The next item on our agenda this afternoon is a debate on the Health, Social Care and Sport Committee’s report on its inquiry into winter preparedness and I call on the committee Chair to move the motion—Dai Lloyd.

Motion NDM6220 Dai Lloyd

To propose that the National Assembly for Wales:

Notes the report of the Health, Social Care and Sport Committee on the inquiry into winter preparedness 2016-17, which was laid in the Table Office on 9 December 2016.

Motion moved.

Thank you, Llywydd. I’m very pleased to open this debate today on the Health, Social Care and Sport Committee’s report on winter preparedness 2016-17, which we’re in the middle of now. Of course, winter is a hugely challenging period for our health and social care services. It’s a time when the year-round pressures of an ageing population, increasing demand for services, and workforce challenges, are thrown into sharp relief. Just two weeks ago the chief executive of the Welsh NHS remarked that the NHS has already faced exceptional challenges this winter, experiencing some of the busiest days ever faced by hospital emergency units and the Welsh ambulance service.

That’s the week the Cabinet Secretary for Health, Well-being and Sport announced that certain targets for GPs are to be suspended temporarily to help free up appointments in their practices, such is the pressure on primary care over this winter. Assembly Members will almost certainly be aware also of the coverage relating to similar pressure on health and social care services elsewhere in the UK and in England in particular.

We as a committee felt it was important to examine how prepared the Welsh NHS and social care services are to deal with pressures on unscheduled care services during what is now the current winter period. As part of this work, we wanted to look at the progress that has been made in this area over the past few years, particularly since the work done by our predecessor committee in 2013-14. Our terms of reference also included a focus on patient flow, including primary care out of hours, emergency ambulance services, emergency departments, and delayed transfers of care.

We spent the 2016 summer period asking stakeholders to tell us their views on whether the Welsh NHS was equipped to deal with pressures on unscheduled care services during the coming winter. We had a really good response to this and we’re grateful to everyone who took the time to write to us and present evidence to us in our formal meetings.

That’s the evidence that’s helped us to come to some very clear conclusions and has enabled us to make what we believe are robust recommendations to the Cabinet Secretary and Minister. Although many of our recommendations are important in terms of managing additional winter pressures, they need to be considered as part of a much wider review of health and social care services in Wales. Indeed, our overriding conclusion is that a more resilient NHS and social care service would be better equipped to cope with the considerable spikes in demand over the winter period. Without that greater resilience all year round, efforts to manage winter-specific pressures will be more about trying to limit their effects than achieving the whole-system change that is so greatly needed. Regular readers of our report will know that paragraphs 71 to 75 tell us this.

I note that the Cabinet Secretary has partially accepted our first recommendation. We are all aware that statutory regional partnership boards were established under the Social Services and Well-Being (Wales) Act 2014 as a way of taking forward the agenda to deliver integrated health and social care. However, I’m glad the Cabinet Secretary recognises there is more to do and that his Government will be supporting further improvements.

Overall, we concluded there is a need for greater integration between the health and social care sectors, both in the planning and delivery of services, and there is a need to include the independent sector, both care home and domiciliary services, in this work. In light of this, I am disappointed the Cabinet Secretary has rejected our recommendation that he should commission or possibly review any available research into the effectiveness of the co-location of primary care services in A&E departments, especially as he acknowledged the evidence from across the United Kingdom outlining the effectiveness of co-location. The information he has provided relating to out-of-hours services working alongside emergency departments is welcome, despite that.

The Deputy Presiding Officer (Ann Jones) took the Chair.

There was a difference of opinion amongst those who gave evidence to the committee about the levels of preparedness—this, in itself, is cause for some concern. There should be more confidence across the entire sector that the problem is under control and manageable. That this is not the case may be due, in part, to a need to improve communication between all the relevant parties, despite arrangements, such as integrated plans, being in place.

Linked to this, we have some concerns about the Welsh Government’s flu vaccination campaign, especially in relation to the relatively low uptake amongst NHS and social care staff. Recent figures provided by Public Health Wales show that only 48.4 per cent of NHS staff who have direct patient contact have, so far, taken part in the influenza immunisation programme. Vaccinating front-line staff is a key preventative measure, and we believe the Welsh Government and the sector should be more ambitious when setting targets in this area. We also have some concerns about the structure, visibility and targeting of the campaign this year. There is a need for clarity about the respective roles of GPs and pharmacists in the campaign and the strength and visibility of national messages to target groups. We recommended that arrangements are put in place to undertake whole-system learning based on an evaluation of the effectiveness of all Welsh Government campaigns relating to winter health. That’s recommendation 3.

