The following amendments have been selected: amendments 1 and 3 in the name of Caroline Jones, amendment 2 in the name of Julie James, and amendments 4 and 5 in the name of Rhun ap Iorwerth. If amendment 2 is agreed, amendment 3 will be deselected.

That brings us to the next item, which is the Welsh Conservatives' debate on the health and social care workforce. I call on Angela Burns to move the motion. Angela Burns.

Motion NDM6745 Paul Davies

To propose that the National Assembly for Wales:

1. Recognises the vital contribution made by Wales’s health and social care workforce.

2. Believes that a valued, supported and healthy workforce will be key in driving forward the transformation NHS Wales needs to be sustainable in the future.

3. Calls on the Welsh Government to publish a comprehensive integrated strategy for Wales’s health and social care workforce to ensure our services are able to address future demand for safe and high quality services by January 2019.

4. Calls on the Welsh Government to make NHS Wales an exemplar employer through its support for well-being at work by implementing priority access to treatment for NHS workers and developing robust policies that support the health, well-being and continual professional development of the health and social care workforce.

Motion moved.

Diolch, Llywydd. I'm pleased to move the motion tabled in the name of Paul Davies. We recognise the immense contribution made to our society by the health and social care sectors, and we want to demonstrate the need for integrated workforce planning, and put forward ideas on how to improve the recruitment and training of staff. Today's debate has four key aims, as set out in our motion. Cabinet Secretary, I am sure you will join the Welsh Conservatives in recognising the vital contribution made by Wales's health and social care workforce, and I'm sure that you will agree that a valued, supported and healthy workforce will be key in driving forward the transformation that NHS Wales needs to be sustainable in the future. However, when we asked you, the Welsh Government, to publish a comprehensive, integrated strategy for Wales's health and social care workforce by January 2019, you appeared to cavil. And, again, our point 4: you appear to be baulking at the idea of supporting the NHS workforce by implementing priority access to treatment for NHS workers. Sure, we must make sure that we have in place the right people in the right places in order to effect the transformation that we need.

Now, I know that, across this Chamber, Members will acknowledge the vital contribution that Wales's health and social care workforce makes to our nation, and, if any of you haven't had direct experience of their care, I'm sure most of us will have had loved ones who've made use of the services they provide. However, all too often, staff feel underappreciated, under pressure and voiceless in an environment that is more about finances and politics, and less about patients and staff. And we want to pay tribute to this workforce, from the consultant undertaking the operation through to the nursing team, all the way to the cleaners and catering staff who manage to keep our NHS operating.

In its seventieth year, let's just take a brief look at what the NHS does in Wales on an annual basis. Last year, the Welsh NHS was there when over—well, in fact, I'll give you the exact number—when 33,729 mothers gave birth. And, in 2016-17, over 8,500 people were supported by mental health services. In 2017-18, an average of 93,000 people went to accident and emergency departments. That's 1 million people a year supported by our NHS, and I'm sure that you will agree with me that this figure reinforces the value of the NHS to Welsh people. However, it does not mean that the operation of the NHS is beyond improvement or challenge, and, Cabinet Secretary, you've been very quick in the past to dismiss our comments on this side of the Chamber by saying we're talking down the NHS and diminishing the efforts that the staff put in. You could not be further from the truth. We all value the NHS. When the chips are down, it is there for you.

Turning the clock back 70 years, Henry Willink, Nye Bevan and the other architects of the national health service would never have envisaged the role it's playing today, and it's worth stressing that however much money is spent on maintaining machines, upgrading equipment, providing sparkling new buildings, the common denominator remains the members of staff. We need staff to administer the machines, read the x-rays, care for the sick, clean the floors. Without them, the NHS would cease to operate, and that's why it's so important that we get to grips with ensuring that the well-being and health of our NHS staff is truly prioritised. The latest set of figures surrounding NHS sickness absences for the quarter up to December 2017 saw a rise in absence nationally of over 5.5 per cent. What concerns me more, however, is how the figures differ so greatly between staff groups. So, for example, the Welsh ambulance service records a sick rate that is well above the average.

Last year, I highlighted the extent to which mental illness is affecting NHS staff. The figures then showed that close to 8,000 staff members accumulated nearly 350,000 days of absence due to anxiety, stress and depression, and this was the equivalent of 948 years—an unbelievable figure, almost—lost to mental health illness over the course of one year. Figures from the Royal College of General Practitioners survey last year showed that severe workforce pressures mean that the well-being of many GPs is suffering. Almost one in three Welsh GPs are so stressed they feel they cannot cope at least once a week. And other survey results by Mind Cymru found that 35 per cent of GPs had personal experience of a mental health problem, while 12 per cent said they use, or have used, mental health services on a consistent basis.

The Deputy Presiding Officer took the Chair.

Cabinet Secretary, these issues alone further demonstrate the need for more effective health and well-being practices to be employed across the NHS in Wales. It's ironic, isn't it, that a profession that looks after sick people finds it so difficult to keep its own staff physically and mentally fit. I believe there is a very good case for NHS staff to receive rapid access to treatment and rehabilitation. An NHS Employers publication in January 2016 demonstrated the case for rapid access with clarity, saying that it will contribute to substantial savings for the NHS, it will lead to a more consistent and healthy workforce, resulting in better patient care, and reduce pressures on colleagues resulting from sickness absence. They also stressed that it will not prioritise the health needs of NHS staff to the detriment of other patients, but that the organisational benefits of such a scheme will result in a reduction in demand for agency staff and provide a reduction in low-level sickness absence.

