Item 4 on our agenda this afternoon is a statement by the Cabinet Secretary for Health, Well-being and Sport on the national planned care programme, and I call on the Cabinet Secretary, Vaughan Gething, to make the statement.

Thank you, Deputy Presiding Officer. I’d like to update Members on the national planned care programme. This was established in 2014, with the aim to reform and improve NHS planned care specialities. The programme uses the expertise of clinicians in Wales to identify and promote best practice. Unless we are able to achieve reform and improvement in practice then we will not continue to deliver high-quality and sustainable healthcare services. Our vision is of a modern healthcare service ensuring patients’ needs are addressed at the right time, in the right place, by the right clinician. The planned care programme is helping to take that forward with a small number of speciality implementation and transformational plans.

Over the last two years, the programme has focused upon ophthalmology, orthopaedics, ear, nose and throat, and urology. These are specialities where there are either unacceptably long waits for treatment or elements of clinical risk to long waits, and a speciality plan for dermatology was introduced within the last few weeks. The national planned care programme is empowering healthcare professionals with opportunities to review their practice, replicate them and implement the very best possible standard. An early focus of the programme has involved working with clinical specialties to help them understand the demand for their services, their capacity, and to support them to develop plans to bring their services into balance. That means reform if we are to see progress. It’s meant acknowledging limitations on the current ways of working and committing to addressing variations in practice within and between organisations, and those variations in practice also lead to some variations in outcome.

When we launched the programme, we wanted to build on good practice that is already taking place within our system. We have a range of positive examples to highlight. In Wales, for example, we now have orthoptists giving injections directly into the eye to treat conditions such as wet age-related macular degeneration and diabetic macular oedema, using a device that has been developed here in Wales by a consultant in Wales. In a number of health boards, people with hearing problems can now be examined by an audiologist without having to travel further than their own GP surgery, and that will now be extended to other health boards following a successful pilot. The redesigned prostate cancer pathway, which is now in place across Wales, involves a multi-parametric MRI scan before a transrectal ultrasound biopsy and that’s significantly reduced the number of biopsies carried out, which we know are painful and potentially dangerous to the patient.

The planned care programme has published a small number of key impact changes and these direct health boards to actively manage follow-ups, which is the next area of priority over the rest of this year. Follow-up out-patient appointments account for a considerable amount of activity undertaken by the NHS. Traditionally, patients have routinely been given appointments rather than the appointment being based on their clinical need and with the most appropriate healthcare worker. Evidence has shown us that around 9 per cent of patients already do not attend their follow-up appointments and that, in itself, is an unacceptable waste of resources. So, we will focus upon reducing the number of follow-up appointments offered as is clinically appropriate and for the right healthcare professional.

Some of the changes that I expect to see rolled out across Wales include the roll-out of more virtual clinics. The introduction of virtual reviews and patient reported outcome measures in Cardiff and Vale reduced the number of hip and knee appointments needed to be seen by a consultant by 70 per cent—that’s 70 per cent. Health boards need to redesign appointments so patients can receive all necessary treatment in one visit, also known as more ‘one-stop clinics’, and these are already being used extensively in urology and are receiving a positive response from patients. And the training of healthcare specialists to undertake appointments releasing consultant capacity—. In Wales, we are rationalising, for example, our ophthalmology services by increasing the number of appointments done in the community using optometrists and nurses, and that’s released capacity in busy consultant clinics—more capacity for people who really do need to be seen by a consultant.

We are already receiving, from these changes, positive feedback from clinicians, operational staff, and patient representatives, who have been involved since the programme was established. So, the planned care programme is starting to deliver changes. So, some of the outcomes already achieved include the introduction of national follow-up guidelines for ENT services. That’s been endorsed by health boards. Evidence from Aneurin Bevan health board shows the potential to reduce unnecessary follow-ups by approximately 40 per cent across Wales, and other health boards are now implementing and following those guidelines. They are already having an impact as patients waiting for their first appointment across Wales have reduced from over 3,000 in March 2016 to 1,949 in March 2017. There have been 863 fewer referrals this year compared to the same period last year.

