Jerry Buttimer (Cork South Central, Fine Gael)
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I thank the witnesses and those in the Visitors Gallery for their patience. I apologise for the delay in starting this session, but as I said earlier this is the second part of the meeting, and we did not know how to gauge the time allocation. We have received apologies from Deputies Regina Doherty, Peter Fitzpatrick and Billy Kelleher. Senator Imelda Henry is being replaced by Senator Martin Conway. I remind members, witnesses and those in the Visitors Gallery that all mobiles telephones should be switched off for the duration of this meeting because they interfere with the broadcasting of proceedings even when in silent mode.
This session of the committee meeting has been convened at the request of Deputy Mary Mitchell O'Connor to discuss the costs and other issues around blindness in Ireland. I welcome members of the National Vision Coalition, an alliance of health care professionals, those working with the sight loss community and service users who are doing outstanding work. I congratulate them on the recently published study Economic Cost and Burden of Eye Diseases and Preventable Blindness in Ireland. Members will have an opportunity to discuss the work of the National Vision Coalition and to consider the cost to the State of vision impairment and the saving that could be made from early intervention. Senator Conway has been a very good advocate for the sight loss community and has been a tremendous role model in the Houses of the Oireachtas.
I welcome those in the Visitors Gallery. They are Ms Siobhan Kelly, CEO and Ms Ciara Keenan, communications managers of the Irish College of Ophthalmologists; Mr. Padraig Mallon, CEO of the Irish Guide Dogs for the Blind and a good friend of mine inCork; and Mr. Gerry Kerr, Service User Representative, who is here with his dog, Orva. I thank them for being present. I welcome our witnesses, Ms Maria Meehan, Mr. David Keegan, Mr. Desmond Kenny and Ms Elaine Howley.
I advise that, by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if a witness is directed by the committee to cease giving evidence in regard to a particular matter and continues to do so, the witness is entitled thereafter only to a qualified privilege in respect of his or her evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.
I apologise to members for the croakiness of my voice but I have a chest infection.

That is why I am half-hoarse.

I formally welcome to the Public Gallery, Ms Siobhan Kelly, chief executive officer, and Ms Ciara Keenan, communications manager of the Irish College of Ophthalmologists, Ms Elaine Howley, chief executive officer of NCBI Services, and Mr. Padraig Mallon, chief executive officer of the Irish Guide Dogs for the Blind. Mr. Gerry Kerr is attending in his capacity of service user representative with his dog, Orva, and I welcome both of them to the meeting. It is good to have Orva in attendance and hopefully Orva will keep an eye on and mind members. Many witnesses appear before the joint committee and it is good to have a dog attend a meeting for the first time. I also welcome Ms Irene Reid, National Rehabilitation Hospital, Mr. David Green and Ms Doreen Curran and Dr. Eva Lindgren from Novartis, Mr. Paul Moriarty, national clinical lead of the national clinical programme and Mr. James Dunny, National Vision Coalition.

I invite Dr. Maria Meehan to make her opening statement.

Dr. Maria Meehan:

On behalf of the National Vision Coalition, I thank the Chairman and members of the joint committee members for giving us the opportunity to speak about the framework to adopt a strategic approach for vision health in Ireland. The National Vision Coalition is an alliance of ophthalmology health care professionals, those working in the sight loss community and, most importantly, service users who were brought together in 2012 by the National Council for the Blind of Ireland, NCBI, and Fighting Blindness. The coalition consists of the NCBI, Fighting Blindness, the Irish College of Ophthalmologists, the Association of Optometrists in Ireland, Mr. David Keegan, Mater Hospital, Diabetes Ireland, Irish Guide Dogs for the Blind, ChildVision, Mr. Mark Cahill, Eye and Ear Hospital, Dr. Maureen Hillery, Health Service Executive, HSE, Ms Irene Reid, National Rehabilitation Hospital and Mr. Gerry Kerr, service user representative. The chief executive officer of Fighting Blindness, Ms Avril Daly, sends her apologies as she is attending another event but I now wish to introduce Mr. David Keegan, consultant ophthalmic surgeon, Mater Hospital, Dublin, and Mr. Des Kenny, chief executive officer of the NCBI Group, who will present our strategy in further detail, in particular on the cost to the State of vision impairment and on what kind of savings could be made from an early intervention.

Mr. David Keegan:

I thank the joint committee for this opportunity and thank Deputy Mitchell O'Connor for organising this meeting. I wish to talk about the cost and burden of blindness in Ireland. What is blindness? What does it mean to be blind in Ireland? Members should think about that for a minute. It is frightening, emotional, disconcerting and anger-inducing. Why should it make one angry? Because 75% of blindness is preventable and avoidable. Blindness is defined as best vision of less than 10% of normal vision. That means struggling with all visual tasks up to total loss of sight, not even being able to see lights. Moderate vision impairment is defined as best vision of just 10% to 30% of normal vision, which means not being able to drive, difficulty with reading and that performing many tasks becomes tough and problematic. There is less immediacy in one's life. Mild vision impairment is defined as best vision of just 30% to 50% vision in one's better-seeing eye. This means one cannot drive and one touches loss of independence.

