Questions now from the party spokespeople. The Plaid Cymru spokesperson, Rhun ap Iorwerth.

Diolch, Llywydd. My colleague Steffan Lewis yesterday asked the First Minister to reopen a specialist mother and baby perinatal unit, following the closure of Wales’s last unit in 2013. The First Minister said that, in the past few years, fewer than five new mothers were referred to an in-patient unit in Wales. I’ve no idea what he was talking about—we haven’t got a mother and baby unit in Wales. Where he got the figure five from, I’ve no idea either. But his argument was that we don’t have the demand.

Between January 2015 and January 2017, we have identified 21 women in the Cardiff area alone who would have been admitted to a unit had that still been open. Of those, six were referred to an out-of-area unit, but only two actually went, because the others did not want to be separated from their families. Do you accept that the demand is higher than the First Minister suggested yesterday?

The First Minister was accurately presenting the number of women who had actually been admitted into an in-patient unit in each of the last three years. And there’s an issue of genuine significance and importance here, which I don’t try to underplay at all. What we have to be able to do is understand the evidence available to us of what a genuinely sustainable and the proper quality in the service we’re able to provide. The previous service, the staff weren’t able to maintain their skills to provide the sort of high-quality service people would want.

And the challenge is not whether a single unit in itself would actually resolve all of those problems, if it was physically located within Wales. As you know, I’ve commissioned, through the Welsh Health Specialised Services Committee, a review of the evidence on what is available in Wales from a need point of view, and our ability to meet that need, whether in Wales or otherwise. That review will report later in the year and, of course, I will expect to share the findings and the advice, and my response, with Members who are here today, and I’m sure will maintain an interest in it. I accept that it is, obviously, important to Members across this Chamber.

Referring to the answer of the First Minister yesterday, Steffan Lewis asked specifically, as I have done today, about mother and baby unit referrals. We have no mother and baby unit in Wales. Community services, they only came in three years after the closures, but, of course, we appreciate that they’re needed. But, in instances of post-partum psychosis, for example, we need in-patient mother and baby facilities. That is what the National Institute for Health and Care Excellence guidelines say. The service standards quoted by the Royal College of Psychiatrists don’t even refer to critical mass figures; they merely say that services should be planned on a regional basis, that people should have equity of access wherever they live. They speak of using staff to work in the community when in-patient occupancy levels are low. They certainly don’t advocate closing units.

The royal college tells us that we can expect 140 women a year in Wales to require admission to a mother and baby unit—more than enough to make a unit viable. Now, there must be, in that context, a case for reconsidering your position on whether Wales should have a specialist mother and baby unit. And, indeed, going beyond the situation in the south of Wales, the RCP figures point to the need not just to reopen that centre, but for a new centre in the north too, if it’s demand we’re looking for.

I think we do need to think again, like I said, to take a step back, and think about what we are able to do, and able to do to the right quality and the right state that all of us would expect. I’ve indicated, the figures—I don’t think it’s fair to suggest that there’s been a misdescription of the figures. We’re talking about people referred to an in-patient unit, who have gone to an in-patient mother and baby unit, that we have actually commissioned that care for mothers and their babies. And the challenge over the figures is really about, ‘Is that enough to sustain a unit in Wales?’ as opposed to politicians’ arguments. That’s why I’ve commissioned WHSSC to undertake the review. So, it isn’t about you and me, as party politicians or individual representatives, trying to make a case on the basis of our understanding of figures. I’m actually going to people who run and deliver a service, and will commission that service, to understand if that need is there, and could and should we best meet that need by locating a unit physically within Wales. Because, of course, you’ll know that the distance to, say, a unit in Bristol is a challenge for a number of women in Wales, just as it would be if you lived in St David’s to a unit in Cardiff, if you lived in Ceredigion, or if you lived in Bangor. There’s a challenge here about that physical access to a unit regardless of where that unit is physically based, whether in Wales or outside. And that has to be part of the honest question that we ask ourselves, and that’s why I’ve commissioned the advice as a proper objective basis upon which to make a decision.

But where units are based does matter. It matters in terms of access, as the Royal College of Psychiatrists say. It is quite clear, I think, from our figures and case studies, that the consequences of outsourcing have been to see mothers choosing no in-patient treatment over treatment that means separation from their families. So, patient care has suffered. There are child safety issues coming into play here, and it makes no financial sense either. It has become clear that the service being commissioned in England, whilst treating fewer patients, has ended up being more expensive. Your Government has pursued centralisation and outsourcing without question it seems. And on this one in particular, is it not time that you admitted you got it wrong?

I really don’t think that that is a responsible approach to a really challenging issue for all of us. Everyone in this Chamber will care that we ensure we get the right response for families and babies here in Wales. Just on the reference to outsourcing, just to be absolutely clear, ‘outsourcing’ is often referred to as ‘privatisation’ in that sort of language. We are commissioning care from the NHS in England. We aren’t privatising the service. You haven’t suggested we are, but ‘outsourcing’ is regularly used as a term that other people understand to be privatising the service. That absolutely hasn’t happened.

