We move on to the next item on our agenda, which is a statement by the Cabinet Secretary for Health, Well-being and Sport. It’s the update on plans to recruit and train additional GPs and other primary care professionals. Vaughan Gething.

Thank you, Deputy Presiding Officer. Our Welsh Labour manifesto made a commitment to take action to attract more GPs to Wales and to encourage more doctors to train here. We also agreed with Plaid Cymru, as part of the compact to move Wales forward, to put in place plans to train additional GPs and other primary care professionals. Our vision for the Welsh NHS is an integrated health service with strengthened and modernised primary care at its heart. More routine healthcare will need to be provided in local communities, closer to people’s homes, preventing the need to travel or be admitted to hospital.

The Welsh Government published our primary care plan in 2014. This sets out a clear approach to stabilising and securing future primary care services, based on the principles of prudent healthcare and a remodelled and diversified workforce. A primary care workforce plan was published in November 2015, and it includes actions to develop, diversify and invest in the primary care workforce, including, of course, GPs.

We know that traditional models of general practice are under pressure as fewer doctors across the UK are choosing general practice as a career, and many of those who do are choosing to work as salaried or locum GPs. There are, of course, other challenges too: retaining older and more experienced GPs as part of a trend toward early retirement, increases in sessional-based work and more GPs choosing to work part time, and there is often a poor perception of general practice as a career choice. These are just some of the career challenges, all set against a backdrop of a difficult recruitment market right across the UK and internationally.

Since the First Minister’s statement in May, we’ve developed plans for a major national and international recruitment campaign to market Wales and NHS Wales as an attractive place for doctors, including GPs, and their families, to train, work and live. Organisations across Wales, including health boards and trusts, will come together under the banner of NHS Wales to harness the best use of local activity, such as the excellent Rhondda Docs website—and I will say, if you haven’t had a look at it, it’s well worth having a look at what doctors are doing for themselves to market the place that they live and work in and are very proud to do so. All of this will take place using the Wales brand. The campaign will take a four-pronged approach. It will target medical students yet to choose a speciality to improve GP training place fill rates, trainees coming to the end of their training to encourage them to live and work in Wales, recently qualified GPs or those in the early stages of their career, and GPs nearing retirement or very recently retired to promote other available options to encourage them to stay or return to practice.

I can confirm to the Chamber today that we will be launching the campaign on 20 October, leading straight into the British Medical Journal careers fair in London on 21 and 22 October. This is the first component of a longer term, sustained campaign to attract more doctors to Wales.

In addition to the marketing elements of the campaign, we’ve been working with our partners, including the GPC and the Royal College of General Practitioners in Wales, to establish a clearer deal for GPs in the form of a ‘Wales offer’. This will communicate the existing benefits of being a GP in Wales and the actions being taken to address the concerns of those who are delivering services everyday so that Wales becomes a country of choice.

To support GPs, and their families, who want to work in Wales, we are developing a single point of contact as part of the once-for-Wales remit of the NHS Wales shared services partnership. This will build on the single GP employer function currently provided by shared services and will offer an easily accessible source of information on medical careers and general practice. It will encourage and support those who respond to the campaign or express an interest in returning to work in the health profession. A network of recruitment champions will also be promoted. The champions will act as a contact for doctors from outside Wales who are considering relocating to Wales to discuss what working in Wales is really like.

We’re also working with the Wales Deanery to develop a potential incentive scheme for a limited number of GP posts as part of a wider package to support areas of Wales facing particular challenges to fill existing GP trainee posts.

Alongside the campaign we will, of course, continue to invest in primary care: £42.6 million has been made available for 2016-17 to health boards to support the delivery of their plans, and £10 million of this has been allocated for the 64 primary care clusters to invest in their local priorities and to enable innovation at a local level.

We will continue to work with our partners to address workload—40 per cent of the points associated with the GP contract quality and outcomes framework requirements have been removed since 2015-16—and to develop solutions to issues such as professional indemnity.

What I’ve described so far represents the initial phase of the campaign, focusing on doctors. The next phase will aim to address the challenges faced by other primary care professions, such as nurses, therapists, pharmacists, dentists, optometrists and paramedics, as the need for greater diversification of the primary care workforce continues. We’re working with our partners and primary care clusters to understand the range of skills needed in primary care to meet the current and predicted future demand. This analysis of workforce need will enable us to deliver targeted marketing campaigns and to develop comprehensive workforce training and development programmes at both health board and national level.

