1. Will the Cabinet Secretary provide an update on the crisis in the Welsh NHS this winter, in light of reports that services are at breaking point? 96

Thank you for the question. The winter, as ever, is a very challenging period. NHS Wales and the wider social care system are under considerable pressure and that is consistent with pressures being reported right across the UK. Despite activity in parts of the system, that at times have been unprecedented, our dedicated and hard-working staff continue to provide a professional and compassionate response.

They do indeed and, in fact, it is these dedicated and hard-working staff who have, over the last 10 days, raised a significant number of concerns with me. We've had royal colleges coming out with commentary and statements about the enormous pressure their staff have been under. I've met with royal colleges in the last few days, I've met with doctors, nurses, front-line staff and an ambulance worker. They all talk about the same thing: comments such as they've 'never seen the Welsh NHS in such a bad way', their colleagues 'are at breaking point' and front-line staff 'are under immense pressure'. The BMA themselves have said that one health board area in Wales had absolutely no cover whatsoever in terms of GP doctors. We've lost over 2,000 ambulance hours in the last seven or eight days. The Royal College of Emergency Medicine said that some people are waiting over 80 hours in emergency departments before being admitted into hospital. 

Cabinet Secretary, this is an enormous issue. I absolutely accept that you are not personally responsible for front-line issues that go wrong. I absolutely accept that there has been an uplift in problems this winter and that this winter was a bit tougher than everyone thought it was going to be. But, my concerns are that you've given some £50 million prior to winter to prepare for this and what I would like to ask you is to undertake an urgent assessment of how that £50 million was spent. Did it get to the front line and, if so, where, how, and what did it ameliorate? Did managers involve the right people in planning? Because GPs say they were not involved in winter preparation. Hospital doctors say they were not involved in winter preparations. Emergency department unit leads say they were not involved in winter preparations. There was no account taken of the three, four days, so, effectively, we had two whole weeks with very, very light bank holiday-style cover. Social services were basically absent for two weeks. We had enormous delayed transfers of care. The Heath themselves had two whole wards full of people waiting to go home.

Would you please also accept, or look at the managers within the NHS, because we seem to be great on strategy, but putting it into action is difficult? When you have a nurse or a bed manager saying, 'I'm not going to open up a bed, put an extra bed on that ward, because that one bed will make that ward risky', I totally accept that, but risk is about the balance of risk. So, what is worse: having one bed open on a ward, or having a person on a trolley for 80 hours in an A&E department? So, Cabinet Secretary, I'm asking you to make sure that we are holding the management, the management of the NHS, holding their feet to the fire on those issues.

You've just awarded, in the last few days, another £10 million. That is incredibly welcome, but we need to make sure that that £10 million goes to the front line and solves these problems. The Health and Social Care Committee held an excellent inquiry. We came up with a strong report on winter preparedness. The people came to us and told us they weren't being involved. They're still saying it today. You need to find out what went wrong, and I would ask you to really, really drill down into this, because something somewhere just didn't work. And as you started off saying, we have a lot of excellent people who are working their socks off and are under immense pressure. It's our job to lift that pressure off their shoulders.

Thank you for the series of questions. To think about where we are and about the pressure that exists right across the system, much of our commentary ends up inevitably being about the front door of a hospital and the emergency department, but, actually, the pressure is right across the system, including in primary care, where on peak days they've had 100,000 contacts in primary care across the country. Part of my idea was not just the £10 million to go into the system, it was also throughout QOF and the admin duties of GPs to give them more time to spend with patients who need to have their care and assistance. 

There's also that pressure across the social care system. I think perhaps suggesting that social services were virtually absent for two weeks was a little unkind and not exactly accurate, because, actually, part of the reason that services continue to work is because of the commitment of social care staff, in addition to their colleagues within the health service. But, part of our challenge in moving through this—and I understand that we'll need to do better in the future—as always, is not just what happens at the front door either in primary care, or in general practice, or an emergency department, but as you get to the other end and needing to return people to their own homes, whether that's their own home in a private residence or residential care as well. So, the money we have announced we think will help at the nexus between health and social care in particular, because we recognised at one point last week when I did an interview that there are about 350 medically fit people in beds within our hospital system. That's a challenge not of bed capacity, but of flow within our whole health and care system. So, there is a challenge that goes across health and social care in resolving this.