There are a number of ways that rapid access can be implemented, and I urge the Welsh Government to look at this. The NHS Employers' paper on this matter highlighted a couple of case studies. Southampton university hospital—the occupational health and human resources team ran a return-to-health scheme, which offers employees a tailored package of care, from treatment and personal consultation through to follow-up and continued support. The project helped to minimise the adverse effects of long-term sickness on both staff health and well-being and on the finances, and it created a personal service where employees felt cared for. The benefits to the organisation were seen in a reduction of the overall absence rates, down to 3.1 per cent from over 4.5 per cent, and in the reduction in agency costs by 26 per cent. Imagine how much the NHS would save in Wales if our agency costs were cut by 26 per cent.

Colchester Hospital University NHS Foundation Trust, they introduced a triage looking at supporting staff that are off sick, which also reduced absence. When an individual reports as sick, their line manager contacts the occupational health and well-being department with details of the absence. That department conducts a five to 10-minute telephone call with the member of staff to establish any support that is required and signpost them to relevant resources. This has resulted in mental health and musculoskeletal conditions being identified on day one, enabling early support and intervention to support staff. So, following the phased roll-out, these were the findings: mental health issues—71.5 per cent of the staff returned to work within four weeks. Compare that to our over 900 lost days a year. Musculoskeletal disorders—there was a 100 per cent increase in referrals to physiotherapy, but 53 per cent remained at work, 21.5 per cent returned to work within eight days, and a further 15 per cent returned to work between nine and 14 days. That really shows the benefit of caring for the people who are caring for us.

Both of these studies make an extremely convincing case, and it's also worth considering that, if we do not keep up with schemes such as this across the border, we will find it increasingly difficult to attract staff to work in our NHS today. That's why I'm so disappointed that both UKIP and the Welsh Government have rejected this element of our motion.

One final aspect that I would like to address is the need for improvement in workforce planning. Findings from a Welsh Conservatives' freedom of information request showed that the Welsh NHS is haemorrhaging nurses. The health boards that provided us with figures—there was a combined deficit of 797 nurses in the three-year period between 2015 and 2017, and, since then, further numbers have come in, which have showed that as an increase, and I'm very happy to provide those to you, Cabinet Secretary.

Coupled with these worrying numbers is the massive amount of money that's being spent across the country on agency staff. The latest figures from 2017 have this at £54 million. In fact, it's £55 million, because it's £54.9 million, and it's indicative of the difficulties that health boards have in employing full-time nursing staff of their own. The British Medical Association recently produced figures that health boards spent £29 million on consultant overtime and private providers. Cancer Research highlighted how the shortfalls in staff are having an enormous effect on the provision of top-quality cancer treatment. Cabinet Secretary, all of this goes to show that we need the staff. The shortage I know you're aware of, but what you do not seem to be doing is pulling that together into an integrated system that would save us money, give us good people in the right place at the right time to provide an NHS that will go on for longer than a simple 70 years.

General practice—I'm just going to end on general practice. It's integral, absolutely integral, in achieving the healthcare model that you outlined in 'A Healthier Wales', your vision for the future, and it's vital that a strategy is developed to boost both the numbers of GPs and the numbers of allied healthcare professionals. We have an ageing workforce out there in primary care, demonstrated by figures from the NHS Confederation that stated that more than 45 per cent of Welsh NHS workers are currently aged 45 or over. People are retiring; not enough recruits are coming in to replace them.

Cabinet Secretary, I'm going to wind up there because otherwise the person who is closing will be very cross with me, but I do want to just make this point once again, that, without an integrated health and workforce plan that incorporates social care, that really looks at great ways of retaining people and values our people, then we are not going to be in a position to offer a good NHS service. I really would urge you to have a good look at the rapid care systems that are around the world. I'll leave you with that last figure: over 900 years of work lost due to mental health issues. We know the stress our staff are under. If we can get the staff we have well and back into work, that in itself will make an enormous difference to the state of our NHS.

I have selected the five amendments to the motion. If amendment 2 is agreed, amendment 3 will be deselected. I call Caroline Jones to move amendments 1 and 3, tabled in her own name. Caroline.

Amendment 1—Caroline Jones

Insert as new point 2 and renumber accordingly:

Regrets that, due to the failure of successive Welsh Governments to undertake adequate workforce planning, the NHS in Wales has staff shortages across many specialities, particularly nursing, general practice, emergency medicine, psychiatry, radiology and endoscopy; and that these shortages are putting existing staff under tremendous strain and impacting on patient care.

Amendment 3—Caroline Jones

In point 4, delete 'implementing priority access to treatment for NHS workers and'.

Amendments 1 and 3 moved.

Diolch, Dirprwy Lywydd. I would like to formally move the two amendments tabled in my name, and I thank the Welsh Conservatives for bringing forward this important debate today. As you can see from my amendments, I agree with 99 per cent of the Welsh Conservatives' motion. I cannot support granting priority treatment to NHS staff, and, while I have sympathy with the need to get staff back on the front line as quickly as possible, I fear this proposal would lead to a two-tier NHS. We could see a situation where an NHS worker and a police officer are both waiting for a transplant and, under these proposals, the NHS worker would have priority, regardless of the clinical priorities. I therefore urge Members to support amendment 3.