To oversee the development, implementation and delivery of the activity that I have set out, a ministerial taskforce has been established. This brings together professional organisations, employers and Government to hold all those responsible for delivery to account. I chaired the first meeting of the taskforce in August, and we are due to meet again early next month.

Our plans for primary care are clear. Delivery depends on getting the best from the full range of the primary care workforce, and we will continue to invest significantly in this over this Assembly term.

Thank you very much. Rhun ap Iorwerth.

Thank you, Deputy Presiding Officer, and thank you also to the Cabinet Secretary for the statement. This is an area that is a priority for us, and that’s why we were determined to see a commitment in this area in terms of the post-election agreement. However, we are facing a crisis and, in the face of a crisis of this kind, we need to act as a matter of urgency. There are fewer GPs per head in Wales than in the rest of the UK. Secondly, the calls and pressure on them is increasing. So, it’s entirely clear that the situation that we’re facing at present isn’t sustainable. So, I welcome several aspects of the statement, but there are several things that are insufficient, unclear or missing from the statement. So, I will ask four questions.

The Cabinet Secretary has talked about an incentives system for some posts. I take it that that will be in areas where recruitment is difficult. Will the Cabinet Secretary confirm that that will include incentives for service over a longer period of time rather than just short-term incentives to fill posts in the short term? It’s very important that we do look at the longer term. There are some long-term elements that are perhaps not included here. There’s no mention here of recruitment of students from within Wales to study medicine in the first instance, nor is there mention made of recruitment of school pupils to want to pursue a career as a GP—which is something that I have an interest in—and to study medicine with that view from the very beginning of going into primary care work. I wonder whether the Cabinet Secretary is willing to look into work that can be done in that particular area.

The third question from me: the First Minister said in an interview on the radio this morning, when referring to the number of GP practices that have been put back into the hands of health boards, that that wasn’t necessarily a bad thing. Does that mean that aiming towards having more GP practices managed directly by health boards is something that you would want to pursue, and even that that could become something that the Government would favour from now on?

Finally—and this is entirely crucial—may I ask what targets the Cabinet Secretary is willing to set for the number of additional GPs that he wants to have, or the number of GPs that we will have in Wales by 2021? If you consider: technically, having one new part-time GP would mean expanding the provision of GPs. But, what is the target that the Cabinet Secretary has in mind? The Royal College of GPs, for example, has said that we need 400 new GPs in Wales. Is there any reason in the Cabinet Secretary’s mind as to why that figure wouldn’t be an appropriate target?

I thank the Member for the series of questions and the broadly constructive manner in which he has engaged with the statement. I will turn first of all to your finishing point, about setting a target for the number of GPs. We have not set a target for the additional number of GPs, for the simple reason that what we are looking to do is maximise the number of GPs that we can train to meet fill rates. We don’t currently meet all of our fill rates, as is the case, sadly, with every part of the UK. This reinforces the fact that this is a UK and international challenge. I am interested in having more GPs where we don’t currently have enough. If we are going to remodel primary care and we are going to have a genuinely integrated workforce with GPs and other primary care professionals, I don’t think it’s helpful to then set a target for one part of the primary care workforce. We are really clear that we will need more GPs, but we will also need GPs to work differently, and that’s a point that I will come back to.

Your point about incentives: we have been working with the Wales Deanery. Also, part of the point about the taskforce is to have discussions with partners about what incentives could and should look like. So, we are looking in particular at bonding schemes—we know that this is something that your party has been interested in as well—about potentially looking at bonding schemes to bring people into areas where there are challenges and, equally, to look at the potential for new GPs and how you can potentially help people with some of the costs of their training, if people agree to undertake a certain period of service here within NHS Wales. So, there’s something there about having something for something, and that is something that we are actively exploring with partners. I will, of course, keep not just him but the rest of the Chamber updated as we properly and actively consider that and bring it to a conclusion.

