2. Will the Cabinet Secretary make a statement on Hywel Dda University Health Board's most recent service-change proposals, which could potentially result in the closure of Withybush Hospital in the future? 108

Hywel Dda university health board is currently testing and narrowing down options for its transforming clinical services programme. A shortlist of options will be released publicly in the spring, followed by a formal public consultation, which will inform any final decisions of the health board.

Thank you for that, Cabinet Secretary. I listened very carefully to the answers the First Minister gave to the leader of Plaid Cymru yesterday, and also the comments made by my colleague Paul Davies in the business statement. And I tabled the question today because I was absolutely appalled by the supercilious arrogance with which our concerns were dealt with.

Do you accept that the public have the right to express their worries to their elected representatives, because your backbenchers—a number of whom seem to think it was highly laughable that people in Pembrokeshire, Carmarthenshire and Ceredigion may be concerned about proposed changes? Do you accept that this, the parliamentary review, does not say 'close Withybush hospital'? Do you accept that the history that has been engaged in Withybush hospital, with botched consultations since 2006, has left people in Pembrokeshire very, very sensitive to this subject? And do you agree with recommendation 4 of the parliamentary review, which says, 'Put the people in control', and talks about openness, honesty, transparency, and engaging with the public in the shape of their future services? Could I please ask you, Cabinet Secretary, to urge Hywel Dda to make sure that their consultation is open, honest and transparent, because skitting around the west Wales area, holding meetings in very small village halls, and then not letting people take the papers out, does not strike me as being honest, open or transparent, nor does contacting the political representatives when the proverbial hits the fan, and there's a leak, seem to be open, honest or transparent.

Could you please give me a comment on what effect this latest series of events might have on 'A great place to work'—recommendation 5—and what damage that might do to our recruitment issues that we have in west Wales? I'd be interested in your comment following recommendation 3. And the reason why I reference this is because I'm particularly angry at the way the First Minister, in my view, traduced the work that I, my colleagues in the Welsh Conservatives, and, to be fair, the other opposition Members, have put into treating with honesty and maturity your efforts to support the panel on their review of health and social care delivery in Wales. Yesterday, he lost pretty much all of my goodwill, because this review is about how we talk to people, how we engage with people, how we take people with us, how we deliver a sustainable future, and how we try to take some of the battle out of the NHS. It is not air cover, before it's even dry, to suddenly say, 'Ha, but, you know, guess what? Tough luck, west Wales—once again, 15 years on, we're going to start going on about Withybush hospital.'

So, I'm asking you to please ensure that other Members of your party, and your Government, respect the people of west Wales. Will you please ensure that Hywel Dda speak to us in an open, honest and transparent way? In fact, my colleague Paul Davies and I have managed now to get a meeting with the chief executive and the chair on Thursday. This is so serious, and it's really, really annoyed me, beyond all description, that this, which I was looking forward to see as your vision, was traduced in such a way. We don't expect that supercilious arrogance from the First Minister. We are here to represent the people we represent and we have every right to ask you to scrutinise Hywel Dda health board to make sure that they go about this in a really fair way and, for once, take the people with them and not just set it up to be a battlefield. 

Well, I have to say, I don't share her characterisation of the way that Members in this Chamber behaved yesterday. I certainly don't think there was any attempt or intention to introduce supercilious arrogance or to traduce the efforts of Members in every party in having a properly mature conversation about the future of health and care in Wales. The parliamentary review was an honest attempt to try and have an informed and mature debate about our future. And in every part of Wales, not just in west Wales, there will be very difficult choices to be made. 

I can't and I won't comment on the detail of an incomplete process within Hywel Dda and their transforming clinical services programme, because as you know, and I appreciate you know this, I potentially have a decision-making role at the end of this. So, I can't comment on proposals, but there is a process going through and the health board have announced there will be a shortlist to go out to public consultation with in the spring. And it's really important there is a proper public consultation through this. It's important that staff are properly engaged in the process as well, because whatever you or I or anyone else says about the future of health services, if there is to be a battle between politicians, then people choose their sides. Actually, I think lots of people will walk away and simply think it's politicians arguing over something rather than, 'What about the future of health and social care in Wales?'