I welcome the fact that the Cabinet Secretary has accepted our recommendation on this matter. I am pleased to note—and I’m sure that other committee members will feel the same way—that learning from the evaluation will be incorporated into future all-year planning, including the campaign for next winter. There is no doubt that there have been some clear improvements within the system. The Welsh ambulance services trust is an obvious example, and they should be congratulated for this. However, a number of matters reported on by our predecessor committee in 2013 have been identified in the course of this inquiry as continuing to need attention as a matter of priority, including inappropriate A&E admissions, patient flow through hospitals and delayed transfers of care. We had a lot of evidence about beds, the need for more beds and the great pressure on social care. More from other committee members on that, evidently.

As a committee, we recognise that planning for this winter has required a great many resources. We welcome the fact that the work on planning for the winter started early. It’s important that the lessons of previous years are learnt. Now, despite this, we are concerned about the ability of the system to cope with the additional seasonal pressures, and the damage that one serious incident such as a flu outbreak or the closure of a care home could cause. We welcome the additional investment of £50 million by the Welsh Government for winter preparedness this year. The Cabinet Secretary said that he expected to see specific outcomes as a result of this additional investment: dealing with the additional demands of unscheduled care and maintaining elective surgery over the winter period. We recognise that these are ambitious targets for this level of investment. That’s recommendation 4. We look forward to hearing from the Cabinet Secretary in May regarding the progress made against those ambitious targets. Thank you very much.

I don’t want to rehearse what Dai Lloyd, the committee Chair, has already said, but I certainly want to put on record that I agree with the comments that we’ve just heard and agree with the conclusions of this report. Of course, there are additional demands arising during the winter months, particularly, as we heard during our inquiry, in terms of the kind of health problems arising with elderly people, and children too. But what struck me more than anything during this inquiry, and in the conclusions of the report, is the degree to which winter pressures are pressures that aren’t necessarily caused by factors that are beyond the control of Government—for example the weather, or cold weather particularly—but they are pressures caused by factors that should be within the Government’s control. That’s what causes many of the problems that we see within the service. We know how important flu vaccination is, and we know that front-line staff in the health service should receive that vaccination. It’s not expensive to ensure that that happens, but we did receive clear evidence suggesting that staff in our hospitals weren’t taking up that vaccination. That’s the kind of thing that should be relatively fundamental in this area.

We also heard that preparations within the social care sector for the winter weren’t as detailed as, perhaps, they should be. I know that these benches often refer critically to the Westminster Government for failing, in the English context, to realise the value of social care within the health and social care service as a whole. But here, I think, we have an example of the Welsh Government also making a similar error of planning—yes, as is required for the NHS—but failing to simultaneously give due attention to the care system more broadly. The evidence that we as a committee heard certainly reinforces our view that there is, perhaps, a crisis facing social care, and we will be focusing on that in the Plaid Cymru debate later this afternoon.

I will quickly turn to the number of beds in our hospitals used at any particular time. Over the last two decades, there’s been a reduction in the number of beds available within the health service in Wales, and that is driven largely by ideology more than funding, if truth be told. But we as a committee heard evidence that the bed shortages have now reached a point that is causing a problem within the health service. We know that occupancy should be no more than 85 per cent or it creates problems in terms of flexibility within the system. Many have suggested to me that those who refuse to accept that concept of not going over 85 per cent are those who have supported an ideological shift towards reducing the number of beds within the health service. I do think that we need to commence a programme of ensuring that the beds are in place, and we will also cover that issue later on this afternoon in our debate.

But, as I say, I think the greatest lesson we can learn from our inquiry as a committee is that the health service is facing pressures throughout the year, and that the pressure and what happens in the winter months—the additional demands from older people and children—is something that’s going to happen next year too, and it will happen the following year. So, we should be able to make preparations, particularly given the demographic changes and the increase in chronic illness and so on. So, we know what the pressures are, we have some forewarning of that and, quite simply, we should be doing more about it.