The £50 million was about maintaining performance, not just unscheduled care, but scheduled care as well. We expect to be in an improved position at the end of this financial year on our scheduled referral-to-treatment figures as well. So, we've made different choices. We haven't had a nationwide cancellation of elective care. We've seen some of that continuing, but there have been some cancellations to make sure that emergency admissions are dealt with. We will, of course, report back to the National Assembly, and I expect to face scrutiny in this Chamber and in committee about what the £50 million has delivered. It's to deliver to the end of the year, so I won't undertake a mid-point inquiry, as opposed to understanding through the whole system what it's done in preparing for and delivering across winter. 

The same for the learning we will obviously take from this winter, both at the point of extreme pressure, as it almost always is in the first week of January, but then to see the whole winter period in the round. Because, at the time when you initially asked this question, that was at one of the peak points in pressure. Fortunately, it has reduced across the country. We see a different level of escalation now. But the winter is certainly not over and I suspect there will be many more difficult days.

So, we need to understand not just what happened this time around with winter planning, and the voices you say there that were not taken account of actually went into some of the winter planning, because there were colleagues representing every part of the service, not just health care, but actually social care colleagues in the room, as well. There's always a challenge in terms of how we gather together the voices of staff and understand how they plan together to deliver our service. We will, of course, learn from this winter. We want to be better prepared again for next winter, and I expect to be completely transparent about what we have learnt and what we expect to do better in the year to come. In addition, I want to improve our response for the remainder of the current winter.

This Welsh Labour Government tells us that the pressure over the 2017-18 winter so far has been down entirely to unprecedented peaks in demand. Now, I have no doubt whatsoever that peaks exist. They exist around winter, as they do at other times of the year as well, and we've heard that there have been some particularly big spikes. But you cannot keep fobbing people off with the same story time and time again, because you're not reflecting what's actually happening and what people on the front line are telling people like me and the Conservative spokesperson opposite.

The truth is that our NHS does not now have the resilience to be able to cope with peaks. Bed capacity has been continuously over the 85 per cent safe level since 2011. Over the same period since then, successive Labour Governments have cut bed numbers by 10 per cent. I don't think that's a coincidence. We in Plaid Cymru say, 'Reverse the bed cuts'. We've outlined how we'd want to train and recruit a 1,000 extra doctors and thousands of extra nurses over the next decade or so.

Hospitals inadequately equipped with both beds and staff, coupled with a lack of integration with social care means cancelled operations; it means ambulances queuing up outside emergency departments; it means patients on beds in corridors; and it means that our excellent staff, who you mentioned and all of us do, and treasure, being put under more and more pressure. It is unsustainable. I've said it before and I'll say it again here now: I fear that having run the Welsh NHS for the last 19 years almost, Labour can't now face up to the depths of the NHS's problems, because to admit to those problems would be to admit to your part in causing those problems. When will this Government take its head out of the sand, admit to the problems and put a proper, long-term, sustainable plan in place to deal with them?

I do regret the tone with which Rhun ap Iorwerth approaches this very serious issue—[Interruption.] Suggesting that we are fobbing people off is a denial of the reality. A 54 per cent spike in red ambulance demand on New Year's Eve is not fobbing people off. That is a real, unplanned for—and how on earth could you possibly plan for—spike in demand. On New Year's Day, the increase in demand was 29 per cent for red ambulances. We've seen extraordinary reversals of the norm. For example, in out-of-hours care, we saw a significant spike in Cardiff and the Vale, when normally in the Christmas period—on Christmas Eve and Christmas Day—you see a fall in calls for services, but this year we saw a significant rise. So, these are not pressures that you could reasonably plan for in terms of those spikes. This is a factual presentation of what is happening.