As we all know, from what the review said, the way we're currently set up isn't fit for our future, so there'll be a need to be a way to deliver change and reform in our system, and that's difficult when it comes to local decision making. It isn't just an issue for one particular site in Wales; every site has a challenge around the attachment to services as they currently exist, to bricks and mortar, and that isn't just a west Wales view. So, I really look forward to a consultation that engages the public and to see the view of healthcare staff themselves as well, because, actually, the real trust is in that which rests between the public and the people running and delivering those services.

There's got to be a serious account taken of whether or not we think the way we currently run and deliver services in every part of Wales is going to last, and if not, how that conversation takes place so the public do get properly engaged and informed before any choice is made. That's what I expect and that is a process that I expect to engage in in this place and, of course, I expect people to ask me questions to try and pin me down on a particular view during the process. I know that is part of what Members will try to do, but I will be direct and honest and I'll continue to say, 'I can't give you a view'. And I won't give you a view about a consultation. There are no proposals as of yet, but I may well be asked to be a decision maker in there so I have to make sure I do the right thing. 

Members in this Chamber are well aware of my views on this matter. I find it completely unacceptable that any options that could result in the closure of Withybush hospital are even being remotely considered by Hywel Dda university health board. The people of Pembrokeshire have seen a constant reduction of services in recent years, and this latest news sends another statement that health services in Pembrokeshire are once again under threat.

Indeed, it would be even more difficult to recruit medical professionals if there is no stability over which services are staying and which are potentially being removed. Therefore, following on from Angela Burns's questions, does the Cabinet Secretary accept that this announcement does nothing to help attract doctors and medical staff to the area when they continue to see services being removed from the hospital? In light of these damaging proposals, can he tell us what immediate steps he is taking to address this matter? 

The move that we wish to see—[Interruption.]

Sorry, just a minute—you've asked a number of questions. Do have the courtesy to the Cabinet Secretary to hear all of the debate, please. Cabinet Secretary.  

The move that we wish to see in health and care is set out in the review. There'll be a concentration of some specialist services onto a smaller number of sites to provide better care. That will mean more physical travelling distance to some of those services. What absolutely compromises that also is that there'll be more care delivered closer to home—we see that already. There are a wide number of services delivered within the community and local healthcare that previously would have been delivered in theatre conditions. So, we're seeing a move around right across the whole country of the way in which care is delivered. 

Our challenge in the future of health and care, not just in Pembrokeshire, not just in west Wales, but in every single part of the country, will be how we deliver change and reform to safeguard the future of health and care services, and not to wait until something is genuinely broken before we fix it, because no change isn't an option, and there's no way not to be honest about that. That is one of the central messages from the parliamentary review. The challenge is how we recognise the way we currently send and deliver services in health and care, how we recognise the weaknesses and the strengths we have to try and deal with our weaknesses, as well as build on our strengths, and, actually, there are real challenges in every health board about locum and agency spend. In some of our services, there's a real challenge in financial terms about the way money is spent. That's why I've taken action on the pay bill, actually, in locum spending in particular in the last few months. There's a pay cap that's come in on locum spend, on the terms available in November from last year, because we do need to deal with some of those costs, otherwise we'll undermine the sustainability of that service. That does affect recruitment into services in each part of the country.

In west Wales, in particular, I still expect the campaign we have on 'Train. Work. Live' to sell not just the opportunity to work in the national health service in Wales, but to live here as well. And, actually, I think west Wales has an awful lot to offer people as a place to work, but certainly as a place to live as well, and the training opportunities that go alongside that. 

