Health and Social Care Committee

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

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

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

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

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

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

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

Thank you. Mabon, you wanted to come in.

Thank you. Two things very quickly, if I may, Dr Pyott. First of all, you mentioned there good practice in Specsavers in Newport. Could you just talk a little bit more about that? I apologise, I'm not familiar with that example. And secondly, I'm interested in this link between dementia and cataracts. Of course, I'm aware of the dangers with falls and so forth, but can you explain that connection with dementia? Just those two things, please.

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

And then the good practice in Newport in Specsavers.

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

Thank you. Thank you, Mabon. Lesley Griffiths.

[Inaudible.]—apologies.

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

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

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

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

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

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

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

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

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

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

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

Lesley.

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

That's correct.

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

Yes.

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

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

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

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

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

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

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

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

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

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

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

Yes, absolutely.

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

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

Thank you.

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

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

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

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

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

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

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

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

Thank you very much, Chair, and thank you for your very interesting evidence thus far. In terms of your report, you mentioned in the report that there were disagreements and conflicts within some eye care units in Wales, and you noted that there had been communication issues between consultants, clinical staff and management et cetera, and that that had led in turn to a lack of co-operation. How do you think that these conflicts have impacted on patient care and the running of services, and have contributed to the long waiting times that we have in Wales?

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

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

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

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

Thank you. So, that blueprint, in terms of recommendations that, hopefully, will improve the situation is there. Do you think that that situation will continue as it is? Four years since writing the report, have you seen evidence that the weaknesses you've just mentioned still exist here?

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

Thank you very much. Thinking of the workforce and the report that you wrote, you mentioned that there were weaknesses or problems in terms of recruiting and retaining staff, particularly consultant ophthalmologists in west Wales and specialised corneal surgeons in north Wales, for example. Do you think, therefore, that there are lessons that can be learned from Scotland in terms of recruiting eye care specialists, and do you think that there is too much use of the private sector at the moment?

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

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

You've just mentioned the trainees there. What about the non-medical workforce? How is the situation with non-medical staff in Wales? You referred to a number of elements within the different workforces we have in Wales in your report. Have things improved on that side? What steps do you think we need to take now to strengthen those things further?

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

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

Diolch yn fawr iawn i chi.

Thank you. John Griffiths.

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

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

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

I'm afraid I don't have that much—.

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

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

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

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

Do you have any further questions, John?

No, that's fine, thank you, Chair.

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

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

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

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

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

Thank you.

James Evans.

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

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

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

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

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

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

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

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

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

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

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

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

Yes. Mabon ap Gwynfor.

Thank you. On the digital element, you've touched, Dr Pyott, on OpenEyes and how useful the OpenEyes programme has been—you mentioned Glasgow, I think, in that context. Could you expand a little on how transformative this programme is, how much it has changed the way that you work and your ability to work within optometry in Scotland, please? How important is the OpenEyes software?

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

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

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

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

Are you asking about Scotland?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I did say 'fax machines', yes.

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

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

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

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

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

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

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

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

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

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

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

Yes, no problem. John Griffiths.

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

Who would perhaps like to address that point? Anyone?

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

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

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

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

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

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

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

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

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

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

Thank you. Any further questions, John?

No, that's fine thanks, Chair.

Thank you. Joyce—no, sorry, Dan. Yes.

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

And how does that happen?

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

How do we do that?

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

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

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

Sure. Absolutely. Joyce Watson.

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

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

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

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

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

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

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

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

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

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

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

No, I'll continue.

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

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

I am yet to see anything that is accelerating it.

Who should be doing it, then?

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

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

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

So, who's the 'somebody'?

DHCW it sits with at the moment, I believe.

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

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

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

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

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

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

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

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

Okay.

But—. I couldn't tell you on a health board by health board basis on that, no.

We need to know about the fax machines, so—.

We can come back on that. We can come back to you if there's a—

Are you still having to fax people?

Until—. Within the health boards I work in, no. But I'm not sure for every health board.

Is that south Wales?

Yes.

Yes. So, how is data on patient outcomes and waiting times collected and reported by community optometrists, and how can that in itself be used to improve service delivery that then, in turn, reduces waiting times?

There are no waiting times in primary care.

No, not into primary, but then into the secondary.

Into secondary care, we get fed back by the health board, so we get the information from the health boards.

So, you're quite happy about the way that that flow is happening.

About the information? So, they're reported through the eye care groups, waiting times. Some health boards communicate through primary care optometry groups—so, for example, the optometry liaison groups in some health boards. We have certain areas that are now meeting regionally. So, in south-east Wales, we work regionally in the primary care part of it, and waiting times can be communicated and distributed through the network of the regional optometric committees—the statutory bodies to represent contractors—through to each individual practice, and then to patients that way. But it's not efficient.

So, we've mentioned the digital infrastructure, so we've gone through that, and the data sharing—you've given us another insight into data sharing by programming. So, are they the main barriers to achieving the digital solutions that we clearly want? Or are there other ones that we are yet to discover, with you telling us in a minute?

I think—. Until we know what the solution is going to be, in terms of the options appraisal that DHCW look to be redoing, it's hard to say what the barriers are, and we need to be part of that, from a profession, to make sure that the individual needs of practices are recognised by DHCW when they choose anew or continue in the direction of travel of OpenEyes. There are going to be challenges in terms of the APIs, getting whatever national solution is selected to work with the maybe 13 different practice management systems that there are currently in Wales, but there is a track record of funding developers to produce the APIs themselves in pharmacy, I believe, and that needs to be learnt from and replicated, if it went well, within optometry then. And the barriers, I don't know.

So, when can we expect that to come through?

That is beyond our gift as a profession to deliver. That is not within our gift. We wanted it last year, and we've moved, we've done pilots off our own back, we've worked with everybody, in terms of groups. Every meeting that we can attend, we're attending to make sure that we're doing our bit as the profession. It is not in our gift to deliver it, currently.

Okay.

Dr Hampson, I appreciate you dropped out for a moment, so you wouldn't have heard the discussion, but is there anything that you want to say around digital transformation at all that you think would be helpful for us to hear?

The irony that we're talking about digital transformation and the connection dropped is not lost on me. [Laughter.] I think in terms of—. I didn't hear what my colleagues were saying, but, in terms of interoperability of equipment, there is a wider project on DICOM standards to ensure that equipment works across the sector, so, rather than being reliant on having the desired or correct piece of equipment, that there's an interoperability standard that's been worked on on a UK-wide basis to make certain that those gaps are closed as much as possible. And I caught the very tail end there of the API discussion, which is one of the key things to making sure that this works, so, again, it becomes agnostic to system. And all of that is just making certain that the data can flow simply between point A and point B.

Okay, thank you. Mabon, you wanted to come in. If you want to then go on to ask your set of questions as well, please do so.

Thank you very much, Chair. I’m going to ask my questions through the medium of Welsh, so you’ll need the translation equipment. On the digital question, very recently, I went to London to discuss digitisation with OneLondon. I wonder if you’re familiar with OneLondon. What’s happening there, in terms of the way that they're integrating digital systems across primary and secondary care in every area, is very interesting. Similarly, Hive in Manchester. I wonder if you’re familiar with OneLondon, and Hive in Manchester, and do you agree that there are lessons to be learnt there? But, more than that, in terms of OpenEyes, I wanted to go after that: have you heard if the Government is going to continue to fund OpenEyes, and would OpenEyes be transformational if it was rolled out across Wales?