I think to try to suggest that this is because a party has run our service into the ground—. It may make great headlines for the party faithful, but actually it doesn't really get us to the point of understanding the nature of our challenges and actually being able to do something about it. I think it's my job in the Government to try and be responsible and responsive and constructive in how we do that. That's actually why, in terms of your final point about the long-term future of health and care in this country and not being prepared to do something, that is exactly what we have done. On a cross-party basis, we've instructed a panel of experts to undertake a parliamentary review of health and social care. We'll have that report within a week, and we will then discuss and have to make choices about the long-term future of the health and care system here in Wales. Far from avoiding the very real and difficult challenges, we have tried to be constructive and mature in doing so, and we will then have a real, meaningful and demanding basis, both for Government and also other political actors in this place and beyond, on which to make difficult choices for the future of health and social care here in Wales.

Cabinet Secretary, despite your own evidence in our committee about winter pressures and how they impact upon the NHS in Wales, we never seem to learn from these experiences; we always seem to be caught on the hop, as though winter pressure was something new. The word 'unprecedented' appears to come out every time, as if this word excuses the very fact that we are not learning from past experiences.

The additional £10 million is, of course, welcome, but I want to ask you, Cabinet Secretary, how was the £50 million spent in combating this situation that happens almost at this time every year? What lessons year on year regarding winter pressures are being learned, and how are they being acted upon? We hear again that flu outbreaks have added to the pressure, which, of course, they would, but, again, flu is not new to our country at this time of the year. We expect it—it gets colder—and flu to be partly a consequence of this. It happens the same time every year and we must be prepared for this.

The Royal College of Emergency Medicine stated that emergency departments in Welsh hospitals felt like a battlefield to staff. We know that A&E attendances topped 1 million. But why, when we are encouraging people to use pharmacies, for example, are they still turning up at A&E? Is this because they cannot get the GP appointments that they feel they need and that A&E is now becoming the alternative?

What discussions will you be having with both primary care and secondary care staff to gain an insight into the situation we find ourselves in? What proportion of these A&E admissions could have been dealt with by other means, such as pharmacy and GP visits? Were the hospital staff in these departments prepared and of full complement? 

You state that NHS organisations have been planning for this period since the end of last winter—supported by the £50 million of funding to help them balance urgent and planned care activity—yet we do not still have sufficient beds or staff to cope with this situation. How can we plan for next year so that we are not cancelling operations for patients that could lead to them needing additional treatment because of this delay, which has a knock-on effect on cost of course, because they cost more in the long run, or they possibly could? What strategy do you have planned for next year—

I think you've already outlined enough questions for the Minister. I doubt if he'll be able to remember them now.

Sorry. What strategy do you have planned for next year so that all GPs and hospital staff can meet to combat this? Thank you.

Thank you for the series of detailed questions. I appreciate we only have 20 minutes on the agenda for the three questions, so I'll try and be brief in response. The questions about the money and the broader look back to winter this year to try and learn for the next year, I think I dealt with in response to Angela Burns. There's a question for the Government, but also for the health service, together with local government and housing colleagues as well, in understanding what we've done this year and what more we need to do in years to come as we progressively design and deliver a more integrated system that understands the needs of the citizen and how we deal with them.

That does come on to perhaps the most interesting part of your series of questions about how the public can be part of this as well. This isn't about blaming the public, but about how we equip the public to make different choices and how we make sure those choices are available. The Choose Well campaign encourages people to think differently, and, just before Christmas, we saw the ambulance service producing a list of calls they'd had for coughs and colds and shoulder pain that weren't 999 calls at all. So, that is a real part of our system, but actually we need to manage demand differently and change expectations around that. Actually, the investment we're making in pharmacy is a good example of wanting to do that.

I expect that, in the lessons to be learned during this winter and from the end of this winter, we won't just have a report and a dry report for operational matters, but one that will have to take account of the real experience of staff in every part of our system, to then try and plan ahead for not just the year to come but, in the response to the parliamentary review, for the medium and longer term challenges that all of us face as our country changes, as demand goes up and, as we all know, as money is tighter and health and social care seem to have less money than before, together with other public services, to manage an ever-increasing amount of demand.

Thank you, Cabinet Secretary. The next question will be answered by the Cabinet Secretary for Finance, and the question is from Simon Thomas.