More patients are now being seen by an audiologist rather than an ENT consultant. That means around 72 patients per month are now being seen on a revised pathway direct to an audiology service. That means, across Wales, patients will be seen quicker as they are not waiting to see a consultant in a clinic but will be seen and assessed in appropriate community settings.

Our national clinical musculoskeletal assessment treatment—that’s CMAT for short—principles document has been agreed, based upon best-practice models currently in place in well-established services. Starting last month, that’s now being rolled out across Wales. That should ensure that patients with musculoskeletal problems have access to a wide range of community-based treatment opportunities in addition to secondary care services. That should ensure that patients are seen by the right healthcare professional as appropriate. It should also reduce demand on our orthopaedic services.

Health boards in Wales have seen a reduction in the number of urgent suspected cancer patients being referred into secondary care since the asymptomatic non-visible haematuria guidelines were adopted.

In ophthalmology, the number of GPs referring patients to secondary care since the programme started has reduced from 17,775 in September 2015 down to 14,268 in March this year. So, as a result, more patients are being seen in the community by optometrists.

It is still the case that some people still wait too long for treatment. Health boards have action plans in place to reduce long waits and, last month, the Welsh Government invested an additional £50 million to help the NHS further improve waiting times. We are seeing improvements in planned care services. However, these are not happening quickly enough. There needs to be a greater pace and consistency amongst all health boards in delivering improvement. It’s why I really do expect good practice to become standard, consistent practice across Wales. I expect health boards to adopt or justify. The planned care programme will therefore become an integral part of the integrated medium term plan process. Health boards that do not plan to deliver the planned care action plans will not have approved plans.

I’ve said this is a clinician-led programme, so I want to finish by thanking Peter Lewis, the consultant vascular surgeon who is leading the planned care programme. This is not a straightforward process. It involves people in different specialities coming together to agree, and that isn’t always an easy process, and it involves service planners and leaders, so every chief operating officer takes part within the conversation. But the straightforward challenge now is how our national health service delivers against this clinically led improvement programme that Peter Lewis has helped us to create.

There is a really significant prize for staff and the wider public in reducing waiting times, reducing variation, whilst improving efficiency and outcomes for patients. So, I look forward to seeing action this year and the next in every health board across Wales.

I’d like to thank the Cabinet Secretary for his statement today. In your statement, Cabinet Secretary, you highlight some welcome examples of good practice. What I’d like to know, though, is when could we see the results of all the pilots that were run—good, bad or indifferent—such as the health literacy questionnaire that was run by Cwm Taf, or the patient activation measures that were run in Cardiff and Vale, because I think we can learn lessons from all the pilots. Is there anywhere we can go to have a look at them so that we can evaluate each and every one of them?

Could you also confirm that you are reviewing best-practice examples not just within Wales but whether you’re looking at other countries, either other home nations or within Europe? What are you using to benchmark these best practices so that something we think is good really is absolutely the best it can possibly be? How are you monitoring against developments in good practice elsewhere?

My third question, Cabinet Secretary, is: I’m a little bit concerned by your comment about the 9 per cent of people who do not turn up for follow-up appointments. That is obviously totally unacceptable, and I agree with you on that, but you mention that your way of dealing with it will be to stop offering so many follow-up appointments. Could you please clarify whether you already know the type of person who’s likely to be in that nine per cent? Have they not been turning up because actually we’ve just been far too extravagant and offered them follow-up appointments when it wasn’t clinically necessary, or are they just people who’ve not turned up because they feel better and so they can’t be bothered? Because what I wouldn’t like to see is by refusing or by deciding to offer fewer appointments, we’re throwing out the baby with the bathwater and the people who do need follow-up appointments are not given those.

