The next item, therefore, is the statement by the Cabinet Secretary for Health and Social Services on valuing the NHS workforce. And I call on the Cabinet Secretary, Vaughan Gething, to make his statement. Vaughan Gething.

Thank you, Llywydd.

A statement on the NHS workforce is, of course, timely, particularly given the extraordinary weather experience over the last week. I am grateful for the opportunity to join the First Minister in placing on record my gratitude and appreciation for the response of public service workers across local government, the national health service, emergency services, the third sector, and, of course, the wider public. The extraordinary commitment shown by NHS staff that we have all seen in the past few days is just another example of why they are held in such high regard by this Government and, of course, the people of Wales.

I want to highlight the work already under way to support, develop and expand the workforce, both now and in the future. We regularly discuss the recruitment challenges facing the national health services. The challenges are real, and, of course, I expect scrutiny. However, it is an undeniable fact that, despite eight years of austerity at the hands of the UK Government, tough financial choices made by this Welsh Government have seen the NHS workforce grow to record levels. Official statistics show that we have a record number of total staff working in NHS Wales. We have record numbers of qualified nurses and midwives, hospital consultants, and ambulance staff.

And this Government continues to take positive action, through our 'Train. Work. Live.' initiative, to support NHS organisations to train and recruit the workforce that they and we need. Already our return on investment has been significant, particularly in terms of the number of doctors choosing Wales to undertake their GP training. This May, I will be in Belfast for the launch of year two of the nurse 'Train. Work. Live.' campaign. And, later in the summer, 'Train. Work. Live.' will expand to include allied health professionals, with a focus on increasing the mix of healthcare professionals in primary care.

As well as recruitment initiatives, the continued investment that this Government has chosen to make in the education and training of the current and future NHS workforce is critical. Members will know that the budget for non-medical healthcare professionals has grown year on year. In December last year, I announced a £107 million package of support for 2018-19, and that is a £12 million increase on the year before.

And this continued investment during the past five years means that there has been a sustained increase in training places in Wales. This includes, over that time, 68 per cent more nurses in training, health visitor training places have more than doubled, an increase of 42 per cent in midwifery training places, 51 per cent extra occupational therapy training places, and an increase of 53 per cent in physiotherapy training places. We have invested and will continue to invest in training for healthcare scientists, dental hygienists and therapists, and in key emerging areas like training in genetics.

The role of the paramedic is changing, and will continue to evolve within a wide variety of care settings. There will continue to be a greater emphasis on critical decision making, treatment and management, rather than the historic focus on transporting patients to accident and emergency. And we are supporting those changes in the paramedics' role, and, since 2014, the number of paramedic training places available in Wales has increased by 139 per cent.

Unlike some other parts of the UK, this Welsh Government recognises how important it is to support our healthcare students during their study. That's why we have kept the NHS bursary. Last year, I announced that we would consult on future plans for the longer term financial support for healthcare students. That consultation will begin in the coming weeks, and I look forward to receiving a wide range of views from organisations and individuals to help inform future arrangements on a long-term basis.

As Members will of course be aware, there has been significant interest in the level of medical student places available in Wales. And in north Wales the debate around a new medical school has, of course, continued. And I have made the Government’s position clear. Our view is that Bangor University, working with Cardiff and Swansea medical schools, can and will deliver increased opportunities for medical education and training in north Wales. I know there has been a significant amount of work already undertaken to inform proposals for the future. 

I hope to be in a position to say more about those proposals in the coming weeks. But I want to make sure that we have a plan that is both deliverable and sustainable, and a plan that delivers the ability for students to undertake and complete their medical degree programmes in north Wales. While much of the focus has been on north Wales, many of the challenges we face in the north are also present in other parts of the country, particularly in west Wales, and I want to ensure that we also address those as part of a coherent plan for Wales. 

Despite the record staff figures, we know that demand continues to grow. That is part of the reason for our need to reform health and care services. We need more staff in certain professions and specialties, but we know that is only part of the answer. The fact that the challenges we currently face are taking place within the context of record numbers of staff demonstrates this. We owe it not only to the citizens of Wales, but to our NHS workforce too, to do this. We need to create a system that allows them to succeed in delivering the best possible care. That is why, when discussing our workforce, we cannot separate it from real and meaningful reform, including, of course, the need for new models of care that were highlighted in the parliamentary review. 

Part of the system reform we're committed to, of course, specifically in relation to the workforce, is the establishment of Health Education and Improvement Wales. This is a major and significant change. It demonstrates this Government’s commitment to a new, multidisciplinary approach to our health services. HEIW is not simply a structural change. It is a new, strategic approach to the long-term future of the health workforce. I was pleased that the recent parliamentary review recognised, in a number of significant ways, how the creation of HEIW could be harnessed to deliver the vision of seamless health and care in Wales. The review also identified the opportunity for HEIW and Social Care Wales to lead the way for partnership across the health and social care system. I expect those two bodies to be working as one across many of the challenges that will face our care workforce in the years ahead.

