The next item is a debate on the Health, Social Care and Sport Committee’s report on medical recruitment and I call on the Chair of the committee to move the motion. Dai Lloyd.

Motion NDM6502 Dai Lloyd

To propose that the National Assembly for Wales:

Notes the report of the Health, Social Care and Sport Committee on the inquiry into medical recruitment, which was laid in the Table Office on 29 June 2017.

Motion moved.

Thank you very much, Llywydd. I’m very pleased to open this debate today on the Health, Social Care and Sport Committee’s report on medical recruitment. As background, earlier this year we debated the committee’s first major report of the fifth Assembly, which focused on winter preparedness for 2016-17. As part of that inquiry, we heard a strong and consistent message that sufficient service capacity and enough staff are vital components in any effective healthcare system. We therefore agreed that, over the course of this Assembly, we would review the sustainability of the health and social care workforce. Our inquiry into medical recruitment in Wales is the first part of this broader review.

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

This work started back in the summer of 2016 when we carried out an initial broad piece of evidence-gathering to help understand the key workforce issues across the health and social care sector. This was designed to help inform our approach to looking at workforce issues throughout the fifth Assembly. We heard from a wide range of organisations and individuals across the spectrum of involvement in training, education, and recruitment.

Last autumn, we launched the inquiry into medical recruitment and ran a further written consultation exercise. Our terms of reference included a focus on the capacity of the medical workforce to meet future population needs, the implications of Brexit for the medical workforce, and the factors that influence the recruitment and retention of doctors. We also looked at the extent to which recruitment processes are joined-up, deliver value for money, and ensure a sustainable medical workforce.

We had an excellent response to our consultation exercise, and we’re grateful to everyone who took the time to write to us and present evidence to us in one of our formal meetings. During the formal evidence sessions, we heard evidence from a specially convened panel of trainee doctors from across Wales, from both general practice and a number of different hospital specialties. I would like to take this opportunity to further thank all those who took part.

The evidence we heard helped us come to some very clear conclusions and enabled us to make robust recommendations to the Cabinet Secretary. As Chair of the committee, I was very pleased that so many people who contributed to the inquiry were able to attend the launch of our report back in June of this year, and I think it is safe to say that the report has been very well received.

Our report covers a wide range of issues and we have made a total of 16 recommendations to the Welsh Government. We hope that they will contribute towards delivering the long-term solutions that are needed. These are the areas of particular concern to us: first of all, the low number of Welsh domiciled students securing places at Welsh medical schools—recommendations 2, 4 and 5; the need to increase the number of undergraduate medical education and training places in Wales, mentioned in recommendations 4, 5 and 7; then the need for better engagement with schools to increase the number of Welsh domiciled students applying to medical school, outlined in recommendation 3 in the report; and, finally, the implications of Brexit for medical recruitment mentioned in recommendations 15 and 16.

Our first recommendation relates to the establishment of Health Education and Improvement Wales, the new single body for the commissioning, planning, and development of education and training for the NHS workforce in Wales. We asked for a clear action plan and we noted with interest the Cabinet Secretary’s written statement, issued shortly after our report was launched, which provides an update on the approach to HEIW’s establishment. I’m also aware that the establishment Order and the first set of regulations were laid before the Assembly last week, and I look forward to hearing more from the Cabinet Secretary about a clear action plan and future timeline.

As I said earlier, we are concerned about the low and declining numbers of Welsh-domiciled students applying to medical schools across the UK. Despite some improvement during the 2017 application round, the number of applications from Welsh domiciled students is still considerably lower than other parts of the United Kingdom. Also of particular concern is the low number of Welsh domiciled students securing places at Welsh medical schools. This is especially concerning in light of the evidence we heard that there is a tendency for students, once qualified, to remain in the area where they studied initially. I note that the Cabinet Secretary has partially accepted our recommendations that relate to these concerns, namely recommendations 2, 4 and 5. While I, and my fellow members of the committee, appreciate that admission criteria are a matter for individual medical schools, I am glad that he has agreed to continue to work with those schools with the aim of increasing the number of Welsh-domiciled students applying.

We said we believe there is a clear case for enhancing and increasing medical school capacity within Wales if we are to address the current recruitment and retention issues, and that this must include agreeing a clear plan to develop more opportunities for undergraduate medical training in key pressure areas and in north Wales in particular, receiving evidence in favour of establishing a medical school in Bangor from many witnesses, and this was outlined in recommendations 4, 5 and 7.

Again, I note that the Cabinet Secretary has partially accepted recommendations 4 and 5, and fully accepted recommendation 7, which relate to our concerns on these matters. The Cabinet Secretary’s written statement of 18 July illustrated the recognition that there is a case for an increased level of medical education to take place in north Wales, whilst setting out his position that this does not mean a new medical school should be established, in his opinion. I know the Cabinet Secretary has committed to a number of strands of work that will take this matter forward, and I hope his contribution this afternoon includes an update on the progress being made.

