We move on to the next item, which is the debate on the parliamentary review of health and social care, the interim report. I call on the Cabinet Secretary for Health, Well-being and Sport to move the motion. Vaughan Gething.

Motion ND6504 Jane Hutt

To propose that the National Assembly for Wales:

Notes the interim report of the Parliamentary Review of Health and Social Care in Wales.

Motion moved.

Thank you, Deputy Presiding Officer. I’m happy to formally move the motion before us today. To go back to where we were in June, I’m still pleased to have received the interim report of the parliamentary review of health and social care in Wales that we shared with Members, sorry, in July, not June, this year, but I tabled this debate today to allow more discussion now that Members have had further time to consider the interim report.

There is, of course, a political reference group that is regularly briefed on progress with the review, and will meet again this month, but this is an opportunity for all Members to comment directly. The independent panel we’ve put together has looked at data, taken evidence and drawn on extensive international experience to develop its own view on health and social care here in Wales. The interim report defines key issues facing health and social care. It sets out the case for change, and identifies areas where improvements are needed. The report signals areas the panel wants to explore further over the next few months before concluding the review and delivering a final report with recommendations to me by the end of the calendar year.

I ought to say that the interim report sets out that there is a compelling case for change, with a general consensus among stakeholders and the people who have given evidence to date on the need for further integration and services that are more available within the community. The report is also clear that inaction is not an option going forward, and the report challenges all of us: are we prepared to support change and to meet those difficult challenges? That requires us to make choices for health and care services in Wales or we will simply allow choices to be made for us. So, the future is a collective effort across political parties and it will require a continuing level of maturity and leadership across parties that led to this review being established in the first place.

Wales, of course, is not alone in facing the challenges set out in the interim report. We need to look at how we can design a way of working in the future that is both sustainable and continues to deliver good outcomes. The report provides us with a renewed urgency for discussion and decision, a need to engage citizens and the workforce in deciding the type of services that will be available in communities in the future. The national strategy launched by the First Minister today, ‘Prosperity for All’, aligned with the direction for travel set out in the parliamentary review and its interim report. It commits us as a Government to respond to the review and publish a long-term plan for health and social care next year.

The panel, though, in their report, have recognised the important legislation that Wales has already developed—the Well-being of Future Generations (Wales) Act 2015 and the Social Services and Well-being (Wales) Act 2014 being two particular Acts that, taken together with prudent healthcare, offer us a powerful set of principles that can apply equally to NHS Wales and social care, and they do enjoy a high level of support. Widespread and comprehensive use of these principles should help us to transform health and social care in Wales, however the scale of the challenge means concerted action is required and at some pace. The messages in the interim report are frequently repeated back to me as I move around the country listening to both staff and patients, and especially the point about the voice of the patient and the service user, because the report recognises the need to involve staff, service users and carers more in the design, implementation, evaluation and subsequent development of new models of care, and to ensure that there are clearer, shared roles and responsibilities.

I recognise that the best results frequently come through active co-production and it’s something that I want to see more of. One of the key interim review proposals focuses on developing new models of care to be trialled, evaluated and then scaled up rapidly. The references to local citizens’ needs are of course important in this, and I know from speaking to the chair of the review that the stakeholder forum that has been established to help progress this work aims to frame the principles and standards that characterise successful models that can then be used to develop and test newer models of working. That should give us some assurance about our consistency at a national level with the freedom and space to adapt to local needs, especially in rural and/or urban contexts.

I note that the review has now been working over the summer recess to gather examples of successful models of integrated care, and I understand there has been a good response to continuing engagement from stakeholders across the country, but they are also looking at examples from outside Wales too. The models, of course, are just one element to this. I do look forward to recommendations that will be framed around the triple aim of improving population health, improving the quality of care and, of course, improving the value and productivity.

The workforce will of course be key to making the changes needed, so it’s good to see a reference to large-scale planning for the skills and career paths required for the health and social care workforce to deliver these new models—these new ways of working. The report states that the current workforce shortages inhibit change and need to be addressed, and that’s something that I recognise. In particular, there are some medical specialities and some geographical areas of Wales where there are particular struggles and, again, we can recognise a similar pattern in other parts of the United Kingdom. That’s why we remain committed to continuing to take action to attract and to train and to keep more GPs, nurses and other healthcare professionals here in Wales.

We launched a campaign to encourage doctors, including GPs, to come to Wales to train, work and live and, as I’ve said previously, that’s had a significant and positive early impact, with a 91 per cent GP trainee fill rate compared to 68 per cent last year, and that includes a 100 per cent fill rate in some of our hardest-to-recruit areas, in particular more rural parts of Wales on GP training. It’s also important that we’re running the Train, Work, Live campaign not just for doctors, but for nurses, and later on this year there will be further campaigns for therapists and pharmacists as well.

