Questions now from the party spokespeople to the Cabinet Secretary. Plaid Cymru spokesperson, Rhun ap Iorwerth.

Thank you, Llywydd. There have been a number of cases drawn to my attention of doctors trained in Wales who want to work in Wales, but, because they’ve worked abroad, or have been further trained abroad, they find it very difficult to register to work again in Wales. In one case—and I wrote to your predecessor about this case—she had to return to New Zealand having returned to Wales because of difficulties registering permanently, and that was a huge loss to the NHS.

The latest individual to contact me talks of hundreds of pages to be filled in, with input required from former employers. And, with the administrative burden so heavy, some in Australia refuse to take part in that process. There is talk of a need for a complex reference document from six previous employers. I’ve heard about confusion about the information required. There is a requirement in terms of further training, and Wales is seen as nation that can’t give an assurance as to where one might be allowed to work.

So, what is now being done to facilitate the process of reregistering doctors in Wales, so that we can attract Welsh doctors back, or other doctors from abroad, for that matter?

I think it’s an important point in terms of our ability to recruit and retain doctors from around the world, including those who may have been trained in Wales or the wider UK and want to come to live, train and work in Wales for the future. There’s a balance here about the assurance we should properly want in terms of a doctor’s professional competence and their previous record where they are currently or most recently have been working. And, actually, it’s about making it as easy as possible for highly trained and welcome individuals to come and provide a service that we do need in this country.

That’s why, as part of the ‘Train. Work. Live.’ campaign, this was actually part of the feature, in trying to make this easier. That’s why we have a single point of contact created to try and make it an easier process for that person, or that group of people—often, doctors come with partners. So, it’s to understand what we do to make it easier for them to come here and to work, as well as to live here as well.

So, that’s part of the work that we’re doing. I’m always interested in specific examples where that doesn’t appear to have been the case. So, I’d be very happy to look at the detail of the issue that you raise, to understand how that matches up to what we’re doing now. And if it hasn’t met our own expectations of how we make it easier, we’ll give appropriate assurance of what we can do to actually improve what we currently do. There’s no point pretending that everything is perfect—it rarely is—but I’m always keen to learn from what’s happening at the moment.

And certainly, I will contact you, as I contacted your predecessor, who also gave me some warm words as you have done. But, unfortunately, it’s clear that there is a problem still facing us.

I will move to the challenge of attracting doctors from England. Now, doctors registered in Wales can’t work in Wales until they’ve been registered, as you know, on the Welsh performers list. There’s a similar register in England. The BMA notes that difficulties in transferring information between the two registers, and the complexities of registering on the Welsh list, make it very difficult to attract locums here specifically. And, in 2015, the BMA recommended that the Welsh Government and the UK Government needed to work together to facilitate that sharing of information between the two registers. So, what steps has the Minister taken since then to make it easier to register doctors from England to work in Wales, something which is crucial, of course, to go alongside any recruitment campaign?

Well, the single performers list is an issue of some frustration for people in the national health service in Wales, and in Government too, in that we have done what we could and should do to make it easier for people to register in Wales. The challenge is the willingness of the Department of Health and NHS England to do the same on a reciprocal basis. So, actually, we make it easier for our doctors to practice over the border—it’s really about their ability to do the same with us.

And that’s the honest challenge. There are times when I will stand up, and I’ll say, ‘This isn’t perfect, I know we need to improve’. This absolutely is an area where the challenge is NHS England and the Department of Health doing their bit. When you talk about making it easier for doctors to come here, part of what makes it easier and better for doctors to come here is that there is a real acceptance within the profession about the nature of the conversation that we are having about the sort of relationships we want to have with doctors, whether in primary care or in secondary care. And, actually, it’s the creation of that culture, more so than incentives in many ways, that is attracting doctors to come into Wales, and we want them to stay here. But the performers list is an absolutely an issue, and it’s something that we are still continuing to persuade the Department for Health and NHS England to move on, to help all of us to recruit and retain doctors within the England and Wales systems.

I certainly welcome any signals—and there are positive signals—in terms of an improvement in the number of those choosing to come to work in Wales, and an increase in the number of those choosing to train as GPs, and the financial incentive can play a part in that. But developing expertise and having the support to develop expertise is also something that appeals to junior doctors. And knowing that our rural areas are facing a very real challenge in recruitment, does the Minister agree with me that there is real scope to use a new medical school in Bangor as a centre to develop expertise, which could become global in its significance in rural medicine specifically, in the primary and secondary sectors, and that that as an aim should be a reason to move quickly towards establishing medical education in Bangor?