We also heard about the importance of engaging with schools at a much earlier stage than current practice suggests. There is a clear need to take the message out to schools across Wales that medicine is a career that pupils can aspire to, and that it is a realistic and achievable aspiration for students from all communities. We recommended that the Welsh Government should work with the deanery, and, shortly, HEIW, and medical schools in Wales, to develop a programme of support and advice on admissions and interviews for pupils in Wales, mentioned in recommendation 3. I note that the Cabinet Secretary’s response makes reference to the 2016 summer work experience schemes run by both Cardiff and Swansea medical schools, and I welcome the fact that this approach will continue.

I would also like to mention the concerns that we heard about the potential and very uncertain consequences of the United Kingdom leaving the European Union on health and social care staffing, including medical recruitment. We heard strong arguments from a range of stakeholders for an early and clear resolution on the ability of EU nationals to be able to work within the UK. We recommended that the Welsh Government should continue its dialogue with the UK Government to emphasise the importance of quickly clarifying the ability of EU nationals to continue working in the UK, and also commence working in the UK in the future, and that’s mentioned in recommendations 15 and 16. I’m pleased that the Cabinet Secretary has accepted these recommendations and I welcome the Cabinet Secretary’s statement that the Welsh Government is clear that it wants to enable people from the EU and the rest of the world to train and work within our NHS after the United Kingdom exits the EU. That concludes my opening statement and I look forward to the debate. Thank you.

I’m very pleased, as a member of this committee, to have a chance to speak in support of this report, and I’d like to put on record my thanks to all those who came to give evidence before us, and to the clerking teams that support us so ably.

Medical recruitment and workforce planning are two of the most important issues affecting our NHS going forward, and we need to ensure that we find the right balance to ensure that the future—or future Assembly Members, actually, here, are not going to have to try to solve this problem in the future.

This report ties in very closely with the cross-party parliamentary review into health and social care, which we discussed yesterday and which is still an ongoing piece of work, but when I was sitting in that committee there were two specific elements that really struck me most forcefully, and those are the two I would like to concentrate my contribution on.

The first is the whole issue of workforce planning. I think that we have to recognise that we cannot rely on our NHS to be a medical-based model, run solely by doctors and nurses, because, with the best will in the world, we simply cannot fill the gaps that we have. We need to be far more effective at bringing in and incorporating and integrating, as valuable members with equal presence within the NHS, allied healthcare professionals of all types. We need to bring in the third sector. We need to embrace care home operators more into the NHS, because otherwise we simply will not get the people, and the people within to stay within the NHS that we need. We’ve got to just broaden our base and not simply concentrate on the very obvious gaps that we see within some surgical specialities, some GP practices and within some elements of nursing. When we looked at the workforce planning, which we only did a very small part of, because it is so complicated, it really struck me that we simply don’t spend enough time on that. If we plan today for what might happen in five years’ time, then we’ve got a sporting chance of actually putting in place the people that we need in five years’ time. So, we know that some health boards, for example, are going to see a dramatic drop-off in key areas because staff are ageing; they’re going to retire, and there’s going to be a gap. If we constantly rely on filling that gap as we get to that crisis, we’re never, ever going to get ahead of ourselves.

So, I would like to talk to recommendation 10, and I would like to urge the Welsh Government—. Because, although you accepted it, you talk about identifying priority areas for investment, you talk about talking to medical and dental commissioning and non-medical commissioning proposals. But have you talked about other organisations such as allied health workers, and have you talked to other engaged bodies such as local authorities? Because, of course, for us to do workforce planning in the NHS, we need to know that we have the social workers, which is a local authority function, for example. I just feel that the impression I came away with, as a committee member, was that this was a very, very big task, there wasn’t cohesion, there wasn’t a coherent strategy at all, there wasn’t a real idea of capacity building at lower levels for the future, and there simply just wasn’t enough forward planning. I would like to have reassurance that somebody somewhere is really getting to grips with this issue.

The other point that I would like to discuss and concentrate some of my remarks on is how we get more Welsh students to study in Wales and remain in Wales. I notice that the Government has partially accepted our recommendations, and I know that Dai Lloyd has already commented on this, but I was quite disappointed in one of your responses. Actually, it was the response to recommendation 2, Cabinet Secretary—but it does speak to all of these recommendations—when you said that admission criteria is ultimately a matter for medical schools, and elsewhere there’s a marginal implication that there’s not an awful lot that the Welsh Government can do because these medical schools are universities within their own right. I simply don’t agree with you. You do have the leverage. For example, widening access, as an element of funding, could be used to lever in more Welsh-domiciled students. Using part of our Welsh baccalaureate as a criteria for being able to take a medical degree could be another lever. There are levers at your disposal, and I think, to be frank, that just sort of stepping back and saying, ‘Well, you know, it is up to Swansea; it is up to Cardiff how they do it. They are independent universities; they can say what the criteria for eligibility are’ is actually letting you and us and them off the hook. I think we’ve got to be far more robust. You do have the power; you simply need to be creative and exercise it.