The report signals for us the need for the streamlining and alignment of governance, finance and accountability arrangements across health and social care. Closely linked to that is the drive for a more systematic and effective approach to continuous quality improvement and how we encourage and develop a culture that creates a supporting and engaging environment for our staff and, of course, the Government shares that ambition; you would expect us to. That helps to underpin our approach to our White Paper ‘Services Fit for the Future’. It’s framed around how we unlock the potential for local health boards to demonstrate that they govern and behave strategically with quality at the heart of all that they do.

The interim report also highlights for us the need to spread innovation and to make better use of data and information to design and monitor the progress of change. This is a crucial area for us, and I look forward to seeing how this can be supported further. There is, of course, a balance to be struck between national direction and local autonomy in generating change, and that is part of our challenge of continuous improvement, based on outcomes for citizens across the whole health and care system, and within that the pace of change that is needed, with clear and accountable decision making.

The report again rehearses for us the drivers for change: advances in healthcare, rising public expectation despite the reality that there is reducing public expenditure as austerity continues—that is an unavoidable challenge regardless of our party political positions. In addition to that, though, we know that demand continues to rise. Part of that is because, unfortunately, we have a less healthy population than in decades past, and that is not a cause for celebration. What is, though, a cause for celebration is the fact that we can all expect to live longer, but that provides us with different challenges and different additional demands coming into our system. That does, though, mean that we can’t pretend to ourselves or the wider public that simply carrying on with the health and care system that we have today will do for the future. If we allow that to happen, our system will become overtopped and we will allow real harm to be done to our citizens before then having to change our system at a time of crisis, rather than trying to plan a way forward to develop and deliberately deliver a changed, reformed and improved system that is genuinely sustainable.

But we should take comfort from the fact that there are genuinely talented people in Wales already delivering change to improve services and offer better care, because I regularly see local innovation that makes a real difference for patients. I’m sure Members do in their constituencies and regions as well. For us, it’s imperative that we understand what could and should be scaled up quickly so that benefits are delivered system wide, and we need leaders with local health and care to be champions for improvement—not just with the public, but with their peers as well.

So, the message of the interim report, I believe, is clear: we cannot make the improvement in quality and experience that we all want to without seeing change in the way our service works. The interim report, I believe, is balanced, and it’s an independent assessment of where we are now. I recognise the progress that we have made, but a faster change is needed so our health and care system is sustainable in the future. I look forward to receiving the final report before the end of this calendar year, and to continue to work constructively with all parties to help implement as many of its recommendations as possible, and I look forward to hearing the views of Members in today’s debate.

The Welsh Conservatives will support today’s motion to note the interim report by the parliamentary review of health and social care. The interim report makes for thought-provoking reading. It lays out, with a degree of frankness not often allowed, the scale of the challenge that faces our country in terms of how we sustain and renew both the Welsh national health service and the care sector.

The panel have made great strides in talking to users, patients, clinicians, experts, management and—for this I’m most grateful—us politicians, but it is only an interim report, and we have discussed this interim report in committees and in a Plenary statement, so I don’t want to rehearse all my previous commentary. The reality is that we need stage 2. The final report will, I hope, give suggestions as to how we might resolve some of the more intractable challenges. Some of these challenges are self-evident, and I am concerned that we may not strive to meet those challenges because we’re waiting with bated breath for the concluding document.

I would like to know what areas, if any, that were identified by the interim report have already been taken forward by the Welsh Government. For example, we all know that the Welsh care sector is very fragile. The employed care force are not always paid fairly or treated well; training is not always available or is minimal; the turnover of staff is high; we have a high reliance on temporary workers; there is little or no career progression available to the employed carer; the unpaid care force is exhausted and often ignored; there’s no cavalry coming to rescue the desperate carer at home who longs for support, for respite, for recognition. It’s a profession that’s often deemed as semi-skilled or unskilled, which is the unkindest cut of all when, actually, to care for another human being goes to the essence of our humanity.

The interim report recognises this fragility and lack of skill base. The report heard that informal carers need to be involved in planning and developing the workforce, that we need to increase skills and develop a career path. These conclusions simply reinforce a situation we’re aware of and that we could start addressing now. I’d be interested to know, Cabinet Secretary, what can be taken. Of course, in the NHS, the position is, if anything, more difficult. We all know of the recruitment issue that is hindering the delivery of first-class care consistently and comprehensively across Wales. We know that we need more doctors and nurses and more allied healthcare workers. But let me give you yet another example where lack of staff is proving problematic. I have an e-mail from an eminent consultant and he says,

‘The difficulty now is that I have no secretary for the foreseeable future, meaning that I cannot organise appointments or tests. I’ve been without a functioning secretary for one and a half years, and I’ve exhausted what I can do to get them to sort this out.’