There is no way to have an easy conversation about transforming any part of the national health service. There will always be a reasonable view about why a change—in particular on a local and individual level—shouldn't happen; you'll see that in any and every part of the country. But if there is not the space to have an honest conversation between staff within the health service and with the public about reasons to try and change the service to improve the quality of care and the quality of outcome that is delivered, then we won't get to a point where we can be certain and have real confidence in the future of the national health service, and that is absolutely where the parliamentary review is. That is the way I expect every health board to behave with their own individual populations, but also in working together on a number of the challenges that we face in the way that services are designed and delivered. 

As I say, I'll be as open and as honest as I can be, protecting, of course, the reality that I may well have to be a decision maker. I can't go into some of the detail in the questions that you asked, because, otherwise, I'd put myself in a position where I could undermine the consultation that has not yet gone out to the public—it's for this spring. And this is not just that one part of Wales would have this conversation; there is a national conversation and some really difficult national choices for us to make. 

You've set great store, Cabinet Secretary, as did the First Minister yesterday, by the parliamentary review but, of course, the parliamentary review was published too late to influence these proposals from Hywel Dda. So, will you join me today in urging Hywel Dda to withdraw these proposals until we have had time to consider the parliamentary review—how it might be applied throughout Wales, and how this mature conversation that you're seeking for us to have can be had on that basis without us dealing with individual proposals to close hospitals, which, to be frank, will not allow any of us to engage in that sort of mature debate that you're urging us to do? It would be far better, would it not, for us to consider that parliamentary review, which was only published last week, and to do that and to urge all health boards to look at how we consider the review and then to implement a series of consultations with their local populations, based on the principles of that review? You're putting the cart before the horse if you now allow Hywel Dda to go ahead with a series of consultations, some of which will be highly contentious, that are not able to be influenced by that parliamentary review at all. And you are at risk, therefore, of losing some of that widespread sharing of concern and support that you've built up around the parliamentary review. 

I would also like to invite you to join with your own Labour colleagues in Preseli Pembrokeshire. Paul Miller, the candidate in 2015, stood on a platform of restoring the paediatric services to Withybush; indeed, I remember him saying that he'd had three meetings with Steve Moore—incredible; three meetings, just imagine it, with Steve Moore—to discuss how they could be restored. We were all waiting for those paediatric services to be restored. They had been taken away temporarily, if I can remind you—not as a decision of a consultation, but temporarily taken away due to recruitment difficulties. Surely, to restore some sort of trust of local people to allow us to have the serious debate that you're asking to emerge from the parliamentary review, you would first restore the paediatric services at Withybush so that people have the trust back again and then ask Hywel Dda not to proceed with this consultation until we've fully considered the parliamentary review. 

At the start of the parliamentary review, there was a conversation about how much would wait until the end of the parliamentary review process and how much would need to carry on in terms of conversation. You'll have seen the lengthy statement from the medical director, Dr Phil Kloer, of Hywel Dda, about an ongoing conversation and consultation that the clinical community have been having within Hywel Dda about a range of difficult choices that they feel they need to discuss with the public.

I don't share the Member's view that the parliamentary review means that everything must stop and the consultation must be restarted at some point in the future. I think the parliamentary review highlights a number of points about needing to have a conversation, about not putting things off, and actually this has got to be openly done by the health board and its employees. The clinical community have to be engaged in that conversation with each other and with the public that they live amongst and that they serve.

I don't think it would be the right thing for me to instruct, or attempt to instruct, the health board to stop its consultation now. I think the test is whether they will have a consultation that is open with the public, where they can honestly explain what is happening and where the staff feel empowered to properly engage in that with their communities. Because whether they are to undertake a consultation with the public in spring or in the summer or in the autumn, there is simply no avoiding the reality that there will always be contentious choices to make in west Wales, in north Wales, in south Wales and mid Wales. We either have a choice over whether we say that the national health service and social care must engage in that debate now and confront some of these challenges and have a difficult conversation and then make choices, or we put that off and make it even less likely that that will happen in the future, until at some point something goes wrong. I don't think that's the right thing to do. 