This inquiry was worth while, and I thank the Chair and my fellow Members and the clerks and the research team. We started from a point where we knew there was a problem, of course, that medical recruitment was a barrier to the NHS delivering its functions, but what we have now, I think, is a valuable document—a very comprehensive document—asking why, and what we can do to try and overcome some of those barriers. It’s also worth noting that at a time when we know that there is more and more pressure on NHS funding, we’re not necessarily asking for things that are going to cost more. In the long term I would argue that savings could be made by sorting out recruitment problems within the health service. Certainly, ensuring that we provide sufficient numbers of staff and rely less on agency staff would bring savings in its wake, so we’re not necessarily asking for further investment in the longer term.

I will look at some of the most crucial recommendations as I see them. First of all, increasing the number of Welsh-domiciled students studying medicine in Wales. I don’t need to explain why this is important, I’m sure, but too few students from Wales are now applying to study medicine and too many of those fail to secure places to study in Wales. We must increase the percentage of students under the current regime who are domiciled in Wales, because, quite simply, they are the most likely to remain here to work once they have qualified. And we must, surely, remember that the main purpose of training doctors in Wales is to provide staff for the NHS in Wales. But we must also increase the number of training places. We could make increases in Cardiff and Swansea, and I very much hope that we do make those increases in Cardiff and Swansea.

But there are opportunities to innovate here too, and recommendation 5 clearly calls for a medical education centre in Bangor. There are so many reasons for that: linguistically, geographically, economically even, in terms of increasing opportunities for students from north Wales to study in their own areas, and also in terms of developing expertise in providing rural healthcare and to do that bilingually. It would provide firmer foundations for the health provision for the residents of that area, making it easier to recruit doctors who want to be involved in lecturing or research work. So, you can imagine my disappointment when the Cabinet Secretary said in July that there was no case for having a medical school in Bangor and that placing students in north Wales was the way forward.

First of all, the committee isn’t asking for a medical school. I, through Plaid Cymru—and I make this clear—am not asking for a full medical school. It may come in due time, of course, but that is something that would take years. But, with collaboration between the Government, the deanery and its successor, Bangor University, Cardiff University and Swansea and some over the border—why not—there is no barrier to taking the first steps towards providing a full course for undergraduates based in Bangor and to move towards that, if not to achieve that tomorrow, but certainly to move towards that immediately. My concern—and I’m sure that many will share this concern—is that if the Government can be so heedless of the thorough work done by the committee and the clear evidence that we’ve received on the need for this, what confidence can we have in the Government to innovate and to be ambitious in relation to the rest of the recommendations?

Yma, mae gennym alwad gyda thystiolaeth dda yn sail iddi dros sefydlu canolfan addysg feddygol newydd ym Mangor. Wrth gwrs bydd yna rwystrau, ond ni fydd y rhwystrau hynny’n cael eu goresgyn cyhyd â bod y Llywodraeth hon yn ymddangos yn amharod i wthio ffiniau’r hyn sy’n bosibl. Yn yr adroddiad hwn, mae gennym ddarlun sy’n peri llawer o bryder—gadewch i ni fod yn onest—o ble rydym gyda hyfforddiant a recriwtio meddygol yng Nghymru. Ond nid yw’r pwyllgor yn dod i’r casgliad wedyn na ellir goresgyn y problemau hynny. Rydym yn cynnig atebion—amherffaith, yn ddiau—ond rydym yn eu gweld fel her. O ran arfogi ein GIG yn y dyfodol gyda digon o feddygon, o ran mynd i’r afael â nifer y swyddi gwag meddygol sydd gennym ledled Cymru, a sut i ennyn brwdfrydedd disgyblion, grymuso ein pobl ifanc i anelu at fod yn feddygon sy’n gweithio yn eu cymunedau ar hyd a lled Cymru, a’u helpu i allu astudio yma os ydynt yn dymuno gwneud hynny, mae angen i gleifion yng Nghymru wybod bod y gwaith yn cael ei wneud. Mae angen i ni weld hynny gan Lywodraeth Cymru. Mae angen i ni ei weld yn fuan.

I welcome the opportunity to speak on the report. I’m a member of the committee, and I found this a very important, stimulating report. The Chair already mentioned in his introduction the panel of trainee doctors that we had. I felt that we really did get to grips with some of the key issues that doctors, trainees and students have to address. I particularly enjoyed the visit at the beginning of the report, where we went to Cardiff University and we saw the way that the students learn through practising their medicine on models as a first step. I thought that was a very good introduction to the report.