One in 20 people in Ireland is affected by one of the four main eye diseases, namely, cataract, age-related macular degeneration, glaucoma and diabetic retinopathy. This rises to more than one in two people over the age of 80. Each individual eye disease leads to a significant reduction in well-being, which is equivalent to more than 700,000 work days or 2.1 million healthy days lost per annum in Ireland. The financial cost to the State also is considerable. Based on our report, the financial cost to the State in 2010 was €386 million and on current trends, that will rise to more than €449 million by 2020. These costs are manifest in the Department of Social Protection through increased welfare payments and fewer people in the workforce, in the Department of Finance through a reduced tax take and the deadweight loss incurred by transferring moneys from the tax take to the welfare side and of course are felt in the Department of Health through supports and interventions for patients affected by blindness and vision impairment. However, if we introduce interventions such as screening for cataracts and diabetic retinopathy and provide for other early interventions, we can ensure that for hundreds of people, their sight will be retained and will be saving the State hundreds of millions of euro over the coming years. Rather than incurring higher costs, up to €76 million per annum potentially could be saved, were cost-effective measures identified in the strategy concerning the four main eye diseases in Ireland to be implemented. This does not require a significant budget increase but rather, services must be improved through efficient use of existing resources and a redeployment in current resources and expenditure.

People with vision loss and blindness are eight times more likely to fracture a hip, three times more likely to suffer from depression and admission to nursing homes on average takes place up to three years earlier than in the case of those without vision impairment. Moreover,the costs to the State rise significantly from €1,700 per annum up to €21,000 per annum if a person slips from visually impairment to blindness. Preventable blindness is an Irish, European and global issue and not just a Third World issue. The National Vision Coalition outlined earlier by Dr. Meehan is committed to tackling the issue in Ireland. Many of the structures to tackle this already are in place but more help is needed from policy-makers in order that we may co-ordinate a comprehensive and cohesive approach. This can be achieved through a national vision strategy.

Jerry Buttimer (Cork South Central, Fine Gael)
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I apologise to Mr. Keegan but must inform Senator Conway that there is a vote in the Seanad.

Martin Conway (Fine Gael)
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I thank the Chairman and apologise to the witnesses.

Mr. David Keegan:

It is nothing the Senator has not heard before.

Evidence of the benefits of introducing a strategy on health already has been felt in Ireland. The cancer strategy of 2006 already has led to improved patient survival rates for cancer and improved patient care. Crucially, Ireland also is delivering globally relevant groundbreaking research in this field. The National Vision Coalition believes this can be reproduced in respect of blindness. The evidence for vision strategies also is available from Denmark and Scotland, with reductions of 50% in blindness rates due to macular degeneration and diabetic retinopathy identified in those countries. The recent establishment of the diabetic retinopathy screening and treatment programme, Diabetic RetinaScreen, and the HSE’s national programme for eye care have provided a real opportunity to achieve improved outcomes for patients with sight loss in Ireland. At present,there are approximately 147,000 diabetics on the national diabetic register under this programme , more than 6,500 of whom already have sight-threatening retinopathy. The total projected cost of this programme over the next six years to include screening, treatment and sight-related costs is approximately €100 million. While this cost will peak in 2015 and 2016, we expect a net saving as we move into 2017 and 2018. Although the gross figure of €100 million seems high, the net figure, when one takes into account the savings from preventing of blindness and vision impairment, is €21 million or €145 per diabetic patient over six years. Moreover, as I noted, this will edge towards savings after the six-year period. The programme will also prevent 235 cases of blindness, nearly 700 cases of moderate vision impairment and nearly 2,000 cases of mild vision impairment. For some, it will mean they can stay working and continue to contribute while for others, it means they can keep their independence and live on their own or continue to drive.

Our job individually within the coalition is to look after patients at risk of, or affected by, sight loss and blindness. We are asking members to help us to fulfil that role in the public interest by the adoption of this coherent national vision strategy, which pulls together all the existing and proposed components of eye care, thereby allowing us to work collectively. A fully implemented strategy reducing preventable blindness will save thousands of Irish people from blindness and vision impairment while saving the Exchequer up to €76 million per annum. I again thank the joint committee for the chance to talk about the cost burden of blindness in Ireland and will pass members of to Mr. Des Kenny to conclude.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. Keegan. Mr. Des Kenny is the chief executive office of the National Council for the Blind of Ireland and he is very welcome.

Mr. Desmond Kenny:

I thank the Chairman. Just as the joint committee has had its first dog present at a meeting, members will now see me reading in a format they hopefully will not see many people using before this committee.

I sincerely thank both the Chairman and Deputy Mitchell O'Connor for inviting us here today, who, with the other members, paved the way towards our attendance.