Virtual clinics: really welcomed step forward. I think that’s a great idea, but could you please tell us what you’re doing to ensure that poor broadband or poor IT knowledge does not stop those who need to use them or could use them from using and being part of a virtual clinic?

And finally, Cabinet Secretary, one co-designing planned care event was held in 2015, and there were two planned for 2016, but search as I may, I cannot find the information that says whether or not those events went ahead. Could you please tell me if they did go ahead, and is this an ongoing programme? Are there more of these co-designing planned care events in the pipeline? Is this what forms Peter Lewis’s thinking on delivering the model that we have here before us? Because I think it’s very important to be able to invest all of our stakeholders with real authority and real ability to take part in delivering truly integrated services. Thank you.

Thank you for that series of questions, which I’ll be happy to respond to. On your first point about all the pilots and evaluation and whether all the evaluations are available: I couldn’t honestly tell you to hand, on each one of the list that you’ve set off, whether it is and isn’t available. What might be helpful, though, is if you write to me with the list of the particular areas that you’re interested in where you’re not sure if there’s been an evaluation of a pilot, I can then respond to you and then make sure that other Members are copied in as a result.

On best practice, it’s interesting; I’ve had a number of interesting meetings with Peter Lewis talking about work from the start of the programme to carrying through, and one of the phrases he uses—I think it’s very useful—is about adopting a ‘best-in-class standard’, so understanding what is the best in class, having evidence to get there and then saying, ‘This is what we now need to do’. And in doing that, there is evidence from within Wales, but across the UK system as well, of course. And what’s interesting, partly, is that actually our surgeons, for example, but also clinicians at every level, are interested in what happens internationally as well. So we have that evidence that is being brought to us and is available. What I don’t want to do is to get stuck in looking for evermore at this before we decide actually, ‘This is what we need to do in the here and now, and here’s how we need to plan our service.’ That’s understanding both the demand coming in and how that’s managed, as well as then deciding when we need different parts of our system to see them: how do we do that? Because otherwise, we’ll never plan for a service; we’ll always be thinking about the next step and the next change in demand and then how actually we have our activity to match it.

Some of that, then, coming back to your next route of questions about the ‘did not attend’ rate and reducing follow-up appointments—we’re exactly in the space of making sure that we (a) want people to attend appropriate appointments and that (b) they will continue to be offered an appointment that’s clinically appropriate. The first point is that we already recognise that we drive unacceptable waste and variation out of our system in some parts of it by offering standard follow-up appointments that are not clinically appropriate. And it is also then about understanding, if somebody needs seeing, who do they need to be seen by. That’s where, in the ophthalmology field, for example, we already now are moving to a system where we’re managing more and more of those follow-up appointments in the community. So, if you go into a range of high street optometrists, they will be able to tell you about a range of services they now provide. Actually, when I spoke to optometrists during eye health week, they were genuinely excited about what they were doing. In fact, one optometrist described it to me as, ‘This is great; it’s wonderful. We’re now having people referred to us on an emergency basis, in one instance, by GPs; that didn’t happen before. But also we’re doing more and more of what happens in the aftercare. So, before, we used to be a giant refraction machine, and now we’re using our clinical skills that we’ve actually got, and it makes the job more interesting.’

That’s the same in a range of other areas as well. Orthopaedics is another example of where we had a hugely inefficient system in some parts of our service, and there are real gains to be made in efficiency and value for the citizen, but also for the whole service as well. That does require changes in behaviour from a range of our clinicians who are deciding on whether to provide people with follow-up appointments.

On virtual clinics, it’s a really good example of how people can receive care from a clinician, or, where it’s appropriate, from a consultant, potentially, who is fixed in one point and where people travel to a different one. For example, I saw this directly in Betsi Cadwaladr: I was in Ysbyty Gwynedd, and the consultants there were able to provide a clinic with very high-quality images from people who were many miles away, but for them it was an easier place to go to. There’s something here about understanding the quality of our broadband network and the work that my colleague Julie James is leading on—understanding how and where we have high-quality broadband available. That may mean a short distance of travel for people, but it will be more local to them to receive their care, and that goes into us having more care delivered closer to home.