If I can pick up on OneLondon first, I’m not directly familiar with it, but integration of—. Connectivity, rather than integration, I think, is what we’re looking for, where all the systems work without needing new systems, many new systems. I’m cautious in terms of the learnings from OneLondon, because I’m not familiar with them, but it feeds into your question on OpenEyes then, which is: is Welsh Government going to continue with it? I don’t know. I think that there’s an options appraisal that’s been redrafted within DHCW. Will it be transformational? Any IT system that is not a letter is, by definition, transformational. Will it be a great one? I don’t know. I don’t think anybody across the UK has quite got an electronic referral system right. There are lots of learnings that we as Optometry Wales would be able to pull in from our UK-wide colleagues, who’ve seen everything that’s gone before, and we would be keen to pull that information in. My concern is that practices end up with double entry, which is a risk in terms of miskeying something. Double entry of information—if somebody gets distracted and then they’ve entered one patient record and not the other one, it’s a risk to the patient; it’s a risk to the professional, then, as well. It needs to connect with practice management software. Whether that’s OpenEyes or something else, something would be good, something that links up would be good. And without it, the speed at which these reforms—which are long-term reforms—the speed at which they’re going to make a difference is diminished, particularly for moving patients who are existing secondary care patients into primary care.

Thank you for that. I’m keen to go on to discuss the workforce. Could you talk about what measures are being taken, or need to be taken, to ensure that optometrists can work to the top of their skill set in primary care, please?

So, the workforce reporting that started last month will record practitioners and their qualifications. So, if you have practitioners with qualifications that are not then delivering services, there should be the facility to identify that within whether it’s the shared services partnership or health boards and to be able to see that somebody has the qualification but they’re not delivering the service, and then you can ask why that is. It may be that they’ve been off on maternity leave, or they’re only working a few days a week and they can’t manage to deliver, say, a wet age-related macular degeneration refinement service, where they need to be in practice more, but it’s there for the future if they decide to increase. But it should be identifiable through the current workforce tool that we have within the SSP and health boards, I would have thought.

Thank you. We’ve heard evidence from you and others talking about how services are being transferred more from the centre, or the hospitals, to the community. But, of course, patients, particularly older ones, perhaps, are used to going to receive services from specialists in hospitals. A lot of that can be done by high-street optometrists now. So, what sort of communication are you aware of to provide that assurance to patients that the services previously provided only by hospitals, which are now being provided by community optometrists, are as good and providing the same level of care to them?

So, in terms of the 'as good' comment, there are joint college—royal college and our college—standards in terms of who can do what. Within, say, for example, glaucoma, it's very clearly defined, whether you're an advanced nurse practitioner, or orthoptist with a special interest, optometrist, doctor, what you can do at what level. For certain things like medical retina, it's less clear, but that has been cleared up through the development of contract reform. In terms of how the patients feel and how that's communicated to them, often these patients are seeing people who they know anyway, and they know and trust. We are often the people who found the condition in the first place. So, you'll have patients who will naturally trust the person that they are seeing. The person is quality-assured, because they've been through a national qualification. In terms of continuing professional development, for example, independent prescribing, that has a separate demand on continuing professional development from the entry-level optometrist. And then—. I've lost the third part of your question. It was a long question. [Laughter.] What did I miss then, Mabon? Give me the other bit; go on.

I was thinking about the confidence that patients have in terms of knowing that they're receiving the same level of treatment in the community as they would in hospital.

I think that patients are relieved to be seen on time. If you're diagnosed with possible glaucoma and you say, 'I need somebody to have a look at it', currently, in some health boards, it might be three years before you get seen. If you then get seen within six weeks somewhere else and you get a decision on it, that's confidence-inspiring in itself. There are other aspects to it, in terms of we talk to patients—you know, 'This is something that would normally be done in the hospital; we're doing it here. We have specialist qualifications around it'—and we work with patients when they come into our consulting rooms to build trust with them. It's what we do for a living.

Dr Hampson wanted to come in as well, sorry.

Thank you. So, Owain has covered some of what I was going to say, but, certainly, I think, in terms of the question, it's a joint profession piece, for ophthalmology and optometry, to reassure patients that, whichever professional they're speaking to, there's a reassurance given that the changes are to tackle some of the waiting list challenges and to increase access, which I think is really important. Owain was just saying there that many patients who come into optometry practices have a long-standing relationship with that practice. They feel safe, they feel reassured, they know the people personally. So, whilst the transfer of care may be different, actually there's a familiarity and a comfort, actually. It is quite well documented that patients feel safe and they feel more able, in many cases, to ask questions, because there's a little more time than in a busy hospital environment, which helps to reassure them and helps to make them feel like they are getting the care that they need. And it's not uncommon, as I'm sure my colleagues would agree, to hear patients say, 'Well, nobody's had the chance to explain that to me previously', and that's just because of the pressures that we know our hospital colleagues are under; there are so many patients. Sometimes, that extra couple of minutes that are available in primary care mean that a patient's simple question can be answered that may have been on their minds for a significant period of time.

Thank you very much for those answers. If I could go on, quickly, to a couple of other elements, there are 'teach and treat' eye care centres, of course, that have been introduced. What benefits do you think have resulted from that in terms of reducing hospital waiting times and enhancing optometrist training? Do you think that they have been successful? And, related to that, how important is the relationship with universities in implementing these reforms?

The 'teach and treat' clinics have been extremely helpful in upskilling optometrists. In terms of your previous question, in terms of the quality assurance, part of the higher qualifications is that you have to work within a clinical placement. The ophthalmology departments have traditionally accepted optometrists in on the belief that it will make a difference to their working lives to provide those placements. But as contract reform has accelerated and more placements have been needed, the previous situation with health boards just trying to slot them into ophthalmology clinics becomes untenable. So, the 'teach and treat' clinics have been essential for delivering the higher qualifications for optometry.

In terms of patient care, they’re another provider in a location where you’ve got a bulk service being provided with clinicians on rotation, through it being supervised by more senior clinicians. So, it’s another outlet that’s providing the service, but also it’s that guarantee that there are placements available for people who have done the academic part of their training.

Thank you very much, Owain. That's all from me. Thank you, Chair.

Thank you. Just following on from that, what are the current numbers of independent prescribing optometrists in Wales?

That's an answer I don't have off the top of my head.

I'll put it this way: what percentage increase has there been in optometrists getting a higher qualification, including independent prescribing?

That's not a figure I keep in my head, if I'm honest. We can write back on that and tell you. But 'significant' is the answer.

Oh, significant. Right, okay. That's important—

And as of today, when the results were published, even more significant.

What evidence exists that independent prescribing optometrists have reduced the need for patients to be seen?

There are two things on that. First, there is unmet demand. Patients are being co-managed by GPs and optometrists and pharmacists as things stand, which is wasteful and inefficient. That unmet demand has been achieved with prescribers. But then the evidence for whether it makes a difference to secondary care is in the number of appointments that are being managed, which is collated by the shared services partnership, and we get an e-mail from that in Optometry Wales. I don't have the details to hand on how many that is, but there has been a significant trajectory in a positive direction.