So, because he doesn’t have his own secretary, he can’t get on and do his job to the top level. He’s unproductive and costly. Therefore, we pay intelligent people lots of money to perform complex tasks and then render them unproductive. This individual is from a health board in south Wales, but I’ve also had this complaint from clinicians across Wales. So, for me, the real strength of this report lies in the recognition of the commitment and intent of the individual within the NHS and the acknowledgement of the difficulties within the system, of which this is a prime example.

I’m pleased that the panel have identified that one of the key barriers to the successful implementation of change is centred around the how. How do we fill the gap between good policies and outstanding local initiatives? How do we ensure that the green shoots of success in local areas are scaled up and applied coherently and with consistency? How do we look at users holistically from illness to housing to end-of-life care? The history of the Welsh Government is littered with reports and policies that have not translated successfully to the front line, and why? It’s because of the how. We need to change some of the culture as well as some of the practices. We need to understand that successful transformation cannot sweep through everything and all at once, but that it needs to be measured and tested. We need a coherent framework and skilled people. Yet the Organisation for Economic Co-operation and Development, in a recent report, identified that Wales lacked the capacity to exploit the innovative practices that we have developed.

The health debate is usually framed around numbers of front-line staff, hospital locations or where the services are. So, I was relieved to find that the interim report challenges culture and process. It identified issues with maturity and flexibility, and skills and training. It’s not all about new policies, new programmes and new initiatives, Minister. I believe this report lays out a vision and a canvas, but stage 2 must now sketch in the details. We need a clear identification of the barriers to change and imaginative proposals to bridge the gap between idea and action.

May I first of all welcome the interim report, as it is very thorough and shows a great deal of research and consultation? It gives us a great deal of detail on the state and challenges facing the NHS and the care sector in Wales today, but we must also say that the findings aren’t ones that should surprise us too much. What we have is a picture of financial pressures, demographic pressures, mixed with poor workforce planning, underperformance and a lack of integration between health and social care. We see clearly the excellence that exists among the professional staff of the NHS and the care sector but also see the stress and pressures they face as they try and work to the greatest of their ability.

Now, the evidence is already clear, therefore, although this is an interim report, that we cannot continue as we are. That also means that we should cease saying that the UK Government can continue with austerity policies whilst the Welsh Government continues to put pressures on local authority funding and social care and that that isn’t going to have a truly detrimental impact on the ability to provide health and care services as people would expect and would deserve.

It’s clear from the report that health service funding needs to increase as needs increase among the population, but that we also need to invest more in social care, and we do know that the demands on the services are going to increase, although the scale of that increase will depend on how this Government responds to these various challenges—obesity, for example, and the need to encourage healthier lifestyles. There are other elements too: the quality of housing, the environment and, of course, cuts in the welfare state, when the weakest in our society are being squeezed by the cruellest policies. We know that homelessness is on the increase, that suicide is on the increase and that the use of health services is also on the increase. Therefore, the case for change is strong and a change in the way that Governments, both here and in London, look at and support the whole ecosystem surrounding health and care services and social support services.

I could refer to some specific elements that are highlighted in this report—workforce planning, for example. Improved workforce planning is attainable if we see the Government taking the appropriate steps, such as introducing a centre for medical education in Bangor and encouraging more young people from Wales, from various backgrounds, including the more disadvantaged backgrounds, to study medicine. It does mean that those necessary steps have to be taken to increase the number of nurses that we train and to provide the support that those trainee nurses need to make this a profession that remains attractive to them.

The report highlights the scope to use technology to provide alternative ways—better and, very often, cheaper ways—of treating patients, but that does mean having services and health and care institutions that are flexible and can respond to new developments. Some of those developments, which are emerging very quickly, will be truly revolutionary, and we in Wales cannot be left behind. So, there are significant challenges, but also significant opportunities.