On co-design events, we have had two events within the last year as public large-scale events. But, it isn’t just the larger-scale events: the PREMs work—the patient-reported experience measures—and the PROMs work—the patient-reported outcome measures—really matter. They’re about us trying to understand on a regular basis what matters to patients in terms of experience and what matters to them in terms of outcomes, and how we then deliver against that. So, people are actively giving information that will be acted on in our system. We’re trying to do the right things. As I say, my frustration and my desire is that we do more of that more consistently and at greater pace.

We have a portrayal here of a situation that is under control. Of course, there are areas, be that geographic areas or areas of specialism, where great ground has been made and things are getting better. There are signs that things are getting better, but, certainly, for too many patients, especially in orthopaedics and ophthalmology, certainly in the Betsi Cadwaladr area, there is real cognitive dissonance here hearing a Cabinet Secretary saying that things are getting better when that does not reflect the reality on the ground.

How can we have 100 plus week waits for urgent referrals in orthopaedics when a Cabinet Secretary claims that things are getting better, although not fast enough? How can we get people to accept that things are getting better—that we’re on a road to improvement—when we have in Ysbyty Gwynedd, for example, a situation where no elective surgery, it seems, took place in orthopaedics between December last year and April or May this year? This is a situation that is getting worse, not just in terms of perception but in terms of realities on the ground, for far too many patients, and I say that, as I referred to earlier, realising that there are areas where, of course, we are getting better. But, these are areas where we cannot brush the reality under the carpet.

Let me ask a number of questions. Would the Cabinet Secretary support a full audit report of management of waiting lists, looking at how management of waiting lists plays into delays, how much of a factor poor management is, and whether the NHS will have systems in place that stop operations being cancelled because a consultant is on annual leave, for example, which is a predictable event?

I’ll ask one of my usual questions on data: waiting time statistics don’t measure follow-up waiting times, which are particularly important, for example, in eye care, where poor follow-up care can miss complications that can lead to irreversible sight loss. Also, for orthopaedics, solid aftercare and a check on the progress of aftercare can have a real impact on the prognosis for patients who have undergone treatment.

Will the Cabinet Secretary also accept that until fundamental workforce issues are resolved we will not be able to have the kind of sustainable NHS that can be confident in knowing that it is on top of the waiting time issue? We have highlighted many times in this Assembly the need to ensure that we have the right staff in the right places in order to meet the demands—the ever-increasing demands—that are placed on the NHS. Can we have an acceptance that at the heart of moving forwards to that sustainability that we all need has to be a much more ambitious and much more rigorous workforce plan that can give us confidence that gaps will be plugged in years to come, so that the increasing problems that we’re facing, for example in orthopaedics in places like north Wales, can be resolved?

I’ve also one final question: ophthalmology and orthopaedics—areas where we seem to be facing some of the biggest problems—are areas where there is among the highest instance of private practice. Is this something that the Cabinet Secretary will look into to see if there is a means of ensuring that the NHS really does become a priority for those people who have been trained to treat patients in Wales?

Thank you for the questions. I’ll start with: I openly want to challenge your assertion that there’s somehow an air of unreality in the statement that I’ve made. I think my job is to be balanced in what I say and do, and I make no apology for being both positive about what has happened, positive about the future, and at the same time frustrated that we haven’t done more. In my statement, I expressed very clearly that some people wait too long. That is why we have had a planned care programme and, several years after we introduced that, we still haven’t done enough, from my point of view. And part of the point of bringing a statement here is to be honest about the fact that the progress we have made doesn’t mean that the deal is done—far from it.