I just wanted to refer to some of the recommendations in the report. I think it’s pleasing that most of the recommendations are accepted and that there are a few that are partially accepted. Obviously, two of the partially accepted recommendations were about the need for more medical education in north Wales, which Rhun has just referred to. I think it’s obviously good that the Government has accepted the need for an increased level of medical education in north Wales and proposes to do this by collaboration between Cardiff, Swansea and Bangor, albeit saying that there is no case for a new medical school to be established in north Wales. I think it’s particularly important that Health Education and Improvement Wales is being set up, and I hope also that we will get a bit of an update from the Cabinet Secretary when he replies to this debate.

I think the issue of the number of Welsh applicants to Welsh medical schools is one of the key issues that we addressed in our report, and I think we heard endless examples of people who are doctors now who tried to get in to Cardiff University medical school, for example, couldn’t get in there, and went and trained in England and, in some cases, they did come back, the people who were giving us evidence, but we all know that if you train somewhere, you’re more likely to stay there, and I think there is evidence about that.

Certainly, when we interviewed the staff of the medical schools, there certainly appeared to be a great willingness to look at this issue, and the actual figures are improving. I think we were told that 61 per cent of Welsh students who applied to Cardiff University for this year have been offered a place, which is a definite improvement, but we’ve still got the issue that’s been raised that the number of students in Wales applying to go to medical school is much less, as a percentage, than other parts of the UK. So, we do need to do a lot to encourage and to do all the work in schools that has been referred to and make schoolchildren feel that they can be doctors. Because I think that did come out of the evidence as well, that, in many schools, there is maybe a bit of a lack of aspiration, and I think that is something that we feel the medical schools and universities should be working on with the schools.

We had great evidence about how what we have to offer here in Wales is an attraction to trainee doctors and to work in Wales, because of the work-life balance and other lifestyle issues, but it was also raised with us very strongly that there is an issue about rurality and how you attract doctors to actually work in very rural areas. And we did get evidence of projects and pilots that have been done to work particularly in rural areas, and I think that would be something that I wonder whether the Cabinet Secretary, when he responds, could talk about—how we could do more of that.

And then, I’d just like to quickly finish on the Brexit issue. We know that, currently, 7 per cent of the doctors working in Wales come from the EU and that there were 1,354 EU nationals directly employed in the NHS in Wales. But in terms of the doctors, I think we also have to acknowledge that there is a huge number of doctors coming here who have been trained in non-EU countries; in particular, India, which is the biggest group of doctors. I’d like to end, really, by paying tribute to BAPIO, which is the British Association of Physicians of Indian Origin, who have worked very hard to bring Indian doctors here. Very recently, I met them when they’d just come back, and they seemed to have the initiative and the determination to ensure that we do try to keep the non-EU doctors as well coming here to Wales. Thank you.

I’d like to thank our Chair of the health committee, and also thank all of the other members on the committee and the people who gave evidence for us to proceed. Problems with recruitment and retention of front-line staff, clinicians in particular, have been well documented in recent years, and we must ensure that we tackle this issue robustly. Staff shortages have led to increased workloads, which have become unmanageable for many front-line staff. Unmanageable workloads have affected staff morale, led to an increase in stress-related illnesses and forced many clinicians to leave the field altogether.

Nowhere is this more evident than in general practice. Some GPs have seen their case loads double in recent years, with practices unable to recruit GPs. A GP seeing over 100 patients during a consultation is not unheard of, so these unmanageable workloads have to be addressed to stop people leaving this profession.

The Royal College of General Practitioners state that we need to recruit an additional 400 GPs over the next four years, and I’d like to discuss how we are going to do this. Above all, we must incentivise clinicians to stay in Wales. We must also ensure young people from all backgrounds are encouraged to train as clinicians. According to the Royal College of Physicians, there is a distinct lack of research undertaken to understand the drivers for recruitment and retention, and decisions on future medical recruitment strategies are not based on robust evidence, so it’s therefore imperative that we do collect as much evidence as is possible to deal with future recruitment campaigns.

But we mustn’t focus solely on front-line staff, because the NHS is Wales’s biggest employer, with around 72,000 people working in it. Collaboration and communication of all departments is a must to ensure its future running. There are just under 6,000 hospital clinicians and 2,000 GPs working in the NHS in Wales. So, without the vast numbers of nurses, scientific and therapeutic and technical staff, patients could not be treated. Without the administration and support staff, our hospitals and GPs wouldn’t function. So, we cannot recruit more clinicians without ensuring that there are sufficient staff to make the appointments, conduct the diagnostic tests, transport patients and nurse patients back to health. The Welsh Government cannot simply divert funds into recruiting more front-line staff. They need to ensure that there are sufficient staff across the whole of the NHS to cope with the increasing demands and changing in demands on the services.