Like all of the public sector workforce, staff in NHS Wales have suffered at the hands of UK Government austerity. That is why we have repeatedly called on the UK Government to end the cap on public sector pay and give workers across the UK a much deserved pay rise, and it remains our view that that pay rise must be fully funded by the UK Government. One of the strengths in Wales is our commitment to social partnership and collaboration between the Welsh Government, the NHS and trade unions. This strength is something we will build on in moving forward once we have received the pay review body's recommendations in May to agree on a fair and affordable pay award.

Our NHS looks forward to its seventieth birthday this year. It remains a truly great achievement of political will and community values to create and sustain our national health service. The NHS that we celebrate is, of course, the story of our staff: people drawn from all communities and all corners of the globe. I am tremendously proud of the people who make up our national health service and I look forward to continuing to serve them as we redesign the future for health here in Wales.

Thank you very, very much for your statement, Cabinet Secretary. Apologies that I'm not Angela Burns for you today. Can I just associate myself with your remarks thanking the NHS staff for their work, particularly during this last week? I think we've all been surprised and delighted in some ways by the pictures of people stumbling through the snow in order to fulfil what they think are their duties to the population of Wales. 

I think one obvious way perhaps to recognise that commitment would be to fast track the staff in the NHS when they need the services of the NHS, not least so that they can get the quickest treatment or attention that they need for themselves, but because of the potential effect of that in making them able to come back into the workforce as soon as possible in order to offer their services, perhaps, in so doing, reducing the strain and stress on health boards when they're having to consider taking on agency staff. We know that 330,000 days were lost to stress-related conditions only last year, 2016-17, and, if those could have been acted on a little bit sooner, perhaps it would have been quicker or easier for those members of staff to come back into the workforce and continue offering the exemplary care to the people of Wales. I think agency staff cost £178.8 million last year. That's quite a big saving, if you can get people back into work as quickly as they would like. And, if you're worried at all that this sounds like preferential treatment, I'd ask you to consider the effect of behaving in this particular way, because it means that those NHS staff are back in work sooner and offering their services to the people who need them. 

We also talked about—. I appreciate that this is a statement on the NHS workforce here, but, following the parliamentary review, I think it's become a little bit less meaningful, if I can put it like that, to talk about the NHS workforce in isolation from the social care workforce. I certainly welcome the investment in the training places for the prevention and rehabilitation professions, and for those training in medical care, but if you're looking at a seamless service—you mentioned it in your statement—I think these kinds of statements need to start talking also now about the impact and career paths of those in non-medical care. So, I was wondering whether we might have a similar statement fairly soon on the social care workforce, not just the NHS workforce.

I'm very, very pleased to hear about the growth in the NHS workforce, but could you give us an indication of where that growth has been concentrated geographically? Where are the staff in certain disciplines, and has reconfiguration and some of the noises off that we've heard fairly recently, not least with Hywel Dda, already been seen to have an effect on where people are interested in working, particularly in the hospital setting but not specifically?

Yes, we certainly do need more staff in certain professions and specialities. The role of the deanery has come up several times in arguments on this in the past, and I'm wondering whether you can give us some indication of whether there's a specific issue—I'll call it that, as there's not necessarily a problem—with the deanery promoting those specialisms that we need at the moment.

Just two more, if you'll bear with me, please, Llywydd. Obviously, I'm very pleased to see that more people are doing their GP training in Wales. Can you tell us how many of those people are actually from Wales and what we're doing to keep them once they've been trained here?

Then, finally, paramedic training—I was very pleased to see that. Can you confirm whether the pay rise that paramedics have recently been proffered, if you like, is conditional in any way on the particular training that you've referred to? Is it a generic pay rise or is it specifically allied to this new training that you mentioned in your statement? Thank you.

Thank you for that series of questions. Again, I think the commitment of staff that we've all seen—stories of people walking miles and miles through the snow to get in—and the tremendous support of the public, with people giving lifts and going up and down roads to give staff lifts as they've seen them coming in, really is tremendously heart-warming, which, again, reinforces the public value that is placed on the service.

I'm going to deal with the range of points. On your point about whether we could fast-track treatment for NHS staff, there's a piece of work already looking at this following previous comments made in the Chamber. I do think that we need to add a note of caution about this, because if we decide to advantage groups of staff, wherever they're from—whether it's the NHS, or whether it's the emergency services, carers or whoever it may be—and if we say that it won't be their clinical need but who they work for that will see them advantaged in the system, I think we need to think very carefully about what that means.

So, I certainly wouldn't stand up in the Chamber today and say that the NHS workforce will get prioritised over and above other people, but there are challenges about the NHS as an employer in any event. Any employer should support their employees with good occupational health support either to keep them in work or to help them return to work if they're out of work, and to understand the reasons for that as well. That's a different point to, potentially, seeing them leapfrog other citizens of the country for treatment.