Getting to the crux of this debate, it is regrettable that Wales is facing staff shortages in a number of key areas, and it's because we have had woefully inadequate workforce planning in recent decades. Wales has failed to take account of demographic changes and the pressures this will place upon health and social care services. As highlighted by the parliamentary review of health and social care, the population of Wales is set to grow by 6.1 per cent. The number of over-65s is set to increase by 44 per cent, and the number of working adults will decrease by over 5 per cent over the next two decades.

Unfortunately, age rarely comes alone. Over the same time frame, the number of adults living with a long-term limiting condition will increase by almost a quarter. The situation we find ourselves in today is made much worse because a lack of future planning has led to shortages of many key staff. Year on year, month to month, we have around 20,000 patients waiting for more than 36 weeks for treatment. We have seen a 400 per cent increase in the numbers of patients waiting more than a year for surgery. Thirty-nine per cent of Welsh people find it difficult to make a GP appointment, and, according to the Royal College of GPs, we are suffering from a severe GP shortage. Wales has 136 training places and, if we are to consider training places per patient, we should be training 184.

The royal college believes we need to train 200 new GPs each year in order to meet the demand and account for the large number of GPs approaching retirement age. But it's not just GPs we're short of. Wales has the lowest number of consultant psychiatrists per head of population, despite Wales having a higher than average proportion of people suffering from mental ill health. Wales has some of the worst cancer survival rates in the western world, yet we are desperately short of clinical oncologists, medical physicists, radiographers and diagnosticians. We are desperately short of nurses. The NHS is currently spending £1 million per week on agency nurses just to cover shifts.

Would you take an intervention?

Yes.

Thank you very much indeed, Caroline Jones, for taking the intervention. You've highlighted the case exceptionally well for why we have such a big shortage everywhere, which is why—and I'm going to read the figure out again—948 years are lost because of mental illness. If only some of those people were put back into the workforce more quickly, instead of having to recruit people. We can't magic them out of thin air. We've got them there; let's make them well, let's get them working.

Angela, I take your point, but for the reasons I highlighted in the beginning I can't accept your—I had to put my amendment in. So, I do apologise. Thank you.

These shortages don't just contribute to longer and longer waits for patients; they are placing existing staff under unbelievable strain, and one out of every three Welsh GPs feel they are so stressed they cannot cope at least once per week. Nurses have revealed they are leaving work sobbing and patients are dying alone because of these staff shortages. We would need an additional 78 clinical oncologists if our oncologists were to stick to their contracted hours. Our NHS is being tested to breaking point and the pressures are due to continue to pile up. 

Yes, the Welsh Government are to implement new ways of working, but we need the staff to carry out these roles. We have to plan for future need. We can't just recruit doctors and nurses overnight; they take years of training. Our health and social care workforce are our most valuable resources, let's support them by ensuring they are not overworked and undervalued. We need an urgent national workforce plan and I urge Members to support the motion and my two amendments. Thank you.

I call the Cabinet Secretary for Health and Social Services to formally move amendment 2, tabled in the name of Julie James.

Amendment 2—Julie James

Delete points 3 and 4 and replace with:

Welcomes the Welsh Government’s commitment to:

a) publish a comprehensive integrated strategy for Wales’s health and social care workforce in 2019 to ensure our services are able to address future demand for safe and high quality services;

b) make NHS Wales an exemplar employer through its support for well-being at work by developing robust policies that support the health, well-being and continual professional development of the health and social care workforce.

Amendment 2 moved.

Formally.

Can I call on Rhun ap Iorwerth to move amendments 4 and 5, tabled in his own name? Rhun.

Amendment 4—Rhun ap Iorwerth

Add as new point at end of motion:

Calls for the opening of a centre for medical education in Bangor and the expansion of medical education across Wales to ensure every region has the health workforce it requires.

Amendment 5—Rhun ap Iorwerth

Add as new point at end of motion:

Calls for future health and social care workforce plans to include robust targets for providing a bilingual workforce and details of how existing NHS staff will be encouraged and supported to learn Welsh.

Amendments 4 and 5 moved.

Diolch yn fawr iawn. I've spoken many times here about the importance of workforce planning and I'm very pleased that we are now talking regularly about health and social care workforce planning; both are vital, of course. Look at many of the problems that we face in terms of health and care—capacity, waiting times, integration. Workforce is central, I think, to the answers that we are seeking. I think it's clear that a failure on the part of this Government to adequately address those issues of workforce is directly undermining the sustainability of our NHS staff, putting them under unacceptable pressure and putting patients in Wales at risk. I'll turn to our two amendments.

I will mention both amendments. There are no surprises, it’s fair to say, and I make no apologies for that, because we will be unable to provide the NHS that we want unless we establish a centre for medical education in Bangor and expand medical placements across Wales. And the other amendment: we’re not going to be able to provide the healthcare that we want and the health services we want unless we recognise and acknowledge that Welsh language services are not an additional option that can be deferred to that mythical future when there are plenty of resources available, but rather that it is a crucial part of delivering safe clinical care today.

I will start on that point. There is some idea out there still that the vast majority of the people of Wales can speak English and, therefore, it makes no difference to them if they speak to their doctor or nurse in Welsh or in English. The Welsh Language Commissioner has talked about more than one health board referring to the fact that some of their staff have difficulty in understanding the need to provide services through the medium of Welsh, when their perception is that there is a clear lack of demand from the public for such services. Many health boards have a neutral attitude towards this, and this in and of itself is problematic. Although it is not hostile, considering English as the norm or the default is a barrier to proactive action in finding solutions to linguistic needs.