Two weeks ago I was visiting a hospital within my region—the cardiac unit—and one of the nurses was really working non-stop. She stated, without really complaining, that at short notice a member of staff had not turned up, and another nurse was doubling back to do a second duty, as this, they explained to me, was easier than filling in a form for an agency nurse, and on a cardiac unit it was imperative that this complement of staff was at its most. Also, what came out was that our nursing staff sometimes have great difficulty in parking their car when they go to do a night shift or an early evening shift, finishing late at night, and as they cannot park near the hospital, it is a risk for them to travel towards their car.

Also, as has been mentioned before, we must train more Welsh-speaking prospective GPs, and encourage them to take part and be in places, in rural areas in north Wales, which are predominantly Welsh speaking. So, we must do more to recruit Welsh-domiciled students, even if that means lowering the entry qualification, because some people are not getting into, say, Cardiff University, for example, but they are going to London, and we’ve lost the opportunity of recruiting those people.

So I look forward to working with everyone concerned on this issue. Thank you.

Can I start with a word of thanks to the Cabinet Secretary for his readiness to make himself available from time to time to discuss issues in relation to NHS services? I personally appreciate the opportunity to have those conversations with you. I’m not a member of the Health committee but, in common with many other Assembly Members, obviously have pressures on GP recruitment in particular in my constituency. I have a practice that has recently closed its list and asked patients to reregister with other practices, and others are under very, very real pressure of a similar nature. Many have adopted innovative ways of practising, multidisciplinary ways of practising, which we should encourage practices to adopt generally, although often they have been adopted as a result of shortages. There are initiatives amongst practices locally and at the health board level to recruit GPs and some of those are succeeding, but they are long term, if you like, in their effects.

The comments I want to make, really, relate to the Welsh Government’s initiatives in this respect, in particular the Train, Work, Live recruitment initiative, under which GP trainees get a substantial incentive to continue to work in their local area for a year after their training ends. That’s obviously of significant benefit to those areas that have been targeted for that support, mainly in west Wales and in north Wales, and I don’t for one second begrudge residents of those parts of Wales the support that they will be getting for recruitment initiatives there.

But, really, it’s a plea to the Government to keep the effects of that on other parts of Wales, where there are also great pressures on recruitment, often for reasons, as Julie Morgan said, of rurality in constituencies like mine, which are not predominantly rural but have pockets of rurality that suffer from similar challenges as those parts of Wales that are predominantly rural.

The risk, of course, is that the scheme may operate not just as a draw to those parts of Wales but create a sort of competitive disadvantage, if I can put it like that, to those other parts of Wales that still suffer from significant recruitment pressures. So, I hope the Government will keep that incentive scheme under review and look in particular at perhaps perverse consequences that may arise in other parts of Wales that suffer similar pressures on their recruitment.

I’m going to focus on the recommendation relating to north Wales, as you would expect. During the last week of the last term, we had a short statement from the Welsh Government stating that it did not support the case for the creation of a medical school in Bangor because it is a long process and because it is a very costly one. Now, perhaps it is going to be a long process, but that, in itself, isn’t a reason for not doing something—because it’s going to take a long time. As far as I see it, that isn’t a reason.

I’m going to challenge the statement that it’s costly as well. At present, health boards spend very significant sums on agency staff, including locum doctors, to do important work, because of recruitment problems. In May 2017, 141 medical posts in Betsi Cadwaladr health board were empty or vacant. This represents 37 per cent of all posts empty in NHS Wales, and they’re the figures of the Welsh NHS Confederation. The lack of staff creates significant costs, significantly higher costs than the relatively low cost of establishing a medical school in the north. The initial investment would pay for itself very soon, and there’s no need for capital investment, even, in Bangor.

I’ve asked if I could see a copy of the business case for establishing a medical school in the north. I don’t know whether there is a business case or if there is an intention to publish a business case. That would be beneficial, so that everyone could see the logic behind the decision, because I am struggling to find that logic at present.

The Government’s statement states that we need more medical education in north Wales, following the recommendation of the committee, and that’s excellent and something to be welcomed. Now, there is a requirement for the universities and medical schools in Bangor, Swansea and Cardiff to work together. But what I would like to know is what the purpose of this collaboration is. What’s the end goal of that collaboration? What’s the aim and objective of it? We in Plaid Cymru suggest an objective of training 40 doctors in Bangor—that is, training from the very initial day when they start their training—and we see that as a very important step on the journey for a medical school in the north.

This report is particularly timely for my constituents in Caerphilly: Bargoed Hall surgery closes its doors next week due to the ending of the practice by the GP there. I’ve had many communications with constituents over the summer, but particularly useful has been communication with the health board, and I have to praise the Aneurin Bevan Local Health Board for what has been improved communication with me with regard to this issue, and I’ve been able to, therefore, give my constituents as much information as I can give them as we had it, and that information has been emerging as we’ve been able to get it. Patients have been moved to a surgery in Bryntirion nearby, but it has not been without difficulties, and we’re still in an emerging situation. I’d therefore also like to thank the Cabinet Secretary for visiting Bryntirion Surgery with me to discuss some of these issues, and also thank the committee for the depth and breadth of evidence that they’ve gathered, which will go some way to helping resolve or prevent these issues from occurring in my constituency and other constituencies in Wales in the future.