I don’t recognise where you say that there are child safety issues that arise from this because we don’t have a physical mother and baby unit here anywhere within Wales. And I simply say to you again: in terms of the location, I accept that location matters. That’s why I say that if you live in St David’s in west Wales and the unit is physically in Cardiff, that practically is a long way for you to travel in any event. Simply saying, ‘Locate a unit in Cardiff’ does not resolve all of the physical access issues. And there has to be a more sensible conversation to make sure we get the right response to this. That’s why we’ve commissioned expert advice, so that there’s a properly objective basis for me to be scrutinised upon, but also for the Government to make a decision upon. And I am proud of the fact that we are investing in community services, because, often, what people do want is support within their community and that’s often more appropriate.

I’m looking forward actually to—. I understand that the Children, Young People and Education Committee are looking to have an inquiry into this area, and I look forward to giving evidence to that committee, answering questions before Members and, again, having an evidence-based discussion for all of us about what is the right choice for families and their babies in Wales.

Welsh Conservative spokesperson, Angela Burns.

Diolch, Presiding Officer. Cabinet Secretary, what assessment have you made of the rates of ill health and absences within the Welsh NHS?

We regularly review absence figures. In fact, it’s part of the appraisal process that I have with the chairs of each of the health boards. I look at their absence rates and whether there is improvement or otherwise. We’ve seen some improvement in the last three years generally, in particular in the Welsh ambulance service, and I don’t think that’s unrelated to their improvement in performance. So, it’s a regular cause of concern, but I wouldn’t pretend to have every single part of the detail at my fingertips today.

Let me give you a little bit of help on that one then. The data that the Welsh Conservatives have obtained from health boards show that anxiety, stress, depression and other unspecified psychiatric illnesses affected 7,945 NHS staff members in 2015-16. Those 7,945 staff members racked up a total of 345,957 days of absence, which is equivalent to 948 years of person hours that were lost to the NHS in one year. That’s 948 years’ worth of person hours. Cabinet Secretary, I’d be really interested to know what you are going to be doing to address this issue. And, remember, that was just on mental health issues. That did not take into account absences due to other diseases, musculoskeletal conditions, or any other physical ailment.

This is why it’s a priority for discussion with chairs in their appraisal process between myself, as the relevant Cabinet Secretary, and chairs of health boards. So, there is an understanding that we want to see further improvement. Some of this, in terms of absence management, is understanding the reasons why people are ill and out of work: sometimes that is about work and sometimes those are reasons outside work. But it’s about what appropriate support is required to help some return to the workplace. That’s why we place importance on occupational health services. For example, we’ve actually expanded, alongside the British Medical Association, the occupational health service for GPs as well, to think about how that works for people employed in primary care too. So, this was also raised with me by Unison, when I recently met them in terms of the campaigning work that they’re doing with their members. I understand perfectly why any trade union would want to raise the issue with me in that conversation. So, it is an issue that we understand; it is an issue where we want to see further improvement because, ultimately, it’s better for the individual member of staff, better for the service that they work in and ultimately for the service that we fund and provide.

I couldn’t agree with you more that this is an issue that needs to be addressed as a matter of urgency. It’s more than just the individual. Yesterday, we had a long discussion about the deficits that we are seeing in the Welsh NHS in some of our trusts. We know that we have a recruitment issue—we can’t get enough doctors, nurses and all the other staff. We also know that, for example, the cost of bank nurses who are on contracts for over a year is extraordinarily high, as is the cost of locum doctors and consultants. We know that health boards are not recruiting secretarial staff when they’re about to leave until after they’ve gone, which of course puts consultants and doctors really far behind because they can’t get the notes out on all the patients that they see, and it’s creating a real logjam. If we could just bring some of those hours back into play through adequate support for those individuals, then that would have an enormous financial and medical benefit for the NHS.

These statistics, in comparison to the English statistics, are pretty damning. You just mentioned ambulance staff, but the latest figures that are available, which are July to September 2016, show a rate of 7.5 per cent of staff off in Wales, compared to only 5.4 per cent of staff off in England. This gap’s been similar over the last five years.

Cabinet Secretary, in England, they’ve been piloting a rapid access to treatment system. I wonder if I can persuade you to start having a good look at this. I have discussed it with some of the health boards. This is not about trying to develop a two-tier NHS, and I want to make that absolutely crystal-clear, but given our lack of financial resource in the NHS, and given the difficulty that we have in replacing staff and recruiting staff to the NHS, it seems to be really imprudent not to try to encourage the NHS staff that we have to come back into work sooner rather than later. It’s good for them. You said it yourself: it’s great to support them. There are some good lessons to be learnt over the border and I’d like to see that you are big enough to be able to accept that there are other home nations that have tackled this in different ways. Let’s see if we can bring some of that best practice over here and get some of our hard-working staff back into the saddle, because we need them and they need to be back in their jobs, earning a good salary, and feeling much better themselves.

