The next item is the statement by the Cabinet Secretary for health on the interim report of the parliamentary review of health and social care. I call on the Cabinet Secretary to make his statement—Vaughan Gething.

Thank you, Presiding Officer. The establishment of the parliamentary review into the long-term future of health and social care in Wales was a key commitment in ‘Taking Wales Forward’. I announced the setting up of an independent panel of experts in November 2016, and today sees the publication of its interim report. The review will conclude this December, with the publication of a final report.

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

The independent review panel is chaired by Dr Ruth Hussey, the former Chief Medical Officer for Wales, and consists of national and international experts in the field of health and social care. At the outset, I want to thank Ruth and her fellow panel members, and, indeed, everyone who has engaged with the panel, for their commitment to this important work. I also welcome the cross-party support for the review, and the nature with which opposition spokespersons, and the chair of the Health, Social Care and Sport Committee, have engaged in it. This of course comes from an initial agreement between my party and Plaid Cymru at the start of this Assembly term.

The agreed terms of reference set for the review are challenging. The panel are tasked with assessing and making recommendations on: how the health and care system might deliver improved health and well-being outcomes for people across Wales; reduce existing inequalities between certain population groups; and how best to enable the whole health and social care system to be sustainable over the next five to 10 years.

Change in the system is essential for future financial sustainability. Without effective action to reduce cost pressures, increase efficiency, or reduce the demand for services, the Health Foundation has shown that NHS spending in Wales will need to rise by an average of 3.2 per cent a year in real terms to 2030-31, just to keep pace. Cost pressures for adult social care are projected to rise even faster than for the NHS, by an average of 4.1 per cent per year.

I am pleased that the panel has responded at this still early stage of their work with an insightful interim report. Over the next few months, the review will be holding discussions across Wales, engaging with key groups, and working with stakeholders on integrated models of care. They will also look in more depth at some key issues and make clear recommendations on key issues for the final report.

The panel rightly recognises the tremendous commitment of the health and care workforce and its significant achievements. However, the case for change in how health and social care services should be organised in future could not be clearer. As the report shows, the changing make-up of the population presents a particular challenge. Wales has the largest and fastest growing proportion of older people in the UK. Whilst that is of course a source of celebration, an increasing older population with more complex health conditions and needs will also lead to a greater need for care. At the same time, the proportion of working age people will shrink, providing a smaller pool of taxpayers, informal carers and potential employees in health and care.

Despite our recent successes in recruitment, Wales—in common with many other countries—sees shortages in certain professional fields. In common with many post-industrial societies, Wales is already experiencing inequalities in health and well-being outcomes. The panel has shared the view expressed by professionals and the public alike, that healthcare is not always provided effectively based on the needs of service users. However, there are positive opportunities to be seized through the faster uptake of technologies and a more systematic approach to innovation, which could help deliver more effective care.

Many people will of course recognise this picture. What comes across clearly in this interim report is the pace at which rapidly changing social and technological factors are impacting on service provision. The report is clear that health and care will not be sustainable if traditional service configurations and ways of working are perpetuated. The report makes clear that new models of delivering health and social care are needed.

But the panel did find significant consensus amongst health and care stakeholders about what the characteristics of a future integrated health and care system should be. These are: a universal primary health service, which promotes well-being of the population; a greater emphasis on preventative care; individuals to be supported to self-manage where possible and safe; greater access to online support; wherever possible, services provided at home first or in the community, with access to hospital care only for services a hospital facility can provide; a more flexible model of home-based care and support that enables the individual to have control over when, and for how long, they use a service; a seamless co-ordination between different types of care; orientation of a care culture to focus on the outcomes the citizen wants and can achieve; and a relentless focus on quality and efficiency, with staff having a supportive and engaged working environment.

All of those above issues can be enhanced by new technology and informed by shared data and analytics. However, whilst there is of course a broad consensus on the vision, the panel reports that health and care organisations are searching for advice and practical support on how this is to be delivered consistently across our system. To address this, the panel suggests that the next steps for Wales are to identify the most promising, broad models of whole-system health and social care, drawing on international evidence, and that new models should then be used at scale to deliver whole-system transformational change.

These new models of care should include a combination of hospital, primary care, community health and social care providers. They should work in different settings, such as urban and rural, and of course take account of Welsh language needs. The panel envisages that a limited number of models could be widely trialled, developed and evaluated. The panel will set up a stakeholder forum to work with them to develop these new models and the principles that should be used to plan future service development.

Doing this work now will create momentum and an environment for progress after the review has concluded. Alongside this, the panel’s view is that new models alone will not be enough to ensure sustainable services without parallel action on a number of enablers. These are outlined in the report as areas where the panel will look to develop recommendations. They are: public dialogue; the workforce; digital and infrastructure; innovation; and, crucially, making change happen faster.

