after the eye needs of the people of Wales. So, to do that, we need people to apply to ophthalmology training, and to do that you want people to have experience of ophthalmology from medical school, maybe through the foundation years, which we can touch on later, and then we have to recruit them.

There are two elements, really, I think, to getting folks or residents into post. The first is the training environment and its capacity, in other words, how much capacity have we to train, because we need very high quality training—especially; not ‘especially’—in all medical specialties, but we want to make sure that the quality of training and the experience that those residents are going to have in that training programme are really great, because if that's the case they're more likely to stay with us in the future. So, we have to look at the environment that they're training in and make sure that they can get what they need.

The second thing is we, of course, need to have the posts available to train, and, to have the posts available to train in, we would usually put an ask in our annual education and training plan for posts for the future. That would depend on priorities. There are probably more than 50 specialties that we put into our education and training plan. Ophthalmology is a high-priority area. So, that's what we do. So, we would place residents into training posts, and then we will ensure that the quality of the training that they receive through those posts is excellent.

And then, of course, at the end of that there has to be a post available for them. It gets a little—. And Helen is more experienced in the numbers than me. But, of course, there are 12 specialist interest areas in ophthalmology and, quite often, residents would like to get some more experience in a specific area, which sometimes will necessitate them moving somewhere else to go and get that, or wanting to get more experience. It's a complicated training pathway. We have some excellent training in Wales. There will be challenges around the capacity and also the number that we can put in. But, at the moment, we have 36 or 35—

Thirty five.

—residents within the training programme.

Helen, do you want to add to that?

Yes. I was just going to build on your question regarding how we support the trainees that we've got within the infrastructure, and how we provide that high-quality training. So, there are a number of things that we've done of late. First of all, HEIW has created a specialty training school for ophthalmology. Our training is currently split, or was historically split, across 10 specialty schools, but, as of 1 April this year, we created a new school in ophthalmology to give that focus to that specialty. It previously sat within the school of surgery, but we recognise there are some unique aspects within ophthalmology that do need that due care and attention.

So, we've appointed a head of school for ophthalmology who will lead on a number of pieces of work for us going forward, one of which is to look at some of the key aspects and challenges around workforce, education and training capacity, to make sure that we are getting the most out of the infrastructure and the facilities and the capacity that is available, but also then what steps we can take going forward to maximise on that capacity. So, he has just started in that role.

In regard to the current trainees that are in the training programme, very recently they have benefitted from the investment that has been made from Welsh Government in Cardiff University in the simulation facilities, and HEIW provides funding to Cardiff University to ensure that our trainees can attend those simulation facilities on a weekly basis for them to undertake their regional teaching et cetera. So, this will provide them with the access to the high-quality technical facilities, equipment et cetera, but also provide them an opportunity to meet collegiately as a team of individuals for their education and training.

And then also, from a post certificate of completion of training perspective, HEIW does not have a remit. Once we've trained individuals to become consultants, that's where our remit ceases and then it is up to the health boards to take on these individuals as consultants. But we have now developed a CCT dashboard, where we share information with health boards around numbers of individuals that are due to CCT over the coming years, so that they can build this into their planning going forward and ensure that they can then advertise and attract consultants to those positions and, hopefully, recruit and retain our own trainees in future consultant posts.

Thank you, Helen. Can I bring Lesley in?

Thank you. Anton, you mentioned there were 50 specialties, and ophthalmology is a high priority for you. How—and you might not be able to answer this—but how easy is it to attract people to ophthalmology? I would imagine, if you've got your mind set on cardiology, it's very difficult to persuade people, but how much of a—? It's not a priority for the residents, I'm guessing, but how easy is it to fill your training places?

So, the number of training places that we have just now, I think are all full. He said, looking at Helen—.

Yes.

So, we have filled our programme up until now. I really can't say much more than that, except that we're full now. But what we do want to do is we do want to give young residents the opportunity to experience ophthalmology earlier in their career, because it's something that they may not necessarily meet in the foundation programme et cetera. So, we are working on plans to put exposure to, for example, ophthalmology practice into the foundation programme in a sort of what I can describe as a taster way, into the longitudinal integrated foundation training type plan. But, at the moment, to answer your question, we can fill the posts that we have. We have not explored how far you can go until you cannot fill any more.