I thank you for your further follow-up question. I’ve been clear and consistent about the question of a medical school in north Wales. I’m awaiting final advice, and when that advice comes in, I’ll make a decision. I’ll also need to have a conversation with my Cabinet colleague the Cabinet Secretary for Education, because the budget isn’t in one particular area of Government; it’s spread across budget pressures for both of us—whether that is a new medical school, or whether it is expanding the numbers of doctors we want to train and recruit here in Wales. So, there’s honesty and, I think, consistency in the questions that you and other colleagues have asked again, and I don’t have any difficulty with you asking the question.

When I get the advice, I’ll be clear about what the advice is, I’ll be clear about what the Government response is and what we then expect to do. But I do recognise that there is a clear aspiration for more people to undertake their medical training in different parts of Wales. And, of course, rural Wales isn’t just an issue for north Wales. There are other points and questions as well about how we keep people in Wales—whether it’s west Wales or north Wales—who want to train to become a doctor, but also about how we get people to come back into the system. If you’re 18 or 19 and you live on the Isle of Anglesey, you may well want to go to London or Liverpool or somewhere else to do your training. But we need to be better at getting people to come back into our system. So, it’s more than one thing, and I don’t want to try and pretend that a medical school is the only answer or the answer to resolving some of those challenges. We see work on this already, for example, in the curriculum programme that Cardiff University are developing, where they recognise that there’s more they could do about the speciality of rural medicine that will be attractive to some people who want to become doctors now and in the future. There’s lots of different work ongoing, and when there is advice and a response from myself, then I’ll sit down and agree and discuss that with my colleague Kirsty Williams. We’ll need to cover all of those in pointing out what the response is going to be.

Conservative spokesperson, Angela Burns.

Diolch, Llywydd. Of course, Cabinet Secretary, one of the ways that we can attract more people into medicine is by ensuring that people have the opportunity to have a good work-life balance, and I’m quite sure that you will agree with me about the importance of ensuring good work-life balance for all workers in the NHS—a very stressful job at the best of times. The recent undertaking to attract more GPs into Wales has been successful, and I do praise you for that, and your Government. But we are still struggling to—[Interruption.] Yes, I’d write it down, too. It doesn’t often happen, but I will give praise where it’s due. But we are still struggling to attract physicians. The route from undergraduate to consultant physician can take over 15 years, and with such a time commitment, especially when you’re starting out so young, an individual’s career and their needs change. They might end up meeting the person of their dreams, marrying, children—the whole lot. That is a huge commitment to go straight from 18 to planning your life forward. What plans do you have to ensure that leadership and management pathways are open during these 15 years, and that there are opportunities for sabbaticals or for them to undertake some research, while still keeping on that very valuable training course? I think that would help to improve an offer that we could have here in Wales that might attract more people to us than other parts of the UK.

I think that’s a fair point to mention. It’s certainly part of what we discussed in the run-up to the recruitment campaign, and equally, what lots of our junior doctors are very keen to positively sell about Wales. At the BMJ careers fair, where we launched the ‘Train. Work. Live.’ campaign for doctors last autumn, what was really encouraging was not just the people involved in the profession already in Wales at a more senior level involved in promoting the opportunities to work in Wales, but actually junior doctors who attended, who had agreed to come and be part of us having that conversation with peers in that particular event and who came back after their allotted time and spent more time doing it because they believe there’s a really positive offer here in Wales. It is about that mix of understanding—about the balance and the different opportunities. You can be a doctor who wants to work in an urban setting and you can work in the middle of a city like Cardiff, or you can work in Pembrokeshire and Gwynedd with a very different sort of approach. It’s about selling all of those different opportunities. That’s why I’m talking about training, working and living in Wales. It isn’t just about one of those things—it’s a range of different parts.

There’s also got to be the recognition that people’s careers won’t simply be to go into one job and stay in that one job for the whole of their career. People do already move around and that’s more likely to be the case in the future. So, there is a point about having generalists as part of who we need to attract and retain here in Wales, but also to think about the whole career path they have and how we can make it easier to move in different parts of their career, because that is what we need to do successfully in the future. That, of course, is a common challenge right across UK systems. We face many similar challenges and we can always learn what is done successfully or unsuccessfully in other parts of the UK. I am keen that we have an open-minded approach to that conversation in the future.

That’s great news. The doctors have been saying this and the undergraduates have been saying this now for a number of years. So, I really hope that, this time, they are heard and those actions are taken. You mentioned, of course, that doctors like to move around. I understand that it’s very difficult to track doctors who want to take a break or leave their training and decide to, perhaps after their core medical training, go out on locum for a few years. I think that these figures would be useful to establish what path those individuals follow, whether it’s in this country, whether it’s abroad or whether, in fact, they’ve decided to step away from front-line medicine because they can’t get the work-life balance that they need. I’ve tried to investigate how we can track individuals who start training here in Wales. One way of doing this would be for every doctor to retain their national training number throughout their career. I understand that if they step out of training, they do have to surrender that national training number. I wonder if you might take this idea forward with the Welsh Deanery, because what we need is data. We need to know who’s joined us, why they don’t want to stay and where they’ve gone, because that way we can learn even more about what we need to do to ensure that we have the right offer in our NHS.