Mae gennym ni heriau sylweddol o'n blaenau, ond mae cyfleoedd gwirioneddol hefyd, os oes gan Gymru yr uchelgais a’r meddylfryd cadarnhaol i fanteisio ar y cyfleoedd hynny, yn hytrach nag esgus mai ein gwaith ni yw rheoli dirywiad a chwyno am bethau na allwn ni wneud unrhyw beth yn eu cylch. Mae a wnelo hyn, yn fwy penodol, â Llywodraeth Cymru, yn dangos ei bod yn barod i dderbyn yr her. Problem graidd, yr eliffant yn yr ystafell yw hyn: Mae Llafur mewn Llywodraeth wedi rhedeg y GIG byth ers i bobl Cymru benderfynu ei ddatganoli bron yn union 20 mlynedd yn ôl. Ni all Cymru fforddio bellach cael Llywodraeth sy’n gwrthod cyfaddef dyfnder rhai o broblemau'r GIG a'r sector gofal, oherwydd byddai gwneud hynny yn cyfaddef mai nhw sy’n gyfrifol am y problemau hynny. Mae angen i bobl Cymru weld newid gwirioneddol ynglŷn â sut mae Llywodraeth Cymru yn rhedeg gofal iechyd a chymdeithasol yng Nghymru ac yn meddwl am ddarparu iechyd a gofal cymdeithasol yng Nghymru. Mae gennym ni adroddiad interim nawr sy’n tynnu sylw at rai o'r prif heriau. Bydd gennym ni adolygiad cyflawn yn fuan a, gobeithio, cyfres o argymhellion a all ysgogi rhywfaint o weithredu o ddifrif.

We welcome the interim report and the frankness of it, and we will support the report today. As the NHS is a major employer in Wales and therefore plays a significant role in the Welsh economy, it is important that this budget is spent wisely, so that patients can, in their time of need, receive care and support that will be delivered in a confident, efficient and caring manner. With wise spending comes the opportunity for change and innovation. We must look at how the demand for our services is changing and how we can best meet this demand. Therefore, the issues facing the NHS must now be identified and a clear vision on how solutions and changes can be met effectively—changes that are sustainable, and changes that we will receive in more detail in the second part of the report.

Wales has the fastest and largest growing proportion of older people in the UK, and so there is a greater emphasis on care. The demographic change has been under way for some time, and my question here is: how will this change be met? Perhaps through the reinvention and reformed version of community hospitals. In contrast to this increase, it is anticipated that there will be a decrease of working-age adults in the same period, and the knock-on effect of this is a potentially shrinking tax base. So, taking into consideration these factors so far, how will care be provided and by whom? We often forget the unpaid carers in our communities and the massive contribution they make. So, it is fair to mention them today.

With people living longer, we are expecting people to work longer, but look at the Women Against State Pension Inequality situation, which has caused much anxiety and uncertainty, with Guy Opperman, pensions Minister, offering people of 64 to retrain for new skills, to enable them to gain employment. As many of my constituents have told me, at 60 plus, you can attend interviews, but there is a 99 per cent chance of no job.

Patients’ involvement and feedback randomly taken is of paramount importance. How can this be achieved in the most cost-effective and efficient way? There is much talk about elderly and frail patients being kept in hospital when they could be discharged but have no persons to look after them. And in these circumstances, integration of services is essential to provide the best outcome for the individual. However, my recent experience of integration between health and social services has left me with mixed feelings as to the care and support we give to our elderly and our vulnerable. There is the case of a constituent who is known to me, who, at the age of 83, went into hospital for a triple heart bypass. He was placed in the hands of a wonderful surgeon who successfully operated. He was then cared for by two hospitals. One hospital was well organised, with staff who were mostly happy, with good humour, clearly enjoying their work. The second hospital exhibited low staff morale and discharged the patient knowing he lived alone and needed just a couple of days or weeks of TLC to get him over this operation. I asked why he had not received a care package upon being discharged, and the answer was that he could walk up some steps, was compos mentis and didn’t ask for one. He was discharged without the supposed phone call to the person he had put to be contacted on his discharge, but simply was taken home in a car, asked if he had some food and then was left. There was no-one to take him to subsequent appointments, and he was left with a huge number of tablets to work out for himself.

His GP, he says, is wonderful. The surgeon he cannot thank enough. His immediate aftercare in hospital was wonderful. And he says he now has a new lease of life, and in six months he’s off to Benidorm. My concern is that aftercare, I feel, was not forthcoming for this person, and the difference in care from one hospital to another has to be highlighted. We need to look at best practice and ensure that it is carried out in all hospitals. A care package would have made a lot of difference in this case, and we need to ensure that all staff are properly trained. Communication between services is important, and the ability to deal compassionately with our elderly or vulnerable patients is a must.

If we are to adopt a change, we need to look at recruitment and retention of front-line staff, the issues of which have been well documented in past years. Staff shortages have led to increased workloads, which become unmanageable for many staff. This has led to stress-related illness and low staff morale. We must remember that support and administrative staff need also to have full complement to carry out, as Angela Burns said, diagnostic tests, nurse people back to health, and ensure surgeries are run efficiently. My question is: how can we incentivise clinicians to train and stay in Wales? Some aspiring clinicians are falling just short of the entry qualifications to become a GP, and we are turning away good people for this reason. It is time to review this aspect.