On the social care workforce, actually, Rebecca Evans, in her previous role, made a number of statements about promoting the social care workforce and a career path for them. You'll hear more from Huw Irranca-Davies on those points in the coming months as well. Also, that will be linked into the commitments that the Government has made in 'Prosperity for All', about the social care sector being a priority sector as part of the foundational economy. So, you will hear more about the social care workforce individually as well as together, as I've indicated in my statement about the development of skills for and with that workforce that is, understandably, integrated, and will be more so, with the national health service.

On the geographical growth in numbers of staff, some of our areas have actually done particularly well with this. In nurse recruitment, for example, Hywel Dda have done particularly well on actually recruiting more nurses in the last year or two. Part of the challenge in different grades of staff is that it can be difficult recruiting in different parts of the country—that's why 'Train. Work. Live' was designed, because you can actually have a great life living in the western parts of Wales, whether north, mid or south, and it's about how you make those opportunities available and then understand what that means for those healthcare staff and their families to move there and to make a positive choice to live in or near that part of the country.

Some of that also, though, goes back to the points that I made in my statement about the models of care that are provided, because there's something about understanding and taking on board the challenges the parliamentary review set out for all of us that if we want to try and run our current models of care, then they won't work—they won't work for the staff or the public. So, our current way of running the whole service isn't fit for the future, and changing that really does matter. And I've given previous indications in the past of models of care that have changed that have made recruitment easier. Stroke care in Gwent is a good example of where change in the way care is delivered has made it easier to recruit the right staff to deliver that improved quality of care. 

I can't tell you what the percentage of Welsh-domiciled GP trainees is, but I'll investigate to see if I can give a meaningful figure and write back to Members on that. And on band 6 and paramedics, you'll have seen that England announced a band 6 paramedic status some time ago. They've yet to agree how to get there, though, so that isn't in place there. We went through that, and, again, in social partnership we had a conversation with employers, with trade unions as well, and we not only agreed a road map for band 6—so, what that should mean—but, actually, how to get there too, because it is about new skills and those skills being consistently applied to have the band 6 pay that goes with it. Not every paramedic will want to do that. There will still be a role for band 5 paramedics within the service. So, we're in a good place, and that is money for reform and improvement. It's good for the workforce to do a job they will find interesting and the skills we will all benefit from in the public at large. We made a difficult choice to invest money in doing so, and that means there is money that we've invested there that isn't available in other parts of our workforce, but that is a choice we have made, again, for the future of the NHS and the people that it serves.

I think the stories that we've heard from across the NHS in the recent extreme weather conditions show the extreme dedication of staff to provide care for their patients, and I hope that they hear our gratitude for their commitment to their work and the service they provide. 

Thank you, to all the NHS staff, for your commitment.

I have a number of questions to ask. One could insist that everything was fine in terms of staffing levels in the NHS in listening to this statement, but I do have a number of issues that I think are important to emphasise and to highlight here. This claim that there’s a record number of staff working in the NHS. We still have fewer GPs working in the NHS in Wales than we had in 2013. StatsWales hasn’t published figures for corresponding numbers of full-time posts for three years, whilst they are looking at the quality of the data. We have fewer hospital doctors than we had in 2014 once you remove that 'general practice doctors in training' category from the figures—something that was added from somewhere to the figures in 2015.

It’s true to say that official figures do show that there are more people working in nursing, midwifery and health visitor roles. It isn’t clear, however, from your statement this afternoon, how many qualified nurses are working—that is to say, fully qualified nurses—within our national health service. And we know from a freedom of information request from the Daily Post recently that 750 fewer nurses are fully qualified in the Betsi Cadwaladr health board than we had five years ago.

And add to that concerns about Brexit, and we haven’t felt the impact of that as of yet, although there is anecdotal evidence about the negative impact it will have. But would you admit that the picture that you painted in your statement is incomplete? Would you also admit that we must give consideration to the full picture, including those negative elements—the problems in terms of workforce planning—rather than just looking at the positives that there undoubtedly are, or we can’t truly get to grips and resolve some of those problems?

In terms of training places, once again you refer to paramedics, nurses and other health professionals in relation to training places. I celebrate any increase in training places, but we can't avoid the difficult question on GP and doctor training specifically. I am very eager to see this Government bringing us a figure as to how many doctors you hope to see trained in Wales in ensuing years, wherever they may be. What is our output to be in terms of the number of doctors trained here?