I very much enjoyed being part of this committee and I’d like to thank everyone who came as witnesses before it. They were very detailed, they were very knowledgeable and, in the main, they were incredibly passionate about the different areas that they represented. I’d also like to thank the clerking team and the staff for turning around and marshalling us all so well.

The report, I think, speaks for itself. There’s an awful amount of detail in the report, and when you read the Record of Proceedings there is even more detail there. But, for me, coming to this in a brand-new way—it’s the first time I’ve sat on the health and social care committee—there were two main areas that really came forward—two big issues. The first issue is that whilst the pressure on the NHS remains constant 365 days of the year, there’s no doubt about it that in the winter it changes shape. We know that it changes shape, and every winter we know that it’s going to change shape because it’s a different type of patient that mainly gets admitted, it’s a different type of patient that needs the ambulance service and a different type of patient that needs the social care services.

Therefore, it should not be beyond the wit of us all here—but particularly the Welsh Government, as it is your responsibility, Cabinet Secretary—to ensure that the health boards really reflect not so much the pressure but that change in pressure, so that we make sure that we do have good collaboration in place and good integration in place, and that we make sure that we have specific types of bed, because we know, for example, that we’re going to have an awful lot more young children and we’re going to have an awful lot more elderly people; that we think about things like co-location and we think about how we can make people’s journey through A&E and through clinical decisions units into hospital and back out of hospital much more quick and efficient.

No-one’s taking away from the fact that that pressure is there all of the time, but we know that as winter turns—and winter turns year after year—that pressure will change shape. We had, as the Chair has already referred to, a committee report in 2013 that raised these very issues, and we’re not learning the lessons. So, my first question to you, Cabinet Secretary, would be to really emphasise to you about the fact that we need to be ahead of the game and understand that pressure is not always the same, no matter how we describe it.

The second area that really came up for me in this committee was the whole story around integration and collaboration. In your Government response to the committee report, you state, Cabinet Secretary, that

‘Health boards are expected to routinely engage with social care and independent sectors as part of the development of their IMTPs’.

I walked away from that committee with a very sure feeling that general practitioners did not feel that they’d been really consulted with and involved in the collaborative delivery of winter pressures and healthcare plans for the winter period, and I also walked away from that committee feeling that the care sector hadn’t been, really, overly involved. And that’s why I was very disappointed to see your comments on recommendation 6 and your refusal to actually accept that recommendation, because I think that market oversight, Cabinet Secretary, is absolutely vital, and I would like clarification of the timings and the depth of the work that’s going to be undertaken by CSSIW and the national commissioning board, because there’s no doubt that the market in social care is extremely fragile at present.

There are a great number of barriers to the further growth of the social care market: there are dwindling care home beds, there is ageing building stock, and regulations and financial constraints are kicking in. If we’re going to accept your response to recommendation 1, which is you believe that we need to go ahead and do more integration, more collaboration, build these IMTPs, which look at the whole sector—all the way from primary care, when somebody might first walk out of their door with an issue, all the way through to going in to hospital and then perhaps back out into a care home—we’ve got to involve all of those elements in those IMTPs. I did not have any sense—no true sense—that any of the health boards that we interviewed or the witnesses that we saw believed that that pan-sector collaboration had really been successfully undertaken. I think that, unless we can ensure we have a robust social care sector ahead of us, then with the best will in the world, with all the planning with GPs, with any planning in hospitals, if we cannot take people who are well out of hospital and put them into a social care setting, then we’re going to end up with this constant jamming of our beds in our hospitals, and that brings all those other problems all the way through to the very front door of the hospital and then the back door of GP surgeries. So, those are my two points, Cabinet Secretary, and I really would urge you to look at a way of getting to grips with the state of the market in social care, ensuring collaboration and integration, and accepting that pressure is always there, but pressure looks different at different times of the year. Thank you very much indeed.

I’d like to thank the clerks, the health committee and the Research Service for their assistance during our inquiry. I would also like to thank all those who gave evidence to us during the course of our inquiry. Over the course of our inquiry, the majority of stakeholders told us that, while things were slightly better this year, they were still unprepared for the winter period and facing year-round pressures. The Royal College of Paediatrics and Child Health told us that services were not quite ready. It is abundantly clear that we need to make substantial changes in order to cope with this additional pressure.