I have no difficulty at all in looking at other parts of UK nations to understand where there is better practice for us to adopt or to adapt. In areas of HR management, we always look at where best practice exists so that staff do feel properly supported. I recognise the comments that you made about the financial position of the health service—about the very real challenges that exists, with health inflation always running at a higher rate than other services too.

The reason why our ambulance rates have improved and why I think, in the next figures to come out, we can expect to see improvement in our figures here in Wales is largely because the working environment has improved and because staff do feel better supported now. I won’t pretend that everything is perfect—far from it—but I do expect to see a continuing effort to see the partnership approach, which we value here in Wales, deliver improvement, not just in terms of our industrial relationships, but actually in our abilities to support people to get into work at an earlier stage because I think that the great majority of our staff want to be in work and want to be providing care directly for the communities that they live in and that they serve. So, I don’t think there’s any disagreement about the policy direction; it’s simply about our ability to deliver that improvement.

UKIP spokesperson, Caroline Jones.

Diolch, Llywydd. Cabinet Secretary, the overspending by the local health boards can be equated to the large amounts spent on agency nursing. Last year, the Welsh NHS was spending £2.5 million each week on agency staff, which will undoubtedly be cut back next year. However, we simply don’t have the permanent staff available to make up the shortfall, so it will be patient care that suffers. Cabinet Secretary, how will your Government ensure that local health boards are sufficiently funded to provide safe staffing levels in the coming financial year?

We fully expect every NHS service to have safe staffing levels. I recognise what you say about agency costs, in that it isn’t just nursing agency costs; there are agency and locum costs across our system that are part of the very real financial challenge that we face in delivering and sustaining models of care. There’s an honest conversation to be had about whether we are sustaining models of care that are right and appropriate, or whether we’re actually spending money in a way that isn’t very efficient or appropriate. So, that’s a conversation that each of us will need to engage in, but, of course, in the field of nursing, we’re extending nursing levels with the implementation of the nursing levels Act. So, I expect to see more nurses recruited to Wales on a permanent basis.

But, following the first question that’s been asked, you’ll recognise that there is a challenge to that with the reality of how European Union based staff feel about coming into the UK. There are figures that are publically available on the number of nurses that have either left the UK, or are no longer considering coming here. In particular, in England, the source of recruitment from the European Union, as I say, has dried up significantly, and that is a real challenge for us in sustaining our services, and what that does mean in terms of having to pay an even higher cost to get staff into our health service to provide the care that all of us would expect to be delivered.

Thank you, Cabinet Secretary. The Assembly passed the nurse staffing levels Act last year with the promise that this new legislation would deliver safeguards for patient safety and put an end to situations where nurses find they have insufficient time to properly care for patients. Your Government is currently consulting on the statutory guidance that leaves out any mention of the recommended nurse-to-patient ratios and any mention of the supernumerary status of ward sisters. Cabinet Secretary, do you agree with me that this consultation sends out the wrong message about safe staffing levels, and will you commit to revising the guidance to include everything that was promised when the Act was debated?

It’s exactly what it is—it’s a consultation. I expect to have responses, I expect to have advice from our professional nursing officers here, including, of course, the chief nursing officer, on what is appropriate in terms of delivering patient care and meeting the objective of the Act that this place has passed, and in delivering high-quality nursing care as we look to further develop the nurse staffing Act in other areas of practice across our NHS here in Wales.

Thank you, Cabinet Secretary. Safe staffing levels should apply to all settings. As we move to a health service that aims to deliver more and more services in the community, we must ensure that community nursing teams do not have an excessive patient workload. The number of district nurses working in Wales has fallen by over 40 per cent in recent years, but, according to the Royal College of Nursing, their workload has increased tenfold. What plans does your Government have to introduce safe staffing levels for community nurses and what actions are you taking to increase the number of district nurses and reduce their workload?

Well, of course, we will be guided by evidence and the professional advice of the chief nursing officer’s office. That’s actually something that the RCN supports. They’re very pleased that we haven’t taken the approach across our border in effectively removing a chief nursing officer from within the Government to give professional advice to the relevant Minister. I’ve been absolutely clear with the RCN and other stakeholders that I’ll be guided by the evidence and advice on the implementation of the nurse staffing levels Act, and taking an evidence-led approach to further expanding that reach across the service. So, we’re looking at different options about where would be the next appropriate place within the service to introduce and to reinforce the Act.

But, in terms of our ability to recruit more nurses in district nursing and beyond, of course, recently I announced a £95 million additional investment in nursing and other professions for the NHS here in Wales, which should lead to another 3,000 training places across professions and that will include 30 per cent more nurses after an extra 10 per cent last year, a 22 per cent increase the year before that and more than a 4 per cent increase in midwives in this year, as well. So, we are investing in our future and I’m proud to have taken that decision to safeguard the future of our service here in Wales.