We move now to item 4, a statement by the Minister for Health and Social Services: Future approach to optometry services. Eluned Morgan. 

Diolch yn fawr. 'The Future Approach for Optometry Services in Wales', published in March, is ambitious and it's transformative, changing the way eye health services are delivered. Aligned to 'A Healthier Wales', and underpinned by the key principles of prudent healthcare, the approach supports our overall aims, which are: to improve access for citizens; to move delivery of services from secondary care to primary care in order to address the backlog in patient appointments and delay in follow-up appointments in hospitals; to reduce demand on hospitals and GPs; and to reform general ophthalmic service contracts.

As Members know, waiting times are significant. Patient numbers waiting for their first hospital eye health appointment, and subsequent follow-up, continue to rise. This increasing demand remains a challenge not just across Wales, but across the United Kingdom and Europe as well. Ten per cent of outpatient appointments are for eye clinics and cataract surgery accounts for about 6 per cent of all surgery in the United Kingdom.

Current capacity to provide specialist hospital eye services is extremely limited due to limitations on personnel. The Royal College of Ophthalmologists 2018 census reported that an extra 230 consultant posts were required across the UK to meet rising demand for services. So, unfortunately, a significant numbers of posts remain unfilled. I'm afraid that the completion of trained doctors each year is on average 74 across the UK. Therefore, there is a significant shortfall of trained doctors to fill current and future hospital posts. In Wales, thankfully, we have had an increasing number of people in primary care to add to the optometry workforce. So, by 31 December 2018, 875 practitioners were able to deliver NHS sight tests, and that's 34 more than in the previous year and a 19 per cent increase since December 2008.

Further upskilling to enable optometrists to work at the top of their licence in their practices, with the appropriate equipment, means optometrists are in an ideal position to support hospitals to address demand and transform patient pathways. Over the past five years, increasing numbers of optometrists have gained additional higher qualifications in medical retina, glaucoma and independent prescribing. Optometrists with these higher qualifications can diagnose, manage and treat more patients in primary care, improving patients' access to care closer to home. This approach will significantly reduce the demand for a hospital opinion and intervention, and we know that is already reducing demands on GPs.

Last year, the then Minister for health announced £4.8 million funding to develop and implement a national electronic patient record and an electronic referral system across primary and secondary eye health care. To support this digitisation, health boards received £3.5 million in additional funding to replace equipment that had come to the end of its life. Introduction of these new digital systems will help to address the demand problems in hospitals, through shared care and monitoring of stable patients within primary care, providing a better experience and improved outcomes for citizens. The digitisation fund and the shift in emphasis complements the patient pathways, implementing and delivering services seamlessly across the patient journey between primary and secondary care. This is a significant move, enabling optometry practices to be the first port of call in primary care for patients with an eye problem.

The pandemic caused whole-system disruption to health services. However, it provided the opportunity, in the wake of the pandemic, to redesign service delivery, ensuring sustainable models for the future. Therefore, with people starting to feel more confident about accessing care outside hospital settings, we now, more than ever, need to adopt a shared care model in providing eye health care. The resources that NHS Wales has are limited, so we need to take the opportunities to transform services, in the way that has been presented in the document 'Future Approach for Optometry Services'.

The NHS has to take advantage of non-medical advanced practice, by moving more services into primary care. The 'Future Approach for Optometry Services' document is based on work and extensive consultation. The document was approved by key stakeholders, including Optometry Wales and the Royal College of Ophthalmologists, and work is now under way to consider further the potential costs in terms of developing the agreed future approach. 

In order to help to move the provision to primary care, we will need to amend the optometry contract and increase the number of optometrists who have additional qualifications. To achieve the best outcome from investment, the Welsh Government will continue to talk to stakeholders, to ensure that optometry services are appropriately funded. We as a society will benefit by investing in a skilled workforce and ensuring that patients can obtain services more easily and have better outcomes.

Unlike other professions, such as general medical services, pharmacy and dentistry, optometry doesn't have a contract. This is therefore a unique opportunity to decide on the best approach for the future. We have considered and learnt from what we have done in the past, to ensure that legislative changes are made to deliver the best outcome for patients and for health professionals. And we have learned lessons from that. If optometry works with NHS Wales in a new, strategic and collaborative partnership, which will build on already strong foundations that have already been set, future eye care will certainly improve.