The other thing is that the evidence within health boards is that doctors have been able to be redeployed from doing eye casualty and acute stuff to doing clinics and the chronic stuff. For example, off the top of my head, Cwm Taf have managed to do that, and in Aneurin Bevan the registrars aren't having to be there at 9 o'clock at night every night, which is huge.

If I can just come in very quickly, on the problems that we have with the training and the provision, we've just seen statistics today showing the numbers on waiting lists, and once again Betsi Cadwaladr has a large percentage of them: 43,000 people are on the ophthalmology waiting list at Betsi Cadwaladr out of the 161,000 in Wales. Why do you think north Wales is so exceptionally bad?

Because other health boards have been quicker to pilot services. A lot of contract reform was based on services that were piloted, for example shared care glaucoma in Cwm Taf. We were starting to do this initially 10 years ago through various different stop-starts, but COVID transformed massively the movement of patients from secondary care to primary care. But until recently, I don't think Betsi have had any services whatsoever in terms of utilising higher qualifications. I can't tell you why the health board have not done that. It's not from a lack of willingness on the part of the profession to be delivering it. There are plenty of qualified people within Betsi who would be happy to receive patients but can’t because there have been no schemes prior to contract reform, and they were very slow to deploy contract reform within the health board.

Dr Hampson, did you want to come in on any point?

I think Owain has covered it. I think there are some challenges. In all honesty, my use on this committee is almost pointing out what hasn't worked well in other places as well as what is working well in Wales, because I'm less familiar with the geography, so I defer to my colleagues who are far more familiar with this. It would be inappropriate otherwise.

No, not at all. Thank you. John Griffiths.

Diolch, Cadeirydd. I'd like to ask some questions on health inequalities. The Pyott report highlighted the very significant gaps between people in more deprived circumstances and those who are more affluent in terms of sight loss and low vision. Do you think in redesigning eye care services enough attention has been given to addressing these health inequalities?

Yes, but there's always more to do. An example of this is WGOS 5 and domiciliary. There's more work to be done around what can be done on a domiciliary basis. For patients who are in more deprived areas that have difficulty in accessing secondary care traditionally, having a mobile optometrist who can come out and prescribe for their eye condition, or eventually manage their eye condition within their home, is huge. Local access to care with somebody that's familiar is fantastic. WGOS 3 reforms are hugely significant and that's a massive thing for optometry, being able to certify as visually impaired somebody with dry macular degeneration in primary care without them having to access secondary care, just to sit on a waiting list for years, because they're a relatively low priority because they've already lost their sight. Now being able to certify them as visually impaired within primary care is an absolute game changer for people. In terms of preventing the sight loss, we still need to keep working on that, because that's a perpetually leaky bucket, making sure that people with poor health are managed effectively and in a preventative way. The public health messaging, for instance, that we're doing in optometry as well is new, and we'll need to measure how well that's impacting things.

Do you see good practice across Wales in the way that you described, or is it quite patchy?

WGOS 1 and 2 is compulsory, so everybody with an optometry practice who contracts to the NHS has to do that, so that does contractually oblige people to deliver those services. WGOS 3 is on the basis of qualification and workforce and looking on a cluster-by-cluster basis at what the level of provision is and what the need is through the health board's eye care plans as well. That's going to give us the intelligence to know where to target the next level of improvement.

Dr Hampson, do you want to come in?

Thank you. Just more generally in terms of rurality, we know that any service, no matter how well designed, is always more difficult the more sparsely populated an area is, the greater degree of travel time there is. As Owain's just said, I think there is more that can be done in terms of access to domiciliary in terms of communities that are less connected to the major urban centres, where we know the provision of hospital care is already better. So it's very much a positive step, but people need to keep raising awareness that there will be these challenges, just because if you've got to travel an hour to get to a patient, a service that you only have to travel 20 minutes to get to a patient for is far easier to deliver in terms of follow-up, ongoing care and so on. So, huge steps have been made. It's very positive, but there's certainly more to do to tackle particularly probably that middle band of Wales where we know that service provision is not the same as it would be at the poles, particularly in the south of Wales.

As we see a shift from some eye care services being delivered in hospitals to delivery by community optometrists, is that shift entirely within the NHS funding model, or are there sometimes charges to be paid by patients accessing those services in the community?

WGOS 4 and 5, so the NHS service that has been moved from secondary care to primary care, is entirely funded by the NHS.

We know that a standard eye test typically costs around £25, but, of course, there may be eligibility for a free service for NHS patients. There's an additional charge for an OCT scan, which I think is usually around £10 to £15, so is there a danger that we might see a two-tier health system developing where those who can afford it have this private care treatment while others may experience delays?

In terms of universal access to eye care, there isn't universal access to routine eye care on the NHS in Wales. There is still an eligibility criteria for certain patients. For those who are accessing the NHS services, there is the provision for an OCT within the scope of WGOS, which is WGOS 2.2, which allows for an OCT to be paid for if it's going to prevent an onwards referral. So, if you are clinically minded that there is something going on, and an OCT is going to confirm the presence of disease or not, then that can be provided under WGOS. What the current WGOS does not fund is baseline data, and that's a case of patients then needing to pay if they wanted. So, there is that aspect, but eye care in Wales has always been slightly unequal in that not everybody gets access to NHS care for routine care. Everybody gets emergency care, but not necessarily routine care.

Yes, it's that piece around screening. OCT is not a treatment per se, but it's screening, initially, which will have a higher sensitivity of detection of early onset of disease. There could be a gap due to the current WGOS funding structure. But this is private, as per the gentleman's question.

Finally from me, Cadeirydd, how has the ophthalmology clinical implementation network contributed to ensuring equal access to eye care across regions and perhaps in addressing disparity in care delivery?

In terms of historically, it's difficult to say. In terms of going forward, having feedback from primary care optometry into the CIN is key so that we can raise these issues within that network, better shape the clinical pathways that we have and to allow redrafting of the clinical manuals to look at these things and to make sure that the pathways address anything that may be highlighted. In terms of historically, it's difficult to say. I don't think I could answer that question. But we could write back on that.

Thank you. Thank you, John. We're just drawing to the end of the session, but the reason we're doing a piece of work on ophthalmology is the high level of patients waiting for treatment. So, from your perspective, just to finish off this session, I'll ask each of you whether there are any key bullet points that you would draw our attention to in terms of us considering what recommendations we can make to Government in order to address the issues that we're aware of. Who would like to go first?

Can I roll my sleeves up and go first? Electronic patient record, electronic patient record, electronic patient record, electronic referral system and an electronic referral system—that works and is integrated and doesn't false-start again. That would be hugely useful. In terms of ophthalmology, if we're freeing up doctor time and the estate's up to date, is there enough capacity in terms of the eye theatres within the NHS infrastructure to deliver? We don’t do surgery; we're identifying and referring them in and we can manage chronic conditions, but patients still need surgery. If we're freeing up doctor time, but the hospitals were built 30 years ago and there's one eye theatre, they can only do one patient at a time in that theatre.