I’d particularly like to make reference to page 49 of the report. There’s some very stark evidence there with regard to GP recruitment and the feelings that new GPs may have. Paragraph 164 says:

‘While Dr Heidi Phillips, representing GP Survival, told us that, according to a survey of Swansea medical students, general practice was not seen as an attractive option because: “…they see what we see, which is a 10-minute revolving door, starting at 8.30 a.m. through to 6.30 p.m., with no protected time for education, no protected time for the expansion of other interests, and no protected time even for administration. It’s relentless. When you look at the other side of it, you see the GPs—our role models—who, from the evidence I submitted, are burnt out, exhausted, demotivated and demoralised”.’

Of course, that is no advert for anyone wishing, then, to go into GP practice. But the report is constructive, and says, at paragraph 168:

‘Developing new models of care will be a key part of tackling these workload and sustainability issues: we believe the pace, visibility and focus of this development needs to be stepped up, which will need strong and structured direction and leadership.’

Key in that paragraph is ‘new models of care’, because what the health board have suggested, in order to attract GPs to Bryntirion Surgery—which needs new GPs as Bargoed Hall closes—is they’re going to have to introduce a new model of primary care. The real difficulty is: how do you explain to the public in Bargoed what a new model of primary care actually means? What it means is Bryntirion having pharmacists, having mental health care professionals and having nurses who are able to deliver standards of care comparable to GPs and ease the pressure on GPs. That is significant, but really key will be explaining that to patients who expect to see a GP. New models of primary care can take that pressure off GPs and ease the problem, but I’m yet to see that explained in a very convincing way.

The report also mentions locum doctors to fill GP vacancies, and when the Cabinet Secretary visited Bryntirion Surgery, he heard from the full-time GP there who said that locum doctors are all very well, but they leave behind a trail of admin work that the permanent GPs then have to pick up, and in addition to that, locum doctors are very expensive. So, it doesn’t really resolve the problem, it just puts a sticking plaster on it.

I’ve also been contacted by Dr Paul Edwards, through Allan Rogers—Allan Rogers used to be the MP for the Rhondda, he’s in his eighties now and still very active in politics—he wants to help solve this problem. He saw my video on Facebook with regard to Bryntirion Surgery and he put me in touch with Dr Paul Edwards who’s working with Guy Lacey, the principal of Coleg Gwent. They’re looking at ways in which the rich, untapped source of talent in the northern Valleys can be recruited to become GPs in the future. Many people growing up in areas of relative deprivation would make good doctors, but because of cultural issues of aspiration in education they’re not encouraged to apply for medical schools. Dr Paul Edwards signed his email to me: Dr Paul Edwards BSc, BM (Hons), PhD, Membership of the Royal Colleges of Surgeons of Great Britain and Ireland, Fellowship of the Royal Colleges of Surgeons, consultant surgeon, honorary senior lecturer, grade C and two Ds at A-level. So, this is a clear opportunity to recruit our future GPs from the areas of the northern Valleys that I always talk about. I’m therefore pleased to see that the report makes recommendations on this subject, and I sincerely hope the Welsh Government commits to working with all relevant stakeholders and experts to ensure that this potentially transformative change can be brought about.

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

Thank you, Deputy Presiding Officer. I want to thank Members, not just the committee members for their report, but Members for the debate today, and the range of recommendations that we’ve had an opportunity to discuss, and their contribution to helping us deliver a sustainable workforce for NHS Wales.

I recognise, as the committee do too, that there are UK-wide challenges in recruiting and retaining doctors in some specialities, and in particular the point that Dai Lloyd highlighted in his opening remarks: the additional risk created by both Brexit uncertainty and our eventual path out of the European Union. It’s worth again highlighting the view of this Government: we welcome the fact that European Union nationals are here in Wales as doctors and other healthcare professionals, but more than that, as members of the communities that each of us is privileged to represent up and down our country. And, again, to take on board Julie Morgan’s point, there are many doctors that we rely upon to help deliver our services from other parts of the world. And back to your really good example of a really engaged medical workforce who want to carry on being proud of where they and their families are from, but also are incredibly passionate and proud about our national health service, and go out and sell Wales to other parts of the world incredibly effectively.