So, we heard how you are increasing some capacity, with a new person going to be helping and things, and you've filled all of the capacity you've got at the moment. If you had more capacity, would there be enough people wanting to train? I'm just thinking, if we've got a shortage in ophthalmologists, which we have, is there a capacity issue stopping us filling that gap? Have we got the people wanting and ready to come on?

So, recruitment into ophthalmology, the same as a vast number of specialties, is undertaken at a UK level. So, from a UK perspective, then, looking at the 2024 intake, there was a 14:1 ratio of applicants to post—so, sufficient applicants in the applicant pool. In terms of expanding the training programme and capacity to train, I think our key limiting factor here is around educational supervision. So, we need educational supervision in order for us to be able to expand our training post numbers. At the moment, that is a challenge for us, and then, as soon as we have that resolved, we then do need additional funding from Welsh Government to fund those posts. But our first stumbling block is the training capacity around the supervisors for those individuals.

That's really clear. Thank you for that. That's what we needed to get into, that bit. I'll move on to my last question before I bring Lesley in. So, looking at specific sub-specialties—there are 12 you said, I think, areas within ophthalmology—I just wondered which of these areas are facing the most severe workforce shortages. Are you aware of where the shortages might be? Would that come through some of the feedback you're going to be having from health boards, I suppose, in a couple of weeks' time? I just wondered if you have identified those areas that are weak. Are you putting in certain strategies to address those shortfalls, or is that something you can't really do?

I guess, from my perspective—. You alluded to the workforce data we're going to get through; that will just look at optometry, so not ophthalmology. In terms of health boards, ophthalmology is a fairly small strategy, so I think we are quite aware where health boards have more ophthalmologists and where the gaps are. Helen, Anton, is that fair to say?

So, I think, for us, we train our ophthalmology trainees in all of the sub-specialities—all of the special interest areas—or they have exposure to all of the sub-speciality areas. But I don't think we would train to specific special interest areas, in other words, into sub-speciality areas. That's something that the residents would choose to go and do, and, of course, they would choose to go and do it where there is the need to go and do it and a post, and somewhere where they want to be, I think. So, I think that's the way to look at that. And that's why it's really important that training programmes, training environments, training infrastructure, and the rest of the infrastructure, are really good, so that our residents have a good experience in the places where they're going and want to stay there.

Thank you for that. I'll move on to Lesley.

Thanks very much. It's interesting to hear you saying about the 14:1 ratio of applications, and also you fill—. So, obviously, you always fill your places. Because the Royal College of Ophthalmologists recommend three consultant ophthalmologists per 100,000 people, and we've been told that that's not the case, and particularly in north Wales and in south-west Wales, and the pilot report referred to that. So, the fact that you're at full capacity, but we're still not training enough consultants, how are you going to make sure that we do have enough ophthalmologists?

So, we train the residents to have a good experience. There are, as you've pointed out rightly, shortages of consultant staff, I think, and I'm looking at Helen: west Wales and some, a bit, in north Wales. What happened—. Of course, we train our residents, but what happens when they finish their CCT is they may apply for a post in the place where they are, because they enjoy being there and want to work there, but they may have to go, for their purposes, somewhere else, to gain some further experience, for example, in a sub-speciality area, and some of those folks—and I think Helen has numbers—will then come back after they've done that. But some people may choose to go and work elsewhere because of the opportunity, or because there's not a local post available at the time that they need it. That's the way I would interpret it. I think you may have a couple of examples, Helen.

Yes. So, we've been tracking and monitoring our trainees when they CCT, to find out actually where they are immediately after CCT. I think it's important to point out that those trainees that we have been tracking are on, or were on, the old training curriculum. The old training curriculum provided very much a generalist training, and then trainees would undertake what is referred to as a post-CCT fellowship, where they would then go and undertake that specialist interest area that they're interested in looking at.

So, the data that we do have clearly does show that, immediately after CCT or within that first 12 months, we do not retain our trainees in Wales. Our intelligence and our discussions with our programme directors and colleagues on the ground have been very much that these individuals are going away to undertake their post-CCT fellowships and that they will be coming back in due course, when those fellowships end. We continue to monitor that and track that and see where they are, two, three years down the line, and, yes, we are starting to see that some of those numbers are trickling back. But I think it's important, going forward, that we need to think about how we can, or how Wales can, retain those CCT holders post CCT, without the need for them to go out to undertake fellowships.