The ability to describe symptoms accurately helps diagnosis. Describing symptoms in your first language makes it easier to give an accurate description, as I know Dai Lloyd would confirm as a GP. It becomes more and more important when you talk of young children, and of people with dementia, learning difficulties or mental health conditions. So, the recruitment of Welsh-speaking staff and providing a bilingual service isn’t something that should be seen as a box-ticking exercise because those nuisance people in Plaid Cymru were able to influence Government once. It is related to the fact that vulnerable patients could die if you don’t provide that service. But, there are still signs of contempt, I’m afraid. The Welsh Government don’t even believe that they need to publish the number of Welsh speakers within the NHS, with the exception of GPs—those are counted. So, we have no idea where the gaps are and what the trends are. [Interruption.]

Yes, of course.

I'm grateful to the Member for taking the intervention, and I agree with the points he's making on bilingualism. But, equally important are other languages to be considered, especially in the city that I represent here in Cardiff, which has a diversity of languages, and the translation system that is available for patients and medics within our health service does need a complete overhaul so that no-one feels excluded and they can use the tongue that they choose to speak in.

The point that I made about the ability to describe symptoms in your first language is equally true whichever language we are talking about, but, of course, there is—I won't even use the words 'special case' for the Welsh language, seeing as we are in Wales. But, of course, the Member makes a perfectly valid point.

To return to the figures, with GPs, we know that there is a shortage of GPs in any case, and Government figures published today show an increase in the number of people complaining that they have to wait a long time for treatment, but the number of Welsh speakers has significantly declined too. So, action is needed now.

We have seen that the statistics in terms of training places for GPs are lower in relation to the population than is the case in England and Scotland. Therefore, turning to that other amendment on medical education, we are facing a problem with a shortage of doctors—we know that. So, let’s start to overturn this by investing and setting an ambition in terms of increasing the number of medical students and the number of placements available for medical students.

We have a whole host of examples that demonstrate the value of training in a rural area in order to persuade people to work in rural areas—examples from Norway, from Calgary, from the USA and, indeed, from across the world, if truth be told. There is good work being done in Swansea, in the university there, to expand the number of training places in west Wales. Cardiff may, then, be the most natural partner to work with Bangor University on a new centre for medical education, because that is truly needed. Ireland has seven medical schools and Scotland has five, which suggests that a medical school for every million of the population is something that works. We need another in Wales. 

In evidence—I think it was to the health committee—the Welsh Local Government Association and the Association of Directors of Social Services Cymru said that

'Key determinants of health are largely outside the control of health services and so the quality of, and spending on, social care has one of the strongest impacts on the demand for health care.'

That might be stating the obvious, perhaps, but it's a statement that should impact more strongly on our thoughts on the recruitment and well-being of the social care workforce in the short to medium term, because it's not just about the NHS workforce. If the social care workforce collapses, it takes down the ability of the NHS workforce to cope with the extra demands on them. And while I accept, of course, that big cultural and structural changes don't happen overnight, and acknowledge that work has now begun on raising the status of the social and personal care workforce through further regulation and training, we are still losing care workers into the health system because of better terms and conditions there, as well as losing them to other jobs as care is too often seen as a stop-gap, temporary, entry-level sort of job.

What we don't know is how many we are losing through ill health, because we don't know how many people are employed in this sector. Six thousand or so are registered, as we know, but Welsh Government estimates that there are about 19,000 domiciliary workers out there who are now eligible to register. But an independent report on the economic value of adult social care suggests that the estimate is nearer 83,000 care workers and more likely that there are 127,000 jobs indirectly linked to adult social care. And if you don't know who these workers are and can't reach them, how do we ensure the well-being of this hidden army? We know about the GPs, and now we know about the ambulance staff as well, but how many care workers experience mental ill health due to unrealistic time demands, variable terms and conditions, low levels of pay—maybe that residual feeling that you're second-best compared to the NHS? How many are leaving for those reasons, when we might be able to retain them?

And if we're asking for cultural change, if we're asking people to come forward and invest in a career in social care, then Welsh Government needs to constantly make the case with the public that social care is not something less than the medical or nursing care that we know of and to show that. So, while Ministers may expect Health Education and Improvement Wales and Social Care Wales to work 'as one', to quote them, there is a real question for me about the value of the education streams of these organisations being separate from each other, retaining the risk of one overshadowing the other. New entrants should be coming into the beginnings of this integrated service with none of the old trappings of healthcare being more highly valued than social care, and certainly in the generalist areas of primary care, new entrants shouldn't be even aware of any difference, even if they do go on to be more specialised as their careers progress.

For all the good work that's taking place in clusters and other multidisciplinary hubs, it still tends to be medical or nursing members who lead teams rather than those with social services backgrounds, although obviously there are some of those. Without role models, new entrants will inherit this existing sense of inequality between the two necessary parts of care, and as we've lost 5,000 jobs in social services departments in the last seven years, who is it that's encouraging those who have taken the social services route to push for leadership in those integrated services?

Now, 'care' is the word we're using here, and primary care cannot continue to be seen as purely medical, nursing or even about allied healthcare professionals. Social and personal care must be valued equally within that definition. Yesterday, we were lucky enough to be visited by Griffithstown Primary School, who came to the cross-party group on dementia to talk about the brilliant intergenerational work that they're doing. Some of the girls—none of the boys, interestingly—said that they'd like to become dementia nurses. No-one mentioned becoming a consultant or a researcher or a care worker or someone running a care home or domiciliary service or someone who helped to keep people well at home when they have dementia. And I am not blaming those children at all, but they've heard of nurses; they haven't heard of social care. And without clarity on what the future looks like, I think it's pretty difficult to prepare new entrants and persuade existing workers to change what they're doing, which is a pretty stressful experience in itself, and how can HEIW and SCW be sure that what they are training for will be appropriate for future models of care? And, of course, it will be models—plural—because this will be different in different parts of Wales.