And that brings us on to plans for a medical centre in Bangor. You’re entirely right in saying that the west is also very important in terms of increasing the numbers trained, but, in terms of Bangor, I’m very pleased now that talk of medical training in Bangor is a central part of any statement on NHS workforce planning. Siân Gwenllian and I are certainly pleased to see that we are gaining ground here, and I’m very confident, having had discussions with Bangor University, that we are moving in the right direction. But, as I always do, I will ask you for a little less ambiguity. You talk about training opportunities; tell us once again that full training will be available in Bangor from year 1 to year 5, because that’s the direction we need to travel in—and I’m confident that we are going in that direction. Also, a bird in the hand may be worth two in the bush, and perhaps I should not just focus on doctors, because I can tell you that there is  pressure already to include dental training in the new centre in Bangor. Again, last week, I was asked about introducing an element of pharmaceutical training in Bangor. So, it’s not just doctors that we’re talking about here, but the whole range of professionals across the health service.

And just very briefly in terms of nursing, can you comment on continuing professional development for nurses specifically? I know it’s something that the RCN is concerned about, namely the lack of time and attention given to CPD. Also, there was no reference in the statement to provisions for the safe staffing levels Bill. Is there a statement on where we are with that?

Thank you for that series of questions. I'll try and take them in a sensible order. I want to start at the outset by saying that I don't think my statement does avoid the reality of some of the challenges we face. I'm very explicit about those challenges in this statement as well. It's certainly not any desire on my part not to paint the full picture. If you wanted a complete, detailed picture, I'd still be on my feet for some time, which I might be happy to be but other Members may not be so. But, it is an undeniable fact, not a claim—it is an undeniable fact—that we do have record numbers of NHS staff. That is an undeniable fact. But, within that, we recognise there are challenges within different staff groups and also how we get our staff groups to work in a different way now and in the future. That's so much of what we have to spend our time upon.

I'll try and deal with your questions about doctor recruitment at this point as well, and training. I don't think we have really been ambiguous about our expectation for north Wales. I've been clear that I wanted to see as much medical training and education as possible taking place within north Wales. I've deliberately not committed to saying absolutely what that would be because I don't have a plan in front of me to do so, and I need to understand the evidence of what is possible, the discussions that I've indicated in my statement that are taking place, and then there will be a signed-off plan. At that point, there'll be more detail.

Not only that though, but hearing the Cabinet Secretary for Education intervene, there's a serious point about the work that we have to do together—that we have to continue to do together—on funding, because there are pressures in the budget, as everyone in this room will know. So, it's not just about having a plan that looks and sounds great, but actually we have to fund it. If we're going to fund a plan to do that, about who we expect to take up those places, and really then see a benefit for us as a whole and actually see more doctors from Wales being able to train, work and live within Wales, but also more doctors then staying in Wales, wherever they come from, at the end of their period of study, we can't avoid these very real and practical discussions that we need to have and it can't simply be that I announce a great policy position and I then say to the Cabinet Secretary for Education, 'You now need to pay for it.' It's not as simple as that and nor should it be.

On the broader point about the future of the workforce, that's why I made reference to Health Education and Improvement Wales, and actually what will come from that and the long-term plan for health and care in Wales. We'll need to understand, for that future workforce, the models of care we want to have and the staff we'll need to be able to deliver that too. I just want to make this point about—. You mentioned GP challenges; well, that's why the first phase of ‘Train. Work. Live.’ with GPs has been so successful and such good news for us that we overfilled our places as a country. But it's also worth pointing out when we talk about GP numbers that the great majority of GPs are not employed by the national health service. They contract with the national health service to provide services, and part of our challenge in delivering a future NHS workforce is having models of employment that allow us to do that.

I'll deal with your questions about nurse recruitment as well. We do have a record number of qualified nurses right across the national health service. Some of that varies from one health board to another. I recognise that you were making points about north Wales, but I'm really clear that this is about qualified nurses, and this goes back to the point about the Nurse Staffing Levels (Wales) Act 2016, which will be commenced in April. Commencement is not being delayed, and I expect to report in the future to this place on the early stages of doing that to see the impact of that and to see whether we are seeing improvements in the quality of care as a result, because that was the point of the Act. It is to make sure that we see improvements in the quality of care delivered. But there's something about saying that those will be qualified nurses, so we're not moving down the track with the NHS workforce that they've been taking in England where they're introducing nurse associates. The Nursing and Midwifery Council have agreed to regulate them, but I am genuinely concerned, as are indeed the chief nursing officers of Wales, Scotland and Northern Ireland, about whether this is really about role substitution and really about the financial saving rather than having appropriately qualified staff to do the right jobs and deliver the right quality of care.

I'll make one final point, because you mentioned Brexit. We have real challenges in nurse recruitment in Wales and across the UK and across the wider western world. We know that we'll need more nurses. It's part of the reason why we continue to invest more money in nurse training—because we know we need to grow lots more of our own. But also, to keep the service running, we need to continue to recruit staff from other parts of the world. That's also why I made it explicitly clear that the national health service has always relied on staff from every community but also from every country around the world as well. It's part of our success story that the national health service has actually made the country more cosmopolitan and multicultural. If you look at the people who exist within Wales now in different communities, they're here because of the national health service.