I understand why opposition Members in particular urge me to intervene and to stop things. I do appreciate that. To be honest, if my party were in opposition we may well be asking awkward questions of a similar nature to anyone in the Government as well. I actually think the reason why Ministers are here to do a job is to make a difference to the country, and some of that is about allowing difficult choices to go ahead and be made. I'm not going to try and attempt to instruct Hywel Dda or any other health board to stop the consultation with its staff or with the public. I think the consultation has to run, the public have to be properly engaged, a choice will have to be made and, ultimately, that choice could land upon my desk.

We've had this leaked document, we know that it is going to form the basis of a consultation and we know that, within that, there is mention of the closure of Withybush hospital. It has already raised considerable alarm within my constituency, the one that I live in. I think that our job here as politicians is to have a conversation that starts to calm down those fears. Because as I read this at the moment in its current format, there are a range of options—nine, I think, in all—on the table, and they're seeking a conversation and agreement with the wider public, and that includes us, on taking this forward, in terms of giving people the very best options that they can in delivering the very safest form of care and services, both medical and social, within that region. 

So, there are two things that run alongside that. I think the first thing is that we give immediate reassurance to the people in Pembrokeshire that Withybush hospital is not closing now. I think that's what I'm seeing on Twitter, on Facebook and in the e-mails that I'm having. I think that's the first thing that we have to do. Clearly, the second thing is that this will be a meaningful consultation where people's views will be first of all listened to and then taken on board. Because I think that's where we're at now, and that's what I will be calling for—for those two things to be very firmly stated.

Thank you for the comments and for the points. I think it is important—and I have to put on record now—that there is certainly no plan to close Withybush hospital at any point in the immediate future. There is a challenge about what the future will be for any hospital. It's not about sending out faint praise for any site, because you could say the same about Glangwili and about Llanelli as well. And actually seeing the way it's been reported, of course whilst the Withybush issue has been taken up, understandably, by Pembrokeshire representatives, the long list that has been leaked also includes options around other hospital sites as well, so it's looking at a whole range of different configurations. That's why I'm saying there's a process the health board is running through. They'll come out with a shortlist in the spring on which there will be a meaningful consultation.

I'm very happy to reinforce that I really do expect there to be a meaningful consultation. Of course we've invested in the Withybush site. There is a range of services there that provide really good care for people. So, there are always challenges about how you have a sensible and meaningful conversation and how you respect and understand that some people will be anxious about the future, and some people will be looking for assurances, and some will be looking for definitives that, actually, any responsible Minister just can't give if we're going to make a serious choice about the future of the health service.

Following 80 different local events over the summer, I know the health board held a further 14 in the autumn, and there's more to come and more to do, but I expect clinical engagement in that debate with each other and in the debate with the public and a genuine and meaningful consultation for the public and the people of west Wales, and I expect the same sort of conversations to be taking place across the rest of the country as we try to remake the future of health and care in Wales fit for the future.

The health Secretary is a kind of professional fire blanket for the failures of the health boards all over Wales and Hywel Dda is no exception to that. Of course, Withybush isn't going to close in the immediate future, but the real question is: is it going to close in due course following a death by a thousand cuts? What we've seen in recent times is the progressive diminution of health provision, particularly in Pembrokeshire, and there is no confidence, I think, in anybody that I've spoken to that Hywel Dda is really going to be responsive to the needs of local people.

I did manage to get a meeting with the chief executive and the chairman of Hywel Dda only last week, and we had a general canter around the course, and it's quite clear what the direction of travel here is. They want to close general hospitals and have smaller community hubs that are not going to be able to provide the range of services that are currently available. 

Of course the health service has to change with the times and Hywel Dda has particular historical problems to deal with—I'm not totally unsympathetic to the predicament in which they find themselves—but how can it be right to close smaller hospitals or close general hospitals and try to funnel everything into one central bigger unit? We had not so long ago fears that Bronglais was going to close in Aberystwyth. Now we're fearing that Withybush is going to close. Given the geography of the Hywel Dda health board, where population is sparse, you can't centralise things in one place; that's an impossibility.