Of course, we will need to monitor the new contract arrangements carefully. We will establish a new national Wales eye care service committee, which will have a clear terms of reference, including performance management against contractual obligations and deliverable patient outcomes. Generally, if we are to succeed, we will have to see changing behaviours from the public, and we have to agree to think about what we are doing in terms of the patient's circumstances. Patients don't always understand the difference between primary and secondary care, but they do understand the need for good eye health care. 

'The Future Approach for Optometry Services' describes the new ways of working and clinical pathways. With a new contract for general ophthalmic services underpinning this, this innovative future approach ensures that Wales's eye care services will continue to lead the way across the UK. Thank you. 

I'd like to now call Russell George, the Conservative speaker. 

Diolch, acting Presiding Officer. Minister, can I thank you for your statement and for the update on the future approach to optometry services? This week, National Eye Health Week stresses the importance, of course, of regular eye tests for all. So, I'm sure that we'll all be surprised that there's been a drop of 180,000 eye tests delivered across Wales in 2020 alone, let alone what those figures are for this year. There's also an estimated loss of £2.5 billion, so they say, in terms of loss to the UK economy because of sight loss.

Since the Government's policy was outlined in March, we're aware that the Welsh Government hasn't ruled out a further lockdown, and we're, of course, acutely aware of the winter pressures. This means that eye appointments being missed are likely to increase even further. I'm sure the Minister would agree with that analysis. So, can I ask what immediate preparations are you, therefore, Minister, making to ensure that opticians and NHS optometrists throughout the winter—? What assurances can you give to the Welsh public that they will be able to receive an eye test for the rest of 2021? 

I'm also concerned that the future approach is short on targets and without a clear timetable. You've even mentioned in your statement today, Minister, that work is under way to consider the potential costs of the future approach, but you don't mention when you expect this by. There have been some really good examples of optometrists, as you say, who have set up services to diagnose, to manage, to treat patients in the community who would have ordinarily been directed to secondary care. So, this is all good news and very much welcome. Can I ask what efforts you are making to ensure that the work of the regional partnership boards means that excellent initiatives, such as what I've outlined, and you've outlined in your statement, are equally available across Wales?

The Specsavers report also refers to reduced ophthalmology appointments during 2020 as well. The most recent eye care measure statistics show that less than half of Welsh patients at immediate risk of sight loss or irreversible harm were waiting within their target date for an appointment. So, my final question is: what actions are you taking to ensure that both patients who are at a immediate risk of sight loss and those who have less severe risks will be able to be seen on time? Will the data for those in R2 and R3 categories also be published, and, if so, when? Diolch. 

Diolch yn fawr, Russell. It is true, of course, that there has undoubtedly been a reduction in terms of the number of eye tests carried out. That is not surprising in light of the fact that actually for lots of months of the year lots of society was closed down. What I'm acutely aware of is that there is huge pressure on our NHS services at the moment and particularly in our hospitals. So, what this approach is trying to do is to make sure that we can divert people away from hospitals. We have people who are highly skilled, who are in place within our communities, who are able to provide the service that previously was provided in hospitals, and we think that we can divert around 30,000 people, a third of the people who would otherwise have been referred into hospitals, through this mechanism. So, we are happy that that is the case. The fact that we've trained more people and that HEIW will be looking at how we're going to be training even more in this space will help us to meet what you are very keen to see, which is making sure that those appointments that have been missed are reinstated because we're able to do that. So, I'm very pleased that that will be happening.

In relation to the regional partnership boards, I think the space here, I think there are real issues in relation to cataracts—you'll be aware that there are very long waiting lists for cataracts. And one of the things that we are looking at is the development of regional cataract centres so that we can get high volumes of people through these cataract centres in a short space of time. We've asked health boards to work together and to come up with proposals in this space, so hopefully, we'll be able to give some further news on that once those have been tested and made sure that they are absolutely in the right place.

When it comes to urgent eye issues, I think you're absolutely right, there are lots of conditions where, if you don't deal with them immediately, people lose their sight. And that's why there is a very clear process for determining who goes first when it comes to people being seen in relation to any issues with eyes. It is a clinical decision, it's based on a clinical model and it makes sure that those who are likely to lose their sight, if they don't get the attention they need, are put to the front of the queue. So, I hope you'll be reassured by that.  

I'd like to call Peredur Owen Griffiths, the spokesperson for Plaid.

Diolch yn fawr, acting Presiding Officer. A diolch ichi, Weinidog.