I think that’s an interesting point to make and one that I’ll certainly discuss with officials, not just in the deanery, but, of course, as we move to the creation of Health Education Wales and to understand what that will look like. I think I’ve indicated that I’ll update Members on the progress of that and the creation of a shadow body to lead to its coming into being in the future. These are subjects that we do talk about regularly with both the BMA and other stakeholders as well.

I met them this week, in fact. I met their representative from the junior doctors committee as part of that conversation about what are the current positions and the challenges over the different contracts in England, and the feeling of juniors in England and how that affects people in Wales and what that means for choices that we want to make here, not just about the contract, but on the different offers that we have on working here as well. Because those different working patterns won’t just be about people going in and out of medicine; it will also be that people want a different work-life balance, as you started off by saying—not just women, but actually lots of men will want a different work-life balance. There’s a very different, and I think a very welcome, attitude to what it is to be a parent, and that means that people will want to work different hours and try to manage having other things outside their life. The way that people trained in the past isn’t something we want to reinvent, where people worked crazy hours as part of what they were doing.

That means that we have to think more about the resource that we have in financial terms and how we use the human resource of the doctors that we’re getting through training and then how we do our best to keep them. So, I’m interested in how we could usefully track the choices that they make and the feedback that they give us and that’s part of what we’re able to do with the current campaign as well. I’m happy to make sure that we share more information with Assembly Members as we get that through the campaign as well about the level of real intent that we’re getting back from people who either decided not to come to Wales—because that’s important too—as well as those who do decide to come here as well. But I’ll certainly take up the particular idea of whether the national training number could be something useful as part of that.

I know that you are going to be starting the nurse recruitment drive as well. I think the thing is that we can’t do these in a linear order—we have to do them all in tandem because we have enormous gaps throughout the NHS. Recent statistics are very clear that we are only filling 49 per cent of placements for core medical training. We are running out of doctors in our NHS and they are going off on to locum or just leaving, or we simply don’t have them. So, that means we’ve got a 51 per cent vacancy rate. I’d like you to consider addressing how we might be able to make up for that shortfall. Because, of course, on round 2, when we might fill up a few of those, first, we won’t get all of the 51 per cent, because we would have got them the first time around, and, of course, secondly, we’re getting people for whom Wales is not their first choice, which means they may be less likely to stay here in the long run.

We’re frankly getting people who may not have made the grade the first time around. So, we’re having people who are not the top of their cohort and we want to grab all the excellent ones first if we possibly can. So, I wondered, Cabinet Secretary, if you can tell us what discussions you’re having with organisations such as the hospital trust and the Royal College of Physicians, in order to increase the number of physicians that we can recruit to the Welsh NHS on that first and very important attempt—51 per cent is a big, big shortfall.

I recognise that core medical training is a real concern. Just because it’s a real concern in other parts of the UK doesn’t mean that we don’t have a problem here, because we do, and it’s a very real challenge for us to take on board. And, actually, it’s part of the conversations that we have had. I had a very constructive conversation with the Royal College of Physicians, as well as other partners and stakeholders. Part of the honest and mature conversation that we have to have is that, given that we all know that this is a big problem, how would we look at what we can positively do, given that we know that those shortages exist in other parts of the UK too?

Some of that is, if you like, the competition between different parts of the UK to try and recruit and retain the same people. Part of the Royal College of Physicians’ concern has been the way in which the health service is often talked about makes it a less attractive career for other people who might otherwise have wanted to go into a career in medicine. There are different things that we need to look at and do.

So, I won’t pretend to you that there is a single answer that I have hidden somewhere in my pocket to reveal and to resolve the whole of the problem—that would not be a smart way to go about this. I couldn’t pretend to you that everything will be fine within six months’ time, but what I can say is that I think we have the right partners having the conversations with us, with officials here in the Government, with health boards, and, as I said earlier, leading into the creation of Health Education Wales to have a more joined-up and intelligent conversation about who we want and how we get them. And it’s the how we get them, I think, which is the more challenging part, rather than trying to understand, in workforce terms, who would ideally like to be working in the service.

UKIP spokesperson, Caroline Jones.

Diolch, Llywydd. Cabinet Secretary, we all know that early detection of cancer is vital to patient survival, which is why screening programmes are so important. If bowel cancer is diagnosed at the earlier stage, more than nine in 10 people will be successfully treated. Screening should reduce the number of people who die from the disease, which kills around 1,000 people in Wales each year. Many people find the current test too complicated, which is why I congratulate you for introducing the simpler and more accurate faecal immunochemical test—or FIT. Cabinet Secretary, can you please provide an update on how the roll-out of the new test is progressing?

