[R] signifies the Member has declared an interest. [W] signifies that the question was tabled in Welsh.

I have accepted an urgent question under Standing Order 12.66. I call on Rhun ap Iorwerth to ask the urgent question.

Will the Cabinet Secretary make a statement regarding comments made by the Royal College of Emergency Medicine that ‘emergency care in Wales is in a state of crisis’? EAQ(5)0097(HWS)

I thank the Member for the question, and I’d like to start by recognising the hard work of NHS and social care staff, who work under significant pressure at this particular time of year. That is, of course, a consistent feature of winter. I don’t accept that emergency care in Wales is in a state of crisis, and in fact we continue to work with Dr Roop and other leading clinicians, as members of the national unscheduled care board, in trying to find meaningful solutions to support improved outcomes for patients who need emergency and unscheduled care here in Wales.

Cabinet Secretary, nobody wants to speak of a crisis in the NHS. It’s worrying for patients and it’s demoralising for our excellent staff. But you’ll be aware that the Red Cross described the situation in England’s A&E as a humanitarian crisis. You’ll also be aware that your party leader, Jeremy Corbyn, has described that as a national scandal, and demanded the Prime Minister explain herself to Parliament. Yet the vice-president of the Royal College of Emergency Medicine in Wales yesterday described current performance here as being as bad as, if not worse than, England. It would be shocking, except that performance of this level is long-standing, and this happens every year. We’re used to it, and it somehow doesn’t generate the same headlines as in England.

The data for December aren’t available yet, but November’s data showed that just 77 per cent of patients were seen within four hours, and that almost 3,000 people waited longer than 12 hours to be seen in major A&E departments. If performance follows the usual trajectory, it’s likely things will get worse as the winter develops. So, if you were in my position here, I’m sure you’d understand the temptation to use the term ‘crisis’. Well, it’s not me saying that; it’s the Royal College of Emergency Medicine, and there’s no ducking the severity of the warning that, due to this crisis, as they put it, patient safety is being compromised.

Cabinet Secretary, both winter and an ageing population are predictable, and we debate this every year. On our side here we call for better social care, for strengthened primary care, better out-of-hours GP services, to take the pressure off A&E, and you agree with us that this needs to happen. So, why hasn’t it happened? Why is there such a gap between the promises that get made here, and what happens on the ground? And are you embarrassed, frankly, that your own Labour Government’s performance undermines your colleagues in Westminster, who are desperate to highlight the failings of Jeremy Hunt?

No. I think, when looking at this, we need to think sensibly about where we are in Wales, and the comparison with England, which has been made. It is, of course, for the Red Cross to stand up for their own commentary on the system in England—they haven’t made the same commentary on the system here in Wales, and there are differences. There are seven different hospital trusts in England that have reached the highest level of alert—and they run a different system, so the pressures are different. Part of the challenge is the use of language and what we’re really and honestly describing. At the start of yesterday, the statement made by the Royal College of Emergency Medicine in Wales was then amended, because they referred to some of the English terminology, so there’s a real danger of not being accurate with our language, and not accurately reflecting the position that we’re in. And objectively speaking, we’re in a better position with less pressure in the system this week than last week. There are real highs, as everyone knows, in winter—real peaks on individual days and, at certain points in the year, peaks that sustain over periods of weeks or months. Our challenge always is: how do we sustainably and resiliently deal with that, to make sure that patient outcomes are not compromised and to make sure that patient care and the experience of care is as good as possible, and that the system does not fall over? You will recall that, when I attended the health and social care committee, in the winter pressures inquiry, I indicated that we’re in a better position than the last two winters: our plans were in a better place, we had learned from the previous two winters, but that did not mean there would be complacency because there will be difficult days. And you and I should be extremely thankful that we’re not members of front-line staff dealing with those pressures on the ground level.

But, that does not mean that where we are now is a crisis, because if you look at the objective levels of escalation in each of our hospitals, it simply does not amount to a crisis. We have a number of hospitals at level 4, but actually the majority are at level 3 or below, and that simply doesn’t reflect the emergency care system being in crisis. There is a need for all of us to have real care in the language that we use, because you were right, in the opening, where you talked about demoralising staff by describing the system in a way that is simply not accurate. I want to see staff supported in doing what is incredibly difficult throughout the whole year, but especially during winter.

There will be no complacency here. And one of the reasons we are in a different position to England is we haven’t seen the cuts made to social care that they have in England. That artificial measure has meant that the system as a whole isn’t working. We try to see the health and social care system as a coherent whole. We will undoubtedly have more learning to take from this winter, and if there is a real crisis, I will happily acknowledge it. I do not accept that where we are now is a crisis, but I do accept that there’s very real pressure and there will always be more for us to learn to do more to support our staff and to be better, not just for the health service, but the patients and the people who it serves.

