The following amendments have been selected: amendment 1 in the name of Jane Hutt, and amendment 2 in the name of Paul Davies.

We now move to item 7, which is a Plaid Cymru debate on a medical school in Bangor, and I call on Sian Gwenllian to move the motion. Sian.

Motion NDM6308 Rhun ap Iorwerth

To propose that the National Assembly for Wales:

1. Notes continuing difficulties with the training and recruiting of medical staff (including doctors) in many parts of Wales, particularly rural and north Wales.

2. Calls for the development of a medical school in Bangor as part of an all-Wales approach to increasing training, recruitment and retention of doctors in Wales.

Motion moved.

Thank you very much, and it’s a pleasure for me to move this motion. A lack of doctors in north Wales and rural areas in Wales creates a huge challenge for healthcare services. It would be possible to tackle the problem in the short term, but we also need to move forward to plan for permanent, long-term solutions. We need to train more doctors in north Wales, the area that has the greatest shortage. This is one way to tackle the crisis in a sensible and permanent way. Last year, half of consultant posts in north Wales weren’t filled—half those posts were unfilled—and the implications of that are far reaching.

Joyce Watson took the Chair.

There’s a problem with general practice, as well. The north Wales medical committee has concerns regarding the sustainability of over a third of surgeries in the region: one in three surgeries is currently at risk. The committee says that we need an additional 70 GPs as a matter of urgency in north Wales. Now, in addition to the impact on patients, there is a financial cost to that shortage too. Expenditure on agency staff increased by 64 per cent over the past two years, whilst the latest information suggests that Betsi Cadwaladr will have spent more than £21 million on agency medical staff in the 11 months up to the end of February 2017—£21 million. That’s their own figure. A figure such as that is not sustainable, neither is it sensible. However, one could open a new medical school and maintain that for a far lower figure.

Plaid Cymru has consistently argued that a new medical school for north Wales, serving rural parts of our nation, is part of the solution. Studies in various nations have demonstrated that there are three factors at the heart of attracting doctors to work in rural areas: first of all, a rural background, second, that the prospective medic has positive clinical and educational experiences in rural locations as part of their medical training as an undergraduate, and, third, that training for rural placements is targeted specifically at the postgraduate level.

Now, one of the most successful medical training programmes in a rural area is a scheme between five states in the USA, Washington, Wyoming, Alaska, Montana and Idaho—the WWAMI programme. Graduates from this programme return to practise in rural areas at far higher rates than graduates from most of the state-run medical schools in the United States. Eighty-three per cent of graduates in the WWAMI programme practise in a rural practice. At the Calgary medical school, graduates from rural backgrounds are two-and-a-half times more likely to practise in a rural practice as compared with those from an urban background. In Norway, 56 per cent of graduates from the Tromsø medical school in the north of the country remained in rural areas, and 82 per cent of graduates who were originally from northern Norway remained there to practice. Quite simply, prospective doctors from rural areas do tend to remain in the rural area where they have been trained.

Therefore, it is practically possible to have a medical school in Bangor? Yes, most certainly, it is. Ireland has seven; Scotland has five, suggesting that one medical school for every million of the population is possible. The population of the Betsi Cadwaladr health board is around a million people, if you take it in conjunction with the Powys health board, but you can also add a part of the rural area of Hywel Dda health board to that figure to bring us to that figure of a million. So, a third medical school for Wales would align with the structures in Scotland and in Ireland.

Plaid Cymru has consistently argued that the new medical school should be located in Bangor. A new medical school at Bangor University would build upon the expertise of the medical sciences school at the university and the clinical training, which is already provided in the three general hospitals of the region. Evidence suggests that a new medical school should initially work with an established medical school. There are a number of examples of new schools building on the expertise of medical science within universities, and therefore there is a clear way ahead, and with time, Bangor can develop into a medical school standing on its own two feet.