Thank you. That's clear. Dan.

I'd echo my colleague's view on connectivity, but I think utilising that, as well, to get more patients out of the hospital eye service when they're under follow-up and review and into the community will definitely start to reduce the waiting lists as well. But where it's an electronic referral system, we need to see it as a two-way communication. As much as getting the patients into the hospital eye service who need it, it's how we get them out and into the community for follow-up and monitoring. I think we've got a key role to play in that, and certainly there's much more we can do in that space.

Thank you. Dr Hampson, the last word.

Thank you. Going last after that—. Again, connectivity, absolutely, I think that’s one of the most important enablers to this whole piece of work. Utilising the building blocks that you've already got in place in terms of the services and the systems that have been created. Making certain that there is a push to use those services as much as possible. And probably just trying to raise awareness with the public about what is now available to them in Wales in terms of where they can present if they have a problem with their eyes, or if they have any ongoing concerns, just to make certain that anybody who can go into an optometrist practice for care heads there as their first port of call, wherever appropriate, rather than perhaps going to the GP or joining the very busy eye casualty department when they don't need to. So, an awareness piece would be a push from me.

That last point is a really good point, actually, yes. I wouldn't have necessarily known that. How can Government do that?

I think probably a public health campaign is the sort of thing I would be thinking. We see many public health messaging pieces that are put out, whether those are very low-level things in terms of when people present to other services, whether it's redirection from other services if people, perhaps, call a 111 equivalent for redirection, or whether it is in some sort of targeted campaign to the groups that we know are more likely to need care, in print, in websites, media, wherever possible, just so that people know what is out there, because lots of good steps have been taken, but they're only good steps if patients know they exist.

Yes, that's a good point.

Can I thank you all so much for being with us? I really appreciate your time. We'll take a short five-minute break and be back in just over five minutes. Thank you.

Welcome back to the Health and Social Care Committee. We move to item 6 and we’re carrying on with our piece of work today with regard to ophthalmology services in Wales. We have a large panel here this afternoon, for our final session of the day, with a number of organisations and patient representatives. I will ask each of you just to introduce yourselves so we know who everybody is. I’ll start in the room first—Sara.

Sara Crowley, Royal National Institute of Blind People.

Ansley Workman, I'm the director of RNIB Cymru.

There we are. And on the screen I'll come to, first of all, Marian, and—. Both of you, please—if you could introduce yourselves.

Good afternoon, my name is Marian Williams, and I represent the Macular Society. And to my left I've got Mr Edward Keena, and he's a patient at Ysbyty Gwynedd, Betsi Cadwaladr University Health Board.

Thank you. And Lowri.

Hi, I'm Lowri Bartrum, I'm from Vision Support, and we provide services across north-east Wales.

And Owen.

Hi, I'm Owen Williams, I'm the director of Wales Council of the Blind, and I'm also a patient of Cardiff and Vale University Health Board.

Okay, that's great. If anybody wants to come in that's taking part virtually, if you do just wave your hand at the screen like that, I'll make a note of you, and if I wave back it means I've seen you and then I'll bring you in at an appropriate point.

So, given that half of all sight loss is avoidable with early detection and treatment, do you believe that—and this is a bit of a mouthful—the national clinical strategy for ophthalmology places sufficient focus on prevention and early detection? Who would like to address that? Ansley.

I can answer that. We did have a discussion before about who was going to answer what questions, otherwise it could be a bit of a bun fight. So, we’re quite clear who’s going to answer questions.

That's helpful.

Thank you for inviting us all here today. We are really pleased with the national clinical strategy, and we’re particularly pleased that we were asked by Rhianon and Will to include patient voice and patient support within the strategy. What we’re really concerned about is these discussions have gone on for years and years and years. We were expecting after the Pyott report for this to be costed, funded, the investment to be in it, and that didn’t happen. So, for us, we know that these problems can be solved. It’s been very well outlined this morning about all the system problems, but the problem with the strategy is that it may have been endorsed by Welsh Government, but there’s no investment, there’s no timeline on it, and that timeline needs to be at pace. The reason for that, as we know—you have got the figures here today—people are going blind in Wales now. So, it is a matter of urgency, and it has been for many, many years. We don’t want to use our time today to talk too much about the systems, because you’ve been well presented on that, and we really want you to hear from patients and the support organisations as much as we can today.

Okay, that’s really helpful, thank you. Nobody else wants to come in on that point—no. So, perhaps I’ll address this next question to Ffion, if that’s all right.

Ffion's not here today—she was called away, so I'm representing.

I do apologise. As I said Ffion, I was looking on the screen—I can't see Ffion. Right, Ansley, thank you. So, in your written evidence, you question the Welsh Government’s commitment to investing in the recommendations of the national clinical strategy. Can you elaborate on that?

We were expecting, from the—. The Pyott report was fantastic, you’ve heard from Dr Pyott this morning, and it really outlined what the problems were in Wales and his 10 recommendations and solutions. So, when all the discussions started about this report, the current clinical strategy had been commissioned, and conversations then, maybe a year and a half to two years ago, were saying that this report was going to be a costed report that outlined the investment needed to take forward the Pyott recommendations. However, sometime during that process, that investment discussion was lost. I don’t know what happened, where that happened. So, what we’ve ended up with is a really, really comprehensive strategy, but it’s uncosted and it’s untimed. So, how are we actually going to move forward? Other people have talked today about—. There’s been a lot of money that has gone into, for example, cataract treatment to reduce waiting lists. Everything needs to be done. We understand that. But as Rhianon said this morning, and we totally agree, you’re only solving a problem today so the waiting lists look shorter, you're not solving the problem of more and more people still coming into the system. So, it's very short-term funding that has been received for a lot of innovation.

So, what needs to happen? I think I know the answer, but to be clear.

The Welsh Government needs to commit to the investment needed, but also the timescales that it needs to be done in, and it has to be at pace, because people are going blind. But that also leads then—

Are there not clear timescales at the moment? Is that what you're saying?

No clear timescales. And we need the mandate from the Minister, because at the moment health boards are working under different incentives, different governance structures, and it needs to be mandated. Health boards are not just going to do this because it's a good thing to do.

And what role should the NHS executive play in driving the changes?

Their role is the implementation. However, my view, our view, is that they need to have much more power to make that happen.

How?

To be working with the Minister, to be working on saying, 'This isn't working.' We're trying this, but it gets to a certain point where they are unable, with the best will in the world, to get that best practice implemented, because health boards are struggling with many, many other priorities.

Okay. That's good. Clear answers. Lovely, thank you. John Griffiths.

Diolch, Cadeirydd. You’ve touched, in the previous answer we've just heard, on some of the issues, then, in terms of getting waiting times down in Wales, because obviously we've seen efforts to improve eye care services and get those waiting times down, but they remain high. What else would you like to say in terms of why that's the case, apart from some of the issues you've already mentioned?

I actually think it's well documented in the clinical strategy, the issues to do with workforce, estates, the EPR, digital connectivity—these are the problems that we know, and certainly there is a plan there in terms of where we should go with that blueprint. It's enacting that now.