This is a strong interim report and I welcome the practical approach that the review panel intend to take to their work. I look to health and care organisations and members of the public to respond with equal vigour and work constructively with the parliamentary review over the coming months.

I’m delighted to be able to speak to this statement and like you, Cabinet Secretary, I would like to add my thanks to Dr Ruth Hussey and to the members of the panel for their work on this. I’ve appreciated very much the open and transparent way in which the chair and the panel have engaged with me and, I know, with other Assembly Member colleagues and with the Health, Social Care and Sport Committee.

I think that this is a seminal moment for Welsh Government—for every politician, actually—for the NHS and for the care sector, and I think that the report that they have produced—the interim report—is very, very clear and lays out not just the scale of the challenge that we face, but some of the possible routes with which we might go down to solve some of those challenges. I think that there's not much in this report that none of us knew about, but sometimes you have to ask somebody on the outside to tell you the obvious, because you know it, but you've got to hear it again. I think they very carefully stated again a lot of the problems, a lot of the issues, a lot of the challenges that we all know so well. But they've done it in a very cool and dispassionate way and they’ve laid it out very clearly. So, it's the sounding board that we needed and we've had that.

I think that the report is very clear, again, on a number of things. One is that the pace of change must accelerate—that doing nothing is not an option we can afford to take, nor should we take. I was very struck by how very clearly they lay out that there are a lot of green shoots already showing within the NHS landscape—great models of innovation out there, but that somehow there is a barrier to those innovative models taking root and flourishing and being able to be transplanted to other areas and being able to gain credence throughout the whole of the NHS. So, for me, this report very clearly identified that we all know the direction of travel, but that the road map isn't clear for an awful lot of organisations with which we need to work. So, as ever, the question is: what are those barriers to improvement? I look forward to the second stage of the report. I met with Ruth Hussey this morning and she was very clear that in the second stage of the report that they want to bring out some of that detail.

Having said that, though, I think that there are some clear lessons we can start learning from now. So, Cabinet Secretary, I'd like to ask you just a few of those questions, because there's so much you could speak about on this report—it's very hard to actually discern the best bits to talk about in the time given. I think the report shows that Welsh Government has struggled to drive some good policies through. So, my first question to you is: how will you skill up your department and your officials, so they are better able to lead and persuade for change? My second question is, given the first: how will you see managing the tensions created by these decisions for Wales that the report talks about, and I can totally buy into that need? And what type of decisions do you foresee that they might be—macro, minor—and what kind of scale? And given those tensions from the first and second question: how will you engage, and take with you, local communities? Because I do note in your statement the one thing you do not mention is public engagement at any great level, and that is something that this report is really, really, really strong on, and I'm concerned that you don't mention it in your statement. I would like your assurance that public engagement and the voice of the patient, the user, and those who have yet to use the NHS will be heard in all of this.

The report identifies areas that already need work and I don't think we need to wait for a second report for the conclusion to know that we need to look at how we bring co-production into health and social care; how we transform and transfer information. I wonder if you can outline what steps you think you might be able to take already; how you might be able to support the highly fragile care sector; how you might be able to support—and I love this word—the care force: the people who give the voluntary care to all of those families at home and all of those loved ones, and what can we do now to support them? I’d be very interested to know what we might be able to do now to look at the training needs and the pay and conditions of our care force, the paid care sector, because I think that they are being left behind in the race towards trying to improve our NHS at the moment.

I was delighted to see that this report talked a lot about housing and about how our homes are going to become the place where we will receive health and social care in the future. I would like to understand, Cabinet Secretary, if you have plans to talk to your colleagues about how we can start to address some of their housing needs. For example, I know in my own constituency that of all of the houses being built, whether they’re being built privately, by the county council or by housing associations, it’s a tiny percentage that are being built to house people with disabilities, or house people with dementia, the elderly, to put in stairlifts—whatever it might take—and yet it seems to me, having read this report, we must ensure that more of our public and private housing stock is able to take care of us. I think the report is very clear about how many people are going to be able to need more and more support in their homes.

I have picked up your very, very gracious comment or nod there, Deputy Presiding Officer; I shall gabble through the last little bit, and, actually, just to ask one more thing. The leader of the opposition asked the First Minister today whether or not this would be the direction of travel. Now, I think that this is a really great cornerstone to start building a future for our NHS. I think the workforce of the NHS, I think the politicians and I think the patients are all exhausted by where we’re at, and that we need to have a clearer, brighter future. And I would like to really understand where your commitment is to taking forward this report. I’m sure that over the years we will argue about the delivery of some of it, and about whether one thing should be a priority or another. But the skeleton that has been drawn up here I think is very, very strong, and I would like to know and be reassured by you—because I don’t think we got that right answer from the First Minister—that this actually is going to be taken and used and not just left on a shelf to gather dust, as so many other reports have been in the past.

Thank you. Cabinet Secretary.