You’re absolutely right, Cabinet Secretary, I think we must be very careful in the language that we all use. I think one of the first areas we have to be very clear about is that we are all entitled to challenge—challenge you, challenge the Welsh Government—about the performance of the health service. And by doing so, that does not impugn in any way the hard work of the people in that health service. Whether they are a top-flight consultant or the porter who takes the person from the ambulance in through the system, they all play a valuable part, and we need to get over this issue of ‘We can’t talk about it because we’re doing people down’, because none of us are doing them down. And language is very important, because the chairman of the Red Cross was utterly, utterly incorrect in the comments that he made about humanitarian crises. That was an appalling use of wording. And when you look at the evidence behind it, it’s mainly two NHS trusts. We have seven, and our seven all respond in different ways to the winter pressures.

Now, of course, the Royal College of Emergency Medicine made some very clear recommendations when they came before the health committee, and I know that you and your officials were looking at the transcript, looking at what people were saying, and have had a number of conversations with all these royal colleges. So, I would just like to ask you a couple of questions in terms of: were you able to ring-fence or ensure that health boards had ring-fenced any unscheduled care beds to ensure the provision was there, therefore elective surgery didn’t take a hit? Were you able to implement any frail and elderly assessment centres in any of the major hospitals in order to triage our more vulnerable people in the same way that we triage our paediatrics? Are you confident that redirection services have managed to work well? And, of course, what causes the collapse in A&E and what has caused this commentary, I believe, from the Royal College of Emergency Medicine, who were absolutely right to have pinpointed what they did and how they see it, is the closure of beds, and I wonder, Cabinet Secretary, if you’re able to say whether or not there’s been an increase at all in community beds and in secondary care, because taking those three or four actions would, in fact, help to alleviate the pressures that the A&E departments are under. They are, of course, the front door to all of our acute services.

Thank you for your series of points, comments and questions. When we talk about the system being under pressure, it does mean that the job of staff is made more difficult and more demanding, and that also has an impact on the patient experience, too, and we should all reflect and recognise that we’re talking about this general area. I don’t, for one minute, say that Members shouldn’t ask awkward questions; I think it’s entirely appropriate, on occasion, to challenge the use of language as to whether it’s appropriate. In terms of the questions that you asked and the points that you made, I think, again, it’s about seeing health and social care as a whole system. It isn’t just the secondary care part, it isn’t just the ambulance service and the paramedics, it isn’t just the emergency department; it’s the whole hospital system and it’s the flow through that system and actually what needs to be done, not just in triage at the point when someone arrives at a hospital, but actually what is done before that, whether that’s with the ambulance service or whether that’s actually in primary care as well. And we are objectively getting better at doing that as a system.

I look forward to publishing more statistics and more information over the course of this winter on what is being done—for example, in the next quarter’s statistics on the ambulance service, the work they’re doing to see, hear and treat people and discharge them either on the phone or at the scene to prevent journeys being undertaken unnecessarily into the hospital system; the work that is being done across primary care with pilots similar to the one, for example, that I’ve mentioned previously on Ynys Môn, but also in other parts of Wales, with similar systems and advanced care to keep people out of hospital and get them out quickly if they do go in. So, people understand who their most vulnerable individuals are and often those are elderly people, as you rightly point out.

We’ve already seen, as I indicated at the committee, that there are, I think, approximately 300 extra beds in the system that are being delivered as part of the response to winter in terms of the plans that health boards have. That’s a normal part of planning. That means they scale down elective activity: that’s entirely normal too. But, even last winter, we saw more elective activity than had taken place than in the previous winter. I won’t forecast and give you any sort of guarantee it will happen now, because it would be wrong of me to say what will happen with unscheduled care not knowing what may happen in terms of the flu or in the weather and the pressures that will come here. But I expect to see progress made on elective care in the remaining quarter of this financial year. I expect to see the system being resilient in terms of unscheduled care too, and that will mean some of our resources and people are redirected to an appropriate point in time at any point in the health and care system. In many ways, what keeps the health part of the system going is the fact they are able to work effectively with social care and the third sector in getting people into and out of health facilities for care and back into their own home with packages of care where it is appropriate. And in that place, we are in a much better place in Wales than other parts of the UK, because we plan jointly between health, social care and the third sector. Undoubtedly, I will answer more questions in this Chamber and in committee on the reality of winter on the ground for patients and for staff.

Cabinet Secretary, the fact that the vice-president of the Royal College of Emergency Medicine in Wales says patient safety is compromised and staff are struggling to cope with the intense demands should deeply concern us all. Rightly or wrongly, the Red Cross described the situation across the border as a humanitarian crisis and Dr Roop says that in some areas performance is as bad as, if not worse than, England. The Welsh Government has allocated additional funds to alleviate winter pressures, but these pressures exist all year round and if we have a major flu outbreak this winter we are in real trouble. Cabinet Secretary, in addition to funding announced to tackle winter pressures, how do you plan to address the capacity issues in the rest of the NHS, which are impacting upon emergency care? We know that there are people in hospital that can’t go home because of the fact that they are home alone and they are taking up bed space, which is quite needless, really, had we had an alternative to accommodate people. I have met over the Christmas period with a voluntary organisation that is seeking to help us, but I will discuss this in further detail at another time. Thank you.

