Questions now from party spokespeople. Plaid Cymru spokesperson, Rhun ap Iorwerth. 

Thank you, Llywydd. Cabinet Secretary, England and Scotland publish data regularly on cancelled surgery. Is there any reason why you don’t do that for Wales?

We don't regularly publish—we answer responses to publish operations that are cancelled. I don't have any plans to add to official statistics on this matter unless there is a compelling case to do so. I'm happy to listen to that case as it's made.

It is something that concerns my constituents. In January, you apologised for cancelled surgery, saying, at that point, that is was the onset of winter, which came from somewhere, that was to blame. But surgery is still being cancelled week on week. I’ve had a number of constituents coming to see me recently to tell me about treatments being cancelled not once, not twice, not three times, but even more than that. There was one man who was starting to see mental health problems emerge in his wife because of the strain of having these treatments cancelled time and time again. The question is: what do we do about this? Is there scope to introduce financial incentives in order for health boards not to cancel? Is there scope to compensate patients even, or why not just ensure that these treatments aren’t cancelled time and time again?

I do recognise that this is an issue that causes significant inconvenience and worry for any patient or their family when an operation is cancelled, whether it's a minor or a more significant one. There's challenge about individual issues, and if he wants to contact me with the particular circumstances that he's mentioned then I'll happily take them up with the health board about the reasons behind that. As well as those times where there are individual issues, there are system-wide challenges that we recognise and actually the majority of operations that are postponed are postponed by the individual in question as opposed to by the health service. Our quest is both to understand why that happens and to avoid those operations being cancelled, whether they're by the citizen or by the service. And, on that, I have to say I'm rather more sceptical about the value of financial incentives or sanctions to do so in terms of the impact that will have on the system, because, when the health service cancels an operation, it is largely because they don't have the capacity to do so and that is often about the overtopping of unscheduled care into the primary care system or is due to unforeseen staff unavailability. I don't think that financial incentives or sanctions would necessarily help that. What I do think, though, is that our ability to plan and deliver across the service is more important. That's why we've brought together regional planning fora in south-east Wales, in mid and west Wales, and it's why we continue to support the health board in north Wales not only to achieve a significant improvement in referral-to-treatment times to the end of the financial year that's just finished, but also they'll continue to receive support for the future.

You talk about patients cancelling their own operations, and it is something that we hear from you and your Government quite often, that it's often the patient's fault for turning up in hospital when they shouldn't and for being ill perhaps when they shouldn't. I can tell you about stories of people having their operation cancelled when they're on the trolley at the door of the theatre, and not for the first time—for the second, for the third time. We cannot continually blame the patient for taking the wrong course of action. We know that cancellations happen for all sorts of different reasons, and, yes, of course, some patients cancel their own treatments. We know of administrative problems—operations being booked in for when clinicians are on leave. It shouldn’t happen, but, okay, it happens from time to time. We know we have staff shortages. I won't go there today—I'll have plenty of opportunity to come back to that one. But, quite often, at the heart of why an operation is cancelled is that, somewhere in the system, there's a bed missing. We've lost 1,000 beds since 2011, either at district general hospitals or in community hospitals. And, yes, we need to get patients home or to their usual place of residence as quickly as we can, but I am absolutely convinced that the loss of community beds is costing our NHS very, very dearly and it's costing our patients very, very dearly. Will you agree with me that the time has come to reinstate lost community beds? Because otherwise what we will see is patients being trapped in a system and operations, yes, being cancelled time and time again and the detrimental effect that that has on patients, not just in the short-, but in the long-term too.

Thank you for the follow-up question. I do think it really is unfortunate that you recast my words in a way that have absolutely not been provided. I'm not blaming the patient for being sick or inconvenient to the health service. It is a fact, though, that over half of the operations that are cancelled are cancelled by the patient. We need to understand why that is, to understand how we can help patients to plan what they wish to do and to understand the impact on the service. In addition to that, we need to deal with those matters that are in control of the service as well. I think I'm pretty clear in stating that, both in writing and on each occasion when questions are asked. Part of that is actually the challenge about beds, and not just the numbers but the numbers of staff you need to staff beds, but also the bed mix and where that is, because actually it's about having appropriate beds for step-up and step-down through the hospital system, and that may be about the rehabilitation focus to get people out of an acute hospital.

But we have seen a significant increase in efficiency through the service already. There is a significant increase in day surgery rates within the national health service in Wales. It's why we're able to be more efficient in actually undertaking a greater amount of surgery than ever before. But, in particular, it is about the planning of that activity through the whole year. Part of that challenge, honestly, is that, in the last quarter of each year—from January to March—we plan too much activity. We're not able to frontload that activity through spring and the summer, and that's part of the challenge that I set for the health service again this year: to do even more of that activity that can be planned and delivered in the summer months. Trying to deliver the greatest amount of activity between January and March obviously leaves a risk, and we saw that this year, where there were significant weather events, and that has affected not just the unscheduled care part of the system but the planned care part of it as well. That is absolutely part of our challenge. The health service understands that, I understand that, and I expect to see significant improvement within the first six months of this new financial year.