So, as part of that, obviously you've already said that Welsh Government has to commit the necessary financial resources, and obviously you would apply that to reducing waiting times for ophthalmology services.

Yes, if the investment is there, for example on our workforce, in terms of better use of our estates, in terms of patient flow, if we've got multidisciplinary teams that are upskilled, then that is what is going to cut down the waiting lists—plus the data. We're looking at making sure that you actually get the kind of sub-speciality data instead of lumping everyone into one thing. People need different things at different times, and you need different specialists at different times as well. So, if what is in the plan is enacted, that would get the waiting list down, and that is a long-term plan, but it's a transformational change that is needed now, and that needs money to do it.

Okay, but when you mention the estate, obviously the estate needs to be improved, and there are issues there in terms of safety for patients, and indeed safety for staff as well. In 2024 there was a survey by the Royal College of Ophthalmologists, and that highlighted that sufficient clinical space is crucial for improving patient services. With that sort of background, is there anything in particular you'd like to draw the committee's attention to in terms of the specific improvements that are needed?

I don't think that it is our knowledge set that can talk about specifics of the NHS estate, from what you've already heard today, but what we can contribute is around patient safety incidents, and that has been mentioned in our evidence. We know that patient safety incidents where people have come to real harm are not reflected in the figures. We know that it's very difficult to actually complete that process, and you may not be aware, but I became aware last week, there's just been a new research paper done through Cardiff University as well, which talks about patient safety incidents in both England and Wales, and that highlights, basically, system inefficiencies that are causing patient safety incidents.

Okay. One further question from me, Cadeirydd. In terms of patient input, patient feedback when we're looking to identify areas for improvement, to reduce waiting times for ophthalmology services, is that working as it should? Is the patient voice helping to identify problems, and then, hopefully, also ways of improving?

Shall I bring Owen in? Did you want to come in on this point, Owen, or make any points at this stage?

Yes. Thank you. I think we've got some good examples where it has worked. So, one example is in Hywel Dda, where patients with macular degeneration were reporting long waiting times for injections, and significant concerns. And we did have patients that were at risk, and, actually, some patients who had lost vision whilst waiting for injections. That was taken up at the eye care collaboration group, it was met very positively by Hywel Dda, and the Macular Society raised this. The health board came out and met with the local macular group, listened to their views and, since that time, they've employed an additional doctor and nurse injectors across the health boards, and we are seeing less of a waiting time across the health boards. There's still more that needs to be done, but I think that is one very good example where the patient voice has directly contributed to improved services, and where a health board has listened and tried to improve services on the ground.

Owen, could we be confident, do you think, that, once across Wales, then, in all the health board areas, that patient voice is feeding through and helping to shape what happens in service delivery?

We have the Wales vision forum, which comprises of local, regional and national sight loss charities. So, we have representatives that sit on each of the eye care collaboration groups, and it is our role to make sure that that patient voice is represented and shared to the sector. We would like to see the patient voice high up on each of the agendas, and we meet regularly as a sector to ensure that that voice is channelled through. We certainly do it through the third sector, for people with sight impairment and severely sight impaired. And as I said, we meet to ensure that—and that's all of us a third sector: RNIB, WCB, the Macular Society, and all of the regional and local societies.

Mabon, did you want to—?

Thank you.

Sorry, John, did you have any further questions?

No. Diolch yn fawr, Cadeirydd.

Thank you, John. Mabon, you wanted to come in.

Yes, if I may, just to go after a point that the Institute of the Blind said just now. You said in your contribution that evidence of harm to people was not being properly recorded—I think I'm right that that's what you said—concerns about the way that harm to patients is being recorded. But we heard evidence this morning rationalising this and explaining why—saying that harm to patients is being defined in a different way in different areas across Wales, and across the UK, and that the definition of what you believe to be harm to a patient is very different to what maybe an expert in the field sees. So, do you accept that as an explanation, and do you think they're right in that respect?

Shall I answer this? Yes. So, it's a complex system, but it is a medical definition of harm and where people have lost sight. And I think there's a lot more being done, because what's being said at the moment is that it takes patients so long to get to their first appointment that you cannot measure, then, that they have lost vision, for example, in that time, or it's stable. I would say that they've been to the optometrist before, and it's the optometrist that has picked up that there are issues with someone's sight, in most cases. So, there should be something that we can follow to actually say people have come to harm.

I think as well it is about—and Rhianon said this this morning—people applying that differently. So, when we did our freedom of information request, the numbers that came back were shockingly low. We know that because there are 80,000 people at the moment who are over their clinical target to be seen. So, how on earth can these 80,000 people over their target—and you'll hear from Edward in a moment, for example—not be suffering harm? We need to know that, absolutely, so we can change our systems.

Thank you. I think that Owen wants to come in on this point also, Chair.

Thank you, Mabon. [Interruption.] Did somebody else want to come in? Oh, Owen did you want to come back in? Sorry. Yes.

Yes. Is that okay, Chair?

Yes, of course.

Thank you. I just thought, while there's an opportunity, just to reflect on optometry reform. Although there is fantastic feedback for optometry from across Wales—we discussed it in our west Wales group—this is only a part of the puzzle. One of the things that we should see is a positive impact on secondary care and a reduction in waiting lists. What we have heard from patients—. One example is of a glaucoma patient who was seen in optometry, the optometrist referred to secondary care, they were not seen promptly, and that patient has lost between 5 per cent and 10 per cent—it's their words, obviously, rather than a medical definition—of their vision. And they're still on a waiting list and still not sure when they'll be seen. I think what we would want is assurances that, when patients who are at risk of irreversible sight loss are referred from optometry to the hospital—so, from primary care to secondary care—they are seen in a way that they will not lose their vision.

We know, from what Ansley said about the recent report, the delays in reporting safety issues. There are some examples with Cardiff and Vale, where they use OpenEyes, where there are functions in place that speed up this process, but we really would like to understand how serious incidents are reported by optometrists with patients on a waiting list. So, it's not just ophthamologists; it would be good to see how our optometry colleagues report serious incidents. And I think one of the things, as Ansley's already alluded to, is that we want to see Welsh Government prioritise and fast track the implementation of the electronic patient record. The electronic patient record would, hopefully, prevent the need for patients to be asked the same questions, which we'll probably talk about; that happens a lot. But also it should speed up referrals and it should free up capacity for clinicians to do more.

Just to stay on that point as well, to respond to what Owen said—but anybody else is welcome to come in—what actions need to happen? What needs to change to ensure that accurate reporting of patient safety incidents happens?

With what we have said today, obviously, it's really clear about training. We need to have people trained to understand it. But, actually, it doesn't mean that people will still do it, and I think, therefore, it is about monitoring, because it's quite well known, the impact that not receiving treatment on time is likely to have on people, and it's about research and it's about monitoring it, so that you can pick up where you think, for example, one health board may not be reporting in as highly as you would expect. So, there must be research that can be done on this that will make that happen.

Thank you. Marian, you wanted to come in on this as well.

Yes. I think this would be a good opportunity, actually, to hear first-hand from a patient from Ysbyty Gwynedd, in Betsi Cadwaladr, of his experience of treatment. So, Mr Kenna.

Thank you for inviting me to talk. I'm glad to be able to tell you what's happened to me. I'll try not to get upset, but it does upset me.

