I now call on the party spokespeople to ask questions of the Cabinet Secretary. First of all, Plaid Cymru spokesperson, Rhun ap Iorwerth.

Thank you, Llywydd. I’m sure the Cabinet Secretary would join with me in condemning the rhetoric of the UK Conservative Government over the past few days and the disrespect that’s been shown towards staff from outwith these isles who make such a valuable contribution to our NHS. I would want to distance myself from virtually everything that Jeremy Hunt has said. But, coming to my question, he has announced this week that he wants to see more training places in medical schools in England. Is that something that the Cabinet Secretary wants to see happening in Wales?

Thank you for the question. I share your concern at the comments that have been made at the Conservative Party conference by Jeremy Hunt. Members across this Chamber will want to see opportunities for a career in medical training and medical practice for more of our young people within Wales and across the UK, but there’s a real difference between that and saying that foreign doctors are no longer welcome, or they’re only here as an interim measure. In fact, I’ve already written to Jeremy Hunt expressing my concern at the rhetoric that he has been displaying this week and the significant damage it could do, not just to the NHS in England, but right across the NHS family in all four nations. So, I’ve been very clear about my view, it’s on the record, and we will have no part in this. We certainly will not support the path that the Conservatives are taking.

In terms of the future for Welsh and UK-domiciled students and their ability to undertake medical training within this country, I’ve already indicated that we’re looking at our current places and how to encourage more Welsh students to undertake medical training at their place of choice. That will, of course, include work here within Wales and we’re actually looking at the number of medical training places that we have. We want to make sure that we build on the excellence we’ve got from both Cardiff and Swansea, with both the undergraduate and postgraduate entry courses that are run, and I want to make sure we maintain that quality, but also that we have a real springboard for more careers in medical education and training, both here in Wales and across the UK.

I look forward to an increase in places, including of course in Bangor and other parts of Wales. I’d welcome any moves from Welsh Government—and I will continue to press Government and offer my co-operation—on the issue of increasing medical training places.

The Cabinet Secretary has, on numerous occasions, said that there are a record number of consultants and doctors in Wales. We’ve delved into these statistics a bit further. Out of the 65 hospital specialities with data on StatsWales, 32 of them have seen a decline in numbers over the past year, 13 have seen no change, and 20 have seen slight rises. One of those, vascular surgery, is up simply because it now counts as a separate specialism rather than being listed as general surgery. So, it remains a fact that more specialisms have seen a decline in numbers than have seen a rise in numbers. Are you happy with that state of affairs?

Well, it is a fact, not an opinion, that consultant numbers have risen significantly over the last decade. Our challenge always is: in what numbers do we still face a challenge and what can we ourselves do about that? Because, in answer to the first question, which I think was from Paul Davies, we recognise there are some specialties where there are real challenges right across the UK family. And, actually, some of that is international challenge as well. So, we do take the view about the overall numbers, but then look at those areas of specialism. And that’s why, in the recruitment campaign you’ll have heard us discuss and talk about, we want to advertise Wales as a great place to work as well to live, and for people to undertake their training here too.

So, there’s no complacency or any lack of acknowledgement that, in some specialities, we have very real challenges, and getting the model of healthcare right is part of what we need to do to encourage people to come and work here. Because, when people are looking for the next stage in their career—where to live, where to raise a family—they’re actually also thinking about, ‘What will be the quality of the workplace, what will be the model of care I’m going into? Is it sustainable? Will it provide me with the opportunities that I want to undertake great patient care?’, but also other parts of their life too. So, it’s that whole picture we’re looking at, as we do move forward to try and understand how do we recruit the medical workforce of today and the future that we want, and the future of healthcare here in Wales.

You have stated as fact, again, as the record will show, that there has been an increase in doctor numbers in Wales. One of the further facts that we found interesting is that one particular speciality has seen an extra 207 doctors in the past year. That particular speciality, although listed as a hospital speciality, is in fact ‘general practice (doctors in training)’.