In summary, a new medical school is crucial if Wales is to tackle the significant shortage of doctors facing this nation. In north Wales and in rural areas of Wales a number of medics are approaching retirement age, and there aren’t enough people being trained in those areas. Governments across the world are responding to similar situations by increasing the training opportunities available. In rural areas, which face problems similar to Wales, new training institutions are established and medical schools are being located in those rural areas. Adapting structures already in existence simply doesn’t work. These new institutions, in turn, create new generations of doctors who stay to serve those areas where they have been trained, dealing with the shortage of doctors and enhancing the quality of care for people in those areas.

It’s time to move forward with long-term solutions, with planning, in order to establish a new medical school along, with the short-term measures currently being put in place. Thank you.

Rwyf wedi dethol y ddau welliant i’r cynnig. Galwaf ar Ysgrifennydd y Cabinet dros Iechyd, Llesiant a Chwaraeon i gynnig gwelliant 1, a gyflwynwyd yn enw Jane Hutt, yn ffurfiol.

Amendment 1—Jane Hutt

Delete all and replace with:

1. Welcomes the Welsh Government’s This is Wales: Train Work Live recruitment campaign to encourage healthcare professionals, including doctors, to choose Wales as a place to train, work and live.

2. Notes:

a) there has been a 19 per cent increase in the application rate for GP speciality training in 2017 and the number of filled GP training places is at 84 per cent compared to 68 per cent at the same stage in 2016 following the launch of This is Wales: Train Work Live;

b) there were more than 1,000 more full-time equivalent consultants working in Wales in 2016 than there were in 1999; and

c) there has been a 12 per cent increase in the number of GPs working in Wales between 1999 and 2016.

Amendment 1 moved.

Formally, Chair.

Galwaf ar Mark Isherwood i gynnig gwelliant 2 a gyflwynwyd yn enw Paul Davies.

Amendment 2—Paul Davies

Add as new point at end of motion:

Calls on the Welsh Government to work with health and education institutions on both sides of the border to build a more in-depth and wide-ranging north Wales medical programme.

Amendment 2 moved.

Diolch. We support this motion’s call for the development of a medical school in Bangor as part of an all-Wales approach to increasing training, recruitment and retention of doctors in Wales. As the Royal College of Physicians states,

Recruitment problems are threatening the existence of many hospitals and general practices in Wales. We need to train more doctors and nurses in Wales with the aim of retaining them to work here.’

But, they said, a third of core medical training places in Wales were unfilled in 2016, with this figure rising to over 50 per cent in Betsi Cadwaladr university health board hospitals.

As the head of Bangor University’s School of Medical Sciences said last week, Wales must expand medical schools to deal with future shortages of doctors, particularly GPs. Relatively few extra academic staff would be needed and Bangor University is an ideal position to foster and recruit students from rural Wales and Welsh-speaking communities.

As the National Pensioners Convention Wales states, adequate access to GP services is essential to maintaining general health and mobility, and, as a consequence, to helping prevent isolation and loneliness, but respondents expressed concern that difficulties with getting appointments in a reasonable time is connected to GP numbers.

As I said here two weeks ago,

It’s many years since I first discussed the need for a Bangor medical school with its previous vice-chancellor…. It’s three years since the North Wales Local Medical Committee warned, at a meeting in the Assembly, that general practice in north Wales was…facing crisis, unable to fill vacancies, with GPs considering retirement.’

And they expressed concern that the previous supply of GPs from Liverpool medical school, where their generation of GPs had primarily come from, had largely been severed.

I therefore asked the First Minister to ensure that the business case for a new medical school in Bangor includes dialogue with Liverpool, to ensure that we keep local medics local. As he replied, what’s hugely important is that any medical school works closely with others in order to ensure that sustainability is there in the future’.

I therefore move amendment 2, calling on the Welsh Government to work with health and education institutions on both sides of the border to build a more in-depth and wide-ranging north Wales medical programme.

Delivering sustainability will require the training, recruitment and retention of doctors locally, and this will require the universities, Betsi Cadwaladr university health board and Merseyside to work together and build a more in-depth and wide-ranging north Wales medical programme, with specialisms being delivered by the relevant major hospitals on both sides of the border.