You take your time. That's absolutely fine.

Right. I'm 80 years old, I've got macular degeneration, elevated pressures, and cataracts in both eyes. Now, I've prepared a statement. If I may, can I read it? It would be easier for me to read it.

Yes, of course. Yes.

And it relates specifically to what you're talking about now. Let me say that I'm grateful for the treatment I'm receiving for my medical problem, but I also feel very angry and let down by the NHS. I do not believe the hospital that treats me, via its staff, where I have been told, on many occasions, that time is of the essence when treating the disease, as they've failed to listen to me. I tell them, but it just doesn't work. 'Listen to the patient; listen to me as a patient', I have to say about the problem. I find that communicating my thoughts to them is very problematic indeed. The constant fear I have, which I live with daily—and that is of going blind—and which I have attempted to relay to them by letter, and verbally, is that, even though the excellent drug Vabysmo is used to fight that disease, it is, unfortunately, used improperly. Now, I qualify that statement by referring to a booklet that I was given at the hospital, which says about the drug, Vabysmo, that it's an excellent drug, but when it's not used properly by the hospital and its doctors it's no good.

And what it says in here, it describes the process you have when you're going to be injected with this drug over a period of time. But it's clear, from reading it, it says—. The main statement is that, after you've had your four loading doses, which is part of the process of using this Vabysmo, you may be injected, but no longer than, it says—. The wording is, actually, 'up to 16 weeks'; and this is where they're failing badly. I can show you this on the screen. I don't know whether it's going to come across, but it says in the booklet—. And this is what's given to you. It's not showing, is it? But this is what's given to you, so that's what you will expect. They qualify the statement by saying that the efficacy of standard 16-week cycles, as created by the manufacturers, after being tested on thousands of patients in America, is being ignored once the failure point is determined by meaningful test data on the patient here in Wales.

Now, what they do, they test you every—. They see you every six to eight weeks and, from that, they see how you're getting on. They test you on a reading test, they take pictures of your eyes and then, eventually, after 16 weeks, the idea is that they will know when your eyes need testing again. In fact, they say that the actual tests should be—when they're doing the four loading doses—to have three further injections over a few months so that they can ascertain what your cycle will be.

Now, in my first case, I failed at 15 weeks. It wasn't a failure, really, because I was delighted. It was better than Lucentis and Eylea, because I didn't have to go through this process of going to the hospital. It's unpleasant. It doesn't hurt, but it's an unpleasant process; it's not nice at all, but you have to put yourself through it. But the 15 weeks as opposed to 16 weeks, I was happy with that. I was delighted. It wasn't a failure, but it's just that the drug failed to function. At that juncture—. The problem is that, at that juncture, once it fails, there's no doctor anywhere in the world who can say when the disease will strike and make you blind, and this is the fear I've got. Because what's happened is they're not injecting me now within that 16-week cycle.

So, I'll read on anyway. No doctor anywhere is yet able to determine accurately when the disease will strike and destroy the macula, thus rendering blindness. This is because subsequent tests to determine macula disruption by the build-up of liquids in the eye are taken at too great a time limit, namely six or eight weeks after the drug fails to function, which, at best, is only 16 weeks. Any tests after 16 weeks, as envisaged by the system, known as treat and extend, have to be taken in small steps of days, rather than weeks. Now, in my case—this is my specific case—a 23 to 24 week cycle would mean that it is likely to add some 50 per cent overload by the hospital staff as to when the disease would kill the macula, which could easily result. They're literally leaving the dark, permanent dark, in my eyes.

You were told it was—

Sorry?

You were told it was a floater.

Yes. Eventually, I spoke to the doctor at the hospital about it, and I asked him about this 16-weeks efficacy period, and he said, 'Oh, we're varying that period. We don't really take much notice of it; we vary it.' Which shocked me, actually, because it says 'up to'. That doesn’t mean 'over', and I couldn't understand. All I could I think about was this black circle. He said, 'It's all right, that's just a floater.' Now, when I spoke to my optician about it, he said, 'That's not a floater.' He said, 'That's macular damage.' He actually showed me a magnified picture of the macula and I could see the damage. Not the little thing showing the bubbles, like the liquid in the eye; it was flesh, my inner eye. And he said, 'It's your macula damaged, and that's the way it is.' So, that's with me all the time now.

I may carry on. So, that's my experience. Week 24, well, that was an absolute disaster. I went on from—. After that 17-week, 18-week period, the next one that came along, it went up to 23; 23 and a half weeks it went up to. So, I've gone from 15 to way over the 16, and I'm worried to death about it. I'm really worried that I'll go blind. I can feel it coming on.

So, in conclusion, I just want to make this point, because a lot of things have happened, and you've not got the time to listen to me all day. The two opticians I use and the Macular Society are alarmed by what they see, as am I, which you can very well imagine from my voice. The inspectorate of health in Wales, HIW, who I contacted, I don't know what they've done, if they've done anything, but they said they don't investigate these matters, so I just didn't know who to turn to. Both myself and my MP have been fobbed off by the hospital, when we've both asked. I've asked about this 16-week period. I can't get an answer. We've been fobbed off with the same platitudes, evasion and obfuscation. They just don't want to answer at all when asked about it. I think it's a relevant question to ask. If the drug says, 'Use for 16 weeks, and then it doesn't function the same', why go over the 16 weeks? It seems absolutely pointless to me. It's a waste of my time, their time, and there's a chance I'm going to go blind. Because what they say to me is, 'Time is of the essence; you could blind at any time, it could strike at any time.' All I can say is I'm likely to be condemned to lose my sight by inaction and apparent incompetence, and this is a serious matter, as I feel that time is indeed the essence for my sight and retaining it. Thank you very much for all your support.

Well, Edward, thanks so much. That's really powerful to hear your situation and your story, and I'm sorry to hear that, and that's why we, as a group of Senedd Members, that's why we're doing this work, because we know and we've heard of others with experiences similar to yours. So, we want to try and make some positive action and make some recommendations to Government, so people don't go through the same situation that you've been through. But thank you so much for your very powerful evidence to us.

Did you have your hand up, Sara? I was going to ask a question, actually, so perhaps I'll ask it to you. So, given what we've just heard from Edward’s powerful testimony there, do you think that people, and those making decisions within health boards, do they appreciate and understand the scale of the issues when it comes to people not having their situations detected early enough? Do they understand the scale of the problem, I suppose? And do they understand the harm that can be done when situations like Edward’s are not followed through correctly?

That’s a good question. I think my first answer would be that I think they try to, but I think there’s so much that just doesn’t get understood from a lived experience point of view. I should have said at the beginning that, whilst I’m representing RNIB today, I’m actually a patient myself, with my own experiences.

I was diagnosed with type 1 diabetes at the age of three, and I can appreciate that a lot of the stories you might hear today might be from older people with sight loss, but I would really want to reiterate what that means when you’re diagnosed at three, or at 13, or any age in your early life, with a condition that is nothing to do with your eyes, but has a massive impact on your eyes. I grew up knowing that I could, at some point, lose my sight. There was no psychological intervention to hold that information. As you’ve just heard, at 80 years old, it’s frightening, and at a young age, it’s just as frightening.