The other point that came out of my discussions with the chairman and chief executive was that they don't see the need for as many beds in hospitals. I heard you say a moment ago that the health service has changed so that more people are discharged from hospital earlier today than used to be the case, and that is certainly true, but bed occupancy rates are at record highs—you know, 88 per cent, whereas the safe level is 85 per cent. So, it cannot be right in those circumstances to be contemplating reducing the provision of hospital beds still further.

I appreciate you can't say today what the outcome of this review and consultation is going to be, and that there are legal restrictions on your ability to answer questions, but I can follow on from what Joyce Watson said a moment ago: it must be regarded as a ridiculous proposal to close Withybush—even in contemplation in the medium term, let alone the short term. The health board should, when it produces the list of options for people to discuss, avoid causing unnecessary alarm and consternation by producing extreme proposals that are not going to be followed through.

But, fundamentally, what we are seeing here is the lack of democratic decision taking in the health service. Health boards are not elected, community health councils are not elected. Everything, ultimately, is funnelled up to the health Secretary in the Assembly, and yes, we can attempt to hold the health Secretary to account in this Chamber, but our capacity to do that is, of course, limited by the structure of the Assembly and the party system within it. People on the ground feel that they have no real voice at all. Yes, ours is a voice, but is our voice being heard, and even if it's heard, is it going to be listened to?

I'll just deal with your point about beds and investment in health services. We're not just the numbers of money that we invest in the health service—[Inaudible.]—the numbers of staff we have; we treat more people than ever before, more successfully than ever before and that includes in west Wales, just as with the rest of the country.

Our challenge is how we organise our services to deliver the greatest value, both in terms of value for money, but also in terms of the value that we deliver in terms of the quality of care and outcomes. And that really is going back to why we've had a review to see if we are on the right track and what more we need to do. I say, you can't get away from the fact that there have to be difficult choices made, otherwise, you'll come back to a further point in the future where the Government will be asked, 'Why didn't you do something about a part of the service that really has gone wrong?' I would much rather be in a position where we're having a debate about how difficult choices are made than not.

I just reiterate that there is no proposal to close Withybush hospital. There will be no proposals to consult on until the spring of this year, and it will be the health board that will be doing that. The health board needs to have that conversation with its clinicians and with the public and that is absolutely the right thing to do. Of course, the voice of the public will be an important factor; people will be listened to, but let's be clear, there are a range of different opinions about what could and should happen right across the health board area.

We saw representatives in Carmarthen, Llanelli and Withybush and in other parts of the health board having very, very different views on what the future could look like. We need to have a process that is fair, appropriate and meaningful and then there will be a decision made, and, of course, that is a decision that if the health board wish to make it, it could well end up being referred to me and end up on my desk and I'll accept the responsibility that goes with that.

Thank you very much, Cabinet Secretary.

We're going to move on to the second topical question, but before I call the question, I do want to remind Members that active proceedings are taking place in relation to this matter, and that Standing Order 13.15 on sub judice is therefore engaged. Members should therefore avoid making any comments about the conduct of the parties or individuals involved, or giving any suggestion as to what the outcome of the case ought to be.

I call Neil McEvoy to ask his topical question to be answered by the Minister for Housing and Regeneration. Neil McEvoy.

Diolch, Dirprwy Lywydd. The question was to the First Minister, but he's not here, so—

No, no. No, I'm sorry. It is for Members to suggest or indicate who they want to reply, but it is for the Government to decide which Minister is best placed to answer it. You will note that there was a written statement issued by the Minister for Housing and Regeneration, Rebecca Evans, on Monday, and therefore, Rebecca Evans is seen as the Minister who will answer your topical question.

Yes, but it was submitted and accepted as the First Minister.

No, no, it doesn't matter who it was submitted to. I have just explained.

Okay, thanks.

So, either you ask your question of the Minister, or we'll move on.