Now, we asked for clarification on what that means, and it does in fact refer to trainee doctors in general practice, not specialist consultants working in hospitals. And the reason for such a large increase was down to the fact that, previously, GPs in training who rotated into a GP surgery would be employed by the surgery, and therefore leave the NHS Wales payroll, and so wouldn’t appear on StatsWales figures. Now, NHS Wales Shared Services Partnership have become the lead employer for GPs in training. So, they do appear in the figures. This is the reason why the numbers have gone up. Without that change in the way stats on the workforce are recorded, the figures would actually have shown a decline of 84 hospital doctors. In fact, six of the seven health boards in Wales have shown a decline in the number of hospital doctors they employ. We also know that there has been a fall in the head count of GPs, and it would be even worse if you published the full-time equivalent numbers. Does the Cabinet Secretary now accept that it is misleading of your party to claim that we have a record number of consultants and doctors?

No, I don’t. I don’t accept the way in which you’ve presented the figures. We’re confident there are more GPs now working within NHS Wales, we’re confident there are more consultants working within NHS Wales as well. You highlight the shared services partnership, and actually it’s a real positive that shared services are now the host employer for doctors in training in general practice. It’s something that the British Medical Association and the Royal College of General Practitioners have been very supportive of, because it allows those doctors to actually have some stability in their employment contract relationship, and it means, for example, getting a mortgage is much easier, having had a stable employer there as well. So, we’re doing a good thing there for GP doctors in training. And, on the only figures that I’ve seen myself, we have more GPs in head-count terms, and we have more consultants in head-count terms as well.

The challenge always is what more do we need to do, what timescale can we do that within, and how do we actually deal with our challenges in a way that we’re not compromising the service, we’re actually attracting people to come here, to train, to live, and to work. That’s our ambition, and that’s where we expect to make further progress on this autumn and beyond.

Welsh Conservatives spokesperson, Angela Burns.

Diolch, Lywydd. Cabinet Secretary, between 2009 and 2014, NHS expenditure on mental health ranged from 11.4 per cent to 11.9 per cent of the total NHS spend. Now, given that mental health budget lines are a catch-all for everything from child and adolescent mental health services to dementia, psychotic illnesses, perinatal services, depression and anxiety, do you believe that 12 per cent of the entire NHS budget being spent on mental health, whilst 88 per cent is being spent on physical health, is a correct balance?

Mental health spend is actually the largest individual block of spending that we have within the national health service. And you’ll have heard both myself and the previous Minister indicate the reviews that we’ve done on, for example, the ring-fence, to make sure that that’s real, to make sure more money is being spent. And our challenge isn’t to simply say, ‘Let’s look at the money’. Our challenge always is: are we getting the right outcomes, are we getting enough people seen who have real needs, and how do we do that? And, often, it’s more than just health spend as well, because a lot of this is about more general well-being. For example, social prescribing won’t come down as spend in mental health terms, but, actually, it certainly is. In preventative terms, it often is part of the picture. So, I’m committed to continuing to have mental health as a very real priority for what we do in budgetary terms, but also in service delivery and outcome terms as well. So, I look forward to the questions on the challenges that we still have—and I acknowledge we do as well—as we continue to try and reduce waiting times, but also to see a real and objective measure for outcomes rolled across the NHS, and I’m confident we will do within this term.

That was a nice slide away from my question, actually, Cabinet Secretary, because I asked about the 12 per cent spend as a percentage, and you immediately replied by saying that the services for mental health are the biggest line. But that’s exactly my point. We have cardiac lines, we have diabetes lines within the health budget, but we’ve put everything into mental health. So, yes, you can say 12 per cent for mental health is great, but the problem is mental health is covering a huge variety of different conditions, with different comorbidities. Now, I’ve been reviewing the Pricewaterhouse Coopers report into mental health ring-fencing arrangements, and they are firmly of the view that a ring-fence based, and I’m quoting this:

‘A ring-fence based on historic patterns of expenditure has little continued relevance in the current operating environment.’

So, do you agree with that conclusion, and, if so, how will you move away from the ring-fence model?