I didn’t mention it in my statement, but I have mentioned before in this Chamber, the point about Wales-domiciled students. I met the deans of both Cardiff and Swansea medical schools, and I met them together, rather than having separate conversations where they could tell me what the other people weren’t doing. I had a joint conversation and it was actually very constructive. Again, that’s been something that I’ve been really struck by and gives me some cause for optimism: there hasn’t been points-scoring. There has been an acceptance of the fact that we need to do better. Part of that conversation was about how we encourage more Wales-domiciled students to undertake careers in medicine, and how we can make it available to a wider range of people as well. So, it’s about widening access as well as widening numbers too. That’s very definitely part of the conversation that we are having, because we want to see more Welsh students choose to undertake their GP training here. A range of Welsh students are ready to go to other parts of the UK and abroad to undertake their medical training. There’s a range of reasons why people do that. If you look at new undergraduates going to a career in medicine, they may well want to have a different experience, away from home. There’s no reason why there shouldn’t be excellent opportunities for them here in Wales. But, for example, a direct comparison is the nurse training workforce. The average age of nurse trainees at the start is 29. They are in a very different position to, if you like, your typical undergraduates, in terms of their roots in a particular area and responsibilities. So, we need to recognise the different groups of people that we are dealing with, and how we make that attractive and remove barriers to having more Welsh students studying medicine here in Wales.

This also feeds into the point about work experience. That is something we are actively considering, not just within the GP and doctor part of the workforce here, but the wide range of careers that exist within the NHS, and making sure the NHS is more proactively engaging with the local population that it serves, works with and for, in highlighting the whole range of careers that are available in the national health service at a younger age as well. I expect to be able to tell you more about what the NHS is doing, but there’s a very clear expectation from Government to the NHS that there will be a much broader work experience offer, about making sure that people have the opportunity to come in at a younger age, as well as for people as they get older and are thinking about different options later in their academic life too. In fact, in terms of experience and making opportunities in medicine, I haven’t yet watched it, but the S4C series has just started, looking at doctor training. Actually, Cardiff University and the medical school were both really positive about the way that that was going to present the opportunity to be a doctor, what it really means and actually what it can give to someone—not just the financial returns, but a really rewarding career within all parts of medicine, including primary care as well.

Now, if I can come back to your final point there about where you start and about the shape of primary care, well, you said that where we are isn’t sustainable. The current way of working isn't sustainable, and so, large parts of healthcare will need to look different in five years’ time—we should want them to. The point is that we should plan for them to look different in a way that best serves the needs of our population. The challenge here is how we ensure that change isn’t the inevitable that happens to us—that we’re taking control and ownership of it. And that’s what I’m looking to do with our partners. I have to say that, so far, in the engagement this term, there’s been a positive approach with other parties in this Chamber and we’re all looking in the same direction at this point in time. Now, that will mean, in primary care, though, we expect there will be a smaller number of practices. We are likely to have fewer of them. We’re likely to see more amalgamations. We're likely to see more federations as well. There's a federation starting in Bridgend, which I think is a positive example. That could mean that, over a broader area, you're going to provide different services for the population, as well as having more robust services. So, I have no particular plan to bring in to local health board control a certain number of practices; our aim is to ensure we have a genuinely sustainable primary care workforce on a footprint that makes sense and is generally sustainable, and that will mean change. And given the number of single and double-handed practices we have in Wales, there is understandably going to be some change, and that is uncertain both for individuals who work for those practices and the local population. Our challenge is how we approach that in a genuinely mature and constructive manner without trying to exploit fear and opportunities for immediate point scoring, but actually saying, ‘How do we make sure that, in five years' time, primary care is in a better place, more sustainable, and people have real confidence about the quality of services that they receive and take part in’.

Well, Cabinet Secretary, I am pleased that the Welsh Conservative debate of last week has had such a galvanising effect on you, because this statement does actually pretty much cover most of the requirements that we put forward, or suggestions, for what we might do to improve GP recruitment in Wales. I do, however, have a couple of questions to ask you.

Let me make it clear that I really welcome this, but I want to ask: did you do a lessons-learned exercise from the previous GP recruitment programme? I think it was in 2012 or 2014; I can't remember, to be honest, which of those two years it was, but I know that it didn't have a great take-up, because I think that would be really useful to make sure that we've covered all bases. And yet, as you say, you're going to target medical students yet to choose a speciality. Will this also involve you working with the deanery to try to ensure that GP practice is part of the rotation of a junior doctor? Because I do think that this is absolutely critical in getting young doctors interested in, and involved in, the complexities of general practice and realising it can be a really fulfilling way forward.

I'm very pleased to see that, you know, you've taken on board the fact that we've got to attract the doctors and their families, but how would that translate in real terms? What do you think we might be able to do, or your Government might be able to do, to ensure that a doctor's partner would be able to also find work at the kind of professions that they might want to work in here in Wales, particularly when we move further away from the capitals of, you know, Swansea, Cardiff and, in fact, north Wales and into the more rural areas? It's tougher to get jobs full stop, let alone the kind of jobs that a partner may want to go for.