Finally, we know there is a need for change, but how can we best achieve this? Prevention before cure: how do we tackle social detriments of health, which affect people of all ages? How can we ensure that, as life expectancy is increasing, so too is quality of life? The more information we give people on healthy living, which may involve lifestyle changes, and must be easily accessible and available to all—. People are then free to make informed choices about change. Therefore, our infrastructure and future technology must be fit for purpose and in tune with our future needs. Diolch, Llywydd.

I was delighted to hear the Cabinet Secretary say that inaction is not an option, and I absolutely agree with that, because there’s rising demand for primary care particularly, and clear evidence that there is a bit of strain in the system, with a significant number of GPs handing in the keys, but also rising public expectations that health services should operate just like any other service that people want to have immediate access to. But I think that there is a need for a shift in the relationship between the citizen and the service to ensure that it is a real partnership, which—. It isn’t about a demand service. It’s not like going into a shop and saying, ‘I want this’; it is a partnership.

Often, people on the Conservative benches—. I have in the past heard them say that this is all because the Welsh NHS is underfunded, but the facts contradict that. The public expenditure statistical analysis for 2015-16, published by the UK Treasury, shows spending on health and social care per person in Wales is 6 per cent higher than in England, and spending on health alone in Wales is 1 per cent higher than in England—so, that’s £21 more per person. So, it is not about money. It is about the way we organise the services, and, in my view, it is important to see a shift in resources away from secondary care, which we constantly talk about, to primary care, which is where 90 per cent of all NHS services are delivered.

It’s good to see there’s a lot of agreement on the direction of travel. Last week, I chaired a meeting about the shape and services that need to go into a new health centre in Llanedeyrn. The building is clearly in need of replacement, as the cladding is falling off the walls and it has a disastrous energy rating. But some of the points that citizens made were really clear about what people ought to expect, as well as some of the things that we need to do in collaboration with citizens.

I think that one of the reasons that GPs are under such stress is because the access to your GP is, if you like, the last open-door service. Many other public services have shrunk, and the GP is the last place you are entitled to go. Often people are going for entirely the wrong reasons to see a GP about something they could be seeing other people for, whether that’s a simple remedy for a minor health problem that could easily be responded to over the telephone, or whether it’s through the pharmacist, who is obviously available during shop hours. We have to see the GP as, if you like, the co-ordinator of primary care, and ensure that they’re using the other members of the multidisciplinary team in a way that will enable them to free up their time and ensure that, for example, working people can actually get a standard appointment with their GP without actually having to take time off work.

I was struck by the—. The Socialist Health Association have written a paper recently suggesting we should trial different models of GP services—on the one hand, independent contractors, on the other hand, salaried GPs. I’d be interested to hear what the Cabinet Secretary has in mind for possibly looking at different models of primary care where things are breaking down.

I think co-production is essential, because it’s completely pointless offering a liver transplant to an alcoholic unless they’ve got their addiction under control. I think one of the greatest roles for government is ensuring that citizens are enabled to get food that is not going to poison them, and contribute to their health. Over the weekend, I was reading a book called ‘How Not to Die’ by Michael Greger, and the chapter on Parkinson’s, something that a friend of mine has, makes you realise that it’s all too late for those of us who’ve already been consuming these toxic substances in our diet. But it is our job as legislators to ensure that the poisons that eventually end up in the sea are not going to contaminate the next generation. Our diet is the No. 1 cause of premature death and disability, he asserts, and that brings me to, obviously, the very important issue of ensuring that we’re tackling health inequalities. It’s completely shocking that less than 3 per cent of all children bicycle to school, which would seem to me a basic right of all children, whereas over a third are taken to school by car, which means they are completely disempowered, unable to choose who they go to school with, what time they go to school, and they’re just dependent on an adult to take them anywhere.

Like others, I welcome the interim report and the opportunity to speak on the hugely important issues that are identified in it. I do hope that the final report of this parliamentary review provides a basis for this whole Assembly to find some fresh political consensus that helps us to deliver the continuing changes that we need to make in order to deliver the ever-improving health and social care across Wales in the future. It’s what people will expect of us and I include in that those staff who are central to delivering those vital services on a daily basis for 365 days of the year.

In spite of the challenges that we face, and many of them are described in the interim report, there are still so many experts who acknowledge that our NHS remains the shining example of the best healthcare system in the world. But I acknowledge that sections of this important review do highlight the significant shifts that still need to be made in the ways that we deliver services, in the places that we deliver services, and in preparing and leading staff to make those changes.

So, I wanted to direct my specific comments today on the issues of workforce planning, on skills gaps, on staff engagement in the future of these services. I’m pleased that the interim report’s recognised the importance of effective workforce planning, interdisciplinary training, and engagement with staff, because I know from personal experience that we have made some progress in these areas but we still have a long way to go, and I know how long these changes can take to bed in. It’s only when some real values on social partnership working are adopted that we see people embrace an agenda for change and actually welcome the opportunity to become part of the solution.