Thank you for the comments and questions. And I welcome your recognition at the start that the panel have been open and transparent, but also that this has, as I said in my opening statement, come from a genuine cross-party engagement. It started as being an agreement between Welsh Labour and Plaid Cymru, but there’s been, not just from those two parties but everyone in this Chamber, the willingness to sit down and agree on the terms of reference, and the panel to undertake this particular report. So, there was a challenge that each of us accepted in starting this process, and I hope that you found the way in which the Government has engaged with each of those parties to be genuinely open as well, because this is a concern for all of us and not just for one particular party to confront. I think it really has been useful to have a genuinely independent group of national and international experts to validate the concerns, the challenges and the imperative for change that we have often debated and discussed in previous Assembly terms, and I do wonder if the Chair of the committee may tell us about his previous incarnation as an Assembly Member where similar issues have been floated.

But the challenge we now have is that the challenge is more acute. We have even more demand coming into our system. We have even more demand based on the age of the population, public health challenges, demand that is driven by the behaviour of healthcare professionals and social care professionals, but also about the reality that the money is getting tighter and tighter and tighter. So, pretending we can run the same system now in five and 10 years’ time will see all of our constituents and their interests compromised. And I welcome the recognition about the change and innovation that is already in progress.

I think the point that you started to make about the balance between having local and regional leadership and innovation that comes bottom-up, and the responsibilities of local groups, whether they’re primary care clusters, whether they’re health boards or organisations in-between, but also the point about the central guiding hand that is made in the report, but also in the previous OECD report—. And Members of this Chamber regularly ask about wanting the Government to intervene and provide a central guiding hand and direction on a whole range of issues, from what happens in a particular ward, a particular GP surgery to health board-wide challenges. We need to find a balance on making sure that central direction is provided to help unblock some of the challenges that have prevented change from taking place previously, without simply then saying that, centrally, the Government will decide everything about health and social care. And that’s the challenge that we recognised before, and, equally, it’s set out for us very clearly in the interim report. I look forward to the next stage with the models of care that should provide more answers about how we do that. But whilst we wait another five to six months for that to happen, we’ve still got business to do now about trying to improve our system. What the interim report does do, as you recognise, is that it allows us to make some of that progress now to validate the direction of travel, and to think about how we provide the additional steps, the initial progress, that we want to make, and empowering people locally as well as nationally as well.

And I do take seriously your point about public engagement. When we talk about the interim report now being used now being used to talk to stakeholders. Well, the public are the biggest group of stakeholders, and I hope now having a report that sets out again the interim nature of this report to engage on and around, not just the big ‘What do you think about health and social care?’, but here’s a report that says, ‘Here are big challenges we face; here are the drivers for change; here’s the need and imperative for change; here’s what’s working already; here’s what we still need to improve on’, and that should lead to a more informed conversation, not just incidentally as our public events take place, but a deliberate and planned way to engage with citizens as well, and that’s important, as much as it is important to talk to staff groups and to the third sector directly as well. So, I’m very clear, and I think the panel are also clear that that’s part of their mission over the summer.

But what this also has, and I turn to your reference of prudent healthcare, well, we see that already in both the social service and well-being Act, the scheme in that, but also in prudent healthcare, involving and engaging the public as citizens who make their own choices, not having choices made for them. That’s very clear and is set out in the report, but also in the work that we’re trying to do to drive it across our whole system. That also goes into your point about the care sector, where Rebecca Evans is already leading on the work we’ve regularly said we want to see in the paid care sector—to have the status of the profession raised, and that includes the training and investment we make in the workplace. I recognise what you say about housing as a key determinant in health outcomes as well as places where health and social care is delivered.

I will finish on this point, Deputy Presiding Officer, but your point about the future direction of travel—. I’m happy to confirm that the mature conversation that led to this review being started in the first place is where I want to take on from today and when the report is provided to us. Because if we think the challenges are too important to ignore, there’s a challenge for everyone in this room and beyond about how we then talk about, discuss and agree on what we’ll do next. I expect this review and the Government’s response to it to form the direction of travel for another decade or so, and to do that we should absolutely engage across party about how we want to find the greatest areas for consensus and agreement on moving forward. What I can’t do, though, what no-one in this room can do, is to say that they will accept everything and anything the report says. We have to have a sense test on what comes back about that, and we have to respond openly about what we can do and how quickly we think we can do that together. But this absolutely will be a key part of setting the direction for the future, and how each of us respond in this Chamber, including, of course, the Government.

May I thank the Cabinet Secretary for this statement? I, too, will take this opportunity to thank Ruth Hussey and her team for the work that they have done to date, and I’m very pleased that we are in a situation now where we can hear this statement, and I’m pleased to see the coverage in the press today for this report. But the Cabinet Secretary, I think, is right in reminding us that we are at an early stage, if truth be told, in the work that this panel is undertaking, and that this is an interim report.