Have you addressed in this, in your recruitment programme, the concerns over buying into difficult or struggling practices? I've really taken on board your point about the professional indemnity, and you talk about addressing the concerns of those delivering services every day, so that Wales becomes a country of choice. Well, of course, we need to also look at the costs of buying into a practice and the standard of the infrastructure that people might be buying into. So, will you be looking at that?

Are you going to be addressing the take-home pay differential between doctors in Wales and doctors in England? I mean, England has typically—. Their take-home pay is about 10 per cent higher, and I wonder if that has any factor, and I wonder if you're going to have a look at that.

I wonder who is going to be paying for this recruitment programme. Could you give us some indication? Have you put aside funds for it, because, given the current combined deficit of all the local health boards is some £78 million, I wondered if they are funding the recruitment programme in their areas, or if this is something that Welsh Government intends to fund, or are you going to be then defraying the costs back out again?

I was very interested to see your comment about your working with the Wales Deanery to develop a potential incentive scheme as part of a wider package to support areas of Wales that face particular challenges to fulfil GPs. Now, a lot of that has got to be rural areas, and I just wonder if you could expand on that a little bit more because, as you know, particularly in west Wales, we are suffering from a chronic shortage of GPs, and I’d just be interested to understand that.

Then, finally, I was delighted to see that you picked up that the next phase will address the challenges faced by other primary care professions. I think I’ve said this now about three times, and I’m going to say it for a fourth: 30 per cent of nurses in general practice in Hywel Dda alone intend to leave within the next five years, so I think we’ve got quite a big issue coming downstream, and I wonder whether you can just give us an indication of when that next phase might start, because we need to try and put, obviously, people in place or in training before we actually get to the point where we are in trouble.

I’m sorry, Presiding Officer—there is actually one more question, which is: do you anticipate raising or increasing within a short time period, and seeking to raise, the number of training places available in Wales? I think you alluded to it when you answered Rhun, but I would be really interested in knowing whether that is one of your ambitions, and if so, how long might it take to deliver that?

Thank you again for the series of questions, and again the constructive engagement, both before today and during the day as well. I’m happy to say that the areas that we are looking to deal with today were in our minds before the Welsh Conservatives laid their debate plan. It’s a funny coincidence, isn’t it? But there we are.

In terms of the points you make about the previous campaign, let’s start with that. There have been lessons learned, both about the time that it took and about the messaging and how focused it was as well. So, certainly there’s that consistency to learn. There’s also something about—and it’s a point that you’ve made that’s been actively in our mind, and has been reinforced by partners as well—looking at the whole person and the whole country. So you look at the whole person as a GP; what else do they want to do? Some parts of Wales have been very good at doing this, and to be fair, in both north-west Wales and south-west Wales they’ve been much better at advertising everything that someone can get from living and working in that part of the world. So, there are some people that really would like the lifestyle that is on offer there. And for other people, it isn’t quite the same, but we’re getting a certain group of people who actually want to buy in to living somewhere as well, and that’s really valuable.

That person, of course—sometimes they do come with dependents, and other times they don’t. That’s part of the individualised point about not just the Wales offer, but about the recruitment champions: to understand what does this look like if you want to relocate to Wales, and what is important to you? It’s not just about the individual location, but of course, within a broader travel-to-work area. We know that lots of people travel a decent distance into work every day, and health professionals are no different in that sense. So, it is about understanding what will make a difference for that individual person, for the family context that they want to work in, and what is important to them as well. Of course, we are funding the national campaign on recruitment, and I’m looking forward to taking part in that at various points in time, but in particular seeing what the response is from our partners and the contact they will have with their members, and then ultimately seeing what that looks like in terms of outcomes for people wanting to relocate and to live and work here in Wales.

So, we haven’t had any particular input that take-home pay is an issue. There is something there about how to use incentives smartly, though. That’s why bonding is an issue, and in those areas where there is a real evidence base it will make a difference. Some of those areas, I imagine, would be rural parts of the country, but there other parts of Wales that aren’t rural where there are still particular challenges. So we need to think about how smartly we potentially use those incentives.