The new curriculum does bring in more of that specialty interest element during your training, to prevent, to some extent, the need for those post-CCT fellowships. But, I think, knowing medicine training as I do, it will take quite a while for that to settle and bed in, and for that to become common practice. That well-established post-CCT route will probably remain for quite a while until the new model comes into force.

I think you mentioned earlier that there were 35 places this year.

So, we have 35 places in total on our training programme.

Yes. Anton, you mentioned the annual education and training plan. How much flexibility do you have to change that year on year?

Every year, there's a little bit of a shift in priorities, and that is completely understandable. So, every year, we can adjust the request for additional posts into the education and training plan. That would be dependent on funding being available to fund those new posts, but also, importantly, that we have—Helen calls it 'supervision', and I call it 'educational infrastructure'—the educational infrastructure available to accommodate any expansion in training, and sometimes that takes a while to set up and sometimes you need the supervisory staff before you can put the new training posts in. So, there are two elements to this. We could invest in new posts if we think we could fill them, if we have the funding for those posts and, importantly, if the educational infrastructure, including training capacity and trainers, is available to support those trainees because we want to keep them in the programme once they're there.

So, it's probably helpful just to clarify. So, our training programme, as I said, is made up of 35 training posts. Those are posts located across health boards in Wales and our resident doctors are currently occupying those posts. So, that is largely a sort of static number, in that that doesn't tend to change because they are responsible for supporting the delivery of service. So, those numbers tend not to change. What we then do, through our education and training plan, is put in requests to Welsh Government for additional numbers above and beyond our baseline establishment.

I mentioned that we'd picked up in the pilot report about the shortage in south-west Wales and north Wales particularly. So, I represent Wrexham and I personally don't think there are any issues with recruitment and retaining in Wrexham. Do you think the further west you go—? Because I think that's probably the case in a lot of specialties: the further west you go, the harder it is to attract consultants to those areas. Do you think the Welsh language is an issue? Particularly in north-west Wales, probably more than south-west Wales, do you think that the Welsh language is an issue there?

Do you want to go or shall I?

I don't think that the Welsh language is an issue myself. I think what is an issue—and we know this—is distance from the M4 corridor. And you can map, the further you go down the M4, how it becomes more tricky to attract people unless they had a really good experience; and if they've had a really good experience, they often want to go back.

And would you say it's the same on the A5 in north Wales?

As an extrapolation, I would think so.

Yes.

Helen probably has more data than me.

Yes, I would agree. It's a picture we see across all of our training programmes: the more rural areas are more difficult for us to fill. We do recognise that, from a training perspective, we currently don't place trainees in Hywel Dda, and that is something that our current head of school is looking at in order to ensure that that training environment and the infrastructure within Hywel Dda will meet both our requirements from a training programme, but also the requirements of the regulator, i.e. the General Medical Council. So, he is currently looking at that with a view to expanding our training programme into that area. That isn't unusual, as there are a number of training programmes that don't have placements in Hywel Dda.

It might be interesting, Chair, to ask Hywel Dda how, then, they attract—

Absolutely.

—consultant ophthalmologists there if there's no training provided there.

Yes, that's exactly right. Yes, good point.

Do you find that there are—? I suppose, going back to retention, do you find, particularly with consultants—I suppose it could go down to junior doctors as well—that there is burn-out and that it's hard to retain in ophthalmology because of the—? You know, there's a huge demand on the services.

Can I start?

Yes.

I think that service—. When we look at surveys, and if we look at surveys for trainees and trainers—. We have a large number of trainers in Wales and we get a really good percentage feedback; we have a very high response rate for trainee surveys and I think we have the highest trainer survey response rate in the UK at the moment. When we look at those surveys from those folks, that issue of rates of burn-out or risk of burn-out is increasing, and it's increasing more, the way I interpret it, in consultants who are trainers, although they really enjoy it. So, they really enjoy the role, but they are at risk—exaggerated risk—of burn-out, maybe not because of the role, but because maybe the conflict between service and training. And this is something that I think is acute in ophthalmology, a high-pressure area, as well as in other specialities.