That's why I really do hope at some point for an outbreak of common sense on Brexit and the position we will take on actually having equivalence in both standards, whether it's pharmaceutical issues or about qualifications, and our ability to recruit staff from within the European Union and also much further afield than this. I don't often say pleasant things about Jeremy Hunt in public, but I actually think that, on the challenge of recruiting staff from outside the European Union and the wider world, I think Jeremy Hunt wants to be able to do that in a way that's sensible. The challenge is that, within the UK Government, the Home Office continue to stand in the way of doing that. That is a challenge for all of us. I really do hope there'll be an outbreak of common sense within the UK Government for the Home Office to get out of the way of recruiting the right sort of healthcare staff for every part of the national health service in all four nations of the UK.

Thank you for your statement, Cabinet Secretary. The past weekend highlighted just what amazing people we have working in our NHS and the wider health and social care sector: doctors and nurses doing double shifts, GPs sleeping in their surgeries, staff walking miles in blizzard conditions, all to ensure that patients continued to receive world-class care, despite sub-zero temperatures and snowdrifts. Therefore, I wish to place on record my thanks to all our NHS staff for the amazing job they do, day in, day out, whatever the conditions and the pressures they are put under. I may disagree with you from time to time on policy, but I will always stand shoulder to shoulder with you in defending our NHS staff.

The only problem with our NHS workforce is that there aren't enough of them. Cabinet Secretary, I welcome the additional investment your Government has made in non-medical healthcare professionals and the increase in training places in Wales. However, there are increasing shortages in some areas of our NHS. As our NHS evolves, the staff requirements will change. Therefore, Cabinet Secretary, how will the LHBs and Health Education and Improvement Wales work together to take a more strategic approach to workforce planning in our NHS? Planning is essential to embrace the changes ahead. Will HEIW be undertaking an audit of staff within each speciality in order to address any shortfalls? When we look at diagnostic staff, Cancer Research UK tell us that there is no data on vacancy levels within endoscopy. If we are to maximise the effect of the faecal immunochemical test on bowel cancer, we must ensure that there are sufficient numbers of staff able to conduct colonoscopies. Cabinet Secretary, do you or HEIW have any plans to create a non-medical endoscopist training programme within NHS Wales?

Of course, the majority of patient interaction within the NHS comes at the GP surgery, despite the fact that general practice receives just over 7 per cent of the NHS budget. Cabinet Secretary, do you support the Royal College of General Practitioners's call to increase the spending on general practice to at least 11 per cent? The royal college have also stated that GP training places need to be around 200 per year. You have made progress in increasing the number of training places in recent years, but do you have any plans to increase this further?

Finally, Cabinet Secretary, NHS England have announced a state-backed indemnity scheme for GPs over the border. Therefore, do you have any plans to introduce a similar scheme for Welsh GPs? As we celebrate the NHS’s seventieth birthday, it is important to highlight that it wouldn’t exist without our excellent staff, and we must do all we can to show our NHS staff how much we value them, both in monetary terms and also in terms of increasing staff. 

Thank you for the comments and questions. I'll start with your first point about, 'We don't have enough staff'. Well, we have record numbers of staff. We will always need to be thinking about how we have those staff organised in the best way to deliver the best possible care, regardless of the financial picture or otherwise. We always have a responsibility to do that, but we are eight years into austerity, and the choices that we are making to put more money into the national health service come at a real cost to every other part of public services and public spending in Wales. If the Cabinet Secretary for Education were on her feet, she would tell me about real pressures, and if the local government Secretary were on his feet, he would tell you about pressures in those sectors as well and beyond. So, let's not pretend that this is simply a matter of political will; this is a matter of our budget being reduced deliberately. You know, people voted for a Government that promised to impose austerity in three successive general elections, and I wish they had not, but that is the choice that people made and I really do think that people who have stood up and campaigned for a Government to do that over three successive general elections need to take some responsibility in those parts of the country in Wales where they are now faced with having to make choices that are as a direct consequence of United Kingdom Government austerity.

On Health Education and Improvement Wales, the purpose of this is to improve strategic planning of the workforce. That's what they will do. As they move into the shadow form for the first six months, I will have more to say specifically about that, so rather than talking off piste now I'll come back, I'm sure, in the future with more to say about them and their way of working.

Just briefly on your point about non-medical endoscopists, we already have some within our system already. I've met a nurse endoscopist within Powys. I think it was actually in Russell George's constituency. So, those people do exist and our challenge is how we have a route for them to continue to do that, as opposed to that person being a one-off.

On your point about the percentage for primary care, I've stood on my feet in this Chamber more than once in the past and talked about the percentage of NHS spend that goes into primary care—it's actually more than 11 per cent. The regular response then back is from the Royal College of GPs, who are actually talking about the general medical services side of it, so a specific part of primary care, not primary care in total. But you will have seen the ambitions that are set out by this Government, but also within the Parliamentary review, to have not just an increasing level of activity within local healthcare, but to actually make sure that resources follow that and we have a plan to deliver more resources in local healthcare where more activity will take place.