Just finally, I want to finish on the subject of third sector providers. I came across a situation yesterday where there was a scheme that pays a small number of third sector personnel with acknowledged expertise to support individuals to have the confidence to make appropriate decisions about their care needs instead of dialling 999. To cut a long story short, they're losing their funding, we're losing the expertise of those members of the care workforce as well as all the benefits, and I want some assurance, if you can respond to this today, about how our care workers from the third sector, and other sectors if you like, will be retained and how we will look after them if we don't even know they exist.

I’m very pleased to take part in this very important debate. Following on from what Suzy Davies has said, I’ll start with the first point, which is the key importance of social care. Now, as a doctor, you’d expect me to talk on and on about the health service, but as has been mentioned several times in the Chamber, without social care, the NHS will fall into ruin as well, and we have to address that. Increasingly, my party favours creating a national care service.

We do have a national health service. Back in the 1930s, we looked at health, and it was dispersed and separate, and there were local authority elements that provided healthcare, there were charities and private bodies, and you had to pay to go to see your GP. Fast-forward to now, when you look at the care sector, there are local authority elements, there are private sector elements and there are charitable elements. How about bringing them all together? Because if it was good enough for the NHS, then, certainly, it’s good enough to have a care service on the same lines. That would bring those who work in the care sector to the same level of respect as those who work in the NHS. As you’ve already mentioned, people always look at nurses and doctors with more respect than those who provide social care. Over the years we’ve managed to downgrade the value of care in our societies, but yet, that is the most important point—the ability to deal with people and to be compassionate with people, to be kind to other people, and that’s the care service. We’ve lost that in the way that we deal with our patients, not just in the health service, but also in our care service.

And, yes, that means, certainly, in the care service, with an increasing number of people suffering from dementia and so forth, that we need to provide that service increasingly through the medium of Welsh because, with dementia, it's your second language that disappears first. That is, for those who speak Welsh as a first language when they develop dementia, it’s only Welsh that they can speak when they’ve developed dementia. And there are several kinds of stroke that have the same impact. You lose the ability to speak in your second language. There are a number of countries across the world with the same kind of experience. When you have a country with more than one language spoken, you lose that ability to speak your second language—with dementia, increasingly, and with strokes.

So, we have to ensure that we plan our workforce to reflect our society. There are more than 0.5 million Welsh speakers here in Wales, and we want to create 1 million of them, and therefore our care workforce, as well as our NHS workforce, should reflect that basic point. As well as what Rhun ap Iorwerth said, you improve the quality of the diagnosis when you can engage with someone in their first language. You can understand the diagnosis, and we come to a diagnosis, as doctors and nurses, 90 per cent of the time on the basis of what the patient tells us on their patient history. So, if you have a better quality of history, you arrive at a quicker diagnosis without having to have blood tests, x-rays, ultrasound and so forth. That provision, therefore, saves money ultimately.

I’ll just finish now. Junior doctors in our hospitals are under a great deal of pressure. There is a call for the NHS corporately to look after its staff. Well, I would make it a special plea that we should now look after our junior doctors in hospitals. I’ve mentioned this before. Back in the day, when I was a young doctor in a hospital, there was a familial element. The administrators and other doctors looked after us, everyone looked after us, and we’ve lost that element. Our junior doctors complain that they’re overworked and that they have to fill gaps in the rota when they’re already on their knees. They have to fight for days off to study, fight for days off to sit exams and fight for days off even to get married. This is not fair, and people think, ‘Well, this is the future of our GP workforce.’ We all start off as junior doctors in hospitals, but if we lose those, if they move abroad to be doctors in Australia and so forth, where they can work fewer hours for more money, and Bondi Beach isn’t far away, it's no wonder that the workforce is leaving. We need to prepare for the future by dealing with our junior doctors in a far better way. Thank you very much.     

This year marks the seventieth anniversary of the creation of the NHS. It is likely that everyone in Wales will, at some time, need the services of the NHS. I know from my own personal experience how important the NHS is. In April this year, my wife suffered a series of strokes and it is a great comfort to know that the excellent care that she received is available to everyone, irrespective of their background or financial circumstances.

The NHS faces many challenges. We have an ageing population, the number of people with long-term health conditions is rising and the cost of treatments and medical technology is growing. The NHS needs to adapt and to modernise to meet these challenges if it is to flourish and provide the world-class services that we all want to see. But its core principle must remain; a free health service available to everyone is still the envy of the world. We all want to see the NHS in Wales delivering high-quality healthcare to everyone. To achieve this, we need a well-resourced and high-performing workforce, a workforce that feels valued and supported. However, it is clear that the recruitment and retention of staff has become a major challenge facing the NHS in Wales.

The Welsh Government has constantly failed to train enough staff for the future. Training places offered by NHS health boards remain unfilled. The number of Welsh domiciled students applying to medical school is declining, and in spite of the Welsh Government offering an NHS bursary for the last four academic years, Wales has failed to fill all commissioned places. Recruiting staff has proved a problem. The impact of the Welsh Government flagship ‘Train. Work. Live.’ scheme has been difficult to measure, with vague measures of success.