As I’ve said, change takes time. It takes sensitive leadership, and it requires effective workforce planning to deliver those solutions. It also remains a constant case of work in progress, because, by the very nature of the demands on these services, it means ongoing change across all the disciplines and all the service areas in both health and social services will be required in the years ahead.

So, the recognition in this report of a need for stronger strategic and integrated workforce planning is very welcome. It will also become increasingly necessary as technological change drives the need for the reskilling of the workforce and presents opportunities for the upskilling of staff that will also help to deliver the integration process that we wish to see.

In making my second point, I would echo the comments of the Cabinet Secretary on the need for more consensus as we face some of these fundamental challenges. So, in the spirit of constructive debate, I will for now put to one side the debate around austerity budgets that have marked the last seven years. But all of us as AMs, taxpayers, and the users of these services, need to reflect on how we can best meet the service demands of the future and whether that is to overcome staff and skills shortages, to face the shortages that many colleagues raise about services in our rural communities, or to meet the complex health and care demands in many Valleys communities, which I am more than familiar with.

We must ask ourselves how will we overcome these challenges if we find, for example, that staff in social services can find better paid and probably less demanding employment, for example, in the local retail sector. So, I continue to advocate that ongoing engagement with staff and their trade unions is vital to address these challenges.

The final point I want to make today is about the information exchange and best practice. I can only imagine, Cabinet Secretary, that it must drive you just a little bit mad when you see in these reports examples of best practice that we don’t seem to learn from. In spite of all the technological changes, and in spite of the speed at which news can travel, it remains frustrating that we cannot get best practice adopted quickly across our services. That’s not a new thing, but I do hope that we can look to this review to help speed up that process in Wales. Of course, we already know about a number of the issues that were identified in the interim report, and they were clearly also a feature in the final report at the end of the year. So, I hope we continue pushing forward and strengthening those actions we are already taking in order to secure progress in these important matters and not let the grass grow under our feet in those areas where we know that we can take action now.

Ten per cent of all healthcare interventions are associated with harm; 20 per cent of all work carried by the health service has no effect on outcomes—this is a quote from the review, and, while that review might be ducking the rather difficult question of how we fund health and social care in the future, it is pretty straight up on showing that we, as a nation, are spending half our block grant on a system that produces these statistics. And I want to stress here that I do mean a system, not the individuals, because, like Dawn, I don’t want this to become a political football in the future; it is far too important. But I think Welsh Government needs to recognise now, actually, that principled and constructive scrutiny of what we’ll be talking about in these next few years can only be a help in this huge policy issue. Good faith is going to be essential in this debate, and I think the parliamentary review—I have to commend the Cabinet Secretary on this—has been really helpful in setting the scene for that, because, in my view, it’s not going to be Brexit, it’s going to be the speed and the bravery of our response to the demands of health and social care, that will define this fifth Assembly. And the fact that that response needs to be both speedy and brave will be a test of our maturity as an institution, certainly, as we consider ideas that may be difficult to discuss, but also as a nation, as we consider ideas that might be difficult to hear. So, I think we need to start preparing the people of Wales for radical change, in which they will be playing the leading role.

Calls for culture change are seeded throughout this report. There’s much in there about changing the balance of responsibilities, but the big one is the balance between the person and the state, as Jenny mentioned, and that is never a comfortable conversation in this place. This report majors on co-production. That’s what I’m talking about, and it is, as Jenny says, a partnership that, in itself, needs culture change within the population, a population that, by and large, is at the moment used to abdicating decisions for care about themselves to healthcare professionals. Now, the king of co-production is sitting behind me—Mark Isherwood—and I know that some of you who have been here for some years will be gracious enough to acknowledge his championing of this principle well in advance of it being captured in legislation. It is a real thing, and this report points us in the direction of models where the individual has more control over the type of intervention they get and responsibility for decisions affecting them.

Our population is getting older, and more of us will sadly reach a stage where we no longer have mental capacity, and then we will need care over which we personally exercise very little control. For the rest of us, citizen-directed services means getting used to making decisions and taking steps for ourselves and for our loved ones, without that being characterised as being refused help by the state. This report is clear: there was a desire to reach an explicit agreement with the public on the respective roles and responsibilities of services and individuals, but there is no point in 91 per cent of people believing that they have responsibility for their own health unless they are, in reality, confident and informed enough to exercise that responsibility without fear of being abandoned. And it certainly applies in terms of making healthy choices, I completely agree, but it also applies to the means by which individuals understand their needs and how they become confident to make decisions about their care, because there is no point recalibrating our system towards co-production if, as a population, we are still programmed to respond to any questions about our care with, ‘Whatever you think, Doctor’.