On your final point about GPs, I just want to go back to the points that I've made about where our workforce comes from. Many of our GPs, from the implementation of the national health service, have come from other parts of the world. Myself and many other people meet BAPIO, the British Association of Physicians of Indian Origin—a huge part of the history of the national health service and of its future. They too are concerned, as are all GPs, about indemnity. The state-backed scheme that was announced as a preferred option for the UK Government in England is still something we don't have clarity on in terms of what it means and its application. I say again: if there is to be a scheme that is negotiated with the British Medical Association and others to support GPs in England, and the UK Government and the UK Treasury stand behind that, I would expect no less favourable terms to be made available to GPs in every other part of the United Kingdom. But those discussions are not complete. So, I'm not in a position to tell you, because I know that the UK Government Minister is not in a position to tell anybody else whether there's agreement on what that will look like. But there is recognition that indemnity is a real mischief for us to conquer.

Like others, Cabinet Secretary, can I also join you in thanking the health and social services staff, emergency responders, public service workers and volunteers, of course, in the efforts that they've shown over this winter and especially over the last few days?

In my former role—I may have mentioned this once or twice—I was a trade union official, and I did represent NHS staff. It's particularly pleasing, I think, to see the paramedic band 6 coming to fruition. I was there at the outset of those negotiations, and seeing that come to fruition is really quite pleasing, and I'm glad that's now happening. When I was in that role, I was aware on a daily basis of the kind of heroic efforts that we saw NHS staff performing over the last few days. It has perhaps been more in the news, it has been more public over the last few days, but actually, if you're in the service, you see people going a step further than they need to every day of every week. I remember very clearly having to talk to some politicians and political parties about the need to be careful in their criticisms of the NHS, which play out, intentional or not, as criticisms of the staff who deliver our service, and the demoralising impact that that had then and continues to have.

So, I'd certainly echo your views, Cabinet Secretary, that if the Conservatives in particular are so keen on supporting and thanking our NHS workers for the terrific job they do week in and week out, then their move certainly should be to lift the pay cap and make sure that all of our NHS staff get the pay rise they so richly deserve. And I'd certainly also echo your views that just calling for extra staff in a vacuum is not going to take us any further forward when we are, as you've said, eight years into a period of austerity that one particular party in this Chamber seem to continue to advocate.

But my questions to you, Cabinet Secretary, are: despite the undoubted record numbers of staff, the pressures are still huge for all the reasons that you've set out, and given those types of pressures, specifically, that we've just witnessed, would you agree that staff well-being has to be a very high priority and that people will need now some time and space to recover from these recent pressures so that we can sustain the services over the medium to long term? And can I ask you what more you think we can do to help manage those pressures on those hard-working staff, both in health and social care? 

Thank you for the comments and questions. You're right about the band 6 conversation; I remember you in a different role when those conversations started, and I recognise you are in Unison and suffragette purple today as well. I do recognise there's something about the good will and the commitment of staff. It's a regular part of what keeps the service going, because NHS staff do not work to the letter of their job description; they go above and beyond it on a regular basis. If that stopped, then large parts of our service wouldn't take place in the way that they do.

On the point about the negative public and political debate, it does impact on staff. I remember meeting, as the then Deputy Minister for health, paramedics, and they were particularly downcast for the way that they felt they were talked about. They didn't feel it was the Government that was being talked about every month when ambulance response times were published, and it did affect their morale in a real and material way. There's something about the wider public debate and the impact it has on the current workforce, but also, potentially, the workforce of the future, because there are some people who are opting not to pursue a career in medicine or in the health service because of the way the NHS is regularly talked about. They see that on the first few pages of newspapers on a regular basis—and the distance and the speed at which the negative news travels about the national health service. So, that's why I try to take every opportunity to thank and praise NHS staff for what they do.

On your point about the pay cap, I know that matters too, and there's something about the value that people feel placed upon them as well. Having seen teachers having the continuation of a 1 per cent pay cap and having seen other public service workers having that pay cap continue, what next happens with the pay review body's reporting, and the terms on which any pay rise is offered, will matter a great deal to today and tomorrow's workforce as well. I sincerely hope the UK Government recognise their responsibilities and do the right thing in providing a fully-funded, decent pay rise. 

On your point about staff well-being, I recognise this all too well. For those staff who work really hard, you can't keep going at 100 mph every single day, because at some point people end up breaking. So, they need to have time to recover and the space to do so. That's why we have decent terms and conditions for NHS staff, but it's also why it's important to look again at what the parliamentary review said about staff well-being. I think it's really interesting their proposal about the emphasis that we should have on the well-being of our staff and how they're treated and managed, and, actually, how they feel genuinely empowered to make choices about the future of the service because that matters too. So, there's a range of things.