This morning, we have given the joint committee a summary of our framework or road map for a joined-up strategy regarding eye health and associated support services. The coalition, on whose behalf we have presented, comprises all the people and organisations that can deliver on a strategy. The strategy can reduce to near elimination preventable blindness, as 75% to 80% of deteriorating sight loss can be arrested. We cannot create that strategy but we can deliver on such a strategy. We can assure the joint committee of its multiple values in savings of €76 million per annum, as indicated by Mr. Keegan, to a health service under severe financial pressure. We also can assure the joint committee that the strategy guarantees an improved independent lifestyle for people in their older years.

As people live longer, the eye diseases of aging must be combatted. There is no inevitability that sight loss has to darken the last years of old age. We all have relatives or know people whose sight is, to use the usual euphemism, “not the best”.

The National Vision Coalition’s framework provides for a seamless pathway to people from their first visit to an optician to the offer of treatments in their local communities by optometrists and community ophthalmologists.

There is only a short window of opportunity from the time of the diagnosis of eye disease to achieve a full arrest of loss of vision. If the Government does not enlarge the framework to a strategy and sees the roadmap of the coalition as leading to cost-effective services, the result will be the unnecessary and scandalous loss of eye-sight in hundreds of thousands of ageing people. When I had my childhood accident in the mid-1950s cortisone was not widely available. Had it been in more general use, I would not have been blinded in my right eye as a result of cross-infection from the blinding injury in my left eye. The treatments for today’s eye diseases are known and can be made more widely available at a fraction of the cost of the €76 million to which Mr. Keegan referred. Those savings could be adopted and made into a national vision strategy.

Today’s blindness is unnecessary. Where it does happen, support services such as those offered by Fighting Blindness, Guide Dogs for the Blind, Child Vision and NCBI can restore or give a new and different form of independence to people like myself. Please do not have people reach into our services unnecessarily because the State will not invest in eye health. The coalition consists of organisations and bodies which are joining our efforts in making a case we know has the sympathy of the Minister for Health. I ask the committee to offer more than sympathy for our cause by helping us to get the Government to deliver on a national vision strategy.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I join the Chairman in welcoming the witnesses and all of those who have accompanied them, and I thank each of them for their respective contributions. I will try to elaborate on some of the points raised. It is encourageing, and I wish it were replicated across other areas, that the National Vision Coalition is an alliance of service users and those who work in the sight loss community. That is not always the story when people present to this committee. I commend everybody on that approach, which is a template that could and should be replicated in many other areas.
The statistics are cause for concern, with one in 20 people in Ireland affected by one or other of the four main eye diseases. It is a huge number and it increases according to the age profile of the community. I ask for clarification on the issue of diabetic retinopathy. Where it is appropriate for people who are diagnosed with diabetes to present for eye screening, does it apply to type 1 and 2 or is it particular to type 1, which is the more severe form of diabetes? For the significant body people with type 2 diabetes, monitoring and diet are the key issues. Type 1 is another story entirely. I understand that the management of type 2 diabetes does not advise particular observation of sight and other matters pertaining to diabetes in terms of limb and foot health which present in type 1.
I take it that the witnesses have a plan for developing a national vision strategy and that it is not just an idea, although they have not yet committed to paper a comprehensive strategy. Is it a document at this point in time? They indicate that a number of goals can be achieved through a national vision strategy but there was a suggestion that such a strategy was already to hand and could be presented. I ask them to clarify that issue.
In regard to what they are asking from us, after clarifying my question on the current status on a national vision strategy, we can use our individual and collective weight as Members of the Houses of the Oireachtas to press for its adoption by the Government so that it has the imprimaturand status it needs. I can only speak on my own behalf but I have no doubt that I would be reflecting the views of all the members of this committee in saying I would be delighted to play my part in achieving what the witnesses have asked from us. This is all the more reason for expressing gratitude to them for appearing before us, and to our colleague, Deputy Mitchell O'Connor, for making the case for inviting them. We are only as good as the information that is shared with us.
In regard to Mr. Kenny's comments on a joined-up strategy, I have argued with my colleagues in Government that we do not have joined-up government. Many Departments operate in silos. That is part of the deficiency of government. It is not a reflection on the current occupants of the posts; it is just a fact of life. I expect that the strategy goes beyond the Department of Health to cross Departments in its construction and approach. Even as a layperson in this regard, I see the sense of that in respect of the areas which the witnesses seek to address.
Mr. Kenny concluded on the interesting point of not requiring people to reach into services unnecessarily. I had to think about the way that was phrased but he was telling us that blindness is avoidable. It is not that people are coming to pilfer but that such a scenario can be avoided by early intervention. That is the critical message the witnesses are delivering. I hope I have not laboured them with too many questions. I thank them again for their contributions and assure them that, in my role as Opposition spokesperson on health and a proud member of this committee, I will work with colleagues of all opinions to support the case they have made.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I thank the witnesses from the National Vision Coalition for coming before us.

I welcome the four people in front of me and all the people in our audience. The coalition represents 220,000 people who have impaired vision or are blind. I have met representatives of the group on a number of occasions. I know I have told them they are too nice. They have spoken about how their cost-effective plans will save the Government money. I would prefer if they focused on the eight principles they want put in place. What progress has been made since the Government signed up to the WHO's Vision 2020 strategy in 2003? In that context, perhaps they can tell us what they want to achieve before 2020. How can we put it in place? I agree with Mr. Kenny that when the members of the delegation walk out of here, it is not good enough for us to sympathise with them and the 220,000 people they represent. I want to see a plan of action that we can take on board. We can try to ensure it forms part of the strategy and budget of the Department of Health. If it is not part of the Department's budget, we are all wasting our time here. I ask the witnesses to outline exactly what they want.