We do have a screening service for people with diabetes, which is one step of preventative measures. From a patient point of view, I think there’s a lot of education—better education—we could do to engage with the health service. I think when you work in the health service, it’s quite difficult to navigate. I think when you’re trying to use it as well, you don’t really understand the difference between your optician, who’s different to your screening service, who’s different to your ophthalmologist, when you’re in secondary care.

But I just want to show you the impact that this can have on someone’s life. At 26—I’m now 37—I got diagnosed—. Well, I got my first letter of background retinopathy when I was 21. That period of time when you get that communication from the screening service is awful. There is no further support at that moment in time, and I feel that’s a really big missed opportunity.

Again, to give you a bit of an example of that—and I’ll try and be quick as I can, to give you some solutions, potentially—when I used to use Twitter—I no longer use X—and when I was a bit of an advocate on there, I used to get contacted by people with diabetes from all over, not just in the UK, about when they’d received that letter, what life was going to look like for them. And they would be really distraught. I did this off my own bat because I’d been in that position. That tells me there’s a need there for a service to be able to hold that person at that moment in time.

Actually, that is really early on in a pathway. I’m now stage 4 proliferative retinopathy. This is background, which can also be reversed. So, I don’t think we’re addressing where we could actually early intervene in a meaningful way for patients. And I think that patients could have a really big impact there, because, as somebody living with the condition, once I was speaking to people who contacted me on Twitter—I don’t even know what they looked like—they said, ‘I feel so much better for speaking to you’, and their psychological issues at that point have come back down. And I said, ‘Here’s what you need to do next’. That’s the first thing.

That's another very powerful piece of evidence. There are some very specific areas in there that we can't go into in this session but we can take away afterwards and dive into. Ansley, did you want to come in? I was very keen as well because you talked about solutions. So, in terms of Sara and Edward's cases—

I'm conscious of time, so just very quickly to say that, a number of years ago, the whole of the eye care sector across the UK, the royal colleges and patients, developed something called the eye care support pathway. It recognised all of the pin points, so pre diagnosis right through to post diagnosis, and that pathway has been accepted, the principles, within the national clinical strategy. So, what we need now is to make that happen, and that is about ensuring that, at every point of your pathway for eye care, you are offered advice, information and support. We are working with the CIN on that, but again it's something that needs to happen quickly so that people have got support.

Thank you. Lowri, you wanted to come in as well.

In preparation for this meeting, I spoke to a few people who we support and there are lots and lots of stories, and we hear them every day, about people's frustrations with clinical support and treatment. I think, for me, it's about that human element and how people are diagnosed and how people are supported at that point, as well as receiving treatment in a timely manner.

One of the stories I have is about a young woman who was a single parent. She's estranged from the rest of her family, so it's just her and her little boy. She was diagnosed with quite a rare eye condition, and the ophthalmologist was scrolling through what he'd found on Google in front of her. He then said, 'Yes, there's nothing that we can do for you. I'm going to discharge you. You're going to go blind.' She then left. She went and sat in the waiting room in the hospital. She was told that she was distressing other people in the waiting room, so she was asked to leave the waiting room. Because she's estranged from her family and quite isolated, she phoned her health visitor because her son was still under five.

She contacted her health visitor and was just panicking, saying, 'I've just been told I'm going to go blind, I don't know what I'm going to do. I don't know how I'm going to keep my son safe', and all of these different things. And she was just basically spiralling. At that point, the health visitor contacted social services and then social services arrived at her front door saying, 'We believe that there's a child at risk at your property.' So, literally everything that could go wrong in that diagnosis process did go wrong. There was no point at which she was offered any support, either emotional or information or advice about where to go to. She eventually found us a number of months later on. So, she went through all of that process on her own.

The eye clinic liaison officer is absolutely brilliant in the Maelor hospital, but he only works part-time. He's employed by the hospital, but he only works part-time. So, on the days when he's not there, people are being diagnosed in quite an insensitive and inhumane manner, really, as well, and being left to just get on with their life.

I've got other stories as well where people have been told that they've just slipped through the net. And it's quite an off-hand way of, 'Oh, yes, you should have had treatment', or, 'Yes, your mum should have had treatment but she's just slipped through the net, so we apologise for that.' And, for that lady, she'd lost all of her vision in her left eye and she's got low vision in her right eye.

We had a good news story, which was quite lovely to hear, but I think, for me, it's partly a good news story, but it's partly not. So, the patient was pleased with the treatment that she was receiving. She had macular, she was receiving treatment within the 16 weeks, which is brilliant, but it had taken six months for her to have her first treatment. NICE guidelines say that it should be happening within 14 days of diagnosis or from that initial appointment. So, even though the treatment was working well after it started, it had taken six months for her to start treatment.

Lowri, you've set out some really horrific examples there and situations of cases that just sound appalling. It did strike me, as you were speaking: do health boards in Wales employ eye clinic liaison officers to support patients and their families?

There is an ECLO in all of the north Wales hospitals now. Abergele was without an ECLO for, I think, probably about two years, maybe even a bit longer. I'm not sure how long Ysbyty Gwynedd was without an ECLO, but they've just had one start recently, and they've got a part-time one over in the Maelor. That is a really fundamental role so that people are picked up at that point and are given the right support. Because the sight loss sector seems to be the best-kept secret—people don't know about the local services. As a third sector organisation, we try and promote our services as much as possible, but people don't know where to go to find that support.

We've got the eye care pathway, which is brilliant, but making sure that that's really embedded within the clinical space so that they are referring into the third sector is absolutely essential. Because we can provide that ongoing emotional support for people, and also make sure that people know what to expect as well. With the lady who was saying that she was really thrilled with her support—she'd waited six months, and actually, that's down to her lack of understanding about what is best practice, what's even good practice. I think that's part of this work that we want Welsh Government to do around this. That's going to take time and I think part of it is that we need to empower patients so that they know how to look after their own eyes and take some responsibility for keeping an eye on their eye conditions and their sight, and go back to the same opticians all the time and go more regularly so that they can keep a track—

Thank you, Lowri. I'm so sorry, we've got a lot more questions that we won't be able to get to, but it was really important, I think, that we hear those examples, because that's so important to our work. So, we'll perhaps have to curtail some of the questions that we did have. But Mabon I'll come to you as well, if you've got any specific questions.

Thank you very much. Can I also endorse what the Chair has said about the direct evidence that we've heard? It really enriches this inquiry and it brings us an understanding of the problems that patients face. I'm really grateful to you for your contributions today.

In terms of looking forward to how we can improve the situation that we have, there has been mention, of course, of establishing three dedicated regional centres of excellence for eye care in Wales. Would that be beneficial? How can the third sector—the charities we have here today, for example—work with developing these regional centres?

I'll quickly start on that. There is a number of people with experience on that, to say that we want to see people that get what they need on time, and the rest of the witnesses today will tell you where there are problems in that, but the patient engagement and support has to be incorporated within any kind of regional model, and a hub-and-spoke model. And ECLOs, to go back to your previous point—some health boards provide some funding and fund them themselves, but in many health boards, every year, you're renegotiating a contract, so it's year-on-year in some health boards, and the third sector provides that ECLO support. So, our view is that the workforce should include the ECLOs within that workforce planning so that you've got that bridge between health and social care. So, can I pass over, then, to Marian, because she has really good examples on travelling to get treatment?