I also recognise—not just in this place, but on a regular basis—that there are variations within health boards and there are variations across health boards about activity, and orthopaedics is a good example. The progress that’s been made in some health boards is not being reflected in others. You’re seeing in north Wales a challenge that is seen more generally about rising demand and about how capacity and demand do end up aligned with each other, but actually there is a bigger problem in north Wales and in other parts of our system. There has been a bigger ballooning in the waiting lists there than everywhere else. And that’s not me telling tales out of school, because the figures are there to view.

And I don’t try to pretend that those figures don’t exist. For me, that is the increase in urgency that is required for lessons not to be learned and talked about, but to be delivered in practice. I do not want to keep on coming here and explaining why parts of our service are not making the progress that others are as well. There has to be proper demand, both from clinicians themselves—they should be frustrated about where they are and about the length of the list they have of the people that they see, and the leaders and managers in our services should be frustrated as well. And that’s why I was really clear, both in my statement, and you’ll see it again in the planning framework for the intermediate medium-term plans, that I expect to see the planned care programme delivered, and that isn’t going to be a negotiable part of what health boards want. If they want an approved plan, they have to plan to deliver it and then they have to be able to demonstrate that they are doing so as well.

In north Wales, you’ll know that I am expecting imminently to see the plan that the health board have for improving their orthopaedic function. I expect that plan to be robust and I expect it to work, and if not, there will be a rather more difficult conversation. Now, that’s not me threatening an organisation, it’s just being honest about where we are. And that’s a straightforward conversation that I have had and that system leaders had with each other as well. So this is not a game; this is genuine and it is serious, and I think it really does affect the ability and the willingness of staff to work in those services as well: to know that there is a real understanding that improvement is required.

In terms of how we manage our system to reflect what actually happens, that again is part of what we need to do better. So there’s something not just about the follow-up point, but how you actually make sure that consultants and people who are saying they will see people are available. It isn’t just an issue about consultants. That goes into one of your other points about how we actually deal with workforce issues and waiting times. We’ve spoken before about Health Education and Improvement Wales, which has finally come into being with the chair having started work, and I think that’s genuinely exciting. We have the shadow body starting, looking ahead to the formalisation and it coming into being on a statutory basis in April next year. That should help us improve our function in planning and understanding who we need, in what number, and across which particular areas of staff.

Again, I make no apologies for repeating the message, particularly because we’ve had more public conversations about austerity and the reality of it: if austerity continues, it will drive public service against public service, and we see that in some of the calls made by some actors in the field outside here. Actually, whilst austerity continues, we have awful choices to make where there can be no winners. It is simply about how we make difficult choices between different parts of the public sector. So my message to the health service, in public and in private, is: there’s a responsibility to use your additional resource to make a real difference in the here and now and moving forward. And that comes alongside not just a demand for having more staff than ever before in our service, the continuing demands for more staff—and in every specialty area and every lobbying group, they almost always call for more staff—actually, what we have to understand is how many more staff we think we need and how much smarter can we be with the staff we already have, because if we only think about expanding our services and numbers being the only answer, we will miss a proper trick in what we are able to do. That’s why the message of prudent healthcare about doing only what you can do really matters. That’s why people seeing the appropriate healthcare professional really matters, because we can create more capacity for consultants if different healthcare professionals have different parts of their job that they can do as well. It’s why the physiotherapy work and the clinical musculoskeletal assessment and treatment service really does matter. It will be a better service often for the individual citizen, they’ll get seen more quickly, and if they do need to then go and see a consultant, the quality of referral will be better and we won’t be unnecessarily putting people into queues for an operation that they may not need as well. That has to be an essential part of what we do.