For year after year after year, the Labour Welsh Government dismissed warnings that we faced a GP crisis in north Wales, given by professional bodies including BMA Wales, the Royal College of General Practitioners in Wales and by myself and my shadow cabinet colleagues on behalf of the NHS Wales staff and patients who raised their concerns with us. With these warnings ignored, we’ve seen GP practice after GP practice in north Wales giving notice that they will be terminating their contracts with the health board. Yet at the BMA Wales conference last year, on the same weekend that another north Wales GP surgery gave notice that they would be terminating their contact with the health board, First Minister Carwyn Jones claimed that there was no GP recruitment crisis.

Responding to the Royal College of General Practitioners Wales ‘Put Patients First: Back General Practice’ campaign during the last Assembly, I met a group of GPs in north Wales whose key concern, they told me, was recruitment. Although the average age of GPs in north Wales was over 50, they told me they couldn’t get medical students to come and train in north Wales. They told me there was a particular problem with the way—quote—’Cardiff recruits medical students’, and that medical students need to be incentivised to come to north Wales, especially Welsh speakers, developing home-grown doctors.

Action is also required to address the nonsensical situation in which nurses are being recruited overseas to fill a nurse shortage in Wales but Glyndŵr university is denied funding to train local nurses who can’t go away to university and are therefore going over the border to the English system in Chester. According to the BMA, 2014 figures show that Wales had the lowest number of GPs per 1,000 people in the UK. However, as usual, the Labour Welsh Government rejected all warnings until crisis was upon us and then—quote—’selected percentages to mask the reality that they were doing too little, too late’. This is part of the solution.

I’d like to call Lee Waters.

Diolch yn fawr, Gadeirydd. There’s no doubt that huge progress has been made with the intervention of the Welsh Government over the last year, with a 12 per cent increase in the number of GPs in Wales since the Assembly was established, and in just the last year, the number of GP training places being filled is at 84 per cent, whereas it was at 60 per cent a year ago. So, the intervention of the Welsh Government to offer incentives and pay exam fees for GPs is showing encouraging signs of progress, but clearly the workforce is changing, and we need to recognise that there is no simple solution to the need to recruit and train more GPs. It’s clear that the younger workforce want to work part time and flexibly, and no longer are attracted in the way that they were into rural areas and away from the cities. We need to recognise that, so we need to change, I think, the model that we have in primary care, and this requires a mature conversation.

I had a meeting last night in Burry Port where over 250 people attended—organised by myself and Nia Griffith, who’s been the MP for Llanelli—and there was huge public concern, exacerbated by the fact that the local health board are refusing to engage people in a conversation early enough when services need to change. In Burry Port, at the Harbour View practice, a single GP practice—one of the last remaining single GP practices in Hywel Dda—the GP there, Dr Lodha, has decided to retire. She notified the health board of this in February, and it’s only now that patients are being told—some being notified only by a scrappy bit of paper on the door of the surgery—that the surgery is to close. They fear being dispersed to ‘nearby’ GPs in Trimsaran, Kidwelly and Pontyates, where there is no easy public transport available and the existing GPs have closed lists. So, there’s understandable anxiety in the town and the health board have refused to engage with the public on this. I think here we have a problem, because we saw in the Minafon practice in Kidwelly, which I was pleased to invite the health Secretary along to earlier in the year—that when they did engage with the community, they were able to bring them along in finding more creative solutions to a different model of general practice that, now it’s beginning to bed in, patients are recognising offers advantages. Instead of relying simply on GPs, having pharmacists and nurse practitioners and physiotherapists on hand can offer a better service.

But, clearly, change causes anxieties, and that’s why it’s important to involve the public in the conversation from the get-go. But Hywel Dda, this time, as before, held a private process where a panel led by their deputy chair analysed data of changing populations and so on and decided, in their best judgment, that the surgery should close without any alternatives being publicly explored. Surely this is a mistake, because, as part of that initial checklist process they go through, there must be patient engagement. When you can treat patients like adults and show them what the options are and bring them along in that choice, you can end up with a better solution.