Of course, the purpose of this committee report was to consider recruitment issues in terms of the medical workforce. Inevitably, there is a significant focus on medical education, but also comments today, and in the report, about other healthcare professionals as well. I want to start by coming back to the statement that I made on 18 July about medical education and training in north Wales. I recognise that the committee did not come out with an explicit recommendation for a new medical school in Bangor, but certainly they were clear that they want to see more medical education and training take place in north Wales, and the recommendation about a centre in Bangor. In my statement, let’s remind ourselves, I recognised the need for increased medical education to take place in north Wales. That is still my view. That is not a fig leaf; that is not something to get through a debate; that is where this Government is. I now confirm my view that a collaborative approach, looking at Cardiff, Swansea and Bangor universities working more closely together, can deliver the increase that we wish to see in medical education and training taking place in north Wales. It’s also worth me saying that all of those parties have confirmed their willingness to make real progress with that work. Those discussions are ongoing, and the detailed arrangements that will need to be put in place, and the challenges that we face, and again—

Rhun ap Iorwerth and Mark Isherwood rose—

I restate my commitment to providing a further response back to Members this year on that work—[Interruption.]

Who are you giving way to?

Well, I saw Rhun. I’ll take one, and then I might take another.

Go on then.

Will you confirm that you will look at going down the route of accepting undergraduates from year 1 right the way through, which I am told without any shadow of a doubt is possible in Bangor, through a collaborative approach between Cardiff, Swansea, Bangor, whoever might want to get involved?

We need to look at what is possible. I don’t want to rule anything in or out at this point. I need to see what is possible, and equally not just what is possible, but what will provide us with the greatest return for the service. I’ll take a brief intervention and then I’ll make some more progress.

How do you respond to the statement made to those AMs in north Wales who were able to attend a meeting with the north Wales medical committee last week that they would want that collaboration—this is the GPs medical committee—to include the neighbouring universities in north-west England, which have also provided student doctors and doctors to the region in the past?

Well, I think we need to be careful about what we’re trying to do and achieve. We want to understand how we can provide more people with the opportunity to train and undertake part or all of their medical education and training in north Wales. There is a different point though, I think, about how we have a more grown-up set of relationships with colleagues in north-west England, and recognise the fact that many Welsh-domiciled students go to north-west England to undertake medical education and training, not because they don’t have opportunities—that may be partly to do with why some people go—but because there are lots of people who opt to leave home and to go further away. That’s part of understanding not just the path that students take, but we need to be better at keeping people within Wales and giving them opportunities to stay here, but also at what we do about recovering those people and bringing them back to Wales. There’s a particular issue here about returning and repatriating Welsh language skills within healthcare professions as well.

I said before that the worst possible outcome would be to invest in additional places in any part of Wales, and then for there to be no increase in the number of graduates that we retain within Wales. So, it’s looking at all parts of it: how many people go into medical education and training within Wales, and also what do we do to keep people when they finish that education and training as well? So, that, in essence, is about much more than medical student numbers and where they are within the system; it’s ensuring we have a genuinely sustainable medical workforce in Wales and all aspects of education and training in the pipeline need to be considered and operate effectively.

This goes back to some of the comments that I’m pleased that people have picked up on, including Hefin David’s regular reference—and can I commend you for it—in referring back to the northern Valleys, but there is a broader point about how we ensure that children do aspire to become doctors: the debate that we have about the health service and people’s understanding that actually you’re in the firing line in many respects if you go into the health service, and the way we talk about the service more generally. There are people who would otherwise have chosen to go into medicine who are choosing different options. That’s a challenge for all of us, wherever we sit politically, about seeing those people have those opportunities regardless of where they live.

There is that point about greater awareness of not just medical roles, but all roles within the national health service. And the consistency of opportunities across Wales for young people to have work experience opportunities to introduce them to healthcare, not just from an employment perspective, but both from an employment perspective and a patient’s perspective too. Because we do recognise that actual work experience opportunities, as they currently exist, have not been as equally distributed as we’d want them to be and, of course, lots of people already in and around the service are more likely to have those opportunities. So, we need to make a proactive effort to ensure those opportunities are more widely spread.

I’m happy to recognise the changes that have been made to admissions processes in both Cardiff and Swansea medical schools and the improvements in the number of Welsh-domiciled students accepted. Admissions data shows that 80 per cent of Welsh-domiciled students were offered a place to study in Swansea. In last year’s intake they took up that place and they say there are 88 Welsh-domiciled students in Cardiff, and that’s the highest number for six years. So, progress has been made, but I certainly recognise there’s more that needs to be done. Part of this is ensuring that our own young students and young people are familiar with the selection process and have the opportunity to practise those skills, so that if they get the opportunity for an interview, they’re in the best place to actually perform well and be offered a place. That’s about positive and constructive feedback, but doing this all on a proactive basis to encourage the applications in the first place.

Because we do need to demonstrate the wider benefit of studying in Wales and that the student experience here is sufficiently positive to encourage individuals to stay and continue working within Wales. That means ensuring there are sufficient opportunities in postgraduate training for people to pursue their careers, including, of course, through the medium of Welsh. That means training in Wales must offer many choices and benefits. But being a compact nation, the experience should be gained in both urban and rural medicine, to provide the opportunities to discover the diversity that accompanies each setting. This does go into some of the work that Julie Morgan referenced, including, in particular, rural opportunities as a positive plus for people who want to just come into and stay within our system. Now, all parts of that jig-saw need to work together if we’re going to capitalise on any additional places that may be established, and I’m already working with the Cabinet Secretary for Education on these issues. As I’ve said, I’ve given my commitment to return specifically to the subject of north Wales this year.