Finally, I just want to deal with your point about follow up on RTT. I don’t want to avoid this, because I think it’s really important. I have acknowledged previously that there are some of our measures in RTT that don’t necessarily make sense, that don’t give us the assurance we’d want because they’re only measuring activity and time, and time at a certain point. And at that point, it may not be driving the right clinical behaviour. So, on eye care, for example, I accepted that our current measures probably don’t give us the fullest reflection and assurance. That’s why work is already ongoing with a pilot that is due to start this autumn in two health board areas—in ABM and in Betsi—looking at what we could do to have a new set of measures to drive more appropriate clinical behaviour. We’ll then have a better understanding of the risks we are carrying in our system, and a proper identification that does look at follow-ups where it’s clinically appropriate to do so. So, we’ll have a system that I think will make more sense, but it won’t be comparable with England. That isn’t about saying that I’m changing the goalposts to avoid a comparison with England—I’m doing it because I think and I’ve been persuaded by the clinical case that it’s the right thing to do for the staff and, much more importantly, it’s the right thing to do for our patients.

Thank you for your statement, Cabinet Secretary. No-one in the Chamber would disagree with the overarching principles of your plan, which include improving patient experience whilst keeping the costs of care to a reasonable level. And in this respect, the 1000 Lives improvement to help Welsh Government and NHS wales establish sustainable services and improved patient experience in planned care specialities is welcome.

Indeed, the Wales Public Services 2025 programme hosted by Cardiff Business School has put the choices in Wales into sharper relief in its recent report, when it states that under certain assumptions, 56 per cent of the budget could go into the Welsh NHS by 2021 and the percentage might be even greater in subsequent years. So, therefore, we do have an issue here where we put more money in and we’re not achieving our targets, so I wonder if you could make a comment on that please, Cabinet Secretary.

The term ‘patient experience’ covers a number of areas that include both patient outcomes and patient waiting times. As you stated in answers to my questions last January, we need to balance the reduction of waiting times with the quality of interventions and outcomes that patients receive in Wales. So, how do you, as Cabinet Secretary, plan to do this?

I welcome the news in your statement concerning the redesign of the prostate cancer pathway across Wales, having heard from many constituents in my region about the difficulties of previous treatments that were around before the pathway. Similarly, the roll-out of one-stop clinics, mentioned in your statement, is also to be welcomed, and also the intention of the programme to develop patient reported experience measures—PREMs—and patient reported outcome measures—PROMs—to capture and analyse patient experience of services along elected pathways. However, I’d like to ask, Cabinet Secretary, about the extent to which community health councils will be involved in the capturing of patient experiences. If they’re not sufficiently involved, then we may run the risk of having two separate records of patient experiences, one in the PREMs and PROMs reports and the other via community health councils. Would it be far better if patient experiences recorded via each of these avenues were put together in order to gain the most lucid picture of patient experiences?

I welcome a holistic approach to patient care and lifestyle modification, and I would ask: what up-to-date advice and research from other groups will be incorporated into the holistic approach and lifestyle modifications?

Previous documents concerning the care programme mention that one of the aims is to reduce variation across Wales. For example, such an aim may result in reducing the number of follow-up appointments that are offered following surgery, as this may be an accepted practice in other UK health services.

Whilst being broadly supportive of the overarching aim of ensuring that NHS Wales’s costs are kept at reasonable levels, I must emphasise, Cabinet Secretary, that every case is different. Sometimes, a variation in services and appointments to treat the same or similar conditions, maybe in different areas also, is absolutely necessary, so there needs to be room for sufficient flexibility within the programme.

The evidence of 9 per cent of people not attending follow-up appointments mentioned in your statement is disturbing, but every case is different, and we must not seek to reduce follow-up appointments across the board if such a practice does not produce optimal results for the patient. The evidence that your statement cites from Aneurin Bevan university health board, which has the potential to reduce unnecessary appointments across Wales, is welcomed, provided that we can ensure that such appointments are genuinely unnecessary—that is to say that they are routine cases without complications or exceptions. Therefore, Cabinet Secretary, could you ensure that health boards have clear guidance on what constitutes exceptional circumstances in a given case? And, moreover, when a case is deemed exceptional, please could you ensure that health boards have clear guidance concerning what further resourcing would be considered permissible or best practice?