Some of those listening in will be aware that my brother is blind. He would tell me that he feels invisible and unrepresented in society. Does Mr. Kenny agree with him that there is a prejudice against people who are visually impaired or blind? What can be done? I want to send a message to medical health people. When my brother and I attend various consultants, he is quite often ignored even though he is the patient. The consultants choose to speak to me and expect me to answer the questions as if he was not there. I also have some concerns about general practitioners in this regard. I do not refer to Mr. Keegan, about whom I heard some good things during the week. He saved someone's life. Are consultants in general, including diabetic consultants, and GPs trained in how to deal with the sensitivities of patients who are visually impaired or blind? The witnesses suggested that the public is not aware of such sensitivities. I have seen medical health professionals treating blind people in a way that is not sensitive. Before the witnesses leave this meeting, I want them to give the members of the committee a list of exactly what they want us to do so that we are clear on exactly what to ask for when the Minister and officials from the HSE and the Department of Health come in here. I am not asking about money that can be saved. I am asking about what the coalition needs to prevent 220,000 people from going blind. Can Mr. Keegan explain to the public what it should be doing? Should people who are worried about diabetic retinopathy, cataracts or age related macular degeneration go to their ordinary GPs in the first instance?

Martin Conway (Fine Gael)
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I apologise if I some of the questions I intend to ask have already been covered. If they have, perhaps the witnesses can tell me and I can check the record. I am one of the 220,000 people who are living with the consequences of sight loss on a daily basis. While my loss of sight was not preventable, I agree with the coalition's aim of preventing as much as possible of the 75% of sight loss in this country that is preventable. Obviously, I have a deep personal interest in advancing this cause. I was pleased to facilitate a meeting between the coalition and the Minister. I am not sure whether it took place before or after Christmas. I know the Minister is committed to the principle of a strategy. The challenge for us is to make that happen. I would like to speak about my role in the Seanad in this respect. I hope that a Private Members' motion on this issue will be debated on 17 or 18 July and that the Minister for Health, whoever he or she is at that time, will reply to it. One has to be positive in hoping that certain commitments will be made during that debate. I would like Mr. Keegan and Mr. Kenny, who are welcome at this meeting, to comment on what is happening in other countries. How far behind other countries are we? I would be specifically interested to know to what extent the European countries against which we should be benchmarking ourselves have advanced this principle. We should be using and following them as an example.

John Crown (Independent)
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I apologise for not being here earlier. Today's parliamentary schedule required me to be in the Seanad Chamber to advance a piece of legislation. I wish to ask Mr. Keegan a question that he may have answered already. My colleagues on the committee will think I sound like a broken record because I ask a similar question of every expert we have in. The answer is always pretty much the same. When we are trying to persuade those who have some influence in the halls of Government to do something, it is useful to ensure they understand the scope of the problem. How many consultant adult and paediatric ophthalmologists do we have in Ireland? What is the ratio per head of population? How do we compare with the figures in the UK and elsewhere in western Europe? What is the approximate length of time one spends on the waiting list from the time one's GP decides one needs to see an ophthalmologist until one has an initial consultation? If one is put on the waiting list for some form of surgical intervention, how long will one have to spend on it?

Sandra McLellan (Cork East, Sinn Fein)
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I welcome the witnesses and thank them for their presentations. I would like to make a few small points. The statistic that stands out is that a very high percentage - 75% - of blindness is preventable. The witnesses mentioned that the financial cost of sight loss to the State, which was €336 million in 2010, will increase to €449 million, which is a huge amount, by 2020. Will blindness become a greater challenge as people live longer? While I accept that there is a need for a national vision strategy, I wonder what plan or strategy we are working from at present. The examples of Denmark and Scotland have been mentioned as models of best practice. The witnesses mentioned that retinopathy has been reduced by 50% in Scotland. What treatment was used there?

Catherine Byrne (Dublin South Central, Fine Gael)
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I welcome the representatives of the coalition and thank them for their presentations. There are experts on this committee, such as Senator Conway, who are better placed than me to speak on this issue. Like Deputy McLellan, I was shocked to find that 75% of blindness or sight loss is unnecessary. Loss of sight is probably one of the most emotional and frightening things that can happen to a person. My family was concerned when my sister had a huge problem with her sight last year. We are all pleased that her sight was saved because she got medical attention at the time it was needed. I compliment the Irish Guide Dogs for the Blind charity, which does a wonderful job. When I was Lord Mayor of Dublin, I had an opportunity to visit its centre and to speak to its volunteers, who are totally committed to training the guide dogs and supporting those who will need them in the future. I have read the assessment and would like to ask two questions about the eight principles set out in it. First, can the witnesses elaborate on the third principle, which states that services should be person centred? Second, can they give us an idea of the kind of research they believe should be prioritised? I ask these questions as someone who knows nothing about these matters.