I welcome this update on the future of optometry in Wales. There are fewer things more precious than sight and we should never underestimate the difference a well-run service can have on people's lives. I'm pleased to hear from the statement that there is work going on to upskill optometrists to enable them to work at the top of their licence in their practices. Any initiative like this that will help the NHS tackle the long waiting lists must be supported.

I must also pay tribute to the strides made since the development of a Welsh eye care initiative in 2002. This has been done in tandem with the ophthalmic profession to change and lead on eye care reform. Practitioners continue to work at a high level to provide an excellent level of care for the benefit of their patients in Wales, even throughout the pandemic.

Turning to the impact of the pandemic, like many other services, eye care has been deeply impacted by the pandemic. During the first lockdown, University College London researchers reported a 70 per cent reduction in new referrals and a high rate of missed appointments. Researchers and national sight loss charity, the Macular Society, have raised concerns about the long-term impact that this will have, as it is predicted that it will have led to hundreds of additional cases of severe sight impairment in the first lockdown alone. In Wales, for example, with a higher proportion of over-65-year-olds compared with the UK average, problems such as glaucoma could become much more prevalent.

The statement mentions the opportunity that the pandemic provides to redesign optometry services in Wales. We must return to a service that responds to the symptoms of sight loss in a timely manner, because many conditions can be treated if they're caught in time. While the onus is on the patient to report symptoms of sight loss, we also need a robust service that can respond to a patient's needs in a timely manner once symptoms are reported. Evidence suggests that optometry in Wales can be mixed, depending upon where you live. Good eye care in the Welsh NHS should be consistent and not dependent on where you live.

In recent years, there has also been a steady decline in vision rehabilitation services across the country. This means that adequate vision rehabilitation support is not being given to many blind and partially-sighted people when they need it. This is key, because research by Cardiff University demonstrates there are significantly improved outcomes for participants who had received visual rehabilitation compared to those on waiting lists. I would, therefore, like to see the Government go further and answer the following three questions. Firstly, will the postcode lottery of vision rehabilitation be eradicated in Wales? Secondly, will you consider adding vision rehabilitation to the list of qualifications eligible for the apprenticeship levy? And finally, thirdly, will you prioritise preventative services, including vision rehabilitation, alongside needs-assessed services, rather than after, once we are fully out of the pandemic? Thank you.

Diolch yn fawr, Peredur, and thanks very much, and I think you’re absolutely right to draw attention to the fact that there have been a lot of missed appointments during the pandemic, and that could be storing up issues for the future. One of the things that we’d like to do is, by moving this care from secondary into primary—it means that people can get that support closer to home, which I know is something that you’re interested in, and I think that’s absolutely right.

I think when it comes to things like cataracts, I think, actually, a case can be made for people travelling a bit further to get specialist support—I think that there will be a few changes that we’re going to have to make if we are serious about making inroads into those very, very long waiting lists. I know that’s something that they do in Cuba very effectively. I’m not saying that we’re going to model everything on the Cuban health system, but I thought it was very interesting that it is possible to do very high volume with very specialist people away, often necessarily, from hospital centres. So, I think it’s certainly a model that’s worth investigating further.

You’re absolutely right to draw attention also to the fact that the situation is likely to become more difficult in future, partly because we’ve got an ageing population. So, certainly, the figures that I’ve seen in terms of demand for services in the next 20 years—we’re likely to see: an increase of 16 per cent in terms of the number of people having issues with glaucoma; a 47 per cent increase in terms of age-related macular degeneration; 50 per cent with issues with cataracts; and an 80 per cent increase in demand in terms of diabetic retinopathy. So, we have to make these changes because we simply will not be able to keep up with that demand unless we do something differently, and this is all part of—. What we’re trying to do is to transform services. We can’t go back to the way we’ve always done it because we simply won’t be able to keep up with the demand. So, I’m very pleased to see that.

In terms of postcode lottery, what we’re trying to do by bringing this support into people’s communities so that they can have it in their local opticians, and they are then referred—. I met a man in Swansea recently, when I visited the hospital there, who had been referred directly by his optician into the health board itself. So, there are ways of doing this that would make life easier for those people living in communities so we do take away that postcode lottery that is sometimes the case at the moment.

In terms of the qualification and apprenticeship, I think the apprenticeship levy is something that is determined by the number of people who are engaged, so that’s perhaps more difficult for us to organise, and is something that’s organised by the UK Government, so we just need to bear that in mind. But, certainly, I think there is scope for us to see what more we can do, going through that apprenticeship route. So, I’ll see if we can look if there’s any scope for us to do more in that area.