I welcome the decision by UK Government to relax immigration rules to allow more non-EU skilled doctors and nurses to work in our NHS. Increased pressure and workload on our current NHS workforce has led to difficulties in retaining staff. We have the lowest number of GPs working in the NHS in Wales since 2013. More than 60,000 nurses have left the NHS since 2015, either through retirement or resignation. This failure to retain, recruit and train the staff has had serious financial consequences. Spending on agency and locum staff reached £164 million; this represents an increase of over 20 per cent compared with the previous years of expenditure. This is not sustainable in the long term, Deputy Presiding Officer. We need a clear strategy from the Welsh Government for future workforce planning. Closer cross-border working and effective incentives must be used to fill geographical and specialist gaps in our health service. The delivery of healthcare is a fast-changing world. We cannot rely on systems to deliver healthcare that were formulated in the 1940s to meet the challenges of this twenty-first century.

Deputy Presiding Officer, the Welsh Government must bring forward a clear strategy to address the problems of the recruitment and retention of NHS staff. This is vital if we are to create the well-resourced and high-performing NHS that the people of Wales need and deserve. If we don't care for our NHS, who else is going to? I'm pretty sure that the NHS will not care for us either.

There are certain areas: the NHS and carers. Mental health is a big issue that we have to look at, especially our veterans. We have to look after them. Also, a couple of months ago, there was a problem with computers and doctors could not get in touch with their patients. That's not good enough. A lot of patients suffered and a lot of hospitals were without work. That is not development. We have to have a plan B. From hospital to hospital, standards are a bit different, so from doctors to doctors, there are different pressures. The quality of our service is great, but delivery is a little bit lacking in certain areas. To modernise our system, the pay system must be equal, the pay must be given to our own doctors and nurses, and they should work in a comfortable and suitable environment in the best hospitals in the world.

Finally, Deputy Presiding Officer, as I said, I will always be proud of the NHS: it is the envy of the world. We must care for our NHS, at any cost, and then the NHS will look after us. Thank you.

Thank you. Mark Reckless.

Diolch. I was listening to Dai Lloyd, who I think speaks with greater practical authority than, perhaps, any of us can, as a doctor. All I really know about the NHS is from my family who work in it. My father was a doctor and my brother is a doctor, and my sister-in-law, my father-in-law, and my mother was a nurse—it goes on and on. I haven't taken that path myself, but I'm proud of what was announced over the weekend and clarified earlier this week: that the NHS, at least in England, is going to get a £20 billion real-terms increase in its funding, 3.5 per cent per year. I think that what that says to people who are working in the NHS is that they are valued, and, of course, it's not all about money, but it is about sending a message about what value we place on the staff. [Interruption.] Yes.

Please forgive me for making the obvious intervention. Perhaps you'd like to explain to us and make it clear that that is not as a result of anything like a Brexit dividend, which doesn't exist.

I was, indeed, coming on to deal with that. The Government identified, I think, two sources of funding: firstly, the, I think, £20 billion gross, £10 billion net we give currently to the EU—a significant proportion of that would be redirected in future to the NHS. But in addition to that, and I think this is a really significant thing politically for a Conservative Government at Westminster, they said that the rest would have to be funded through tax rises. But because of the value we put on the NHS, not only are we redirecting funds that we currently pay to the EU, but in addition, at least for England, taxes will be increased.

What I think NHS staff in Wales would like to have seen, and what they would have been listening for when they tuned in to the news that night and the days ahead is what the Welsh Government is going to be doing. Did they value them in the way that the UK Government was? All they heard, instead of anything from the Labour Government about what they wanted to spend on the NHS or how they valued NHS staff—all they heard was whingeing about Brexit. They don't like Brexit very much. Wales voted for Brexit, but these Ministers don't like it. So, all they got were carping comments about, 'Oh, we're not sure the money's going to be there, so we're not going to give any commitment at all.' What our staff need to hear is that they are going to be valued at least as much in Wales as they are in England. I look to Ministers in the Welsh Government to do that—

Will you take an intervention?

—rather than carp and complain about Brexit. Yes.

I very much appreciate you taking an intervention, and I declare on record that my wife is a member of NHS staff. Can you therefore tell the Welsh NHS staff when they will have that increase and what it will be paid for by? Because, at the moment, your own Government in London is saying, 'Tax rises'. That's it—full stop. We have no indication as to when it's going to come or the details of this. It's all pie in the sky at the moment.

It's been announced that it'll be a £20 billion real-term increase, a 3.4 per cent real-terms increase per year averaged over six years, and that it will come partly from the money we currently pay to the EU, but the rest, and, potentially, even a larger part of it, to come from tax rises. Given how the Barnett formula functions, that spending then comes through to Wales where we would look to the Welsh Government and this Welsh Assembly to tell our NHS staff, 'You are valued at least as much in Wales as you are in England, and we will be spending that money on you here as well.' Unfortunately, that has not happened.

I would like to address the rest of my remarks to other things aside from money, because, actually, it is quality of life and quality of their working life that our NHS staff value. Many of my constituents who will go to the Royal Gwent Hospital find the transport of getting there very difficult. Many of the consultants at the Royal Gwent actually commute from Cardiff to Newport to work at that hospital. Many of my constituents in the south-east Wales region will come in and work at the Heath hospital in Cardiff and find they're being fined hundreds of pounds for trying to park their car. There are huge challenges on transport, and we need not just the metro, which is a wonderful concept—I congratulate the Government on the new franchise—but we also need an M4 relief road and we need it quickly.