Jerry Buttimer (Cork South Central, Fine Gael)
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Who wants to start in taking the questions?

Mr. David Keegan:

If it is okay, I will respond, first to Deputy Ó Caoláin's questions. I thank the committee members for their comments. I appreciate all of the questions. Due to the nature of the questions, I will probably end up doing most of the talking but I would appreciate if Mr. Kenny and Dr. Meehan would come in at any stage if they want to make a contribution.

Regarding diabetic retinopathy screening and treatment, and type 1 versus type 2 diabetics, the new national diabetic retinal screening programme, Diabetic RetinaScreen, which is overseen by the national screening service, provides for all diabetics, type 1 and type 2, over the age of 12, excluding patients who are pregnant. They get a screening photograph and if eye disease, diabetic retinopathy, is detected on those photographs, the patients are referred to one of the seven treatment centres around the country where they will receive their treatment and care subsequently. It does not discriminate between type 1 and type 2. Does that answer the question?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Yes.

Mr. David Keegan:

Regarding the document itself, we do refer to a strategy. We have published a framework document, hard or soft copies of which we can make available. As Mr. Kenny alluded to, the framework provides a roadmap for what we feel is the best route to go. The committee will have heard me name-check the cancer strategy from 2006 earlier on. When one looks at that strategy, a lot of good has come out of implementing it and a similar strategy on eye care would deliver the same sort of benefits as that programme has delivered in this country.

Jerry Buttimer (Cork South Central, Fine Gael)
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How far have we gone in the establishment by the HSE of the national programme for eye care to the strategy? Mr. Keegan might touch on that as well.

Mr. David Keegan:

I was going to deal with that a little later but I will answer it now. The key point about the strategy is that it is a cohesive approach. The national eye care programme looks at hospital eye services and community eye services. It was tasked with doing that through the clinical care programme overseen by Dr. Áine Carroll. Mr. Paul Moriarty, the national clinical lead for ophthalmology, has drafted that document. Ms Siobhan Kelly, from the Irish College of ophthalmology, is here - I was speaking to her this morning. That document is just ready to be published. It document oversees the immediacy in hospital services and community eye services.

What the strategy seeks to do is to build in a full longitudinal care plan, right from when somebody needs to go to his or her optician for glasses to the stage if, unfortunately, he or she has to attend the NCBI Fighting Blindness, guide dog services or Child Vision with cane or guide dog. The strategy also manages to fold in as it were, much like Deputy Catherine Byrne's comment about the holistic approach. This is a patient-centred approach. The individuality of those with sight loss and blindness is protected or cared for under this strategy as well.

Also dealt with within this strategy is the importance of research. It is well known around the world that best outcomes happen in countries that adopt or embrace a research culture. If countries are open to research, they are more likely to adopt best evidence medicine and to do so quickly. Those countries that do not have research at their core do not adopt it and, therefore, one does not get better patient outcomes. That is something that has been seen in the cancer area in this country also. The strategy incorporates the eye care plan but it brings in the extra components that all the stakeholders here represent.

I agree on the multidepartmental issue. It was one of the startling findings for me when we did the cost of blindness study. I was not expecting this. I thought the cost of blindness would highlight, much like the cost of sight loss did, a lot of the costs in and around health care, but this transcended so many different departments. The impact became immediately obvious, not only on the health services but on the Department of Finance through both the reduced tax take because fewer persons with vision impairment or blindness are active in the working community - there are notable exceptions - and the dead weight loss because where one transfers those payments from those who are paying taxes to those on the welfare side there is a leakage. The Department of Social Protection provides payments, such as the blind pension and the social welfare payments associated with those with vision impairment but also the supports for those affected because more of them are out of work.

Following on from that, there are also those informal care costs because there is the assistance and help that those with a vision impairment or blindness require. We are lucky in this county we still have a good social and family fabric, but there is the lean on the time of that network. Their productivity reduces and there is also the result of a friend, colleague or family member being affected by vision impairment or sight loss. That is one of the hidden costs in and around this. I stress that is a financial cost. The economic cost is more startling, but I felt in this environment it was not relevant or, necessarily, the best way to present that data. The economic cost is over €1 billion, but that factors in loss with respect to well-being. When one factors in the other costs it becomes an even more staggering figure. These are the financial costs that we talk about.

Mr. Desmond Kenny:

I will take that back to Deputy Ó Caoláin's question about joined-up government. As Mr. Keegan has illustrated there, the Deputy would have been pointing to this. It looks as though it is a multiple need in the different Departments to join it up, but if one looks at the figures it is the outcome of neglect that is causing the cost. The solution is simpler because it is substantially within Health and the HSE, and the allocation of those kind of resources at an early stage. Through the clinical lead programme, we have already made a start but we are coming in as poor relations on the end of other type of interventions or strategies, and the danger is that we will not get that investment. We have to argue for that investment to be made at an early stage. It is a case of being joined-up in the Department of Health rather than joined-up Departments. The outcome will be there in the longer term but the immediacy of the preventative programme lies in Health.