Thank you for the comments that you raise. Again, I go back to saying that, of course, I’m concerned about the language used and the comments made by Dr Roop. But, as I say, objectively, the pressure in the system is not as great as it has been in the past. It is not as great as even last week. There’s a real issue here, and I have no issue with people saying that the health and care system is under real pressure through winter and that makes the job of staff more difficult and more demanding. That’s very different to saying that it is in a state of genuine crisis. I do take issue with some of the points that are made about the fact there is year-round pressure. There is year-round pressure, but in winter that pressure is different. You are more likely to see people that are older and sicker come in to our health and care system. They’re more likely to occupy beds within the healthcare part of the system and that puts more pressure on the transfers of care and packages of care within healthcare, but also between health and social care as well. So, winter is a different sort of pressure. That’s what we’re seeing now and we’ll see more of it in the next few months. There’s no point in pretending winter does not provide this pressure that is extraordinary. That is why there is an extraordinary response in planning for winter and in delivering in winter as well. But I am really encouraged about the fact that we’ve not seen a collapse in delayed transfers of care here in Wales. We’ve actually sustained and been able to manage some of that pressure at the start of winter. I look forward to saying more about what’s been done when the next figures are published later on this month, because that tells us something about the health of the whole system and the ability to move people effectively from the point when they need some sort of support and care back into their own homes with that package of care and through healthcare if that’s what they need. So that, of course, is the focus of our activity, on what we expect health and social care to do together, but I think, really, every one of us should recognise not just the work that staff do, but think about how we talk about the jobs that they do and the care they provide for each and every one of our constituents at various points in time.

Cabinet Secretary, I listened very closely to the answers that you have given, and you said that the pressures are not as great as they were this time last year. In your most immediate response, you said that. Yet, the last figures for A&E, for people waiting over 12 hours or more, went up by 22 per cent to 2,955. Are you in a position to confirm that those figures are on a downward trajectory, given your comments this afternoon, and that those wait times are becoming more responsive in our A&E departments across Wales, and that, when the latest figures come out, because you will be in possession of the figures, we will see a decline in those figures, given that they’ve shown a year-on-year increase, on the most recent figures up to November, of 22 per cent in people who are waiting 12 hours or more in A&E departments across Wales?

There are two points to make here. The first is that I recognise that some people do wait too long, whether it’s in November or whether it’s in June, and that’s part of our challenge in improving the system. That doesn’t necessarily mean they have bad outcomes in terms of the clinical outcomes, but that isn’t always a great patient experience. And there’s something here about our measures on four and 12 hours as well. They tell us something about the care that’s provided, but not everything that we would think that we are being told. You, for example, could go into a hospital and, actually, you’d be seen, treated and discharged in four and a half hours. Now, the way our figures look, we’d probably say, ‘That’s someone who’s waited too long.’ But you could actually have a very good experience of care in that time, and you could actually be really happy with the treatment that you’ve received. Equally, you could be in an A&E department for three hours and our figures would then say, ‘You’re a success’, but that might not be a great experience as well. So, it doesn’t tell us everything that we think the figures actually might do. So, I expect to see that there will be more pressures through winter on both four and 12 hours, and, you know, it would be fantasy to try and claim otherwise.

The challenge must be: how resilient our system is, what the quality of care being delivered is, and what the patient experience tells us about that as well. And the point that I was trying to make was that, actually, objectively, we’re in a better position this week than last week, and if there is a system in crisis, you wouldn’t have thought the system would have coped and de-escalated with the pressure coming through the doors, and maybe see what happens on different days through the rest of winter as well. For example, on 27 December, there was a five-year peak in admissions. On 1 January there was a much higher admissions rate than the previous January as well. So, we’ll see those different peaks and troughs, but we will all know there is more pressure in the system in winter. We need to understand what we’ve done in advance in the plans we’ve had, how successful they’ve been, what we learn for the next year, and then that broader trajectory of improvement through the whole health and care system to try and make sure that people do get seen, treated and discharged in an appropriate period of time, but also in the appropriate place, because every single part of the NHS in the UK recognises that still too many people, even at the points of highest pressure, are going to a place that isn’t the appropriate place for their care and treatment.

So, there’s something about educating and empowering the public and informing them where to go for the appropriate treatment that they need. And that’s why I’m really encouraged by the early results from the 111 pilot in the Abertawe Bro Morgannwg area, which I think has been really helpful in getting people to the right place to get the right treatments and care. I look forward to providing Members with more information on that pilot and then seeing if that will then be rolled out in other parts of the country.