We’ve had this review in the past, and I’m happy to look again at the best way to protect mental health spending to make sure that it is there as a real factor in the minds of people planning and delivering our service. But the budget lines collected within mental health are not the only indicator, as I did indicate in my answer. There’s more to it than just simply saying it’s only 12 per cent on mental health and everything else is physical health. And, of course, the ring-fence isn’t the only indicator of all the money that’s spent. We actually spend more than the ring-fenced amount of money on mental health services. I come back again to my interest in saying, ‘Let’s have a line, in percentage terms, on what we should spend in mental health terms and what we should spend elsewhere’—the challenge should always be: are we getting proper value from the money that we spend, are we delivering against the real needs that our population has, and can we further improve that, bearing in mind that we have a finite resource available to us? That’s why I refer to the work we’re doing on outcomes and the work we’ve done with the third sector alliance, where they have difficult questions for us as well about waiting times, and about outcomes as well, but there’s real development. There is a programme here that is not just about how we manage a diminishing resource and diminishing outcomes, but how we set our sights on what we can do to further improve what we are able to deliver in all areas of mental health spending, but also the whole service as a holistic service for the whole person.

First Minister—I keep calling you First Minister; this must be an indication. Cabinet Secretary, you said again just then about delivering what the people of Wales need. And, frankly, we don’t deliver what the people of Wales need on health, on mental health. How many of us here have always talked about child and adolescent mental health services? We know that there are an awful lot of problems in the whole mental health arena. We don’t have enough of the specialists, and we don’t spend enough money on getting the services to people. And it is important, because one in four of us will suffer some kind of mental health episode in our life, and that’s a staggeringly high number. So, in physical health, there is much recognition by your Government of comorbidity, but the same is just not—there’s not the same sort of view within mental health.

So, what I’d like to know, Cabinet Secretary is: in your soon to be announced mental health plan, how much can we expect in terms of capacity and demand, and an end to silo working? Because I think we sometimes forget, and I have had constituents who can reaffirm this to me again and again, that a person with dementia can also have cancer, a person with depression can have a physical condition, a child in a wheelchair can have eating disorders, but we tend to only pick the physical element to treat first and leave the mental health issue second. I would like to see an end to this silo working, so that we can get to people, the one in four of us who will have some kind of mental health condition at some point in our life, and get those services to us, and I fear that at the moment we’re simply not going down the right track.

There’s always more that we can do to objectively recognise what we do well and what we don’t do as well and need to improve on. But I think it’s rather unfair to suggest that the national health service is only interested in treating people’s physical conditions or the health commissioning separately. What we do need to do is see the whole person and treat the whole person and understand, in many instances, the risks they’re prepared to take legitimately for themselves—this isn’t about capacity, but saying they’re entitled to make a choice about what they want to do and the sort of treatments that they want to engage with.

For example, in dementia care, we know that, with lots of people who have dementia, there are challenges about understanding their physical health and making sure that they’re not avoided and, actually, that the person who has charge and responsibility for their care sees that whole person, understands their physical needs and their mental health needs as well. When you look at the work that is being done with stakeholders that will lead into the next delivery plan, which I’ll be proud to launch on 10 October on World Mental Health Day, you’ll see that there is a great recognition of people’s physical health and mental health and wellbeing being inextricably linked and tied up.

We see that in a range of things that we already do within Government. For example, Healthy Working Wales. I’ve been very interested to present the awards, not just because I like turning up and having my picture taken, but actually you hear different stories from different employers—small, medium and large employers—and there’s a real feeling that, in the work they’re doing with us, they’re actually recognising the mental health challenges and the well-being challenges for their workforce and understanding what they need to do to improve that. So, it is something that I’m seeing more and more and I expect to see it more consistently in the work we do and in the programmes that we fund. So, it isn’t just about looking in the one budget line to see where mental health is—it is much broader than that, and I expect that we will see that progressively through the national health service.

UKIP spokesperson, Caroline Jones.

Diolch, Lywydd. Cabinet Secretary, with the number of people aged 65 and over projected to increase by 44 per cent in the coming decades, we must ensure that our social care sector can cope with the inevitable increase in demand for social care. Unfortunately, we have seen massive cuts in social care budgets and we are simply not training enough social care workers, or the ones that we already have feel undervalued, many of them. Social care workers are overworked and, in many instances, are not given enough time to properly care for the people that they have to care for. What is the Welsh Government doing to ensure that social services are adequately funded and ensure that we have sufficient staff to allow our dedicated social care workers time to care?