Mr. David Keegan:

Does that answer Deputy Ó Caoláin's question?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Yes. I appreciate the two points.

Jerry Buttimer (Cork South Central, Fine Gael)
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On diabetic retinopathy, in Cork, for example, Dr. McQuillan has done a considerable amount of work around that with HSE South. Returning to Deputy Ó Caoláin's point in terms of the joined-up thinking between the different regions, how advanced is that clinical lead being taken?

Mr. David Keegan:

I suppose I am biased. As I am now the national lead for the diabetic retinopathy programme, I must declare a bias. However, it has shown us the route. If one wants to deal with conditions on a modular basis, eye care in Ireland is one of those areas which one might be able to deal with. We have been able to take a big issue, such as diabetic eye care, and develop a plan and strategy around it. We have made it a national screening programme. Proper screening programmes cover a population where a significant number of that population attend for screening and a significant number of that population are retained within that group. That is the essence of a screening programme.
Earlier there was a point made about what we can benchmark off other countries. We should be showing a lead. We have an opportunity to show a lead on diabetes because we have brought a treatment alongside the screening programme. We are the envy of those concerned in the United Kingdom around this. We also have an IT system built in around this programme so that we can track the patients, right from their screening visit with their photograph, through the treatment centre, what outcomes they have and what treatments they have. We have a fully auditable trace through.
If I may turn to Deputy Mitchell O'Connor's question as to what we would like, we would like an integrated IT system around eye care in Ireland that is accessible by all eye care providers, right from somebody in an optician's shop through to the service bodies, Fighting Blindness, NCBI or guide dogs, so that they would have a history of those individuals. Such integration would be a key point. We will show, through the diabetic programme, that such is the way to go.
On Deputy Mitchell O'Connor's questions, although that is one of the main measures we would like, the first would be the adoption of the strategy. The framework and the roadmap is here. If, as Deputy Ó Caoláin pointed out, it is adopted as Government policy, we can start working with the committee members, the policy makers, on how we will implement it. One element would be the integration of an IT system. We want the process put in place.
Looking at diabetic retinopathy as a model, the processes are now in place to prevent blindness. In a country such as the United Kingdom that has this for ten years earlier this year the British Medical Journalpublished findings which show that, for the first time since records began, diabetic retinopathy is no longer the leading cause of blindness in the working age population. That is a significant public health impact from introducing that programme. We want to get the processes in place.
We want to replicate that for the other major diseases, such as cataract, glaucoma and age-related macular degeneration. Age-related macular degeneration is a crisis that is happening in this country. We can tackle it through getting the processes right, which are around access, proper treatments, and proper follow-up and care. As the Danish experience has shown, when one gets that into place, one will half the blindness rates from macular degeneration in this country. Macular degeneration is the leading cause of blindness in this country.
The other measure we want is the adoption of a proper research strategy within this. I will ask Dr. Meehan to elaborate on that.

I reiterate that one of the key stand-out features of the cancer strategy was the involvement and involution of research into it. I will ask Dr. Meehan to follow up on the importance of research around eye care.

Dr. Maria Meehan:

I thank members of the committee. Research obviously goes hand-in-hand with the National Vision Coalition and Fighting Blindness has supported outstanding research, as part of the coalition, for the past 31 years. Irish scientists are at the forefront of vision research in the world. One point of which the National Vision Coalition is greatly in favour is the use of registries because, at present, Ireland does not have a national registry of eye disease. Therefore, we need the framework in place and consequently must work together to build our registries together to make clinical trials and better treatments happen for Irish people. While a lot of these might take place in other countries, some will take place here and we need something that can work internationally to allow best outcomes for our patients.

Another point I wish to make in respect of research is that with our strategy, we also need to educate. Deputy Mitchell O'Connor touched on the point of somebody who is visually impaired being invisible and this comes from educating our secondary schoolchildren and we are also very much in favour of integrating that.

Mr. David Keegan:

If I may, I will answer Senator Crown's question as another part of the question asked by Deputy Mitchell O'Connor was on how many consultants there are. At present, there are 40 ophthalmic surgeons in the public sector working with the HSE. That represents approximately 1:110,000 per population. In Scotland, the equivalent figure is 1:70,000, while in other countries around Europe, the ratio is variable. As it is based on the definition of an ophthalmologist, which is not directly comparable, we are better leaving it at Scotland for the present. For example however, in Greece-----

John Crown (Independent)
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May I ask one question? While this is a crude indicator across jurisdictions, Ireland tends to be under-provided compared with western Europe in that we have perhaps one fifth of what we need. The British tend to have approximately one quarter of what they need and they actually constitute a very low bar for comparison. Consequently, if we have approximately two thirds of what the Scots have, I am guessing that we are even further below the European average.