The Conservatives' spokesperson, Suzy Davies.

Diolch, Llywydd. To the Minister, these questions, I think. In July 2016, your predecessor told us that the carers strategy was being refreshed and, 

'That will be happening later this year', which, of course, meant 2016. It's now 2018, and the most recent carers strategy for Wales is still branded 2013, and, in a written statement last year, you still referred to the strategy as being a 2013-16 strategy. I know about your ministerial advisory group, but I think it is a surprise that a change of Minister seems to have comprehensively derailed the publication of a strategy that was, to the naked eye, virtually ready for publication. Can you tell us what's happened, please?

Yes, indeed. Thank you for the question, Suzy. It's not the case, actually, that the strategy refresh and review has been derailed. It is under way, but we're not waiting for that either. We're getting on with a range of matters in respect of carers, and not waiting for the carers ministerial advisory group, either, to do it as well. I refer back to the statement that I made previously here, in the Assembly. So, for example, we only recently launched the toolkit for schools on identification of carers. So, there's some tremendous work going on, and it's focused on identifying, providing the advice and support for those carers, including on respite—and flexible respite as well—but also focus on bringing together the third sector, local authorities and other public bodies that can actually provide that wraparound service for carers. But the critical thing is that we're getting on with it while we also look to refresh and review that strategy. Strategies are fantastic, and we need them refreshed and reviewed. We also need to get on with the actual actions that will deliver the right outcomes for carers as well.

Thank you, Minister. I'm always happy to welcome action, as long as that action is both forthcoming and effective, shall we say. I don't think your answer quite explained what's happened in the last 18 months, in terms of what happened to a strategy that was nearly ready. Perhaps I could move on to some of the other points that have been raised with me by carers in meetings, one of which is the variety of understanding of carers' rights that there is between different local authorities, and actually within some departments within local authorities. Can you clarify who is responsible for ensuring consistency of assessment in different councils, and why this is an ongoing problem?

I think you rightly identify an issue that follows on from the approach that we've taken of co-production, which is supported by all Members here, that, in terms of assessing the needs of carers, it should be something on which we work in collaboration with the individual who is looking to see the right care package—the right package of support and advice for them—but they also, of course, have the right to advocacy as well, and they also have the right to make representations when they don't think the right package has been put forward for them. All of those places are not only there in terms of the legislation, but also the codes as well.

Now, if there are specific instances, Suzy, that you want to draw to my intention, I'm more than happy to look at them. There will, of course, be variability in the way that this is done between local authorities, but our expectation, as the Welsh Government, is that the entire focus in every individual circumstance is that this is done with the individual to provide them with the right package of support for them as a carer, and, if they're not satisfied with that, then they have that recourse to advocacy, they have that right to challenge that package that's been put forward. There's tremendous work, I have to say, being done on the ground as well by people such as the Carers Trust, who I meet regularly, and take these issues up on behalf of individuals who aren't happy with the package.

There is the backdrop to this as well, I have to say, which is the context—that in putting the right support and advice package together, including respite support for carers, we do it against the context in which we exist. You will see local authorities in the region that the Member represents as well saying, 'Ideally, we would like to provide something that is more enriched, more deep, wider for that individual. We cannot do it because of the cutbacks in local authorities', and that is the reality of some of the decisions that are made in a co-productive way. It's right to do it in a co-productive way, but when a local authority says, 'Well, because of the financial constraints we're under, which is because of where we are with austerity funding, we cannot provide the entirety of services that we wanted', that has an impact on the individual at the end. It's a tragedy to see, and I saw it when I met recently with young carers in Carmarthen; they liked the approach that we were taking to this, they liked the fact that their voices were being heard now more than ever, but they were frustrated when, with the best will in the world, in their local area they were being told, 'Well, that day club, that evening out, that whatever—it isn't available anymore. We'll have to look at something else'.

So, we have to wrestle with this all the time, about how we put the right package together. But they have advocacy, they have the right to co-determination of this package being put forward, and I think that's the right legislative framework to be put in place. 

Thank you for the answer. I can't say that I'm particularly happy with your response that co-production might be responsible for the variety in terms of delivery, because of course we all agree that, if this isn't patient centred, then no strategy is going to work. My question was about assessments, and the standard and consistency of those assessments, and I don't think you captured that. I think we're all aware, of course, that when it comes to giving people rights, the delivery against those rights is pretty spasmodic and very, very variable in a range of areas across Wales. 

You mentioned the Carmarthenshire young adult carers. You may be aware that I'm supporting the principle that's been captured within that petition, to help young adult carers take better advantage of post-16 education and apprenticeships without unnecessary financial disincentive. I think combined with the Welsh Conservative offer on free or discounted transport, which doesn't depend on renationalisation of any buses, this is a new policy targeted at helping young adult carers find a future alongside or after caring. 