They’ve failed to do that in this case. They’ve failed to engage with me as the elected Assembly Member and with the other elected representatives in the area and, as a result, we now have great local concern. I’m hoping that they will rethink that and will properly engage with the community, because they rightly feel that they deserve a proper service, when the town of Burry Port is growing and when the needs of the population are changing. So, I would urge the Government to consider how, when these changes occur all across Wales, the need to engage with communities is hardwired in at the beginning of that process, so we don’t have the farce of a situation where the first patients hear of a change to their service is a scrappy bit of paper on a door.

I’d like to call Michelle Brown.

Thank you, Deputy Presiding Officer. I’d like to thank Plaid Cymru for tabling this debate. UKIP fully supports this proposal, but the question that I asked the last time this idea was discussed in this place still stands. Do we not think that more needs to be done to improve and promote the life offer available to professionals in order to have them come to north Wales or not to leave in the first place?

We undoubtedly have a recruitment problem in Wales. Whilst a medical school in Wales may result in a number of medical graduates remaining in Wales—hopefully, they’ll realise what a wonderful place it is to live and work and remain here—it isn’t a cure-all. I would also like to add that a medical school in north Wales also has a greater chance of attracting and retaining Welsh speakers. So, I am fully in support of the proposal. But qualified doctors can pretty much choose anywhere in the world to live and work. So, the fact that they moved a couple of hundred miles down the road to train isn’t going to be a deal-breaker when deciding whether or not to return to their roots.

Labour’s amendment shows that they’re trying to deny there’s a problem. It is because of Labour’s refusal to accept the problems they have not fixed that the Welsh NHS is in the desperate state it is today. Labour make such a play of claiming to be the sole guardians of the NHS, but, for electoral reasons, they cannot admit that, after years of being in charge, they still haven’t got it right.

We need to be selling the lifestyle on offer here. Wales is a beautiful and peaceful place to live, you get more bang for your buck property wise, and commuting distances between your own little piece of heaven and work can be as long or short as you like. I’m sure, between us, we could come up with an extensive list of reasons why it’s such a great place to live and work.

But even if we can sell Wales as a desirable place to work and show off the beauty of north Wales, if you have a family and hold education in as high a regard as a medical graduate clearly does, would you want your children thrown onto the lottery that is the Welsh school system, undoubtedly the result of the Government’s failures? Something must be done.

Although I’m not convinced that a medical school in north Wales will solve the recruitment and retention problems, I support a plan like this that increases jobs and employment possibilities in north Wales, which the opening of such a facility would undoubtedly do. The medical school would also increase the number of training places on offer nationally. I therefore support Plaid’s motion and would urge the other Members of this Assembly to support it also. Thank you.

And the last speaker, Rhun ap Iorwerth.

Thank you very much, Chair. I will keep my comments brief. Earlier in the Chamber, we discussed Plaid Cymru’s aim of training and recruiting and extra 1,000 doctors in Wales. I was extremely disappointed with the response of the Minister.

‘Mae hyn yn uchelgeisiol, ond nid yw’n gyraeddadwy’ were the Cabinet Secretary’s words. Now, we’re talking here of a 10-year programme. This is something that is necessary—I hope we can agree on that: that we need more doctors in Wales. It is something that is an ambition—it certainly is one of mine. Hopefully, that ambition could be shared across the Chamber by other Members. But it is also realistic, but it can only be realistic if we actually increase how many people retrain as doctors in Wales. What’s also disappointing, in listening to the Cabinet Secretary, is that medical schools in Wales are telling me that they’re confident that they could train so many more doctors in Wales over the next 10 years, and it is clear, I think, that there is a growing consensus within the medical world in Wales that Bangor can play its part in contributing these additional doctors.