As a committee, we carefully considered the evidence put before us and cross-examined the witnesses before coming up with just nine recommendations. It is therefore disappointing that the Welsh Government were able to fully accept just three of our recommendations. I’m particularly disappointed that the Cabinet Secretary has rejected recommendation 5. Many of the witnesses to our inquiry highlighted the fact that the current service model for unscheduled care is unsustainable. While the Choose Well campaign is a step in the right direction, it is going to take much longer to totally re-educate the Welsh public. It is so ingrained in the public’s mindset that when we get ill we need to see a doctor that convincing people that sometimes a community pharmacy is a much better option is going to take a long time.

When you couple this mindset with the fact that it is getting harder to see a GP because of underfunding and overwork, it is no wonder that people inappropriately turn up at A&E. While this is shouldn’t be the case, we have to face reality. Until we employ more GPs and have better integrated primary care teams, our hospitals are faced with picking up the slack in the system. It was pressures on A&E that led to the creation of minor injury units, and therefore the co-location of primary care services would seem to be a natural progression. Both the BMA and the Royal College of Emergency Medicine suggested that we look at co-location of primary care services and the use of front-door physicians. We should listen to them.

We learnt that up to 30 per cent of those attending A&E would be more appropriately dealt with elsewhere in the health system. We need a better way of dealing with these people. Having a single-point gateway service that can funnel people to the appropriate service is a much better solution than what we currently have and warrants proper investigation.

Cabinet Secretary, I urge you to reconsider. You say that this a matter for health boards, but with the majority of our health boards requiring some form of Government intervention, you need to show leadership. This issue is not going away. We can’t just sit back and hope that we can solve winter pressures with an ad campaign. Our committee carefully considered the evidence put before us and we have suggested solutions based upon that evidence. I would hope that the Welsh Government will heed our report. Diolch yn fawr.

I, too, welcome this report from the Health, Social Care and Sport Committee. When considering the challenges facing our healthcare system, we must do so in a way that fundamentally incorporates health and social care, as a complete circle, as noted in this report. No-one is denying the many pressures facing health and social care, and we are fully aware that, during the colder months, it is obvious there is going to be a seasonal spike. The report highlighted a number of serious causes for concern in terms of the level of preparedness and the ability of both sectors to cope: individuals living longer; respiratory complications over the winter months; hospital infection rates peaking at various times of the year; and, of course, delayed transfers of care and readmissions are all pressures at this time of the year.

Readmission into hospital is costly and often avoidable. Latest figures from Age Cymru show that over 15,000 over-75s in Wales were readmitted to hospital within just 30 days of discharge. Having adopted a care in the community model is applaudable, but, in my view, there has been a tendency to cut down the number of beds in our hospital wards with a natural assumption that these beds will then simply be occupied at home and with a complete package of care available to the patient on arrival home.

Reablement support across Wales, certainly in north Wales, is inconsistent and patchy. Where it works well, we know that 70 per cent of people then go on to no longer require support or need further hospitalisation. That has to be the ambition of this Government and also anyone working in the health and social care sector.

The Royal Voluntary Service highlights the inconsistency and complexity of reablement services delivered by local authorities and health boards. There is no definite standard of reablement across Wales. The spend per head by local authorities on reablement services can be up to 10 times more in some areas than others. Good care in the community for an individual often requires a fully integrated care package tailored to that person’s own particular and complex needs, and can often also require the input of a social worker, care providers, district nurses, occupational therapists, physiotherapists, GP provision and sometimes even a dietician. The latter, of course, to address any nutritional or hydration issues. Again, all agencies working in a consistent and well-communicated manner is vital in order to ward off, for instance, any potential infections, to maintain good skin integrity, and generally to support the overall well-being of those receiving their care out of the hospital setting, but inside their own home.

Further evidence taken at committee stage noted that social care is now at tipping point, and we all know the loss in our constituencies of many of our nursing homes and a shortage of care provider agencies. Indeed, Care Forum Wales state that we are only one significant nursing home failure from complete calamity in any part of Wales. They go on to say that there isn’t anywhere in any health board in Wales where they could sustain 60 individuals quickly, following the closure of a home. Can Wales’s policy adjustments such as the introduction of stay-at-home assessments, called for by Altaf Hussain here as a Welsh Conservative, could provide a key early intervention measure, preventing hospitalisation, avoiding delayed transfers of care upon leaving hospital, and easing the pressures for our hospital wards at peak intervals. The report recommends the co-location of primary care services into A&E departments, and I just ask myself why this isn’t happening and why you reject the recommendation. As they say, it is a no-brainer. The whole purpose of taking evidence in committees I thought was to better inform Welsh Government as to how concerns raised by our professionals—those actually carrying out health and social care—and to educate on what is needed. That is the whole purpose of why we’re here and why it’s called scrutiny. I would urge the Welsh Government to accept the recommendations made, all of them, and to implement them, and I would like to thank Dai Lloyd, Assembly Member, and all the members of this committee for such an excellent report. Thank you.