I note that your statement says that there has been a reduction in the number of non-urgent suspected cancer patients. However, I have mentioned in the past that, when someone is given a cancer diagnosis, and diagnosis is of the utmost urgency for them, we need to ensure that they have the best patient outcomes and that when a person is told that they possibly have cancer that we treat all of this as urgent, because to that person, the word ‘cancer’ means that something is going on that needs urgent treatment.

Finally, I understand that the planned care programme currently focuses upon four surgical specialities: ophthalmology; ear, nose and throat; orthopaedics; and neurology. I have read in your statement since that there are more in the pipeline. So, without wishing to run before we can walk, I would like to ask whether there are any long-term plans for the programme to apply to other surgical specialities or other areas within NHS Wales and, if so, what methods would be used to evaluate the effectiveness of the programme upon the initial four surgical specialities. Thank you very much.

In responding to the questions and the points made, I’ll start by repeating and then adding a little to some of the points that I made earlier about finances and the reality of services. You’re right: our current projections show that we’ll spend comfortably more than half of the Welsh Government budget on the health service in the medium-term future. That is because of the choice this Government is making on the one hand to prioritise the health service, to make sure that front-line services are funded and that we have a generally sustainable system. We’re not doing this simply on the basis of our long-standing political commitment to the service but because of the objective aims that we’ve taken both from Nuffield and then the Health Foundation about the gap that needs to be met to keep the service sustainable. That includes not just more money going in; it includes continuing efficiency gains being made year on year within our service. The risk in that also is staff. It requires a continuing element of wage restraint, otherwise the service is not affordable. And then we come back to both the pay cap and the UK Government decision and whether they are prepared to be serious about the pay cap. I notice they have recently confirmed they are going to put off putting evidence in for the pay review bodies. That means that our public service workers, who are expecting the review to take place, won’t know what the position is until much later in the year and any pay rise of any level is likely to be delayed as a result. That may produce a saving to the Treasury, but I think it puts more pressure on our hard-pressed staff. It goes back to the central choice about austerity. The financial lead for the Welsh Local Government Association, Anthony Hunt, this weekend made the point that Tory austerity pits public services against public services. If it doesn’t end, we’re going to have catastrophic results for communities up and down the country.

On our challenge here within the service to reduce waiting times and to make sure there’s no trade-off in quality, I recognise what you say about how we try and measure and get an understanding of what the patient experience is. It isn’t just PREMs and PROMs versus the community health council movement. It’s about understanding where there’s a differing role for different parts of our system. I think PREMs and PROMs could and should be really useful in understanding people’s experience and proactively asking people what matters to them and then designing services around what patients tell us, but equally it’s about understanding that there’s more than one place to go and get this. So, it’s in the numbers that we have, but it’s also in the clinical audit work that takes place as well. There are rich areas for improvement there as well, and that benchmarks us across other parts of the UK system. In each of the implementation groups we have for major conditions, the third sector are always involved within that so you have an area of challenge from those groups that are acting, if you like, as the voice of the patient within those services as well. A good example of where a third sector group helps us to understand the patient voice is in the Macmillan survey we’ve just had, telling us about cancer services and the direct patient input. So, we understand from a variety of sources what patients are trying to tell us about the services they value and how they want to see them improved. And in trying to make those more consistent or complementary, we should not choke off different areas to understand what people tell us.

Your points about follow-up I think I’ve broadly dealt with. I’m pleased you recognise that ENT appointments in Aneurin Bevan have reduced by 40 per cent. The challenge, as Angela Burns was asking, is how we make sure that follow-ups are clinically appropriate and we don’t drive unhelpful demand into our system that is of no value, either to the clinician or to the citizen. And I don’t think there’s a great level of reassurance to be asked to be told to come to a hospital site for a follow-up appointment with a consultant, if you’re then waiting for a period of time, you have to try and park somewhere, go along and take up a significant part of your day, and if you then have five minutes of time with a clinician who says, ‘Everything’s fine, thank you very much’, that isn’t a great use of that consultant’s time and it often isn’t a great use of the citizen’s time either. So, there’s much more efficiency that we could get by actually, in a clinically appropriate manner, changing the way that follow-ups happen and who people actually go to see.