Now, on training numbers, a point you made, I want to be clear that I’m not going to set an increased target for training numbers. We need to fill the current places that we have. We have actually got a slightly better fill rate than other parts of the UK—we’re just over three quarters—but the challenge is that we’re still not filling our numbers. When we’re getting much nearer to that, I’m happy to look again at both what we need within our workforce, the regional setting that we have to work within, and to see whether it is then sensible to look at expanding that. But let’s get right what we want to do now: that is, fill the places we have and make sure we have a good quality of experience as well, because the recent survey on the experience of training, again shows that doctors themselves, in training, say that Wales is the best part of the UK for the very best training experience. That’s really important as well, so there are lots of things for us to positively sell.

One of the challenges that we do recognise is the primary care estate—not just the idea that if you’re the last man or woman standing in a practice, and you’ve got all of the liabilities, with an old building that is no longer fit for purpose, that can be a real burden—that can be a disincentive for people to buy into a practice. That’s something about the model as well. It’s also something about—and this is a challenge about how we use public resource in terms of remodelling and reshaping primary care, and if you look at almost all the examples of new primary care buildings that the Welsh Government and health boards have invested in, then it is a different model that we’re investing in, and it provides not just the different sort of quality and experience for the patient and the staff who work there, but almost always it provides a new experience, and not just a new experience but new services. And that’s really important, too, so we’re trying to make sure that the design that we want for primary care, in a more joined-up, integrated way, is actually what we’re then investing in—we’re investing in a part of the new primary care estate. So, again, that’s part of being smart for the future, making sure the two things are joined up.

In terms of the point about exposure to primary care, it’s regularly raised with us by partners. There’s some interesting work in Cardiff going on with the C21 programme, making sure that primary care exposure is definitely part of that—that it’s deliberate rather than accidental—and that also goes into our work with other professions as well. So, we’re looking at career frameworks, and I’ll have more to say on allied healthcare professionals this autumn as well. We’re looking at expanding training numbers for a range of different professions as well—a decision made by the previous Minister—and so we’re actually really serious about growing the workforce in areas where we need to. We recognise that’s an important part of what we’re doing, and it’s also about the model changing too—so not just the numbers, but how people work together, so not just community pharmacy, but all the different parts, the therapists and the scientists as well and what they can do, working alongside GPs. There is a changing attitude and a willingness from the GP community to engage with all of those people in really actively reshaping primary care, and I think clusters are going to be an important part of that, too.

Thank you for your statement, Cabinet Secretary. I am pleased that the Welsh Government accept that there is a crisis in the primary care field. We wish you every success with this campaign, because Wales badly needs more GPs, otherwise we have a massive problem. Unfortunately, your proposals will do little to help us in the here-and-now situation. With the NHS preparing for the annual winter pressures, we are already seeing more burdens placed on primary care. The Royal College of General Practitioners tell us that some of the health boards’ winter pressure plans call for greater work throughout—that primary care services in some areas are already at, or over capacity. So these plans are not viable at present.

What is the Welsh Government doing to ensure that winter planning does not place additional burdens on primary care? Until we have sufficient numbers of GPs to reduce the workload on our existing primary care staff, we must do more to reduce the burden on general practice. Cabinet Secretary, what consideration has the Welsh Government given to providing additional funding to GP practices to employ clinical staff in order to reduce the GP workload? We welcome the news that the next phase of the campaign will look at the challenges faced by other primary care professions.

However, Cabinet Secretary, much more needs to be done to encourage and train staff, such as paramedics, physiotherapists and occupational health nurses, to work in primary care instead of their traditional role in secondary care. Will the Welsh Government undertake the work to ensure that primary care is seen as a viable career option to those considering a career in secondary care? The Royal College of GPs tell us that currently most GPs and their staff are currently overstretched. What is the Welsh Government doing to ensure GPs and their staff, who are suffering from stress due to excessive workloads, are fully supported and have access to occupational health services themselves?

And, finally, Cabinet Secretary, it is widely acknowledged that primary care is vastly underfunded, and while we welcome the funding you have announced today, the Royal College of GPs tell us that the clusters are not working in some areas, with money slow to filter through. What is the Welsh Government doing to ensure that the funding announced today actually makes it to the front line? Thank you. Diolch yn fawr.

I thank the UKIP’s spokesperson for her series of comments and questions. I’ll just start at the beginning with the unfortunate but necessary.