No national system can offer a personalised service, but we get much nearer to it in a system that facilitates, not blocks, a person who has the confidence to say, ‘I’m getting my check up from a high street ophthalmologist at my convenience, instead of waiting in a consultant’s outpatient clinic’, and, equally, which facilitates, not blocks, a GP who has the confidence to say to somebody, ‘Why are you here? Go to the pharmacist’. Citizen responsibility works both ways and Jenny is right there. We get much nearer to it, as well, I think, when we have an elderly person who has the confidence to say, ‘Do you know, I don’t want to pay a care worker to make me a cup of tea; I want to pay for community transport so that I can go somewhere and have company’.

This report says we don’t have time to go slow on co-pro. Now, brave and speedy culture change on Welsh Government trusting people, on silo mentality, on processes, on staff expectations and leadership is one thing, but I don’t think we can neglect either how we help our constituents to become confident decision makers, because without them the changes that this review is pointing towards will die at the interim stage. If we’re going to look at this as a serious way forward, we’ve got to help our citizens trust themselves. Thank you.

Thank you. And, finally, Eluned Morgan.

Diolch yn fawr, Dirprwy Lywydd. I would also like to welcome this work done by Ruth Hussey and the expert team. I think it’s clear that, if we look at the ageing population, more of the same is simply unsustainable, and I think that’s what really comes out in this report. That further integration of health and social care is something I think that most people now accept. It has simply got to happen.

It’s clear that prevention has got to take centre stage, and we’ve all got to be encouraged to take more responsibility for looking after ourselves. I’m delighted that the report asks for new models to be trialled across Wales. There’s already great work being done and I think it’s really important that we recognise that. I went to an extra-care home in Newtown in Powys recently, partly financed by the Welsh Government—an excellent example. More of that is the kind of thing we want to see. That’s an expensive model; there will be other models that we need to look at. But it’s an opportunity for us to road test some radical new ideas.

Can I welcome the fact that the review is also sensitive to the fact that delivery will be different in different parts of Wales, and that the Welsh language needs of older people in particular need to be taken into account?

Dawn has talked a lot about the need for skills in the workforce, and for that workforce to be recognised and appreciated. Unless we really address that issue I think we are going to see that continuous revolving door of unskilled workers in our care service, and that is not something either that is sustainable. So, at some point we have to talk about financing those people properly.

The key thing to remember is that it’s got to be people centred. The end user has got to be centre stage here. We heard this afternoon of the national strategy ‘Prosperity for All’, and the need for an innovative care model in the community. There is one area that I think is missing from the report—and I understand why it wasn’t part of their remit—and that is housing. Unless we get the housing right, I think it’s going to be really difficult for us to look after the care needs of our public. So, we need to somehow, at some stage, pleat housing into this discussion, and then we can build an economic development strategy on the back of that as well, with the whole skills agenda to go behind that. I think that’s really important for us to keep an eye on.

But at some point we have to have a conversation with the public about, actually, first of all, what is the current situation. Because most people walk into a care home and are quite surprised to find a £700 a week cheque being demanded of them. They’re not aware of that. We have to tell them what the current situation is and then have a conversation about what they’d like it to look like in future. We’ve got to be brave about this. We’ve absolutely got to be brave. And one of the things that’s really heartened me this afternoon is the fact that, actually, we’ve heard really constructive suggestions from all parties. Unless we work together on this, I think the people of Wales will not forgive us, because if we get this wrong, if we don’t address this, it’ll be our neighbours, our family, our friends who will pay the price, and they won’t forgive us. So, we’ve got an opportunity here to take a lead in Wales, to do something before the rest of the United Kingdom, but the only way this is going to work is if we work together and that we’re brave and we’re honest with the people of Wales about what needs to happen. At some point, that conversation needs to be also about what they can contribute. It’s partly about carers, and us helping carers, but it may be at some point a financial discussion that we may need to have. We started the NHS; it was in Wales that that was started. My dream is to see a national care service developed in Wales as well, and I think together we can make that happen.

Thank you very much. Now I call on the Cabinet Secretary to reply to the debate. Vaughan Gething.

Thank you, Deputy Presiding Officer, and also thank you to all Members who have contributed in today’s debate. I don’t think I’ll be able to cover all the points, but again, part of the point of having this debate today is for Members to put on the record a range of views as we go forward to the next stage of having the final report and then still having to make some choices. And I think that some of what we’ve heard—it’s been interesting in the debate to hear from a number of people, from Jenny, Caroline, Eluned and others, about the determinants of health and about the social determinants of health as well. And actually, the service, in terms of our health, only contributes a fairly small amount to our health outcomes. It’s actually those other, wider choices that we make and are made for us that contribute to our own health outcomes and the impact that has upon our care needs as well. That’s recognised in ‘Prosperity for All’, the whole-Government approach we’re taking. We recognise it isn’t just about saying the health service could and should do everything in that sense. It’s recognising there’s a relationship with other services, yes, but also that our economic prosperity and future matter so much as well.