I welcome many of the findings that have been brought to our attention—many of them, as the Conservative spokesperson said, are relatively obvious, but what’s important now is what is done with these findings as the work of the panel continues, and what kind of recommendations will be made based on these findings and what kind of models will be developed. I look forward to seeing that happening over the next few months.

Although it is an interim report, I do think that some of the questions that I’d like to ask refer to the steps that could be taken now by Government, if truth be told, given what we heard from the Cabinet Secretary himself, stating that the case for change in how health and social care is arranged for the future is entirely clear now. Well, if it is clear, then, surely, there are some steps that the Government could be taking now, without awaiting the final report.

The interim report, again, emphasises the value of integrating health and social care. I would also add to that that integrating local government housing services is also important. And we know that there is a realisation of the value of integration, but that doesn’t happen. So, although the final report will put more meat on the bones, as it were, I wonder whether the Cabinet Secretary would agree that we perhaps don’t have to wait to start to see how guidance and protocols and action points for organisations and institutions, to enable them to work together, could be tightened up so that the work can happen now.

Related to this is the problem of individual institutions and organisations taking decisions on their budgets, which are sensible from their own perspective, but sometimes lead to additional pressures on the budgets of other services. So, how can the Welsh Government start to encourage that culture change within public services so that this ceases, because that will be an important step towards delivering this concept of integration?

The interim report also supports far more investment in primary care. We agree entirely with that, so what changes can the Cabinet Secretary make now in order to ensure that we start to think more about putting primary care first?

And finally, the report also recognises the value of technology. On occasion, technology and particularly the pace of change that we see in technology, and the new possibilities provided for by technologies, are not sufficiently understood by managers and commissioners within the health system, and that may have meant that the appropriate attention hasn’t been given to this area in the past. Given that, does the Cabinet Secretary believe that we should now think about professionals in IT and professionals in other technologies—that we should start to consider them as professional health workers who play a central role in delivering services and ensuring that services work and ensuring that technology is included as much as possible in care pathways for patients in Wales?

I’ll leave the questions there. It is an interim report, yes. It’s an important step, but I do think that there are certain steps that the Government could be taking at this point in the process.

Thank you for the comments and questions. I too look forward to the models of care—the new models of integrated care—that the review team will bring forward to us with their final report, and I’m sure they’ll be challenging for us in a number of different ways. That’s part of the point of setting up the process. It is supposed to be challenging and difficult. It’s supposed to ask us awkward questions.

A number have come back to the points that both you and Andrew have made about delivering change and the difficulties in doing that, partly because it’s a big and complex system. Even in the private sector—I used to work in a firm that had 20-odd offices around the country—delivering change within a system where everyone was employed by the same organisation, you found that the culture was different in different offices. Delivering a single system, say for case management, was actually more difficult than you thought it would be. So, to deliver something across our health and social care sector—not just health, but health and social care—is going to be understandably difficult, but our challenge is to recognise, as I said earlier, that imperative for change and the fact that we haven’t done as much as we would have wanted to previously.

We should be honest about the fact that, even on a real evidence base, all of us are pulled in different directions by local pressures. Every time there is a significant service proposal for change, understandably, Members in every party will be put under pressure to fight local and to say that there is a different reason why change could not or should not happen. Now, we have to be prepared to recognise that, and when those new models of care are provided to us to consider, and with the suggestion and recommendation from the review panel that they are then trialled and then scaled up significantly and quickly across the country, that will be difficult for every party, not just for one in this Chamber, and for people locally in a range of different areas. But the challenge otherwise is that we go back to, ‘Well, actually, we slow the pace of change and we allow change to happen to us rather than making an informed choice about what we want to do differently’. That goes back to some of the points you then made.

I think it’s interesting your point about how we incentivise or require integration within the health system—actually, between different parts of secondary and other acute services, as well as primary care and secondary care, but also between health and social care and other partners too. Some of that is already happening. We’ve got pooled budgets coming in in the scheme in the Social Services and Well-being (Wales) Act 2014 from April next year in a number of services. We’ve got public services boards and regional boards already working together as partnerships and making decisions together. Some of that is about, if you like, the more genuine bottom-up approach where people are sitting together and realising that they could and should do more together, and that there’s more value to be gained by those different public sector budgets working together with decision making.

What the review also sets out for us is that, on its own, that is unlikely to be enough. So, the outcomes framework, the competencies and the key performance indicators we set for people have enough in common across different sectors to enable and require people to work together at the same time. We also have the challenge of working with the police—the most obvious non-devolved group that have a real interest in and an impact upon health and care outcomes. So, that also goes into some of the steps we’ve already taken in, for example, incentivising primary care to work differently together. We’ve required people to work together in clusters. We had points that were dependent on the quality and outcomes framework taking part, but also money that went with that. So, there was an incentive as well to say, ‘Here’s money. You get to choose how you spend it locally to meet the needs of your collective local population.’ So, some of that is already happening and the review team are positive about the work of clusters. The challenge again is: how do you then understand what local innovation looks like, and then how do you get to the point of evaluating that and deciding what to do, what to do more of, and then what to disinvest in, as well? That’s the more difficult choice that we often have to make.