Yes. There's always been—. I've done this role for many years, and there's always been a tension between service delivery and training. There has always been that challenge. But what we are seeing and what we have seen is that those specialities where there are acute clinical pressures, and particularly pressures where there are higher waiting lists, then that tension is worse than in other areas. So, it does bring additional challenges.

How do you attract more trainers, then? Because clearly we're going to need more trainers to fulfil demand.

There are different ways of attracting more trainers. Most of our trainers are in a consultant or a general practice space. They don't have to be; we can have trainers that are of the SAS-grade doctors, and we encourage SAS doctors to become trainers when they have the qualifications, ability and experience to do so. So, the first starting position is having a specialist in post to be that trainer. The second thing then is for them to have an interest in developing resident doctors, and I think we're quite fortunate that many people do have a real interest in supporting our young doctors, so that's great. They then have to have the time built into their job plan to deliver that training. This is a challenge across the United Kingdom, and it's not limited to Wales: time is a pressure for everybody.

Is there enough flexibility within the consultant contract to allow that?

Yes. I think there is supporting professional activities time built into the Wales consultant contract, and that time can be used for training. It would have to be protected for training. And then, of course, there are other implications in training, for example, in clinics, where there might be a little bit more time needed to do something, and the supervision required for doing procedures and learning to do those safely over time.

Thank you.

Are you doing the next section?

That sort of encompassed it.

Yes, okay.

Thank you.

Right. So, I think you're going to go on—. Aren't you going to go on—? Oh, is it John? Right. Sorry. Yes, non-medical workforce. Sorry, Lesley. John, please.

Yes. I'd like to ask some questions on the non-medical workforce. Dr Pyott stressed the importance of units, saying that units would be best equipped to be efficient if they had dedicated nursing teams. He stressed that very strongly. Have you considered how you, HEIW, could support health boards to improve their team structures in that way? Or would you not agree with him?

We're not the nursing director of HEIW, but I can give you a little bit of oversight. I would agree that there doesn't seem to be a great—. It's really key to get the nurses operating efficiently for an ophthalmology unit to work efficiently. I think there are pockets of education and training available, but I don't think it necessarily works; there isn't the kind of whole-system approach to that. We, as HEIW, commission nursing training in ophthalmology, and they can access that. There isn't always awareness that they can. And certainly, in the past, the nursing director has been looking at how we support that, and we have developed a lot of modules that link with ophthalmology to give them additional skills like theatre skills, like intravitreal injection skills, and that training is offered to nurses. I think it's very much a parallel that, often, the difficulty is there aren't the trainers on the ground in nursing, and I think that's possibly one area where there is a struggle to find enough nursing accreditors, for example, for Agored modules and things like that. In ophthalmology nursing, my understanding is it can be quite transient, so often nurses move through. But I'm not on the ground in that and, as an optometrist, I wouldn't want to speak out of turn for them.

No. Okay, is there anything either of you, Helen or Anton, would add to that?

No.

No. Okay. Could you tell the committee, then, about the strategies that are in place to better integrate these non-medical professionals—the ophthalmology nurses, orthoptists and technicians—into the ophthalmology services, and how you're ensuring that they're effectively utilised where there are workforce shortages?

Again, tricky to answer that one. Certainly, there are plenty of initiatives in health boards where they do use orthoptists and others to see patients, and they tend to happen at that local level, absolutely. There are examples in Swansea where they've used orthoptists.

In terms of the non-medical workforce that I'm involved with in optometry, it's definitely an opportunity for more optometrists in hospital ophthalmology units as well. We've been working to try to—and we have, indeed—put together a better career structure and banding in optometry for those working in the NHS directly, in ophthalmology hospitals. I think there is that opportunity to expand that, and we've seen that in some health boards, like Aneurin Bevan, where the workforce in ophthalmology has increased the number of optometrists that can fulfil roles in seeing patients in those hospitals. So, there are pockets of really good initiatives, and the health boards have taken it on themselves to employ optometrists to help with their out-patient clinics.

Okay. Thank you very much. Nothing either of you would—? No.

In terms of technological change and advancement, which sometimes proceeds at a quite incredible pace really, doesn't it—things like artificial intelligence and telemedicine and the OpenEyes system—are you confident that the ophthalmology workforce is being properly prepared for those sorts of developments?