You must have had the results of the assessment of the 2013-16 strategy by now. What are the findings for meeting the education and employment needs of young adult carers in that strategy?

I'm more than happy to write to Suzy with the details of the outcomes of that, but also the wider strategies that we are taking forward for employability. But, of course, there is also a wide range of other measures of support that we can put in place for young adult carers as well, and I know that she will join me—and I'm happy to write to her on that specific issue—in welcoming the number of local authorities that are now also providing exemption for carers on their tax as well. 

So, I'm happy to write to her on that specific issue to give her an update on that, but also happy as well, and I'm sure she will support the fact, that the ministerial advisory group for carers now will be looking to take forward many of these issues and develop workstreams around them.

The UKIP spokesperson, Caroline Jones.

Diolch, Llywydd. Cabinet Secretary, according to the national survey for Wales 2016-17, obesity in Wales is worse than in any other nation in the UK. Fifty-nine per cent of adults are considered overweight, and 26 per cent of children starting primary school are classed as obese or overweight. What steps are the Welsh Government taking to tackle child obesity in Wales, and in particular in the economically deprived regions of Wales, such as my own region, South Wales West?

We have a range of measures in place already, for example the healthy schools network, the 10 steps to a healthy weight, and, indeed, the daily mile introduced by my ministerial colleague Rebecca Evans when she was the public health Minister. There is a range of things we're already doing to undertake both greater physical activity, greater awareness of health behaviour, including diet of course, but we're looking also to the obesity strategy, which this Assembly passed as part of the Public Health (Wales) Act 2017, and I'm looking forward, before the summer, to reporting back formally to this place on the steps that we're taking to take forward a consultation on the future of that strategy.

Thank you for that answer, Cabinet Secretary. Troubling research undertaken by the University of Southampton has shown that only 15 per cent of schools provide two hours of physical exercise each week for seven to 11-year-olds, and it is felt that the Welsh Government should engage with schools, nutritionists and parents to reverse the increase in child obesity and that this engagement is the key to maybe solving the obesity crisis in Wales.

There are a range of measures here and, actually, when we think about the challenges that we face, this is part of the common challenges we face in a range of public health outcomes: smoking, alcohol intake, diet and exercise, and in particular diet and exercise where it refers to obesity but also alcohol as well. As to the role of schools, it isn't just about the children when they're in school of course, but that is a significant part of it, which is why I'm really pleased to be continuing to work with my cabinet colleague, the education Secretary on curriculum reform and the health and well-being domain about behaviour we want children to take on board whilst they're at school.

But there's actually a broader point about the family and the community that children live in, and what are expected behaviours within that family and the choices people make, as well, of course, as encouraging people to alter the way in which they provide food. So, steps that have already been taken, for example to reduce sugar content in drinks, are to be welcomed. There are more steps that I'd like to see food manufacturers undertake. I'm thinking about the fat content and other issues too, but we can't simply see it as one part of it. That's why I see the child in their context, the family in their context, and our obesity strand needs to think carefully about how it addresses each of those, the levers the Government has available to us, and the partners we need to work with to make a real difference for public health now and in the future.

Thank you for that answer, Cabinet Secretary. It's positive to hear that family engagement is a priority for you, and I'd like you to also look at exploring avenues of increasing the range of extra-curricular activities. I appreciate the Welsh Government has been working in this area. Forty-eight per cent of school pupils in years 3 to 11 in Wales are taking part in organised physical activity. I wish to highlight Wales's success in the Commonwealth Games. We must encourage all children to be as active as they can and encourage children who excel at sport at the same time. So, what is the Welsh Government doing to encourage the 52 per cent of children who do not participate in any physical activity, whilst at the same time encouraging and assisting the local sports clubs who are struggling financially along with individuals who have a talent but lack the necessary funding to excel in their sport?

I'll try and give three particular points there. On organised sport, whether it's elite sport, and the role it can have as regards role models, not limited in terms of a media profile, but actively going and engaging within their community, and its role linked to community sport—. In work that I did previously with Rebecca Evans when she was a public health Minister—work that I'm looking to repeat and undertake with my ministerial colleague Dafydd Elis-Thomas—I'm looking at the continued contribution of organised sport to broader physical activity, and the role that governing bodies have to play and the role that significant and elite sporting organisations have to play in promoting community engagement are part of what we're doing. That is organised as opposed to incidental. I'm looking forward to more information on that.

In terms of physical activity, and this is, of course, not just about activity within the school, but it is about how people choose to live their lives and how we encourage and enable that and make it easier. That's why active travel is a particularly important policy to normalise walking or cycling to school, and to normalise walking or cycling outside of trips to and from the school. And that is also why we continue to fund activities like the summer holiday enrichment programme—additional activity linked to physical activity, linked to learning within the school, and also, importantly, as I said at the start, linked to proper engagement with the whole of that family, making a real and lasting difference.