Finally, just on this particular area, I’ve already required and am expecting some things to happen. We know we’ve had a challenge on working across health board boundaries. That’s why Hywel Dda and ABM are working together. They’ve had a joint planning meeting already and they’ve very sensibly and wisely agreed to my invitation to meet on a regular basis to plan services together—and the same in south-east Wales as well, with Cwm Taf, Aneurin Bevan and Cardiff and Vale. Because, actually, there are services, not just in specialist services, but in the way in which we deliver normal elective services as well, where there could and should be planning across those boundaries to make sure the services make sense. And if we can’t drive that sort of way of working into our service, then we’re unlikely to see the sort of significant change that we want to, and that you and I and everyone else in this room thinks is necessary for the future of the service.

That goes into how and why we invest in primary care, the choice that we’ve already made, but there needs to be more of that because the pressure is almost always to invest in staff and expensive services in a hospital-based setting. We need to do more to hold a line and to see that investment come into primary care and community care. I recognise the well-made points that you highlight on technology and the ability to have not just a ‘once for Wales’ approach in key systems, not just to have a system where you can transfer information between primary and secondary care and the social care sector, but also for the citizens themselves to have more control over their information and access to how to use the system. We can do that in so many different areas of our life already. You can bank online and have access to really sensitive information. Our challenge is: how do we enable a citizen to have access to their own healthcare information in a way that should help them to manage their own conditions and make more informed choices? There’s real potential there, but again, we need to be much better at meeting the expectations about how people already live their lives and I want to enable that to happen on a consistent basis across the country as well.

Cabinet Secretary, I’d just like to follow up the point on public engagement. We haven’t lacked expert analysis over the last decade or so on the challenges facing the NHS in Wales, but one of the things the system has found extremely challenging to do is engaging with communities. Llanelli is a famous case study in how not to do it, in the reshaping of services at Prince Philip Hospital, and, with all credit to the team there, they’re a case study in how to do it, in the way they then picked themselves up, drew on the clinicians and the community in coming up with a new solution, which is now being seen as a model for elsewhere.

I’ve been disturbed in recent weeks by the changes we’re seeing in primary care, where doctors’ surgeries are having to close lists or having to hand back their contracts, and the way that’s being communicated with their patients leaves some room for improvement. I met recently with the chief exec of Hywel Dda to discuss, and he fairly points out that these are privately run contracted businesses—a point that is little understood, I think, amongst the general public—and there is a limited amount that the health board can do if these private businesses aren’t willing to co-operate. It’s these doctors’ surgeries who often communicate these difficult messages by imperfect means. So, for example, a poster on the door as a notice to people that the doctor’s surgery has been closed to new patients.

So, I just wonder if the Cabinet Secretary could tell us about the next stage of work, how public engagement is going to be hard-wired into the approach that’s needed, and also whether or not the models that we’re working with are going to be reviewed as part of that, because if we do have a primary care model that relies upon private businesses, who may or may not want to co-operate with this agenda, is it time to look again at that model?

Thank you for the question; it’s one that I’ve discussed previously with the Member for Llanelli, and not just, to be fair, in relation to his own constituency—not just with the Prince Philip Hospital where, as you recognised, there was a good example of what not to do, as well as then the way in which that was successfully achieved, and the same in Kidwelly as well, in some ways. There’s a really important message here, I think, for being able to talk to the public early enough, but in a way where they trust where the message comes from. I’ve got national responsibilities that I certainly don’t try to walk away from a contract out of. I’m quite happy to take on board those responsibilities; it’s the privilege of the job. But equally, if clinicians aren’t part of that, it makes it very difficult for people to trust the information and the imperatives for change, and we really do need a conversation that isn’t just between the health service in the shape of people who are chief executives and executive members of a board. They have a responsibility to do that, yes, but actually, local clinicians, people are used to seeing and trusting. Because otherwise I don’t think people trust the reason and the rationale.

It’s easy to understand why members of the public are instinctively suspicious and almost always think the first reason is, ‘This is about money, and you’re not prepared to spend money on the service,’ rather than it being about much, much more than money, and there are things even if we were in times of plenty in public service spending, there would be a need to change some of the ways in which we deliver care, and that’s part of the challenge that we will have. If we can’t engage our clinical communities and healthcare professionals and social care professionals in being part of that conversation, we’re unlikely to see the sort of pace and scale of the change that we are told, yet again, is absolutely critical to the future of our health and care system.