Thanks to the health committee for bringing today’s debate. Health issues are frequently discussed here in the Chamber, and that merely reflects the fact that they’re one of the major concerns of our electorate. As a newcomer to this place, I’m interested in the process whereby a committee, 50 per cent of whose members belong to the governing party, produce a report with concrete recommendations and the Government then decides which ones, if any, it will choose to implement. Clearly, the Government has to be able to govern, but if it ignores a lot of recommendations after a committee has conducted a rigorous evidence-based inquiry, then that Government does leave itself open to an awful lot of criticism if things do subsequently appear to go wrong.

At the moment, a lot of time is being wasted with patients being stuck in ambulances parked outside A&E departments, sometimes for hours at a time, attended all the while by paramedics. This is a real waste of resources, as well as being an unpleasant experience for patients. I appreciate that the Government is awaiting a report from the Wales Audit Office on out-of-hours services, and that that will affect what it decides to do about co-location of GP services in A&E departments. All I can say is, the sooner the Government gets this report, digests it and then takes some meaningful action, the better. It seems to me that co-location may well be a sensible option to relieve the strain on A&E. Thank you.

Thank you. I call the Cabinet Secretary for Health, Well-being and Sport, Vaughan Gething.

Thank you, Deputy Presiding Officer. I want to start by saying that I do welcome the committee’s report and the range of comments that were made in today’s debate, even though I won’t agree with all of them. But I’m really pleased that the report acknowledges improvements that we have already made in planning for winter, and the continuing challenges that we still face.

The committee make, of course, a number of recommendations right across health and social care that reflect not only the importance of managing winter pressures, but also the year-round challenges that face our services. At the outset, I do want to acknowledge again that our health and care system is under very real and significant pressure. I said before Christmas, when I appeared before the committee, that we are better prepared than before for winter but that there will, of course, be difficult days, and there have been. Our hospitals and social services have seen surges in demand, especially from patients with increasingly complex needs. And I say again: there will be more difficult days to come before winter is over, and each of us should be very grateful that we’re here in this Chamber, not facing those pressures on the front line. Because it is a testament to the commitment and skill of our staff that despite the pressures they face, the vast majority of patients and citizens continue to receive high-quality care in a professional and timely manner.

That does not mean that, as a Government, we’re complacent or ignore the scale of the challenges that our whole system faces. We rely upon our staff, and we’re proud in this Government to see them as partners. That is why I have not and will not pick a fight with junior doctors. That is why I have not and will not blame GPs for winter pressures. And that is why I’m proud to be a member of a Government that is investing in our social care workforce.

We have deliberately taken a whole-system approach to planning, and I don’t accept the criticism of Rhun ap Iorwerth that the social care system is somehow being forgotten or overlooked. We continue to fund social care at a much better level than in England, but that does not mean that social care here in Wales is pressure free; it certainly is not. Social care is very much part of the planning and delivery in winter, and social care is also very much part of the market analysis work that is ongoing. We work, and we’ll continue to work, right across health, local government, in partnership with the third sector and our emergency services. Now, that doesn’t mean to say our system is currently perfect, but progress really is being made and will continue to be further strengthened in an integrated way, working between those services.

Now, I recognise, of course, that designing services that can anticipate and respond to the changing nature of demand can take time to get right. However, we’re determined to drive forward further improvements, and I was pleased to see the committee’s recommendations reflect much of this work. Organisations have been encouraged to build upon their plans and experience of previous years to prepare for this winter and beyond. I’m encouraged that delayed transfers fell again in December—that’s unusual; it’s not the case we see across our border—ambulance response times are better than last winter and holding up; and 111 has been a success to date in its pilot area of Abertawe Bro Morgannwg, and that was not the case when it was rolled out right across England. So, we are getting a range of things right, and we’re getting a range of things that are improving year on year. The challenge is: do they improve at a fast enough rate to keep up with the ever-changing and ever-increasing nature of demand? And actually, we are seeing more people at home this winter; that’s part of the reason we are continuing to cope. There’s lots of evidence about the approach that we are taking being in the right direction, but there’s always the question: is it enough and can we do more?