When you say that the—. The Government doesn’t accept that there is a crisis, and I think the language really matters. We accept there’s a very real challenge, and it’s particular in different parts of Wales, and there’s a challenge right across the UK and internationally, but it’s not something that is about to imminently fall over within the next day. So, I’m really clear about the language. That doesn’t mean that staff aren’t under pressure; it doesn’t mean there aren’t services under pressure; it doesn’t mean that change is going to be avoided or is going to be easy. But when we look at this—and I’ll deal with the point you made earlier about how we’re supporting staff—we’ve actually worked with primary care to make sure that we’ve got better access to occupational health support for staff within those settings. So, it’s a positive move we’ve already made forward. That’s part of what we’re trying to do, working alongside the wider primary care profession.

I’ll deal with your winter pressure comments and questions as well. Part of the challenge about every winter is that we know that we will face, inevitably, more people coming into hospital who are generally going to be older and sicker; as our population ages, that’s a profile we’ll have. Interestingly, the numbers are smaller in winter, but the need is greater. So, that’s why we have our different challenges. I regularly get told by some people that there’s no such thing as winter pressure any more, the pressure is year-round, but we know very well the profile of people who need access to healthcare support does change, and it is more acute when it comes to winter. Part of the solution isn’t just about trying to increase capacity within secondary care, it is about how we work to avoid people being admitted in the first place, to avoid them going into a hospital. If your experience is that you go into an accident and emergency department and you don’t get admitted, if you could have been cared for in your own home and could have been spared that experience, that’s eminently preferable.

So, it’s also then about how we work with different partners, not just to keep people in their own homes, but also to get people back to their own homes as soon as possible. So, it’s about admissions avoidance, and also reducing delayed transfers of care. And there should be reason for some optimism, because we have a range of different examples across Wales of where that admissions avoidance works and works well, and it’s almost always because GPs and the wider primary care workforce are engaged with social care and housing partners to understand who is at greatest risk of potentially needing admission to hospital, and then what you do to make sure that person is properly supported to make sure either that they don’t need to go in or that they can be repatriated to their own home, with appropriate support, if they do need an admission and hospital-based care.

Our challenge, as ever, is to learn across the whole system, doing that more consistently and at pace across the system. So, I won’t pretend that winter is going to be a breeze. It would be a foolish Minister in any Government of any political shade that said that nothing will go wrong in winter. There are bound to be pressures and challenges, and the biggest challenge won’t be for me, it’ll be for staff within the service in trying to deliver a high quality of care whilst demand is rising. But, like I said, I think the approach we have here, which we should be really proud of, is the ambition to have more care closer to home and actually properly recognise the whole-system approach, the whole of healthcare, with social care and with partners in housing in particular.

Finally, I’ll deal with your point about primary care clusters and about money going to primary care to help support some of our ambitions about the money that people can spend themselves. I indicated in the statement, and I’ve said before in this Chamber, that the £10 million for clusters has been allocated for them to spend. They have to work alongside their local health boards, but it is fundamentally money that they have within their own control. So, that is new money that’s getting to the front line, and equally it’s being spent on delivering more front-line staff. Lots of clusters have decided to employ clinical pharmacists. GPs recognise that has real benefit. So, there are more staff that are being introduced, but there’s a range of different professions that each cluster will choose to employ, and how they choose to deploy their money with their partners. The reason why they exist is to make sure that people can manage and understand their local healthcare populations, to manage that healthcare and to deliver the very best for that population.

So, I would not expect to see the money spent in exactly the same way in every single cluster, but it has got to be about each of those primary care clusters having the ability to decide what to do, to decide how the health gain will be met, and actually to be able to get on and spend their money. That’s the point that I made when I met NHS vice-chairs this week: we need to see the money getting through to the front line, and I do not want to be in a position where clusters complain to me they had significant plans to make real differences but they were not able to get the money through local health boards. After the first year, I think there were complaints, but I don’t expect to see those problems arise within this year at all.

I welcome the points made in the statement by the Cabinet Secretary, and I think they will certainly help the situation. During the recess, I visited North Cardiff Medical Centre, and was very impressed with the efforts that they were making there to try to treat the whole patient to try to avoid unnecessary medical treatment and try to avoid admission to hospital. I was also very impressed by their efforts to work very closely with other medical professionals and to work in a way that is reaching out to the community. I’m sure the Cabinet Secretary would agree that all these things are essential in a successful GP practice. One of the points they did bring up with me, which I also raised last week, was the concern they have about the huge growth of population that is likely in Cardiff. I know that there are difficulties in providing GPs in rural areas, for example, and possibly, perhaps, in Cardiff now, but they are very worried about what will happen in the future. So, I wonder if the Cabinet Secretary had any views on that.