Thank you for the question. I’m actually pleased when social care gets mentioned in these questions. It’s very easy to simply default to simply talking about the health service and doctors in particular in this set of questions. I don’t share your suggestion that social care has had massive cuts in Wales. Actually, we’ve seen health and social care together. Massive cuts have taken place within England and, if you look at what’s happened here in Wales, we’re in a much, much better position—not just in terms of the funding, because funding is, I think, 7 per cent per head higher on health and social care in Wales than in England, but in the way in which we see the whole service: the way we fund it, and how we look to organise it. That’s why the Social Services and Well-being (Wales) Act 2014 is such an important indicator of the move forward. We see health and social care needing to work more progressively together—not because there is more need and more demand coming through, but actually we think people get a better service with better outcomes.

How do those people collaborate and work together? That’s why the Minister will be setting out, progressively, throughout the rest of this term, how we’ll implement the social services and well-being Act, the areas of mandated working together, and the areas where we encourage people to work together as well. If you just want to think about the workforce as well, it’s right to say that this is a highly pressured profession. It is not an easy job and social workers are often held up as the bad people when something goes wrong. Actually, we need more people to value the profession and recognise what they can do in supporting families to still be together as a family, to make choices together, and to help make people get out of very difficult parts of their lives.

I’m delighted to say that the British Association of Social Workers have recognised that, in Wales, it is a much better environment to work than other parts of the UK. That’s the profession itself talking about the reality of working here. It doesn’t mean that it’s easy in Wales, it doesn’t mean to say that there isn’t pressure, but we definitely have a better service and a better system and a better response than you’ll find over the border. Our challenge is how we continue to improve, bearing in mind the unavoidable reality that we will have less money to work with each and every year within this Assembly term.

Thank you for your answer, Cabinet Secretary. The Regulation and Inspection of Social Care (Wales) Act 2016 will introduce massive changes to the social care sector. The entire social care workforce will now have mandatory training standards. There are currently many working in the domiciliary care sector who are likely to require significant training in order to meet the new training standards. We also have a shortage of social care workers, particularly in domiciliary care. What workforce planning is the Welsh Government undertaking to ensure we have sufficient training places available to meet demand and that we are recruiting and retaining staff in sufficient numbers to meet the future needs of the sector?

I’m delighted to hear you mention the regulation and inspection Bill, now the Regulation and Inspection of Social Care (Wales) Act 2016, that the Minister is taking forward, and, indeed, the work that she is taking forward on understanding the future needs of the workforce. There’s a range of actions in place and I’m sure you’ll be delighted to hear further updates from the Minister in due course. If you want to understand the detail, I’m sure she’d be happy to meet you.

Thank you, Cabinet Secretary. Without the more than a third of a million unpaid carers, our social care sector would be massively overloaded. It is estimated that unpaid carers save the health and social care sector over £8 billion a year. Research by the Carers Trust found that 30 per cent of carers don’t take any breaks and that 65 per cent of carers spend what little breaks they have doing household chores. Carers need regular breaks if they are to remain healthy and able to continue providing care. Without respite, carers’ health and well-being is put at risk and there is an increased likelihood that those they care for will have to be admitted to hospital or residential care. Carers Trust are calling for a carer well-being fund to be established in Wales to provide breaks for carers. Will the Welsh Government consider establishing such a fund? After all, it is a small price to pay considering the savings that Wales’s 370,000 carers deliver to our NHS and social services each year.

I’m sure that Members across the Chamber will recognise the significant value that carers provide, not just simply in financial terms, but also in terms of the ability to be cared for by a loved one or by someone they know. Many of us in this room will, of course, have had experience of being carers for friends and/or family members. Members will also, I hope, know that the Minister is the lead Minister for carers and, indeed, as she’s taking forward the social services and well-being Act, and the carers strategy within it, there is an understanding of the fact that carers now, for the first time, have the ability and the statutory right to have their own needs assessed by public services as well. That’s a real step forward.

So, I expect that carers in Wales—I certainly hope that they will see and recognise that we’re taking positive steps forward. I know that Carers Wales have contact with the Minister and I’m sure that any proposals they have will be considered seriously by the Minister and me as we look to understand how we can further improve the provision for carers, for their ability to have respite breaks as well, but also to understand that you need to see the carer and the person they care for individually and understand what they mean together, to and for each other. But, again, if you wish to have a more detailed discussion on this, I’m sure the Minister would be very happy to make time to have that conversation with you.