On your other points about other areas of the planned care programme, well, that comes down to the advice we’ll get about the right number of areas, but also the capacity of our system to make a real difference in these high-volume areas of activity. On cancer, there’s more work that we’re doing on how we refine our cancer pathway to understand how we get the right system to deliver the right results for our patients.

We obviously have to get citizens more involved in looking after themselves rather than clogging up our GP surgeries with sore throats, for example, when they could easily self-medicate.

But I just wanted to speak about the visits that I had with you to Pearce and Bowler Opticians in Pentwyn, where Clare Pearce and Francesca Bowler have piloted a real-time imaging connection with the Health hospital to enable the consultant in the hospital to instantly see the patient’s eye, who may or may not have a macular disorder, which might need urgent treatment, or maybe not. That seems to be a fantastic innovation that enables more people not to have to go to hospital unless it’s absolutely necessary. We want people to be going to hospital because they’ve got a life-threatening condition that needs to be treated immediately. So, I think that was a fantastic example of innovation that we could be pushing forward on, I hope, in other parts of Wales.

Tomorrow is World Obesity Day and I’m horrified to read that adult obesity is going to go up from 27 per cent to 34 per cent if we do nothing about it, and we clearly need to change the conversation with citizens if we are going to prevent the collapse of our health service, which is under pressure from increases in cancers and diabetes and other conditions that are related to obesity.

I welcome the virtual review that’s gone on of hip and knee appointments, which has reduced massively the numbers of people who need to be seen by a consultant. When there was a flurry of activity around excessive waiting times for operations just before the end of recess, it was obvious to me that Cwm Taf had consistently not had a problem over several years, so I wondered how the Cabinet Secretary is ensuring that best practice, which appears to be present in Cwm Taf, is being rolled out across the rest of the health boards to ensure that we’re doing the right thing to ensure that people aren’t waiting longer than they need to, and that we’re eliminating unnecessary consultations from the system.

Thank you. I think there were a couple of comments and a couple of questions and I’ll try and answer promptly, Deputy Presiding Officer. On common ailments, I think you’re right—it’s a fair point to make—we want people to go and see the appropriate person in our system, or that they self-medicate and care for themselves. It’s why the roll-out of our community pharmacy programme—the Choose Pharmacy programme for common ailments—is really important. And we’re making very good progress—we’re making more and more pharmacies available for that first point of contact without needing to take up GP time.

On the point about PB Opticians in Pentwyn, I’m genuinely excited about the pilot that they’re taking part in with another larger multiple optician, Specsavers, in the middle of the city and also in your constituency. I’m interested in having a follow-up visit with them, as the model of their piloting is then used throughout a greater period of time. So, I hope to go back over the new year and to look again at, with months of practice, whether that is delivering the gain that we think it could do, both for the clinicians in either setting, but also, importantly, for the citizen as well. Assuming that works, I am then keen to see that rolled out across the rest of the country as well. So, it’s a really exciting pilot to be taking forward.

On the point about obesity, you’ll know that Rebecca Evans is leading our national strategy, to draw together, because we recognise that our challenges about diet and exercise are real and significant challenges in almost every area of activity, and actually, encouraging people to maintain a healthy weight and more activity is a really important part of driving demand out of our system. If we can’t do that, we have very real challenges about having a more sustainable service, so I do look forward to us being able to take advantage of the ability to do that, and I’m optimistic about where we will be as a Government. The challenge is: can we persuade the public to do more things for themselves, because it’s in their interests to do so, and not simply about making life easier for the Government?

Thank you very much, Cabinet Secretary.