I’m also disappointed on a number of levels today that the Government in its amendment has withdrawn any reference to the development of medical education in Bangor. I understand why you want to highlight what you see your successes in terms of medical recruitment over the last few years—I’ll give you that—but why withdraw the reference or delete the reference to Bangor from our motion today? As Sian has explained, achieving a full-blown, if you like, medical school that is self-sufficient in Bangor could take some years. We acknowledge that fully, but that has to be the ultimate aim, and we must move as a matter of urgency now towards having medical students embedded in a medical education department in Bangor. I will refer to Keele University, which has a medical school now, but started as part of the Manchester school of medicine. There are those kinds of partnership that we can put in place from next year on, working with Cardiff University and Swansea University, for example. This is necessary. We need the doctors, we need to develop the expertise in rural medicine, and we need to develop expertise in developing Welsh-medium medical education also. Therefore, on a number of levels, I need to see us moving towards a consensus in terms of the direction of travel here.

Nawr, fe orffennaf drwy gyfeirio at un neu ddau o bwyntiau a wnaeth Michelle Brown. A yw hyn yn datrys y broblem recriwtio a hyfforddi sydd gennym yng Nghymru? Mawredd annwyl, nac ydy. Nid yw’n ei ddatrys, ond gallai fod yn andros o gyfraniad at yr hyn rydym yn ceisio’i gyflawni. A Lee Waters, fel chi, rwyf wedi treulio gyrfa mewn cyfathrebu felly rwy’n cytuno’n llwyr fod ymgysylltu’n bwysig. Gallwch ymgysylltu cymaint ag y dymunwch. Gallwch anfon y bwrdd iechyd lleol a’r prif weithredwyr i dŷ pob claf yn unigol i esbonio bod yna broblem gyda’r feddygfa leol, ond oni bai bod gennych feddygon yn dod drwy’r system, byddwch bob amser yn wynebu’r broblem hon sydd gennym, sy’n arwain at gau meddygfeydd ym Mhorth Tywyn, ac ym Mhorthcawl ac mewn llawer o leoedd eraill y clywn amdanynt yng Nghymru. Felly, cefnogwch hyn, ac anelwch yn uchel. Gadewch i ni gael ysgol feddygol yma ym Mangor. Mae ar Gymru ei hangen. Mae ei hangen ar gleifion Cymru.

I now call on the Cabinet Secretary for Health, Well-being and Sport—Vaughan Gething.

Thank you, Chair. I’m grateful to Plaid Cymru for tabling this debate today. As a Government, our amendment makes clear: since devolution, we’ve seen a significant increase in the numbers in our medical workforce, but this Government is far from complacent. Despite the successes that we highlight, we recognise there are still challenges for some medical specialities and some geographical areas of Wales, just as there are across the rest of the UK. That’s why we committed, in our programme for Government, to continue to take action to attract and train more GPs, nurses, and other health professionals to Wales. To deliver that commitment, we launched our campaign to encourage doctors, including GPs, to come to Wales to train, work and live. We have seen a significant early impact with GP trainee fill rates at the end of round 1 at 84 per cent, compared to 68 per cent at the same point last year. That includes a 100 per cent fill rate in Pembrokeshire, north-east Wales, and north-west Wales GP training schemes.

Members will be aware, of course, that I launched the second phase of Train, Work, Live for nurses last week. The initial impact in terms of social media activity has been very encouraging, with our promotional video being viewed 30,000 times, and our content reaching over 110,000 people.

Now, I know the motion calls for a medical school in Bangor, and Sian Gwenllian has been very consistent in her calls on this issue. As the First Minister made clear in this Chamber, in the coming weeks I will make a statement—as I indicated I always would do—on the conclusion of the work that I commissioned to consider the provision of medical education and training in north Wales, including the case for a new medical school. I’m not about to try and sign myself up to a commitment one way or another before that work concludes—that’s a simple explanation for the Government amendment in not making reference to the medical school. It’s part of a case that I’ve committed to deliver on, committed to respond and return to Members on, and I will do so.

But regardless of the outcome of this work, we know that we need to be flexible and explore all options in terms of education and training in north Wales. Cross-border working already exists in places such as speciality training for paediatrics, and sub-speciality training posts established for higher anaesthesia. So, despite the unremittingly negative contribution by Mark Isherwood, I’m happy to confirm that the Government will support the amendment in the name of Paul Davies.