As you rightly point out, technology is really advancing rapidly. In terms of the training for our residents, I think I'm assured, with the simulation equipment that they have and the simulation experience that they're getting, that they will have access to what is required at the moment for their curriculum and for their training. HEIW, as an organisation, is very mindful of the rapid advances in AI, robotics, genetics, et cetera, et cetera. I know that, within the digital directorate, we have an artificial intelligence lead, clinical lead, at the moment, and it is something that is discussed and considered in lots and lots of internal meetings. So, as you've quite rightly pointed out, keeping up with the developments in AI is literally a daily thing. But in terms of the training required today to deliver a curriculum for our residents, to be able to deliver what they need, that we are able to do at the moment. We will have to keep pace with technological advances, and I know that's noted in a lot of reports and feedback to the Welsh Government.

We do have digital online modules that are accessible to all healthcare staff, which has had a lot of work put in from HEIW. This committee, I know, has heard previously about the challenges for optometrists wanting to take the workload off ophthalmology and manage patients out in high-street practices, and, really, one of the key developments there is having the electronic patient referrals, electronic patient records. As I said, I know this committee’s heard about that, but that is clearly one of the barriers, because if you’re in practice and you want to see what happened to the patient last time they were in ophthalmology clinics, it’s crucial for ongoing care that you can understand what they've already had, the medications et cetera. So, that is a real wish for our profession.

I know there have been advances, and I know the OpenEyes system is used in some health boards, but not necessarily all. So, it would be good to have that consistency and continuity, both in terms of electronic records as well as electronic patient referrals.

Given, as we've discussed, the pace of technological change, does that pose any particular issues for continuous professional development, and how that’s structured and ensured? Or is that technological change part of the general continuous professional development picture?

We’re certainly mindful in practices. With the advances of AI, already you can obtain some AI that works with the equipment that you have in practice, for optical coherence tomography units, and so on. And we’ve actually got a clinical fellow this year looking at AI advances to see how it might impact on optometry, in terms of things like triaging, in terms of interpreting algorithms that happen on the machines that they’re using, and what that means. So, it’s something that we’re very mindful of, creating also the CPD to inform, so that they understand what skills they need to interpret the machines, as well as how it may be used in future—definitely, yes.

Thank you.

And from an ophthalmology perspective, the Royal College of Ophthalmologists will continually monitor the pace of change in this area, and look to change or make modifications to the training curriculum that they approve and then provide to the General Medical Council for approval, which is then the basis upon which all of our training programmes are delivered. Our head of school and training programme directors will attend those meetings at colleges. So, they will be part of those UK discussions, and will have early eyes on some of the information, the intelligence that is coming out of that, and potential changes, so they can then feed that back to HEIW, and we can start to prepare for any changes that may be coming as a result of that.

I am hopeful that some of the residents that are coming into training now are growing up with these technologies, and may be far ahead of where Helen and I and Nik are at the moment. But, as Helen has pointed out, we have to make sure that our residents can attain their curricular requirements, and the colleges who set those curricula will be extremely mindful of the new developments, and we’re a part of that conversation continuously. And our colleagues, for example, in the digital team within Health Education and Improvement Wales and Digital Health and Care Wales will also have eyes on the technological developments, which are, as you’ve pointed out, rapid and frequent.

Okay. Thanks very much. On optometry then, which we’ve already discussed to quite a significant extent, how are you ensuring the integration of optometry into secondary care and supporting the advancement of qualifications for optometrists? Is that a positive picture?

Yes, certainly it’s been our whole reason for trying to, basically, prevent referrals going into ophthalmology, as well as monitor more patients in high-street optometry practices so that you keep them out as well as moving patients into primary care. I'm sure you've heard a bit about that before. In terms of our work in HEIW, we're absolutely aligned to supporting the services to make sure that that monitoring in practice and keeping patients out of secondary care is happening. So, we do commission higher qualifications in education and training for optometrists, and we have done a lot of those over the years, and we work with health boards to make sure they're apportioned out to the right optometrists in their regions so that there aren't service gaps.