But not only that, we want to see hospitals designed, working with local government and other partners, to make sure those hospitals work for staff as well as the patient. It's fantastic we have the Grange university hospital, and it's at least as important that it's made an attractive place for staff to work—and hopefully live nearby, to reduce the difficulties of commuting. Yet, at the same time, we have this new hospital proposed. We have the Torfaen LDP, which has only now 300 houses there; it used to be about three times that many. They're building fewer than 200 houses a year over the plan period, compared to the 300 plus that they should be. The latest review only looks at house prices up to July last year, even though it was published in April, and, in the year to April, we've seen house prices in Torfaen go up by 12.7 per cent. They should get on with providing more infrastructure, more facilities and more accommodation, as well as the hospital. Yet, the LDP for Torfaen says the delivery of the strategic site should come forward in a phased way, with enabling works for the hospital, including any necessary highway improvements, delivered first, followed by the hospital itself. Only then does it say,

'The nature, timing and order of remaining uses will be determined by market conditions and further studies'.

Surely they need to get on with delivering the housing and delivering the infrastructure, to help all those workers who are going to be coming in be able to live so they can easily commute to work and enjoy a good quality of life. Welsh Government needs to back our NHS, but also work with partners to ensure that when it is backing the NHS, as with the Grange University Hospital, we get the support from Torfaen borough council and other partners we need too.

Can I now call the Cabinet Secretary for Health and Social Services, Vaughan Gething?

Thank you, Deputy Presiding Officer. I'm grateful for the opportunity to respond to today's debate, and, of course, this Welsh Labour-led Government supports and values the national health service that my party helped to create 70 years ago. And I'm grateful to hear Tories coming on board and saying that they value the national health service too. There's much in the motion that we can agree upon. There are, of course, points that we disagree on, hence a Government amendment.

I do want to refer back to Angela Burns's opening and the figures that she quoted, underlining the significant scale of NHS Wales activity. That isn't delivered by me, and that's a good thing for the people of Wales. That is delivered directly by our staff, and it's the staff that people refer to when they talk about what they value within the national health service and, indeed, within our social care system. It is a fact, of course, that we have more NHS staff than ever before, and it's their skills, experience and values that are fundamental to a successful NHS and social care system.

Now, the differences that we have are one thing, but we do all agree that we want to support our staff, and this Government fully recognises that fact. That's why, in 'A Healthier Wales', our long-term vision for health and social care, we've ensured that the health and care workforce are at the heart of the way that we expect to shape future services. That's why we'll implement the quadruple aim recommended by the parliamentary review. We're committed to ensuring that, with the workforce, we improve well-being, capability, engagement and leadership. Those are part of the four interlocking aims that will drive the changes that we would all want to see, to ensure that we're achieving our future vision of a whole-system approach to health and social care here in Wales.

The third part of the motion calls for the Government to publish an integrated strategy for the health and care workforce. I previously committed to a long-term plan for the workforce in this Chamber, and that is now embedded in 'A Healthier Wales'. We have a clear commitment to deliver an integrated strategy for the health and social care workforce by the end of 2019.

Will you take an intervention? I just wondered why you were not able to commit to delivering it by January 2019, because I fear that, unless there's a real target on it, it could drift?

There is a real target; 2019 is a real target. I want to make sure that we have a workforce strategy that is within the time that it really is achievable and, indeed, by making proper use of Health Education and Improvement Wales. That has been established to lead on workforce planning, and they will be responsible for developing the strategy as one of their first priorities. HEIW will become operational in October of this year, and, whilst it will be one of their first objectives, it is not possible to deliver such a detailed and important piece of work within the first three months of their lifetime. 

I've already given a commitment to expand medical education and the training landscape in north Wales and, indeed, in west Wales. Work is progressing between myself and the Cabinet Secretary for Education to consider proposals submitted by universities to take this work forward, and I hope to have more to say in the near future on that.

The parliamentary review, of course, recognised that a key factor in delivering high-quality health and social care is the well-being and engagement of our staff, and there is already significant work under way. North Wales has been highlighted recently, and I managed to highlight 20 specific programmes of work currently undertaken by Betsi Cadwaladr on well-being and engagement. And this level of activity is replicated across health boards and trusts here in Wales. But we recognise that we need to do more. That's why, in our long-term plan, we committed to making NHS Wales an exemplar employer in its support for well-being at work and a healthy workforce.

We want to see the NHS leading change in this area across health and social care, and in other sectors too, by sharing good practice, guidance, online promotion, and evaluation—and indeed, further steps forward this week, with the agreement between ourselves, the Welsh NHS Confederation and BMA Cymru, to create a fatigue and facilities charter for doctors and clinical staff, building on the good relationships we have here in Wales, and the first within the UK, warmly welcomed by staff within the service.

In terms of the call for implementing priority access to treatment for NHS workers, I've already made my position clear in this Chamber before: we need to think carefully about the issues if we decide to advantage groups of staff wherever they're from—the NHS, the administrative services or carers—and on the basis of their work rather than their clinical need. But, as I have made clear, work is under way to consider this and the approach being taken in some parts of England, and I will consider the issue further once it is complete.

But I really can't leave the nature of this debate without reminding people in this Chamber, particularly Conservative politicians, that the issue of stress, strain and funding facing our staff across health and social care comes from the real impact of austerity. [Interruption.] The eight years of austerity that public services have been subjected to, has caused real harm. [Interruption.] Don't take my word for it. Ask front-line staff within our health and social care services—[Interruption.]—and they will tell you. They understand very well where austerity comes from. They understand the political party that's responsible for that choice.