Mr. David Keegan:

We are. I would have to answer that question by also including our community ophthalmology and medical ophthalmology colleagues, who account for a further 25 full-time equivalents in Ireland in both full-time and part-time posts. That provides a better measure to then benchmark against other European countries. In countries such as Greece, Germany and France, the ratio is approximately 1:25,000, whereas in Ireland, if one includes the aforementioned group, the ratio is approximately 1:85,000. Consequently, we are very under-represented in this regard. I published a manpower report that was submitted to the Department of Health in 2010, in which we recommended an additional 13 ophthalmic surgical consultants and an additional 17 medical ophthalmologists to meet that need. That was simply in the context of bringing us up to close to the levels of the United Kingdom, rather then to European levels. We are supported by the private sector in Ireland and many of the indicators from around Europe might merge the two sets of figures from the public and private sectors. There are a further 40 full-time equivalents, approximately, within the private sector here. Consequently, we seek an increase in the number of appointments in hospitals. When one considers all the hospitals providing eye services, they would require an increase in consultant surgical staff. However, additional medical ophthalmology staff are also required and such additional staff would be both community and hospital based. This would tackle our waiting lists, as while routine waiting times vary around the country, in general one is looking at one to two years for a routine eye appointment.

John Crown (Independent)
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One to two years.

Mr. David Keegan:

Thankfully, however, in the case of urgent eye care many units will help to deliver urgent eye care quickly. Consequently, if one has a retinal detachment or acute macular degeneration and one attends the accident and emergency services, one tends to be dealt with promptly. However, that circumstance is reflected in many conditions with which patients present. The urgent care meets the standard but it is the less than urgent and the routine care that fall short. The waiting time for a cataract, because it is a Government target, is nine months. While it drifts over that from time to time, this was helped by special initiatives along the way. Does that answer the Senator's question?

Jerry Buttimer (Cork South Central, Fine Gael)
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While I will bring the Senator back again, I want to-----

John Crown (Independent)
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The witness asked me a question, which I wish to answer.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will chair the meeting. There is one Chair of the meeting and it is mise é. Mr. Keegan may proceed.

Mr. David Keegan:

I wanted to ask the Senator if I had answered his question in the context of answering Deputy Mitchell O'Connor's question.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will bring him in at the end but I want to bring in other speakers, if they wish. I will bring the Senator in at the end, as we normally do.

Mr. David Keegan:

Deputy Mitchell O'Connor makes a good point regarding the prejudice towards the vision impaired. I was going to ask Mr. Kenny to answer that question.

Mr. Desmond Kenny:

When one looks at the strategy and while so much can be done with the heavy lifting at the health end, I have noticed that in replies to parliamentary questions, it reaches into other areas because where people live and how they live is multi-Government or multistranded. However, much of how one lives or how one is accepted into an included lifestyle has improved considerably over the years and decades of my involvement or experience of inclusion. My involvement started in one of the segregated special schools, which now form part of the redress board's problems. It led to more segmented special-type services such as limited employment opportunities. That expanded as the years and decades passed and I believe we have become a more inclusive society. We are now just about accepted as being equal and the day we are accepted as being superior will be most interesting. I only jest but it is a question of to whom one is equal when one is perceived as having arrived somewhere.

We have the care services and an infrastructure of society in which one will see we have level access, which is a barrier-free environment for all. While that started as a wheelchair lobby, it was then realised that people have ambulatory-type problems in walking, as do women with buggies and mothers with buggies and, consequently, a barrier-free environment for all helps people who have the greatest need. Just as visibility and colour contrast help low-vision people, it also assures one fairly quickly that the yellow rails are there to be grabbed if one is to travelling on the Luas and so on. People will always be at a disadvantage and I do not think it is prejudice; I think it is ignorance. It is people's need and wish to do the right thing that actually makes them clumsy in doing stupid things, such as asking does one want sugar or does he take sugar. We have a society with organisations in which we and the Government in indirect ways have invested in the provision of an infrastructural society that has audio pedestrian crossings and that now has in place a taken-for-granted infrastructure that has been won. There are announcements on trains that started with us - when they are working. I note they do not work all the time on the Cork train on which I was travelling recently and the Chairman might do something about that. However, while such announcements help us, they were provided initially at our request. In working through the Government and through European legislation, much has been improved and a lot is happening in respect of taking the acceptance of disability and vision impairment into something that is more normal and into creating and building rights around it. I thank the joint committee and the Deputies who have come before them for allowing this to happen.

Jerry Buttimer (Cork South Central, Fine Gael)
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Senator Crown, to be followed by Deputy Mitchell O'Connor.

John Crown (Independent)
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On my question, there is an eerie resonance with other areas, whereby, for example, although the waiting list for a colonoscopy is ten months, if it is urgent, it is not. How does one know in advance which symptom is urgent and which is not? How does a general practitioner know which candidate ophthalmology patient going to a clinic has an urgent problem and which does not? That is why the patients need to see an ophthalmologist.

Mr. David Keegan:

Yes, that is why I stressed the need for processes. We need a process, we need screening programmes and then we need awareness at general practice level of the condition. There also is the question of public awareness about with what people will present. In recent years, we have been pressing to raise public awareness, particularly now that we have treatments for macular degeneration. As for what is an urgent condition, in this case it concerns progressive loss of vision but the Senator is aware that an urgent condition is one in which by making an intervention, one can prevent or reverse that loss. A non-urgent condition is either when there is nothing one can do about the condition or if it can be addressed down the road. For example, a cataract is a less urgent issue, as one can address it down the road.