The second point—there’s been quite a lot of discussion about training and medical training here today. Would he agree that it’s essential that the medical curriculum does address hands-on training and makes the students aware of the actual jobs that they will do when they do actually enter employment? I know that the new curriculum at Cardiff medical school does offer now a lot more hands-on experience for the students and they believe that the breadth of experience that’s being offered to them in that training has resulted, this year, in 55 per cent who have chosen to stay in Wales for their first foundation post, which they see as an achievement. Certainly, some of those people will end up as being GPs. So, I’m sure the Cabinet Secretary would agree that the content is vital in making the students aware of what can be achieved by being a GP. I think in the Cabinet Secretary’s statement or in his response to questions he did say that the job is perhaps not seen as an attractive job and I think that it’s really important that as much is done as possible to show the opportunities that can be there through general practice.

I was very interested in the North Cardiff Medical Centre telling me about a visit that they’d made, along with other officials—I think possibly the Welsh Government officials went too—to Bromley by Bow Centre in east London, which is quite a famous centre, where the GP practice is situated in a community hub where there’s a community café, and where there are lots of health and well-being issues. It’s there to address the needs of the whole community and I think that is the point that the Cabinet Secretary has been making in his responses today. So, would he agree that that sort of development would help to make potential GPs see the value of being a GP and being able to work in the holistic way that some practices are trying to do?

I thank Julie Morgan for the series of questions and the examples she gives from her own constituency of Cardiff North. I’ll start with the point you make about the position that Cardiff finds itself in, which is different to lots of other parts of Wales. It is an expanding city: that is a positive thing but that does bring different challenges. It’s why I’m careful, when other Members urge me to accept that the biggest challenge is always in providing rural healthcare, that we say that we have to accept that the context in which healthcare is provided differs and there are particular circumstances—I always get different versions of ‘treat me fairly’, whether it’s rural representatives saying there are different challenges in rural parts of Wales, or the city of Cardiff having particular challenges, or that there are Valleys communities that have particular challenges as well. It’s about how we appropriately and properly address those, and we have a fair way of actually understating how extra funding is allocated, but also actually about how we attract people into different parts of our country to work, because some parts of Cardiff are more attractive to work in than others as well. So, within the city there are different challenges as well as those challenges outside. But it is a point well made that we do need to consider those in our particular policy prescriptions and responses.

I’m really pleased to hear her refer to North Cardiff seeing, if you like, the whole patient in terms of their social setting and their family setting and to understand what matters to them and what’s important to them, because people with similar conditions may want different responses. There are different levels of risk people are prepared to take in what they do and don’t want to do and how they’re actually able to cope and manage. So, it’s really encouraging to hear that conversation taking place. We need to see more of that and actually the patient being properly engaged in having a conversation with the medical professional about what matters to them, what they actually want to achieve and how the healthcare choices for treatment are then made, as well as prevention.

In terms of those other issues that may have an impact on someone’s health, we know that a range of GPs are being more proactive at understanding where and how to refer people to other sources of help and advice. Other fields of their lives may be affecting them and they may actually present at a GP practice with a healthcare need when actually it’s a different sort of issue that needs to be addressed and resolved—benefits issues, for example, are ones where we know that there is a range of GP practices involved. I met one just a short distance away from here that has a very proactive arrangement with Citizens Advice, for example. That proper referral process has been really helpful to them in knowing where and how to send people.

That also leads into your point about the primary care estate and how we build it. It’s not just the Bromley by Bow Centre, there is a range of other examples of where how you design and deliver a GP practice can help to set the context in which that healthcare is delivered, and how you properly link in other parts of not just the life of the patient, but also the practice and how it sees its actual mission in providing healthcare to its community.

That again goes back to your final point about the experience within training and what happens when people are studying medicine. For example, the Cardiff course is different, it’s an undergraduate one, to the graduate entry in Swansea, but I’m encouraged by the initial feedback from both Cardiff and Swansea regarding the numbers of people who train there who choose to make their career in Wales afterwards as well. They both have good records of not just bringing people to study medicine here in Wales, but of keeping them here as well. What we want to try and learn and understand, in looking at medical education and training in the future, is what more we can do to make sure that the experience is a rewarding one, that primary care is properly held up as a genuinely rewarding career and that the experience helps you to be a fully formed professional, not just to understand, if you like, the technical sides of medicine, but that point about seeing the whole patient and understanding how you help them to make choices for themselves to have a genuinely rewarding experience.