Will you take an intervention?

No, I won't take an intervention from the grinning Member opposite, who has been laughing through this debate about choices that he helped champion. In three successive general elections, you championed austerity. [Interruption.] Here in Wales, we have made choices to put more money into our national health service, more money per head, a higher rate of growth than in England, and you dare to say that you are the party of the national health service. Nobody buys it, not even people in your own group.

I am a happy to support both of the Plaid Cymru amendments. Firstly, the amendment on medical education in north Wales, as I've given that commitment on a number of occasions. Secondly, of course, the 10-year workforce plan will contain actions to increase the number of Welsh-language healthcare professionals. Now, we, of course, want to train and retain more of our staff. We invest record amounts in both medical and non-medical staff training. In the eight years of austerity we have been subjected to, the NHS is the only public service to increase its staff, with a continuing appetite and demand for more. We still face real risk to recruitment from EU nationals in particular to our NHS, and the reduction of EU nurses entering the Nursing and Midwifery Council register is a matter of real concern to all of us. It highlights how the terms of a Brexit deal will be crucial to the future of our health service workforce.

I do, though, want to welcome the change of heart and change of approach from the UK Government on tier 2 visas for doctors and nurses. The Welsh Government has consistently called for change, together with virtually every organisation representing health and care workers. I hope for similar common sense in our approach to Brexit and NHS staff.

I also want to mention the fact that, before we celebrate NHS70, we will, of course, as Julie James highlighted this week, be celebrating Windrush 70—a generation that helped to rebuild Britain, a generation that helped to create our national health service and staff our social care system, and a generation that has been poorly rewarded. We look for action and justice to be delivered for the Windrush generation, and for promises to be delivered upon. At this point in time, we cannot have confidence they have been.

As the NHS marks its seventieth year, we know that it is an NHS that needs to transform to meet the needs and demands of today, but one thing will remain, as it always has over the past 70 years: the NHS will continue to be delivered by passionate, committed and talented people. We owe it to each and every one of them, and the wider population of Wales, to support and value them and their colleagues in social care in the best way possible. I urge Members to vote for the Government amendment and support us in delivering our unified vision for health and social care here in Wales.

Thank you. I call on Mark Isherwood to reply to the debate.

Diolch. Well, thanks very much, everybody, for contributing, and to Angela Burns for opening the debate—her tribute to the immense contribution made by the health and social services workforce in the seventieth year of the NHS. As she said, even the NHS is not beyond challenge and improvement. Caroline Jones said that the situation was made worse by a lack of future planning, putting the workforce under considerable strain. Rhun ap Iorwerth rightly called for medical education to be provided in Bangor. I'd just add that we also need action on the calls by the north Wales local medical committee to incorporate connections with Liverpool and Manchester medical schools, and restore the supply of new and young doctors from there, many of whom will be from north Wales originally. We heard from him about Welsh Government contempt in not publishing the number of Welsh language speakers in the NHS, and his highlighting that Wales has the lowest level of GP training places per 100,000 patients amongst all UK nations. 

Suzy Davies said we're losing care workers. We need to know how many are experiencing mental health problems. We need to show that social care has equal value with healthcare careers, and for leadership and integrated services. Dr Dai Lloyd—we need the same level of respect for people working in care services as in the NHS, and he talked about the pressures on junior doctors and the risk of losing them if we don't address that. Mohammad Asghar—the pressures of patient numbers rising and an ageing population, and he talked about the importance of a free health service being available to everyone and the envy of the world that our NHS is, and he celebrated the UK Government's relaxation of immigration rules to recruit and retain doctors and nurses.

Mark Reckless told us about his family connections, coming from a family of doctors and nurses, about the UK Government's announcement of a 3.4 per cent real-terms increase in funding for the NHS annually, which compares to the 2.2 per cent committed to by Labour at the last UK general election. It equates to £1.2 billion more for the Welsh Government, so we need to see a clear commitment from the Welsh Government to investing that in our NHS and social care services.

The Cabinet Secretary provided the normal combination of the same old, same old 'long-term vision' and 'we want to sees'. I won't debate the austerity issue other than to point out that, under Labour, Wales has been the only UK nation to see a real-terms decrease in identifiable expenditure on health. You caused austerity, your policies would make it worse, but even with the money you've had, you're the only Government anywhere in the UK to have ever cut the NHS in real terms.

The Royal College of General Practitioners tell us that almost one in three Welsh GPs are so stressed they feel they can't cope at least once a week. There's been an increase in newly qualified social workers, but 9 per cent of all social worker posts are vacant, a figure increasing every year. The latest Nursing and Midwifery Council figures say that although nursing and midwife register numbers are at the highest level for five years, the number leaving the register outstrips those joining. 

Are you winding up, please?

They say there are 3,000 vacancies including those in the independent care and GP surgery sectors. 

So, I will call on you to endorse the motion as unamended, and I regret, as did Angela, the removal of January prior to 2019 in the Welsh Government amendment calling for an integrated strategy for our health and social care workforce. We need a clear commitment, and I hope we heard it from the Minister or Cabinet Secretary, that that does mean we're guaranteed a plan next year. Thank you.

The proposal is to agree the motion without amendment. Does any Member object? [Objection.] Therefore, we defer the voting until voting time. 

Voting deferred until voting time.