It comes back to my point about the NHS as an employer, employing over 90,000 individuals in the country, and it needs to make sure that it's a good employer and looks critically at itself and the way it treats all of its staff and recognises opportunities for improvement. I've never said the NHS is a perfect employer because it is not, and that is something we will always continually need to look at and that will definitely form part of our response to the parliamentary review.

Can I thank the Cabinet Secretary for his statement on valuing the NHS workforce? Following on from Dawn Bowden about staff well-being, I was going to concentrate on junior hospital doctors and their continuing well-being, and ask specifically of the Cabinet Secretary what he is doing to address the concerns of junior hospital doctors in Wales today and to explore the culture of how their rotas are managed within our hospitals.

Obviously, there's been mention of 70 years of the NHS this year, and some of us have been working in the NHS for more than half that time, now, I shudder to think back. But anyway, back in the day, as junior hospital doctors, we worked in fixed firms—consultant, senior registrar, registrar, senior house officer or SHO and house officer. It was fixed, you had the same team day in, day out, and it was the same team for six months. There was no problem with rotas; we worked very hard—over 100 hours a week. There was no problem getting time off for study or exams and there was no problem getting time off to get married. Even the administrators were there all hours, helping us all out—one big happy family. Fast-forward to today and our juniors feel undervalued and unloved. They no longer work in fixed teams. Modernising medical careers has wrecked that firm and juniors now work with different people every day; they're not in a fixed team. Litigation has risen, they're held to blame, as individual errors, for systemic failures, when the gaps in the rota mean that they have to cover two or three and sometimes four or five wards on call. If something happens, it is automatically their fault and not the fact that there just weren't enough doctors around and they were having to cover multiple wards.

There is a schism between hospital administrators, particularly the ones who arrange the rotas—they're no longer part of the team, so juniors now have to battle to get time off for holidays, time off for study leave, time off to study for the exams that they need to progress in their careers, and even have to battle for time off to get married and have a honeymoon and things. Now, that wasn't the way it was; there's been a subtle change in culture. Juniors feel harassed, bullied and exploited and that's why they're leaving. So, in terms of valuing the NHS workforce, Cabinet Secretary, can I ask what you're doing specifically to address the concerns of junior hospital doctors in Wales today? Diolch yn fawr.

Thank you for the comments and questions. I think it's a reflection of the fact about how much the NHS has progressed in terms of the level of activity that now takes place—the level of demand that comes through the doors of the national health service in local healthcare and in hospital settings and the ability of the national health service to do more. This is part of our challenge. It also goes along, of course, together with the demographic rise and the fact that more of us live longer—a celebration, yes, but also a challenge for the health service. But also the fact that the health of the nation has not improved in every single aspect. Part of the challenges we see coming through our doors are driven by poor population health outcomes.

I agree with you that individual staff, particularly—and this is almost always where it happens— . I go back to my previous life when I, at one point, represented some of Dawn Bowden's members and others in and around healthcare services, in Health and Care Professions Council and Nursing and Midwifery Council hearings and fitness-to-practice hearings, and, actually, you tend to see more junior staff carrying the can for individual system failures and you tend not to see senior registrars being brought for those regulatory hearings. I don't think that's right and we need to think again about the culture we create and the regulatory environment that recognises individual and collective responsibility in doing so.

I also recognise that part of the reason why juniors feel particularly put upon—. I don't think you can really underestimate this, but I'm still struck, even in Wales, by the anger that exists about the junior doctors' dispute and strike. Even though lots of juniors said they felt grateful for the fact they were in Wales and not in England at the time, it really has poisoned the well in terms of how juniors feel about the whole health service and their willingness to not just train here but then to commit to remaining within the UK as well. That contract is part of where we are in our conversation with junior doctors. So, I meet the British Medical Association on a regular basis and they regularly bring the chair of their junior doctors committee to that, partly because it's time we had a conversation about the contract and the dispute, but it's more about what we then do, because rotas—that's all part of the conversation that we have. So, I continue to have an open and constructive conversation with the British Medical Association, and I expect to continue to see representatives from their junior doctors, because we need to particularly understand the particular challenges they face, because, after all, they're part of the future of the service.

Thank you, Cabinet Secretary, for your statement today, and I think it's important that we remind ourselves of the importance of the workforce in the NHS. Can I join you and others across the Chamber—and I'm sure I'm speaking for everybody who might not even speak today about the support we give to the NHS staff, the appreciation we have for their commitment, particularly during recent days and the difficulty in travelling? Even at times when police have said only to travel if it's essential, NHS and care staff believe their attendance to look after patients and clients is essential, and they've made that effort. I was at Neath Port Talbot Hospital on Friday morning—we weren't as badly affected—dropping my wife off to get into work, but I saw staff bringing in overnight bags, because they'd come from areas that were affected and they knew that they needed to be at that place of work to deliver the care for the patients. We should always appreciate that and never forget that.