I want to deal with the recasting of the 1,000 doctors—1,000 doctors over 10 years in terms of what’s additional, or in terms of what we currently train now. We already train—over 10 years, we’ll have trained that number of doctors. But the training of doctors is part of a long-term future for the health service—the amount of time, we understand, it takes to train doctors, so recruiting and retaining our current workforce is a big part of where we need to be, including those training rates, as I mentioned earlier. There is a long-term approach to all of this, and that must take in the models of work that we expect people to come to, and it also takes in how we’ll actually provide that training as well.

If we want, as Lee Waters indicated, to have that broader point of the differing model of general practice, where general practitioners work as part of a wider team, we need to train people to work in that way as well, because the way that general practice works now is very different to 10 and 20 years ago, and in the next 10 and 20 years, it will be different again. There is always a constant need to adapt—we’re having to understand what numbers of different medical professionals we need to provide the sort of service that people, quite rightly, expect. So, that’s why we continue to invest in the education and training of the wider healthcare workforce—that we already do within north Wales and at Bangor University. So, courses are commissioned in nursing, midwifery, radiography and pilot courses for physician associates, as well as the courses offered at Bangor’s clinical school. Now, physician associates are a good example of the development of the wider workforce within healthcare. They’re still in pilot phase, but we think they’re part of the future, so understanding what Swansea and Bangor provide in terms of that new cohort of physician associates is important to us, as well as the measures that we take to make sure that they’re part of our healthcare system in Wales, with a real career path in models of care that will make a difference.

The Deputy Presiding Officer took the Chair.

I don’t think there was much to agree upon in terms of Michelle Brown’s contribution, but we’re really serious about protecting and standing up for the national health service—it’s not about electoral calculus, it’s about our commitment and our values, not just in creating the service, but in sustaining it for the future. And I recognise the challenges that Lee Waters outlined again—as the local Member, he’s absolutely right to highlight concerns within his community, and I do understand the point that is made about how change of any kind is discussed with the public, rather than simply being presented to the public about what must now happen. That is a good point that is well made, and I understand you’ll be taking direct representations to the health board in the coming days.

But here in this Government, we are committed to delivering an NHS workforce that continues to provide high-quality care, and on the medical front, it continues to grow in the face of continuing austerity from the UK Government. There are a number of challenges that we honestly and freely acknowledge, but they are challenges that we are confronting head on, and I look forward to reporting on more success that this Government will achieve with our partners in the national health service and beyond.

Thank you. And I Call on Sian Gwenllian to reply to the debate. Sian.

Thank you very much to you all for your comments. I thank Mark Isherwood for presenting a number of arguments, and I do agree—yes, we do need to work jointly across north Wales and with Liverpool and Manchester, and whoever wants to work with us to improve the situation. Lee Waters mentioned problems in the Hywel Dda board area, but don’t blame the health boards only. Workforce planning is the responsibility of your Government, and the lack of planning by you has created some of the problems that you face in your area. As you mentioned, I am talking as the Member for Arfon—yes, and of course I would be arguing for locating a new national institution in my constituency. But I’m also convinced that a third medical school, in Bangor, would improve care services for everyone across the north and across rural areas in Wales.

Last week, I published this—’Tackling the Crisis: a new medical school for Wales’, an independent report that brings the evidence from different countries and the arguments all together. I genuinely hope that you have an opportunity to read it. It does set out the case clearly and robustly that the medical school is needed here. So, I do hope, as the Cabinet Secretary has mentioned, that we will have an announcement soon about this, and I greatly hope that that announcement will be a positive one—the Cabinet Secretary has read it; thank you for that—but that we have a positive announcement soon, stating clearly that there is the need for the medical school and that you as a Government are going to plan, in a detailed way, for that very soon. Thank you very much.

Thank you very much. The proposal is to agree the motion without amendment. Does any Member object? [Objection.] I will defer voting under this item until voting time.

Voting deferred until voting time.