Yes, Okay. We are really stretched for time; I hate to say that, but just to make that clear as well. Marian.

Thank you. I'll be quite brief. Because of the rurality of Wales, we know some patients have to travel up to 100 miles to get their injections, with little support for transport. We also know that, in some areas, hospitals are now delivering treatments on weekends to reduce the waiting times. However, in some parts of Wales, no public transport is running on the weekends, so how are patients meant to get to their appointments? Some do not have families or friends to take them, and again, there is no offer for support for these patients. One gentleman I know has been waiting over 20 weeks for his injections and was offered treatment at another health board, where he had to travel 150 miles with no offer of support. Luckily for him, he had a family member, and that family member was able to take time off from his employment to take him. Otherwise, he would have lost that appointment and potentially lost some of his valuable sight.

But another thing I just want to quickly bring in: the geographic atrophy dry AMD treatment—we know that the Medicines and Healthcare Products Regulatory Agency recently rejected the drug Syfovre. However, we understand that another drug called Izervay developed by Astellas is imminent. Now, if Izervay is approved by the MHRA and NICE, we could see this drug being available in the NHS within the next sort of 18 months or so. So, my question to you is this: how will the health board deal with the influx of patients needing treatment for dry AMD, when they are not able to treat wet AMD in a timely manner? We know that some patients are experiencing irreversible sight loss every day due to the delay in treatment now. What plans are put in place for the next influx of patients with dry AMD? And thank you for the opportunity to speak today. Thank you.

Thank you, Marian. Did you want to come back in, Mabon, at all?

Yes, I did want to—. Thank you for those points. I think that there are questions that Marian has brought up that we can pick up in our report, and we will include them in the report, I'm sure, so thank you for that.

I just wanted to very quickly consider—I know time is short—your impressions, everyone here today, of the digital system, or the problems with the digital system, and how systems can't talk to each other, and how we continue to work with paperwork, with fax machines and so on. We've heard a lot today about the need to see how people with real lived experience see that affecting their treatment. So, I wonder whether there's a brief comment you can make about that, please.

Sara.

Thank you for the question, and I'm happy to answer in Welsh. I think it's vital that systems and different conditions can speak to each other. As I said, the windows of opportunity in terms of your health aren't open for very long, so, for example, when I was having my screening for diabetes, that went to the GP, but because I've got type 1, secondary care is looking after that. I go to the GP, then, and they say,

'There's nothing we can do, because we don't interact with your insulin pump.' Whose responsibility is it—

ophthalmology or diabetes, to look after our self-management? So, you have to have systems that speak to each other, so that the right people have the correct information, and that there's not a lot of repeating your story. You can say it today, but it's quite traumatic to have to repeat your story all the time. So, having digital things, especially for people with sight loss, can be very advantageous, because digital technology can be more accessible for people. We discussed apps such as Be My Eyes today before coming in. But we have to look to see how everybody can have digital systems that speak to each other. I think patients want their data to be shared, because, ultimately, they want the best treatment available.

I'll bring in Joyce, if that's okay, at this point. Do you have any further questions to add in this area, Joyce?

Yes. In terms of using the digital advantage, and I heard what you said, and thank you, first of all for sharing your stories, because they really do add the value, but there are limits about sharing data that organisations actually have to follow, so it isn't whether you're willing, it's the system in place, the legal system, about it. And I understand that some apps are also very useful because they will speak to people so that they can clearly understand what they need. But we've also heard about digital changes, and you've heard the previous sessions about the access of patients in a timely way to their information, so that they're getting the right treatment. So, have you had any experience about that impeding timely care?

Yes, and there are solutions. We know, I think it was said this morning, that people are still faxing and sending information from primary to secondary care. It's absolute madness in this day and age. We know that OpenEyes has been successfully rolled out in Cardiff and the Vale for some sub-specialties, and millions have been spent by the Welsh Government on this over many years, and we're now at this position where there's an impasse and we need this. OpenEyes is used very, very successfully in Scotland. In Northern Ireland they've got a system called Encompass that they use. Are we learning from other places across the UK who've implemented systems that are actually joining up primary and secondary care? It's shocking that we're still in a position where we do not have a system, when so much money has been spent on developing it, and these are issues that could be solved. If the will was there to solve these issues, we wouldn't be in this position now.

Thank you. That's it from me.

Thank you. The session really is drawing to a close, but Ansley, is there anything else that you want to say that you think's important for our work?

I think there are a couple of things and one goes back—thank you very much for the time—to Lowri talking about that patients don't know what their clinical risk is. So, if an appointment is cancelled you might just think, 'That's okay, it'll be fine, it'll be fine.' You're not fine. Lowri's example was of someone who, after six months, was, 'Great, I've got an appointment.' She was well over the time she should have been seen. So, patients do not know what their risk is and the health risk factor, so they're not chasing, and patients also don't like to chase because they think it might affect the care and support that they get.

The last thing that I would want to say, and I don't think it's been brought up today, is that health boards have actually got two different sets of measures for ophthalmology. They're meeting the referral-to-treatment time and the health risk factors—they're competing, so you can tick off your referral-to-treatment time to say somebody's had appointments and are in the system, but these are not the people who are at clinical risk.

Okay, understood. And in terms of our work, we're going to be making recommendations to the Government. Is there anything specific that you think that we should include within our recommendations?

It's very much repeating what I said at the beginning, which is about, you know, commitment in terms of investment, both financial and resources. That can include training everything, implementation at pace, and a timeline, and a mandate by the health Minister, otherwise health boards are not going to see this as a priority.

Yes, thank you. I always end the session by thanking the witnesses, and it's so helpful to us, the session that we've had, with all four panels today. But I do want to give a special 'thank you' to Edward, Sara and Lowri, because it is more powerful for us to hear the specific examples. I'm sorry to hear—we are sorry to hear—of your situations, but we're grateful that you've been able to come to committee and outline your story so powerfully to us. We hope that that gives us the ability to put those within our report, and our report will be directly seen by the health Minister. So, we hope that your stories will shed a light and bring about change, so other people don't have to go through the same journey that you've gone through. So, thank you so much for your time today. Edward, you're saying something; I couldn't quite—. Say it again, Edward.

Thank you very much for listening to me.

No, not at all, Edward. Not at all. Thank you, all. I appreciate it. That draws this particular item to a close, but diolch yn fawr iawn. Thank you for your time today.

Thank you.

Diolch.

I move to item 7. We have a number of papers to note, which are also in the public pack. There's correspondence from the Minister for Mental Health and Well-being following the committee's scrutiny of the Welsh Government's draft budget, and also correspondence from the Petitions Committee with regard to the petition, 'Establish a "Care Society" to Tackle the Long COVID Crisis in Wales'. Are Members content to note those papers? Yes.

I move to item 8, and under Standing Order 17.42, I will propose that the committee resolves to exclude the public from the remainder of today's meeting. Do we all agree? We all agree. In that case, that draws the public session to an end today. Diolch yn fawr iawn.