We have had some challenges in the past where some of the qualifications have placements associated with them. So, things like independent prescribing will have—. You have to do a number of placements and those traditionally have been in ophthalmology, and, as Anton and Helen have already alluded to, there are challenges in trying to get enough education time for their own workforce, let alone optometrists. So, we've worked hard for an initiative to actually have independent prescribing trainees in high-street practices with experienced optometry independent prescribers. And where previously that was a block to qualification, which meant that they then didn't offer service, over the last six months, we've cleared a backlog pretty much all across Wales. There are a couple left in Aneurin Bevan, but we have cleared the backlog of those waiting for placements and that should expedite services so that they can—. Well, it'll certainly allow them to qualify quicker so that they can then offer those services quicker.

As I said before, we also think there is a role for optometrists in actually working in secondary care in some circumstances. We also see that some of the training in the future could be done between them—rather than just optometrists going into ophthalmology units, actually having ophthalmologists come out to optometry practices as well. We're looking at that as a possibility.

Our whole set-up from—. If we have anybody outside of Wales coming to work in Wales, they have to go through training, because we do have a lot more that optometrists do in Wales than they would do in most parts of England, for example. So, we have a training structure that they have to go through before they can practice in Wales and it's the same for our newly qualified. And then the undergraduate programme, our regulators changed so that it gives the opportunity for universities to add additional clinical training and, they are doing so in Cardiff. So, we will have some optometrists start coming out into the workforce a bit more clinically ready than they have been before, so that they will come out with some of the qualifications that we currently commission straight from training—not all of them, but some of them, which will help with the pipeline, really.

We do get problems in north-west Wales—the same as earlier. We were talking the other day with a practice, and it is a part-time practice, but there have been some practice closures around north-west Wales, and they have the highest waiting list in Wales. For routine optometry high-street appointments it's of a couple of weeks. But in terms of this practice, because a lot of practices nearby have closed, and it's in Dolgellau, it means that they can have routine waiting lists of 10 weeks, which is the highest we've ever seen in optometry practice before. So, I know that Powys—. We've had conversations where Powys are looking at trying to get somebody into the extreme western parts of Powys to take some of that workload off. It's fair to say that that is a part-time practice. So, yes, we're aware of the regional variations as well and that the patients in those areas need equitable access to service, as does everybody else. So, we're working with the health boards.

Do you think Wales is attractive to those wanting a career in optometry because it's a more developed role—they would do more and they'd be more highly skilled, I guess, and better qualified in Wales than in England?

Yes, currently the evidence is that there isn't a lot of outstanding employment—there aren't many jobs in optometry in Wales. They tend to get filled quite quickly, so we are reasonably confident on that level—there aren't a lot of outstanding jobs available, which is good. We also think that with the emphasis on clinical, and through the new optometry contract, because there is remuneration for additional clinical—so keeping those patients out of secondary care—there has been a big shift in the way that optometry operates, and we think market forces will mean—

[Inaudible.]—in Wales than they are in England.

It's definitely a more attractive place to work, and we were already hearing that going out to conferences in England. There is that, you know, 'Crikey, in Wales, it's a much better place to work.'

That's very positive, isn't it? And I guess that those developments are in keeping with Welsh Government's mantra of 'only do what only you can do', really, in terms of secondary and primary care, and who should be doing what.

You mentioned addressing the gaps between health boards. There are varying growth rates in optometry services across different health boards, aren't there, but from what you say, you're on the case as far as that's concerned.

Yes. It's multifactorial in a lot of cases, the reasons and why it falls in the way that services have been set up. What we try and do as HEIW is make sure that we've got a trained workforce who can deliver when the services are ready, and the services are pretty much ready across Wales, but there are lots of different reasons why they're not necessarily embedded, but we're now seeing, pretty much—. Swansea Bay were the last ones to do the kind of glaucoma monitoring and filtering, but they will be ready within weeks to provide those services as well. So, it's getting there, with coverage of services. It's a question, perhaps, for the clinical leads about how we make that even faster.

Okay. Your paper, which you've kindly provided for us, refers to Cardiff University and the student numbers for optometry, and those from Wales and so on. Is it very important, do you think, that those studying optometry at Welsh universities are from Wales? Is that very significant?