You also highlight today that, clearly, there are record levels of staff in the workforce. I totally agree. There are record levels of staff in the workforce. But we also have to recognise that we're no longer generalists, we have a lot more specialists in different areas and, therefore, we have large numbers of staff, but some of them now specialise in areas that were far more general before. I will take my wife's area as an example. In radiography, we've got ultrasound, MRI, CT—computerised tomography, nuclear medicine, ordinary extra diagnostics, radiotherapy—[Inaudible.] There are so many specialisms in that one area that we might have more radiographers, per se, but perhaps less per different area. So, I'm also pleased to see the intent statement yesterday that highlights the work being done in that particular imaging area, which is good news, as well. We do have to recognise that that means there are going to be shortages elsewhere.

Dai Lloyd mentioned junior doctors, but let's not forget the out-of-hours GPs, which are also a big issue we have to address, because we are facing challenges with out-of-hours GPs. That's not necessarily the number of GPs, that's just some people being able to have time to do out-of-hours work and not feeling so stressed in their normal day work. That's part of the problem we need to look at.

But we also have to recognise that training is great, but it takes years. It doesn't happen overnight. There are several years of training and then they need experience, and, sometimes, we need the cover now. So, I'll go on to one of the issues for nursing, for example. Banking is an issue I think we need to look at very carefully across all health boards to ensure banking is consistent. I have met with trade unions that have concerns that—there is a limit on banking, or if you're going to do banking, you actually take out a new contract, so you're not being paid overtime. Therefore, the value of NHS staff—make them feel valued by simply not saying to them, 'You can't have overtime, you've got your own different contract and therefore you're getting flat-rate pay for maybe working 70 hours in a week.' We need to look at banking to ensure it's consistent across Wales and it rewards staff, because it's cheaper than having agency staff. Many people don't do banking now, and you get agencies in, and that costs you a lot more money. So, please will you look at talking to the boards to address this issue on banking?

You also talked about paramedics—fantastic news about paramedics, but we are also seeing a wider range of paramedics now—they're being used in GP practices as well. So, as we train more, they are being spread across areas more. So, I think we need to increase the numbers of paramedics being trained.

Similarly, as has been mentioned by Suzy Davies, the deanery—. The Welsh Government need to address some of the issues the deanery raised, to increase the number of doctors being trained to be GPs. The numbers have to go up to the limits of 170 that were being talked about. Now, I understand—. Can we fill the 170? That's the question, but if we don't put the number there, we'll never know. So, I think we should be addressing that as well.

Llywydd, I'll stay at that, because I see I'm out of time. But I think it's issues of valuing staff, not just simply saying the words, but putting into action the value we have for our staff.

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

Thank you. That's a really helpful point about the appreciation and the value that we do place on the staff, not just at extraordinary times, but, as Dawn Bowden has mentioned, all throughout the year, and the remarkable service that we are privileged to have within this country. I recognise your point about the balance of generalists and specialists to see—[Inaudible.]—about the shape of training in the medical field, but it's a part of what we need to understand and part of the work that Healthcare Inspectorate Wales will be there to understand and help the system to understand as it plans the different levels of staff and the different numbers of staff and how we then expect them to work together.

I'm pleased to hear you recognise the imaging statement of intent. I think you're the only Member to have mentioned that, but it is an important step forward, and it's been worked through with staff in the field as well to have a coherent vision for those staff in the service that we know that we'll need them to deliver. This impacts on a wide range of the national health service.

On the bank arrangements, I recognise there's a challenge for us here, and a real challenge about the rates of pay, how it's organised, how convenient it is, and I think there's a link to e-rostering as well—how we can make it work for staff to undertake shifts that work for them and for the service. There is a piece of work already under way on those areas. So, in the coming months I expect to be able to report back on those for you in any event.

On GP training numbers, you're right—I'm interested in seeing how we go this year, and if we again fill or overfill, we'll then have a different conversation about the infrastructure we have for how many training places we could accommodate, as well as an understanding of how many more people we think we can actually have to undertake GP training numbers here within Wales, and, of course, that conversation about the budget to support those people as well.

I'll finish with the point about paramedics. Again, there'll be comments about the numbers of paramedics we need to train. Paramedics themselves are a highly desirable commodity, and lots of people look to recruit them outside the Welsh system as well. But also the roles—and you're right, the roles are changing, as I recognised in my statement. There's something also about the rotas and how we expect them to work. Because if you take a paramedic out of the emergency ambulance service and you place that paramedic into primary care, if they're there for a long period of time, they may not be able to easily move back into the emergency service, and there's a potential to de-skill them for all parts of their role. There's something about understanding how experienced paramedics, in particular, have a rota and a job description, and a role map that allows them to move into different parts of the service and to continue to add value to those parts of the service. If it's about a regular rotation in different parts of the service, we may well see greater value both in terms of the delivery, but also for that person still feeling valued and having a job that they want to do and not being burned out by one part of it or the other.

Thank you very much, Cabinet Secretary.