I’ll be as quick as I can on this. We hear, albeit anecdotally, that one of the deterrents to recruitment and training in Wales is this rather unfortunate myth that you have to be able to speak Welsh to work in the Welsh NHS. But it’s a Government priority—and it’s one that I agree with—that key individuals within professional primary care need to be able to speak Welsh in order to offer a service to those that they serve. Can you tell me how recruitment and training for those, regardless of where in the world they come from, will ensure sufficient Welsh language speaking skills amongst key individuals so that they can at least communicate with young children, individuals with learning difficulties and those with dementia? I appreciate that you might have wider ambitions for the skills base as a whole, but for those three individual groups of people, what focus are you putting on those within your training?

It’s a fair point about how we deal with Welsh as part of the importance of communication to deliver effective health and care. We know that for a range of people who have dementia, they often default to their first language and so it becomes more difficult to understand and communicate in other languages that they may have learned in life. So, there is a real imperative about the quality of healthcare—about how we have the healthcare team being able to deliver that. Some of that will be about how we help people to give them opportunities to learn Welsh once they come here, but it will also be about the wider team as well, because it doesn’t have to be the GPs themselves necessarily who have the Welsh language skills and ability. It’s got to be about the way that whole team works together where it is a genuine need, and to see it in that context. That then is something about how we recruit all of our professionals here in Wales and what that means in those different roles within that primary care team, not just in nursing but all the therapists as well, because sometimes when you understand what people want it’s in a slightly different context to when we actually then need the help, support and advice, ultimately, as well. So, it’s a genuinely joined-up approach; it recognises the language as a genuine issue, but at the same time it has to see it within that wider team context in which we want to provide excellence in care. Our first priority is to understand what we can do to attract more people to stay in Wales and to come to Wales to train, to work and to live. This is about how we enable people to do that, rather than creating a barrier that need not be there.

Of course, other primary care professionals that are included in your statement include specialist nurses working in the community and the home. In November 2011, I hosted an event in the Assembly on specialist nurses. At that time, for example, there was only one multiple sclerosis specialist nurse in Wales. I noted that we couldn’t afford to make knee-jerk reactions and cuts because specialist nurses ultimately save money and provide an important service. I talked about how much money was being saved across Wales by epilepsy, Parkinson’s, MS and other specialist nurses, and how they cut down admissions to hospital.

The Royal College of Physicians and the Association of British Neurologists recommend three clinical nurse specialists per 0.5 million population for MS, for example. The Steers report recommended one per 300 patients, but we still only have, for example, one MS nurse in north Wales for a population of patients of 1,100. There has been recruitment of other multidisciplinary team members, but other health boards providing better clinical nurse specialist and patient ratios also employ staff in these positions. How, therefore, will you address a situation in which, for example, the recommended level by Steers in Cardiff and the Vale is 2.3, and by the RCP and the ABN it’s 2.9, but they actually achieve 3.5, whereas north Wales has recommended levels of 3.7 or 4.2, but they still only have one? So, how can you tackle this on an all-Wales basis to fill in those gaps, recognising—and I’m sure you’ll agree—that it doesn’t always have to be a specialist nurse relevant to an individual condition; that it can be generic neurological nurses, but how to tackle the gaps that continue?

Well, it neatly reinforces the fact that we face workforce challenges in a variety of different areas within healthcare professions. And there’s been no attempt to hide from that. In fact, we want to positively be proactive and go out and say, ‘Who do we need within the primary care team?’ That’s why I talk about other professionals. It’s why I’m really pleased to hear that we’re not just having this conversation with the currency of doctors being the only currency that matters within the health service. And, in the way that we then plan our workforce and what we need within the workforce, we need to take account of that full range of professionals.

I expect, though, that you’ll see that, in some of these, the challenges that we face are not localised; they’re part of a national picture. And, this is also why primary care clusters actually being able to understand how they manage the healthcare needs of their local population is really important. The money they’ve been given to spend as they choose is actually about understanding how they will, with their particular knowledge of the people they serve, actually address some of the different challenges and gaps they face.

But, in every single sphere of workforce planning, at health board level and at national level, there will be some challenges that will be more difficult than others, and I’d be more than happy to have a more detailed conversation with him about where we are on this particular field of specialist nurses, because I do recognise that he does have a particular interest.

Thank you to the Cabinet Secretary.