Thank you for the questions. There are, I think, two broad points I’d make. The first is that I think it’s too early to talk about the roll-out, but we expect to provide information through this year on the roll-out of the new simpler and easier-to-administer test. It’s been part of the challenge in the past about bowel cancer rates, because, broadly, it was a difficult and unpleasant test to administer by the individual. So, lots of people were just put off and didn’t comply, and the fact that, actually, detecting earlier a potentially fatal condition didn’t matter to people enough. So, we knew that there was something about improving testing rates, and the new test should help us to do that. My colleague, the Minister, will take a lead on providing that information with her responsibility for the screening programme.

The second point that I’d make is that, when we talk about earlier testing, there is always a challenge and a demand to have more testing and more screening and surveillance programmes, and this is really difficult, because, as with other parts of the UK, we follow the expert advice that we have about where is the appropriate point and the appropriate group of people to test to actually save the greatest number of lives. Because, potential harm is done in the testing programmes as well, and we’re making choices about our use of resources. Now, that is always difficult, because, as people in this Chamber will know, with the recent passing away of Sam Gould at a young age, that’s someone who was younger than our standard bowel cancer testing programme. That’s because we’re acting on the advice we’re given about how to get the best return for the public and the health service and how we save the greatest number of lives.

So, whilst I understand that Members will often want to come and say, ‘Expand the screening programme; test more people’, it often isn’t as simple as that, and I’d ask people to think and to try and engage with us on the level of where the evidence takes us and why it’s there, and whether we actually want to run this sort of campaigning, the sort of work that the campaign around the testing programme led by evidence, or led by who’s going to have the loudest voice about what they’re trying to change. This isn’t an easy choice for anyone to make, and I think that anyone in my position now or in Rebecca Evans’s position would still have to be led by the evidence about what is the right thing to do for the service and the public.

Thank you for that answer, Cabinet Secretary. Wales has opted to set a much higher sensitivity threshold for the FIT screening. While it is lower than the level set in England, it is double the level set in Scotland, and eight times higher than the threshold set elsewhere in Europe. Cancer Research UK state that the reason for the much higher threshold is due to the lack of endoscopy capacity here in Wales. Wales routinely sees around 1,000 patients waiting more than eight weeks for a colonoscopy. If we are to maximise the benefits of the FIT test, we must increase endoscopy capacity. Cabinet Secretary, what actions are you taking to increase capacity and will you consider lowering the FIT screening threshold once we have sufficient colonoscopy capacity?

I’m happy to deal with both parts of that. I’m certainly not aware that we set the threshold in the test on anything other than the evidence base on what is the right thing to do for patients. If she wants to write to me with specific issues that have been raised by Cancer Research for either myself or the Minister to respond, we’ll happily do so. In terms of endoscopy capacity, we do know that we have a particular challenge in the south-east part of Wales, and we’ve actually made significant progress on reducing waits and improving capacity, but also improving quality at the same time, in west Wales, in mid Wales and in north Wales too. Our challenge is for south-east Wales, where most of these waits exist, in the Cardiff and Vale, Cwm Taf and Aneurin Bevan health board areas. And whilst they’ve made progress over the last year that has really been significant, there is still much more to do over the course of this year, and I expect them to make a real and significant difference again into the backlog they have, so we then have a much more sustainable system where people are seen within their target times.

Thank you, Cabinet Secretary. Bowel cancer screening is offered to those aged between 60 and 74. Scotland has opted to screen those aged between 50 and 74. Bowel cancer can, however, strike at any age. A few weeks ago, we sadly lost a colleague to bowel cancer, and he was aged only 33. Cabinet Secretary, does your Government have any plans to offer routine FIT screening to those deemed to be at a higher risk of bowel cancer, whatever their age, and to roll out screening to the over-50s as they do in Scotland?

As I think I said in the second part of my first answer, we have to be led by the evidence, and if there is evidence that changing the age limit is the right thing to do, then you can expect the Government to do that. But what I don’t think we can do is to set an arbitrary limit on age that is driven by a campaign that isn’t supported by evidence. And that’s really difficult, because I understand the emotion and the understandable impact for people that are outside the screening programme window but nevertheless acquire conditions including cancer. But I just don’t think that any responsible Government is going to be able to say that it’ll make a choice about running a national screening programme outside and without due regard for the evidence that exists on what to do with what we recognise are finite resources in the health service, and the real harm that is done potentially by screening for those who don’t need it, as well as the real gain to be made by an appropriately resourced and high-quality screening programme undertaken across the country.