And I’m afraid that your third point I didn’t quite get, so I’ll come back to that at another point. If you’re happy to write to me, I’d be grateful.   

Thank you for your statement. This is prudent healthcare in action. Well done. You know, given all the problems we face in the health service, it's really important that we are moving services to primary care, where it's safe to do so. And I'm sure this is going to be very much welcomed by people who can now get an excellent service in their local communities.

I visited a really excellent optometry service in Pentwyn with your predecessor, Vaughan Gething, who piloted the electronic referral system and the digital imaging that enabled them to share these images of the eye with the ophthalmologist, where there was an urgency to get a specialist opinion. And I wondered if you could tell me—there was £4.8 million to develop the electronic patient record and £3.5 million to replace equipment—does that mean that all optometrists with higher qualifications can be certain of having that level of equipment, to enable them to quickly push through any serious concerns they detect in their examinations? Because that seems to me really important in relation to your answer to Russell George around ensuring that people don't lose their sight because we're hanging around.

And, secondly, I wondered if I could ask you about how we're dealing with cataracts, because a friend of mine runs a very successful charity called Second Sight that deals with thousands of cataract operations in Bihar, which is the poorest part of India, using ophthalmologists from across the world. In Bihar, they can do 1,000 cataracts a day, which is obviously transformative. Do we have the same ambition in Wales to have these sort of production lines of cataracts? Because, yes, there are lots of them, but it's a pretty straightforward operation to do, and, therefore, we just need to get shot of the problem, and I'm sure people will be prepared to travel.

Diolch yn fawr, Jenny. I'm glad you agree with our move to primary care, and you're absolutely right, this is all about 'A Healthier Wales', it's delivering on what we set out, and it's about the transformation of our services.

What we're doing now in terms of those optometrists who have those higher qualifications that we're encouraging constantly to work at the top of their licence, is that we're working now with the national ophthalmic planned care board to scope the requirements in terms of not just the estate that's needed, but also the equipment and the staff. So, if we are to meet the demands that I set out earlier, what does that look like, what will we need to put in place? So, that £4.8 million that you talked about for the national eye care electronic patient record, that's money that's already gone in. We now have to calculate how much more we need to put in in order to make sure that everybody who goes through this process is able to access. So, that is now being worked up by the partnership that has been put together, so that we can deliver on exactly what you're talking about.

And I agree with you: I gave the example of Cuba; you gave an example that you're familiar with, and I very much agree with you. We've got to make sure we don't dehumanise people when we're doing this, but I do think that there is scope, when we're in the kind of situation that we're in at the moment, where, frankly, people need a quality of life that they are losing every day, I think you're right; I think there is a case to be made for asking people to go to specialist centres—this is not for routine, but it's for specialist centres for cataract operations—and that's what we're working up at the moment. So, I do hope to be able to bring you some further news on that in the next few months.

And finally, Janet Finch-Saunders.

Thank you, acting Deputy Presiding Officer. Minister, I'm becoming increasingly concerned of late to see a number of constituents presenting to me, in my office, whereby they suffer with wet macular degeneration and usually have drops every month. Obviously, during the COVID pandemic, some of these were then decreased to every six weeks. However, I now have constituents coming to see me whereby they're not able to obtain these injections—it's taken three months to obtain them. And, in fact, the specialists, or consultants, are saying, 'Go and see your Member of the Senedd, because you should be having these drops every month; three months is simply not enough, and there is a risk to your eyesight.' Minister, with that in mind—I can write to you outside of the Plenary today, but with that in mind—would you send out guidance to our health boards that this is vitally important, and that if these injections are due every month, then those patients should receive them every month? Diolch.

Diolch yn fawr, Janet, and I met with a constituent recently also who had a similar situation. Of course, there were examples where what happened before was that those people were sent into secondary care. What we've been trying to do is to move some of this support out into other areas. So, for example, I know there was a case in Crymych, for example, where they tried to develop an opportunity for people to get that support in a centre in a very rural area. So, there are opportunities to do this in a different way.

As I tried to explain earlier, what we're doing here in relation to eyes is we are prioritising on the basis of clinical need, and certainly I know that there has been an attempt to see if it is possible to give those injections in a way that doesn't need to be given quite as often as they were before. That has got to be a clinical call; it can't be a political call. And so I'm certainly happy to look into it to make sure that, if those decisions are being made, they are absolutely being made on a clinical basis, rather than any other reason.

Right. That brings that item to a conclusion. Thank you, Minister.