I think there's an advantage, certainly, in getting local people to study, and then be able to—. They'll be more likely to stay afterwards if they've got connections. I think that's the key thing, especially in those hard-to-reach areas that we've already discussed—that's kind of why. But having said that, as I say, we do get—. I mean, I myself qualified in Cardiff, went away and then came back, so we do get a lot of that happening as well. So, whilst the figures show that people who lived in Wales and studied in Wales—they're quite low, those that stay, or the percentages are quite low of those applying to do optometry from within Wales. We still do have a pretty robust workforce and pretty good numbers applying, and a lot of those, like myself, once they've done some working, they do come back, and we're hopeful that the clinical nature of the services that are being offered will make it more attractive as well.

Yes, okay.

I'll bring Lesley in on this.

On that point, I was at my local optometrist and optometry practice last week, and both optometrists were from overseas, and this goes for ophthalmology as well as optometry. Are you having difficulties attracting students from overseas because of leaving the European Union, because of the visa issues with the previous Government, and after last week's speech by the current Government? Is it having an impact on people wanting to come here? Because if you look at—. I'm thinking of the ophthalmology department in Wrexham, I would say 90 per cent of the clinicians are from overseas. As I say, I think it goes for optometry as well.

Do you want to go for the ophthalmology first, or do you want me to address—?

I'm not sure about the numbers. I don't know if Helen knows. So, I think it comes back to the question of do we want folks who live in Wales to train in Wales and work in Wales. I think there are two parts to that question. If somebody is born somewhere, they're likely to go away and more likely, I think the data will show, to come back. But people who are from somewhere else, like me, who come to a place in Wales and have a great working experience or do what they see as valuable work and are treated well are then likely to stay. If they are bringing expertise and work et cetera, then that might be a good thing for them to stay.

Looking at the UK statistics around the number of people that are applying to ophthalmology, but across all medical posts, what we are seeing is a year-on-year increase. The competition ratio back in 2013 was lower than the 14 that I mentioned for 2024, and then for 2025, there has been an increase in the number of applications as well again. So, based on that, I would say that we don't currently have any problems. There will be an increase in pool there that are UK graduates, because, obviously, across the UK, there has been increased expansion across the medical schools. So, there will be increased numbers from that route, but there will also be increased numbers from international medical graduates as well.

Going back to the 14:1 ratio, Helen, that you just mentioned, is it a feature of when you choose people? So, 14:1 is, I think, quite low. If you're trying for a place, you've only got a 1 in 14 chance. Where do they come from? Anton just said we want people from Wales to train in Wales.

Geography isn't a feature. So, the trainees will apply for a place on the training programme. They will be interviewed via UK interview panels. They will then be ranked in terms of how they perform, and then that ranking will align to their preference in terms of where they want to locate. There is a computer algorithm, then, that allocates them to their posts. So, in terms of where individuals come from, that doesn't feature in that recruitment.

So, how do we get more people from Wales, then, training in Wales?

We need to make our training programmes attractive. We need to give, as Anton mentioned, our trainees early exposure to ophthalmology and increased exposure to ophthalmology. If you have a good experience, you're more likely to consider that as a career going forward. I think, during that early years experience as well, we need to give our trainees as much exposure to that specialty to make them as competitive as possible and to give them that competitive advantage. So, we are providing our foundation trainees that express a preference in ophthalmology the opportunity to go and spend that time in that simulation suite at Cardiff University. So, then they are more prepared for their interviews. They can then be more competitive, higher ranked and, therefore, if they want to stay in Wales, they can do so. So, that is very much the strategy.

John, do you want to finish on that point?

Yes, if I—. Sorry.

I was just going to talk about optometry.

Sorry.

In terms of overseas working in optometry, I've got to be honest, I'm not quite sure of the data. From the undergraduate programme, there's always a number of overseas students that qualify. I do know, over the last few years, we've had a lot of Nigerian applicants come from Nigeria for various reasons. They tend to want to stay and work where they do their training and where they're working. I know there are visa issues with doing some sort of additional training that they might need to do before becoming qualified, but I don't know the stats, I'm afraid.

In terms of getting more people from Wales interested in optometry, for us, it's a bit different than medicine, because you might know from an early age you want to do medicine, but sub-specialties don't come until later in the training, but for optometrists, we're really interested in getting school years 10 to 12 interested in it as a profession. I think a lot of people come into it because they have had some eye problems as a child and they visit an optometrist, so they know about it that way. But otherwise, it's not necessarily well known. So, we've been working—. There are plenty of careers fairs that we go to, but there's also something online called Careersville, and there's an eye care building that includes all the eye care specialties in there and it's all very interactive for school leavers. But we're also looking at what would make a more attractive work experience, so getting years 10 to 12 actually in optometry practice in a structured way in Wales. So, that's something we're definitely interested in doing to try and get more students into it.