There has been a great deal of focus, of course, on hospitals, but I’m pleased that the committee recognises the critical role of GPs, social care, the intermediate care fund, out-of-hours and ambulance staff in treating and caring for people. Recommendations 1 to 5, 8 and 9 in particular focus on the planning, delivery and learning across our whole system, and I should say, as comment has been made on it, that recommendation 5 was rejected because we’re essentially doing what is being asked of us, and I’m keen not to duplicate our efforts or to restart. But I think there’s much learning to take place about how we design, deliver and co-locate our various services, and there will be those in favour of co-locating in an A&E and those who say, ‘Actually, you shouldn’t co-locate everything within a hospital setting.’ We’ve got to think about how we deliver that care in different settings around our whole community.

We recognise, of course, that the report makes mention of this as well: that health boards have to manage both scheduled and unscheduled care over the winter. This winter, health boards have changed their focus of their activity, with more out-patient and day-case activity, which is not reliant on in-patient beds. And we have provided that additional £50 million to the NHS this winter to help manage demand, and I expect that at the end of this year we’ll see further improvements made in both RTT and diagnostics, and we’ll see further increase in elective activity through winter. And I expect the end of March position for this year to improve again upon last year.

We will, of course, evaluate how our whole system has managed through winter. I’ve made it very clear that we can expect to have lessons to learn and to improve. That includes, though, the success, or otherwise, of Choose Well, and the impact of the public and their use of the whole system. We ought to educate and inform our public, not blame them. But, actually, the public are part of helping us to make the very best use of the whole system. I’m pleased to say that the views of both clinicians and the public will be sought as part of the evaluation of our response to and delivery within winter.

I recognise what Angela Burns has said because it’s a point that I’ve made on many occasions in the past. We regularly get told throughout the year in health that, actually, there’s no such thing as winter pressure because there’s pressure year-round across our system, and it’s true, there is pressure year-round across our system, in both elective care and in emergency care as well. But then every single winter, we talk about the particular and heightened challenges of winter, and it is because we have a different sort of patient and a different need coming through our doors in different numbers in winter. The overall numbers actually go down, but the nature of the demand changes significantly. That’s why we plan to deliver, and we are delivering, extra bed capacity in winter. That’s why I listen to GPs, as Dai Lloyd acknowledged, and I relax quality and outcomes frameworks through the rest of this winter to give more time for GPs to actually take care of their patients.

We should, though, acknowledge the year-round context of our health and care system, and the choice that we have to make—not just in the winter, but in planning and delivering our system throughout the year. We all know the well-rehearsed pressures of public expectation and ageing population, the impact of poverty, our long-standing public health challenges, and, of course, the unavoidable impact of UK Government austerity. It’s a regular and understandable feature of politics that people call for more money, and resources where there are challenges, and that is every bit as much the case in health and social care as in any other activity. But calling for increases in health, local government and third sector spending is a demand for the impossible, whilst we face the reality of austerity.

Angela Burns rose—

We can’t fund all of those areas to an increased level when we all know that our overall budget is reduced. And I’ll take the intervention.

Thank you. I think this report was quite clear, though. We understand the financial constraints that we live within, but if I could just bring us back to recommendation 6, one of our real concerns is that those financial constraints are having an adverse effect on the care home sector, which is why we believe it is so important for the Welsh Government to have a really good, clear understanding of where the care home sector is now and where it is likely to be in the next five, 10 or 15 years, because without that sector, we are completely lost in the NHS, because we need to be able to bounce people into the care sector.

Well, that work is ongoing with the care sector. They are partners that come around the table, and I have heard the comments by Care Forum Wales, for example, but, actually, whenever there have been home closures, and there have been, each time, health and social care have managed to actually help people to move into different accommodation. We want more stability in the care sector, particularly that part that we pay lots of money for, to commission, with public funds, and that’s work that the Minister is leading with officials. So, this is not an area that is being ignored.