That’s why it is important, as I said in response to Angela Burns, that in the next stage, the biggest and most important group of stakeholders is the public—citizens themselves being engaged in the conversation as far as possible. I think the way this has been covered today has been helpful in that, but let’s not pretend that this will be the first item on the news agenda for the next six months. There will be a challenge about how we make sure that engagement is real and meaningful, even if we honestly accept that not every person in Wales who has an interest today will be engaged in the same way come, say, November, when the report is being written and prepared to come back to us, but that isn’t a debate that can stop then. It isn’t simply we get the report and say, ‘Right, that’s it. We’re not interested in anyone else.’ There’s got to be the constant process of engagement, and it goes back to your point about the way in which people engage in change at a local level, and often people are surprised to hear that change is required or necessary or proposed, and the first reaction is to fight against that change, and again, I understand that completely. It’s a reaction in every single community across the country.

If we don’t get clinicians engaging in a more open way to discuss and debate these issues with the public, we’re not going to see that change at all, and on your point about the primary care model, there is change already taking place. Some of you see this as a bit of a threat to the independent contractor model. Well, actually, the biggest change to that model comes from new entrants into the profession, many of whom don’t want to buy into that way of working, either because they don’t want to buy into a building and the potential liabilities of that for the future, or because they simply want to be more flexible about their career. Not every person who comes out of training to be a doctor, or any other form of healthcare profession, wants to say, ‘I’m committed to being in one community for pretty much the rest of my working life.’ We need to recognise that change and find a way to allow those different models of care to work. And to be fair, I actually think that both the Royal College of General Practitioners and the BMA are being very pragmatic about that discussion, in supporting their members who want to maintain the independent contractor model, and at the same time enabling those other members of their membership bodies to actually find different ways of working with health boards in that wider multidisciplinary team. So, I think there is genuine cause for some optimism, but that doesn’t mean to say that that makes it easy.

Thank you for your statement, Cabinet Secretary. I would also like to place on record my thanks to Dr Ruth Hussey and the panel for keeping me and my team regularly updated on the review’s progress. The interim report starkly lays out the challenges facing health and social care in Wales.

We are at an evolutionary moment with our health and care systems: we adapt or we perish. This is not a problem that can be solved by simply throwing money at it. As Dr Hussey correctly identifies, we have to make urgent systemic changes to the way we deliver care. We have to work smarter. We have to spend smarter. Cabinet Secretary, I welcome this interim report and the findings set out by Dr Hussey and her team. We now have a much clearer view of the challenge facing us as a nation and the challenge facing us as politicians.

I am convinced that we have to change the way we deliver health and social care in the future. It is now up to us here, in this Chamber, to convince the public of the need for change and to engage with them in designing our future health and care system. Cabinet Secretary, how do you plan to encourage as many members of the public as possible to engage with the parliamentary review?

The panel suggests that a new number of models of care could be trialled and evaluated.Cabinet Secretary, if you can answer at this stage, how long will the trials run, and how do you plan to run such trials concurrently?

Whichever new models of care we adopt, they will all rely on new technology and shared data. Cabinet Secretary, can you outline the steps your Government is taking to improve the NHS Wales Informatics Service to ensure it can adapt to future needs?

However care is delivered, we need a workforce to deliver it. We need to encourage more young people to become doctors, nurses, physios, occupational therapists and pharmacists. We also need experts in machine learning and big data, computer network specialists and programmers. Cabinet Secretary, what is the Welsh Government doing to encourage more young people to study STEM subjects to ensure we have the workforce we need in future?

It is vital we deliver the necessary changes as quickly as possible if we are to ensure that future generations will have a health and social care system that meets their needs. Regarding our infrastructure, as has previously been mentioned, if people are to be encouraged to stay in their homes, we must make sure that, with an ageing population, new housing is built to recognise the changing needs in building regulations to accommodate disabled needs. Our infrastructure regarding public transport is, in future, also going to have to change.

I look forward to working with the parliamentary review over the coming months, to receiving the final report, and working with you, Cabinet Secretary, to deliver the recommendations made by Dr Hussey and the panel. Diolch yn fawr. Thank you.

Thank you for the comments and questions. I’ll do this in reverse order. Again, I recognise the points about housing, but, again, you make a point about transport and transport needs, both to specialists in hospital centres, but also physical access to local care as well and how that will be delivered, and how much will be delivered in the centres that people travel to, and how much will be in someone’s home. That is intrinsic and, I would say, also linked to the way in which we deliver telehealth and make that much more accessible and commonplace. We already have good examples of that and, again, this will add to the comments that Rhun ap Iorwerth made earlier on things we could do now. And, actually, delivering a more demanding but evidence-led approach on telehealth is one of the things I think we could do, and I’d be surprised if that doesn’t form part of the final discussion in the report and recommendations.