We have to educate both general practitioners and the public about identifying the signs and symptoms so these patients will be referred quickly up the system. Proper processes will de-stress those urgent services and we can get these patients in appropriately. The treatments are available. It is about getting the patients treated in a timely manner. A patient with an acute leak from macular degeneration has only a matter of weeks before they get up to the point of irreversible vision loss.

John Crown (Independent)
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Having an ophthalmologist in place would also help in the first instance too.

Mr. David Keegan:

Yes, that is critical. Senator Crown knows well about the issues of recruitment across the medical sector which must be dealt with.

Our obligation is to provide the roadmap and then we can come back with a clear idea of the resources we need for this field. We feel we have an idea about these resources now. If we implement them, they will become cost-neutral because one is tackling the cost implications on the other side of the network. I accept the point made by Deputy Mitchell O’Connor about being a little more upfront or aggressive. If the resources are provided, we will make a commitment to deliver on them.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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Again, I thank those who have attended today. On behalf of my brother, the visually impaired and the blind, I cannot praise anymore the great work NCBI, the National Council for the Blind of Ireland, does. When one discovers one is blind, one has no one else to turn to. I also thank Fighting Blindness, Diabetes Ireland, the Irish Guide Dogs for the Blind and its chief executive officer, Padraig Mallon, ChildVision, all the doctors, nurses and other medical staff involved with the visually-impaired, as well as employers. Mr. Keegan said people are ignorant rather than prejudiced. Is there a prejudice for people who are blind when they are looking for work? Teagasc in Athenry employs my brother and have put resources to assist him.

There is a 3% target for the employment of people with a disability in the public service. Is this happening for blind people?

Catherine Byrne (Dublin South Central, Fine Gael)
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Is there any eyesight screening scheme in primary schools?

Mr. David Keegan:

There is a school vision testing programme which is in the process of being revaluated. There was a feeling there was a number of unnecessary referrals to hospital eye services that were causing blockages in the system. These are being revised under the new national care programme with Paul Moriarty.

Jerry Buttimer (Cork South Central, Fine Gael)
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How regular is the screening?

Mr. David Keegan:

It used to be at two-time points but now it is at a one-time point.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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It used to be from seven years at senior infants.

Mr. Desmond Kenny:

With contraction of employment in the public service, the 3% quota is nearly being met. That is not due to expansion of opportunity or people entering it. Visually-impaired people had a designated form of employment in the public service from the mid-1950s in the role of blind telephonists. All members in their public service life in local authorities and what not will have encountered visually-impaired people on switchboards. That designation is now gone. Due to the need to reduce numbers in the public service, telephone systems have become automated. NCBI currently supplies telephonists within the public service but this is shrinking as a designated form of employment which we regret.

Employment generally in the public service by way of opportunity has not been expanded. The telephonist 1 grade gave an access grade that allowed people graduate and there was an entry grade of computer programmer but these are disappearing. The number of manual or manipulative types of jobs that visually-impaired people can do, such as making baskets or working in workshops or on assembly lines, have disappeared. It was seen as not providing enough in earnings but when it was taken away, there was nothing left. The problem is to have the dignity of work with a decent wage and being allowed to make a contribution to society. There is a crisis around employment for visually-impaired people.

We have made representations several times to the Minister for Social Protection on behalf of people with a visual impairment who are on a blind pension but who cannot get on the JobBridge scheme while those on a disability allowance can.

Martin Conway (Fine Gael)
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I agree that it is more ignorance than prejudice. The challenge of employment opportunities for the visually-impaired or the blind, about which Mr. Desmond Kenny spoke, has not been grasped by the Government. We need to have effective gradual programmes where companies and human resources units are educated as to the benefits of employing visually-impaired people and how assistance can be put in place to ensure a level playing pitch for them.

I know the Minister is aware of the issues around JobBridge which need to be dealt with. There will always be challenges in that regard. I thank the delegations for their presentations which provided a most worthwhile engagement and hope something positive comes from it.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I certainly intend to be as proactive as this institution will allow. The volume of material that can come through is so overpowering, so I would appreciate if Mr. Keegan could make the framework document referred to available to committee members. I have no doubt we would appreciate the content and that it would, in turn, help us focus on the job he has asked us to do.

Mr. David Keegan:

I thank the committee for having us in to discuss the issue of blindness and vision impairment, and the provision of eye-care services. We feel the framework document for the national vision strategy that we have produced as a national coalition is the way to go. We would love to see it adopted as government policy to form a national strategy.

Jerry Buttimer (Cork South Central, Fine Gael)
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Arising from this meeting we will write to the Department seeking information on that national strategy framework. Is that agreed? Agreed.

The good news for members is that there is no meeting on Tuesday, 8 July 2014, so we stand adjourned until this day week. That will be our quarterly meeting with the Minister for Health.

I thank everyone very much for attending the joint committee today.