I’ll go into some of the specifics that people have mentioned as well. I’m grateful to Angela, Rhun and Caroline as spokespeople, but also the constructive approach they’ve taken to today’s debate and the broad welcome for where we are, and again, highlighting this has been a genuinely independent review where the terms of reference have been agreed and people have had to make compromises and choices about what goes into the terms of reference to make sure we have a manageable piece of work to give us something to come back to that we can then make choices on to help determine the future of our whole system.

On the points made about staff across our whole service, the Minister Rebecca Evans already made some statements about the future for social care staff, career progression and the skill mix in the social care workforce. So, we are going to hear more from the Government on that. We won’t just wait for the report to be published. But there is definitely something there in terms of, in particular, some of the comments that Dawn’s made about needing to make sure that our staff are engaged in the conversation in the here and now, and not just for workforce planning but for determining some of those models for the future and making sure that the wider trade union will be involved in doing that as well.

What I wanted to pick up on, in terms of the comments that Rhun and Angela made as well about needing more doctors, nurses and other healthcare staff as well, is that this is perhaps the only area where we still expect the public sector to expand and for more staff to be available year on year on year. The demand is never, ‘How can you make do with less?’ in terms of staff; it’s always, ‘We need more doctors, more nurses, more healthcare professionals.’ There’s something about the honesty in the debate we need to have about this, because every group will come and make a demand for more of them. That’s understandable. Even as we talk about having a different spread of healthcare professionals delivering services, whether it’s in a hospital setting or within a community setting, we still need to have that honesty about, ‘There is a limited sum of money that all of us have to spend here’. And it doesn’t matter what your position is on austerity, it’s a fact of political life that we need to take account of in making our choices in the here and now and in the short and medium term.

Thank you for taking an intervention. Just very briefly, it’s not always about more and more staff. It’s making sure, for example, that where we train doctors in Wales, we keep more of them in Wales, because far too many medical students who are trained in Wales end up working outside Wales, and we want to train more of our own students here in Wales, including in Bangor.

Well, we don’t disagree about the fact that we want to train more people from Wales in Wales and keep them. We also still need to make sure that the international reality of recruiting healthcare staff is effective in who we get and why. There’s something here about how competitive we are with the rest of the world—the rest of the developed world—still competing for those same staff, and the review gives us an opportunity to recast our system to make it more attractive for people who are already here and those we want to attract in the future. I’m pleased to hear something that Suzy Davies said. She was quoting from the report but actually that sets out the prudent healthcare approach that my immediate predecessor set out in recognising the harm that is caused by some interventions in the service, when some things don’t actually do any good. There’s something here about the conversation with the public to understand that we need to fundamentally recast the way we deliver our service to deliver not just high quality and high value, but actually we could do so much more if we took out that unnecessary intervention.

I just wanted to say something before I finish on the comments that have been helpfully made about citizen voice and personal responsibility. I was interested to hear about Jenny’s conversation that she would have had in the Maelfa about the future of local healthcare and about people being properly engaged now about making choices and the level of pragmatism that many of our communities have about what they want and why. And this report gives us a staging post to try and continue that conversation about personal responsibility. So, what is the deal from the health and care system’s point of view? What will we provide? And then, what do we expect the citizen to do and how do we empower them to make more of their own choices? Because, typically, citizens who make their own choices—active choices—tend to make better ones, and it’s really important for the future health of our nation that that isn’t something that we allow to happen by accident. It’s something that we want to encourage positively, and that’s why the review has such an important function.

I’ll come to a conclusion now, Presiding Officer, because I see I’ve only got about 30 seconds left. I really do look forward to the independent review’s final report and the debates that we will then have to have, but also the choices that we will then have to make—difficult but necessary choices about our future. I do remain optimistic about our willingness to choose a plan path for the future. Because it isn’t just that the alternatives are awful if we allow things to happen to us, but there’s a real prize for all of us to grasp by having a system that we choose to design and deliver and really take forward the high-quality system that all of us wish to have now and in the future in every community in Wales.

Thank you. The proposal is to agree the motion. Does any Member object? No. Therefore, the motion is agreed in accordance with Standing Order 12.36.

Motion agreed in accordance with Standing Order 12.36.

And that brings today’s proceedings to a close. Thank you.

The meeting ended at 18:41.