I do welcome the committee’s recognition of and support for the Train, Work, Live campaign. Again, 91 per cent of GP training posts were filled last year, an increase from 75 per cent the previous year, and the increases are in those parts of Wales where the new financial incentive scheme was introduced. I am happy to confirm to Jeremy Miles that we will review the impact of the incentive scheme to make sure we’re genuinely helping to bring more people into our system, rather than shifting numbers around by simply creating different problems in different parts of the country. That also brings me to Hefin’s point about local healthcare. There’s something about the language we use about who is speaking to who about what people can expect. I think often in the health service we use a certain language that actually doesn’t mean much to the public and we exclude them with the language that we use, but also the understanding of what it will mean for them when they still want a service to be provided.

I recognise I need to finish, but I want to point out the Train, Work, Live campaign will continue and there’ll be a particular focus on psychiatry training to address the low fill rates we’ve seen there as well. So, all our efforts, including the establishment of HEIW, which I will return to again in the future, will be about how we improve recruitment and retention across our workforce, and I really do welcome a very constructive report and debate from Members and the committee today.

Thank you very much. I now call Dai Lloyd to reply to the debate.

Thank you, Deputy Presiding Officer. May I thank the Cabinet Secretary and other Members for their excellent contributions this afternoon to this very mature debate on a report that is a very thorough one?

Now, I’d like to reiterate the importance of recruitment and retention as key issues in the future of the health service, because we need to teach and train sufficient numbers in the first instance and also we have to keep them in the system. There is a challenge, as Hefin David suggested. I’m the first doctor in my family and it was a significant challenge for someone like me, out in a rural area, to go to medical school in the first instance. We need to make it much easier for people, wherever you come from, to go to medical school.

May I thank Angela and Rhun and Julie for their contributions, as well as, of course, Caroline, Jeremy and Sian Gwenllian with regard to Bangor medical school, and also Hefin David? One matter, as there was a lot of emphasis on GPs and vacancies and the pressure on family medicine, one issue that I didn’t mention initially was the importance—. Even if we teach every GP that graduates from the medical schools that we have at present, we’re not training sufficient numbers at present even if we could retain every one of them in the system. We’re not training enough of them at present. We need to increase the number that we’re training and that’s why we’re calling for a medical school in Bangor.

The other point to make is that after training, once graduated, it’s important to retain doctors in the health service wherever they are. That is at the heart of the matter, that it is our young doctors who graduated two or three years ago who are working in our hospitals, who are the junior doctors, who are the future GPs, who are the specialists of the future, and at present they feel under significant pressure. That’s down to the way that they’re treated, very often, by managers within the health service, because these young medics have to fight for time off away from their jobs to study, to research; they have to battle to sit exams and battle for vacations, even, with constant pressure to fill vacancies in the rota, the on-call rota, and those posts are very busy already. We’ve heard about the pressure from Caroline Jones and others.

As well as that workload and the way that they’re treated—having to battle for everything—there’s also a duty to tell the truth when things go wrong, but when doctors complain to their managers about deficiencies in the service, when things happen that shouldn’t happen—becoming a whistleblower, that is—then those doctors are also in danger of being prosecuted themselves. Now, that is unacceptable. It undermines the morale of doctors who are totally committed, and when facing such pressure and such a lack of support from their managers, it’s little wonder that young doctors are leaving to work in other places, and they don’t get the opportunity to become local GPs or specialists, locally; they’ve left because of the way that they’re treated.

So, we need to increase the number of doctors that we’re training and we need to retain them, and that’s the major challenge facing us. A lack of doctors and nurses brings great pressure on the remaining staff, as we’ve already heard. And, yes, we do need to train more doctors. We’re not training enough here in Wales at present to meet the need. Even, as I said, if we could retain every single one of them that we’re training, we’re not training enough. And, yes, we do need another medical school in Bangor. We were having these debates 20 years ago when we were part of the process of establishing a new medical school in Swansea. One of the first steps that this Assembly took was to agree to that idea that one medical school for Wales wasn’t nearly enough, and I remember those early debates and the early steps taken to establish that medical school in Swansea, and we’re repeating history again, here: the same steps, the same debates. But I’m sure that there will come a medical school, ultimately, in Bangor. I also have a message for the managers in the health service to work much harder and with greater confidence to retain and to look after and to care for our young doctors, so that they remain in the health service here in Wales. We need to retain the brightest and most talented here in this nation. Thank you.

Thank you very much. The proposal is to agree to note the committee’s report. 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.