Thank you.

If I could, Chair, just a few more questions, or a couple more questions there. In your paper, Nik, I was struck by the 28 per cent figure from the 2021 survey for those working full time. It seems pretty low, doesn't it, 28 per cent, or has it been that way forever?

So, I'll be really interested—. As I say, when we get the figures, that will include full-time equivalents. This was a sample, it was a really strong sample—it was 530 and we reckon there are about 900 optometrists circulating in Wales.

I think what you have—. There's a mobile workforce a lot of the time, so a lot of people do locums in Wales and they might do locum in England as well, but we only see the part they do in Wales. But also it's a great career for people who want to do part-time, in a way, and that appeals to, perhaps, families with young children so that they can do part-time work. But we are really interested to find out what the latest data shows, because that was a surprise, if we're honest. For us, a locum or part-time workforce isn't ideal for delivering services for practices, because if they're only there a couple of days a week, and they're the only ones with qualifications to provide that service, it's a problem. So, we're really intrigued to see where the latest data takes us on the full-time equivalent optometrists working in Wales.

Is there a cost issue to the health service in terms of locum use? Are they more expensive for the health service?

We're a contractor profession, so it's very much business related, so the cost to the NHS would come in on service delivery, rather than, obviously, paying the locums, so it doesn't quite work with, say, ophthalmology or those directly employed by the NHS.

Okay. Just to finish, then, sorry, Chair—

We're running very short on time—

Yes, I know we are. I'm sorry, Chair.

We've gone over—

Yes. I mean, we've covered some of this already, but in terms of hospital optometry, which represents a small proportion of the workforce but has potential for growth, what would you say are the key barriers to recruiting into those roles, and why are those positions crucial for the success of ophthalmology services?

So, if we look at elsewhere in England compared to Wales, there tend to be a lot more optometrists working in hospital practice. We would really like to see a diverse workforce where they perhaps do some time in hospital and some time in primary care. There have traditionally been barriers between ophthalmology, medical and optometrists. Those are coming down, and they have been coming down in the time that I've been involved in optometry, which is great. But if you are working in a hospital as an optometrist, you're working day to day with ophthalmologists, and you trust each other, and we think those barriers are really important to break down, and that's why we feel that there could be more optometrists working in hospitals. As I say, there are some hospitals now—. There are more in Aneurin Bevan, for example; they've employed a few. The barriers to getting them to go are salary discrepancies. At the moment, if you're working in a high-street optometry practice, you can command a much higher salary than you would do if you worked for the NHS. We've redone the bandings, working closely with NHS Wales Shared Services Partnership, myself and my team, for hospital optometry, so that it does make it a more attractive proposition, but it still doesn't reach the same levels, so it is financial.

Yes, okay, thank you very much.

Thank you, John. Thank you very much. I'm conscious that we've gone over time a little bit. I would ask a couple more questions around regional working and perhaps some of the issues that that might cause you in trying to balance the need across the country. Is there anything, quickly, you might want to share about regionalisation? Does it cause you a problem, or how might you be balancing the regional need?

I think regionalisation is a slight challenge for us, particularly in ophthalmology, because our ophthalmology training is an all-Wales training programme and so our trainees will be required to rotate across all of those regions in Wales. We recognise that that is a challenge. It is a barrier for some people, particularly if you want to set down roots in particular areas; you don't necessarily want to be working in a very different location for a 12-month period. So, we are looking at where we can regionalise our programmes as much as possible. There are challenges associated with that in terms of curriculum delivery, because there are certain regions that just do not deliver, then, the entirety of the curriculum, and so we may then need to move our trainees. But it is something that is very much on our minds at the moment, and something that we are very much looking to focus on.

Thank you. Anybody else want to add, or—? Well, thank you so much, it's been really, really interesting. There will be a transcript that you will all receive so you can just check that you are content with what has been said. Once again, special thanks for coming in. This is really important stuff, and, to get underneath it, that has helped us understand a lot around the training side of things.