On your point then about education and encouraging people to study different subjects, well, of course, that is a cross-Government perspective, not just through the pre-16 curriculum and early years, which both Alun Davies and Kirsty Williams have a direct interest in, but about how we equip and encourage people, and our childcare offer and what that does to improve people’s attainment and other aspects of the future all the way through school education and beyond, where, actually, people then make different choices about what they want to do. There is something again about the curriculum for healthcare professionals. They undertake their own training. If we want people to work in a different way as part of a multidisciplinary team, they need to be trained to work in that way whilst undertaking their qualifications too. So, I recognise the points there that are being made.

On NWIS, or the NHS Wales Informatics Service, there is a challenge there, which is set out in the report, about how they adapt to future needs, and it’s more than just the points that were made by both Angela Burns and Rhun ap Iorwerth. It is also about the ability to actually think about how we actually gear that up, not just about delivering ‘once for Wales’ methods and making sure that health boards and trusts buy into that, but how it actually manages to maintain the work that is already done. Because the report recognises that much of what NWIS does is maintaining what already exists, and the space for it to develop and deliver new systems is not always easy—the ability and, if you like, the capacity and the power to do that. It poses some questions in the report about how much it’s about developing either in-house capacity or actually about working in partnership with other software developers working to a commission provided by NWIS. I think that that’s a very sensible conversation to engage in and take forward.

On your point about how long the trials will run on the new models for care, I’m not in a position to answer that. I don’t even know what the new models of care are yet. I definitely haven’t seen an advance copy of the report for five or six months’ time, I assure you of that, but, when that is provided, we’ll then have a sense from the panel itself about at what point in time they might advise us that we would need to wait to then have enough evidence to look for system-wide change in the way in which we deliver services. So, we’ll all have to wait a few more months to see what the trials will look like, let alone how long they will then run for.

On the point about engaging the public, again, this has been mentioned by previous speakers too, and I certainly recognise that we need to consider how we do that deliberately and specifically. I think calling for the public and encouraging the public to engage is one thing, not just about what we’ve done today, but in future engagement as well. I don’t think anyone seriously expects me to knock every door in the country, asking people to respond to the parliamentary review. Some people might not want to see me on their doorstep, frankly. But there is that broader point about all the different actors around our health and social care system, and how they are part of wanting people to engage as well. The third sector have a large reach, potentially, into their own support and engagement networks in ways that other organisations don’t, and they could be really important in getting the public to genuinely engage, debate, and discuss these ideas. The final thing I’ll say is that, whilst I don’t quite agree with your analogy to Darwinism and whether change will just happen to us or we’ll wither away, the point about this is that we have a choice to make. Unlike people where change happens to you in that evolutionary process, we have a real choice to make about how we choose to change our system or whether we sit back and allow change to happen to us. I absolutely believe that we should choose what to do with our future whilst we have the ability to do so, and not wait for someone else to make that change for us.

Can I thank the Cabinet Secretary for his statement and thank Dr Ruth Hussey for her hard work—her and her team—so far? Would the Cabinet Secretary agree, however, that some matters need urgent action now? We’ve heard some of them from Rhun and others, but, in particular, the recruitment and retention of junior medical staff in our hospitals. Now, once qualified, you stop being a medical student and you end up being a junior hospital doctor—everybody’s a junior hospital doctor, in other words—before you carry on further training to become a consultant surgeon, a GP, a consultant physician, or whatever. So, that’s where our doctor pool comes from. But our junior doctors are feeling unloved at the moment, and their tremendous commitment to their vocation is going unrecognised by managers in hospitals at all levels, as they cope with huge workloads, rota gaps, high-risk life-and-death decisions, and having to battle for time off for study leave and exams and even time off to get married. Now, it wasn’t like that in my day as a junior hospital doctor, admittedly some time ago now. But, Cabinet Secretary, how do we address these matters today?

Thank you. To be fair, it’s an issue that is regularly raised with me by both the royal college and the BMA as well. What I think is helpful and, again, different, and partly what gives us an opportunity, is that we do have a different relationship compared to other parts of the UK. It’s a much more adversarial relationship across our border. That is a point that is regularly raised by junior doctors themselves. The challenge is how we capitalise on that and actually take proper advantage of it and encourage people to come here to work and to stay, and, equally, they don’t simply say that, because I’m not Jeremy Hunt, that means everything is fine, because there are very real challenges. The report again recognises some of the opportunities that exist about e-rostering, about giving people different choices about how to manage their own life, where people often have other responsibilities, and not just their work, as well. Again, you talked about ‘in your day’. I hesitate to say how long ago that might have been. But, in the past, people expected to work very long hours, and they accepted that that was what you had to do. Whereas, actually, now, whether there are men or women in the workforce, lots of people who acquire different responsibilities outside work—with families, in particular—make different choices. So, you don’t find doctors who are prepared to say, ‘Someone else will bring up my child while I’m in work for 80 hours a week’.