But, whilst we face the reality of austerity, and it’s part of the context—these are comments made in today’s debate around this area—I can’t and I won’t pretend to take seriously the voice of those who demand what they know to be impossible when it comes to funding, and funding every single part of our system to an increased level. It isn’t possible. I will, though, take seriously every voice in this debate and those to come that follow the serious, honest and mature approach of the committee in this report. We’re privileged to be served by staff who work under tremendous pressure in our health and care system. They deserve our support, but, more than that, they deserve honesty from us about the challenges we face, what we are doing to meet those challenges and what we can and will do within our financial resources.

I’ll finish here, Deputy Presiding Officer, but I know that much of what we can do is not about money, but how we use the advantages of our whole-system approach as we continue to integrate services around the needs of the citizen, and I look forward to working with the committee as we continue to learn and to improve right across the health and care system.

Thank you. I call the Chair of the Health, Social Care and Sport Committee to reply to the debate.

Thank you, Deputy Presiding Officer. I’d like to thank the Cabinet Secretary for his contribution, and also other members of the committee, and Members who are not members of the committee as well, for their contributions this afternoon.Rhun ap Iorwerth started by referring to the importance of acknowledging that we have to do something about flu and the pressure on social care, the pressure on our beds, and the need to tackle that situation.

Angela Burns, then, also discussing in her own mature, inimitable way, and making very valuable points in terms of the fact that’s recognised by everyone: that different patients appear in the winter and that we should be able to plan for that because the same kind of thing happens winter after winter. We are expecting another winter at the end of this year as well. She also made the point about integrated care.

I’m very grateful for the contributions of Caroline Jones, Janet Finch-Saunders and Gareth Bennett to this debate, because this was a very important report on the NHS’s preparedness for winter pressure. It was a result, of course—a report had been issued previously in 2013-14, and therefore building on those recommendations was the intention, and seeing what kind of improvement there had been in terms of the work that’s being done in this area.

Of course, the overriding conclusion of the committee is that the entire system that we’ve been mentioning—not just the health service, but also the social care system—should be more resilient throughout the year, and therefore in a much better position when additional pressures are applied at those very busy times in the middle of winter, so that the system in its entirety can deal with that in terms of capacity when a great number of patients appear on certain days, as we’ve heard about recently. Of course, we know that the arrangements in place for this winter will be evaluated soon and we look forward eagerly to the findings of that evaluation.

And just to close, and just to echo the thanks of those who have contributed this afternoon in terms of recognising the heroic contribution of the staff in the health service. Naturally, I meet them very often in the workplace, and I felt the emotion and that passion in the different contributions made to the committee inquiry. There is a passionate love towards our health service—yes, from the patients’ side, but also particularly from the staff as well. You can’t put a price on that passion and that commitment to a system that is vital so that we can keep it and develop it to be even more innovative than it is at present.

We’ve been looking at new ways of working, but to do that we have to get over the difference between primary care out there, compared with hospital care. We have to bring those sectors together. We like to see that aspiration that doctors and nurses can work in those hospitals, but also in our communities—a dual approach for the way ahead. We expect to see exciting developments of that nature in the future, not just GPs working in the hospitals, but also hospital specialists increasingly working in our communities. We have to tackle ensuring that every specialist can look at the patient in more general terms—not just at one system that is struggling. We have enough specialists now that just look at the thyroid, diabetes, or the heart, but increasingly we need specialists who can look after the patient as a whole, because we have a growth in the number of older people. The way to cope with that is to have specialists who can look at the patient as a whole, as we used to have. Now, it is only GPs, basically, aside from certain specialists who look after older people, who have the necessary skills to do that. So, we need to look again at that system as well.

So, can I thank from the bottom of my heart the staff in the health service for their contributions—our doctors and nurses, physiotherapists, OTs and so forth? And also, in closing, could I thank the clerks and all the officials who support my work as Chair of the Health, Social Care and Sport Committee for all the support, and for their hard work in ensuring that this inquiry and this significant contribution that you see before you in this report could see the light of day? It means a lot of work behind the scenes to bring this to life in the first place, but I thank everyone for their contributions this afternoon and for their attention. Thank you very much.

Thank you. The proposal is to note the committee’s report. Does any Member object? No. Therefore, that motion is therefore agreed in accordance with Standing Order 12.36.

Motion agreed in accordance with Standing Order 12.36.