So, we do need to think properly about how we manage that, and the numbers of people we need in our workforce to make the whole system run. I recognise the point you make about the differing way in which health boards engage their junior doctors. That’s an issue that’s brought to me by stakeholders, and an issue that’s recognised within the service about improvements that they need to make as well—but also the point about study leave and how we think creatively about how we could do something around that that could make a real difference to whether people choose to stay in the profession and in this country, too, as well.

Thank you. Finally, Eluned Morgan.

Thank you, Deputy Presiding Officer. I think the way we deal with our elderly population in future will be the way that we are judged as a nation, so it’s critical that we get this right. I think there are some very eminent professionals on this review board, and I’m looking forward to hearing their final recommendations. But I think one thing’s come across very clearly in this report, and in others, and that is that the current situation is unsustainable because of the demographic challenges that we are facing. So, what we need is some radical thinking. I’ve always been of the view that elderly care should form a part of an economic development strategy, as well as being a social and health strategy. Some of the ideas that we’ve been proposing in pilots in the economic development plan for rural Wales actually do that. It brings together this idea of economic development and care being part of the same thing. And I would encourage the Minister really to speak to his colleagues about how we really, comprehensively, have an all-Government approach to this; it cannot be simply in the silos of health and care. We have to extend it beyond that.

Now, over the past few months, I've also brought a group of experts to do some blue-skies thinking together on how we tackle this issue of care in Wales in the long term. And I think we're very aware that you’re firefighting, that, actually, there’s a problem now. We're trying to do some broader thinking in an atmosphere where we are able to say things that are difficult to say. And what we've done, following a discussion with the chair of the parliamentary review team, is that we’ve focused on areas where the review is not concentrating. So, despite the suggestion in the interim report that there’s a need for capital planning, it doesn't really focus on the issue of buildings and housing relating to care, although there’s an appreciation that more care will have to be done at home. And, crucially, this review doesn't look at the issue of financing care, either.

So, I think, in Wales, we should be leading, and, to do that, we need to find some answers to these difficult questions. But we will only do that if we work together on these issues, and it's got to be beyond Plaid and Labour. I'm really glad that already we’re extending beyond that, but we have to answer this cross-party or we simply won't find a solution, because these are really, really difficult conversations to have with the public.

And just finally on that point of communication, we have to appreciate that communication with the public—. You know, there are so many people who don't understand that actually you have to pay for your own care home now. They don't appreciate that. So, if we’re suggesting something different then we've got to be aware, people have got to be aware, of the current situation before we suggest other things in future.

And just finally—

Can you come to a question, please?

Just finally, on my question, there was a report this week that 32 per cent of long-term carers had not had a day off in five years. Is this something that also should be addressed?

Thank you. Cabinet Secretary.

Thank you for the comments and questions. Again, in the report, one of the drivers that’s recognised is the significant expansion in our older population—we both import older people who want to retire to Wales, as well as more people who've been here for a longer period of time actually just living longer. And, as I said, it's a cause for celebration, but it does come with a challenge for us. And I think it's fair to say that, in discussions, not just with the Minister, Rebecca Evans, but also with Ken Skates, there's a recognition about the economic value of the care sector, in recognising it's a big employer already, and, if we improve the working conditions and the pay of people in that sector, there’s an economic impact as well, and often for, broadly, poorer people. People who go into the care sector tend not to be people from significantly economically advantaged backgrounds—certainly into the paid care sector—and there is something about raising the status of the profession, as I said earlier in response to Angela Burns, and also what we do about how we actually help the sector in actually understanding in the future what that looks like. That's why things like market position statements are important in taking forward the scheme of the social services and well-being Act, so people can make choices and decisions about the future, whether they are small independents within the sector or larger operators as well.

The point about capital planning—this is about the health and care estate. And, by that, I don't mean people's homes—you know, where people are constructing areas to provide health and care in primary care, secondary care, and, of course, in residential care as well. But there will be a need to think about, again, about our housing quality standards, because our housing associations are not just people who provide, if you like, standard social housing that people live in. Lots of the housing they provide are care homes, and they provide lots of extra care now as well. It's a developing feature, and the challenge will be: is what's being created really what we think is going to match the needs of the population we have now and in five and 10 years, and longer as well? And that's a challenge about how people do work across, not just the Government, but partners outside Government, too, as well.

And, on your point about funding, we specifically ruled out and didn't go into the funding of the future for the health and care system. The review’s remit is significant already. To add that in again would be even more of a problem, and, actually, general taxation funds a large part of what we’re talking about. To try and then say we’ll have a different view here—actually, there are wider, UK-wide questions about the funding of public services, not just in Wales, but across the UK.

Your final point, on carers—the Minister will have something positive to say, I believe, about how we actually provide more support for carers in the here and now to make sure they do have the opportunity for respite and a proper break, because that isn't something that we should put off until five or 10 years’ time.

Thank you very much, Cabinet Secretary.