Item 7 on the agenda this afternoon is a statement by the Cabinet Secretary for Health and Social Services, 'Brexit—The Risks for the Future of Health and Social Care in Wales'. I call on the Cabinet Secretary for Health and Social Services, Vaughan Gething.  

Thank you, Deputy Presiding Officer. The United Kingdom is due to leave the European Union in March next year followed by a transition period until December 2020. Brexit has significant implications for the people, public services and businesses of Wales. Today I'll set out some of the main challenges facing health and social care. In particular, I want to address challenges to our workforce, public health systems, access to current and new medicines, medical technology and innovation, the necessity of continued international research, collaboration and innovation, protecting access to essential healthcare for EU citizens in Wales and indeed Welsh citizens in the European Union. I've issued a written statement to complement this oral statement, setting out more detail.

As the UK leaves the European Union, significant aspects of the devolved settlement will no longer be constrained by EU law. There are 64 areas relevant to the Welsh Government, 11 of which are directly relevant to health and social services. To protect the interests and promote the priorities of Wales, my officials are actively engaged in groups established with the UK and Scottish Governments to assess the implications of these returning powers, to identify any necessary legislative changes and to resolve the co-ordination arrangements needed across the UK post Brexit. In particular, they're considering the implications if no deal is reached and the implications for Wales if that wholly catastrophic situation is allowed to happen.

The Welsh Government set out six priorities for our new relationship with the European Union. One of these priorities is that any new migration system should link migration policy more closely to employment, so that we can recruit the doctors, nurses and other health and care workers that we need, whilst protecting them from exploitation. Right from the start, our messages have been clear and consistent: we recognise the value we place on staff from other countries; we remind stakeholders how the NHS and social care sectors have always drawn on talented people from across the globe; and, in a European context, free movement benefits not only people who deliver services but also, of course, the people who receive them. EU nationals make up an important part of the NHS and social care workforce. Every single employee must be made to feel welcomed and valued for the role that they play in delivering services that benefit the people of Wales. More than that, we welcome the contribution that people make to communities across Wales as friends, neighbours and citizens of our country.

Health threats do not respect national borders. UK citizens currently benefit from EU systems designed to protect public health across Europe. For example, the European Centre for Disease Prevention and Control provides countries across the EU with protection against notifiable communicable disease outbreaks and public health risks through a single database. Delays in communication around crisis management, or divergence in standards and procedures between Europe and the UK post Brexit could lead to delays in action being taken during a crisis and pose a significant risk to public health. So, ensuring close collaborative links from day one after Brexit will be key to ensuring the people of Wales maintain full protection. This relies upon effective data sharing to avoid returning to the days of quarantine. The EU-wide system on data sharing is overseen by the European Court of Justice. If that is not agreed for the future, then the default position will be that data cannot be shared with the UK. That would pose an unacceptable risk to public health here in Wales. 

The UK has, of course, become used to a high level of food standards and safety, including labelling. Much of this legislation is derived from European Union law. There are effective and rapid systems for exchanging cross-border intelligence and information about serious food risks and food fraud. These systems supply the UK with a warning of any identified threats to food safety from across the EU. That's essential for the protection of public health, to maintain consumers' confidence in their food and to maintain the reputation of UK food businesses. There is a real risk that a European transition could adversely impact the quality and transparency that we have come to expect in this area. So, we want to see strong communication internally across the UK and with our European counterparts to manage risks related to food safety.

Decades of co-operation and harmonisation of standards on medicines and medical technologies have produced proven benefits for citizens across Europe. All medicines and technologies must be of a high standard, proven to be safe and effective before they can be placed on the EU market. Any substantial divergence from Europe would leave us worse off. Restrictions on trade, custom checks and trade tariffs are likely to reduce the availability of some medicines, cause delays in supply, and lead to higher prices. This will also affect future investment choices for companies developing medicines and medical devices. Without a customs union and tariff-free trade with the single market, Wales and the rest of the UK will become less attractive for these well-paid jobs.

Separate approval systems will impact the pace at which we can access new medicines and technologies. For example, in Switzerland and Canada, which have separate approval systems, medicines typically reach the market six months later than in the EU. Any delays on that scale are simply unacceptable. We will continue to press the UK Government to ensure that Welsh and UK patients continue to get early access to new effective drugs, treatment options and the latest medical technologies.

Countries and regions across the world face common and significant health and care challenges. Those challenges can't be addressed in isolation. So, continued collaboration in research, development and innovation is essential. EU programmes provide robust opportunities for health and social care professionals and businesses to collaborate with each other on common goals. We want our health and care researchers and innovators to continue to work with partners throughout Europe and beyond, building on our track record of success.

Finally, I want to address the implications of Brexit for cross-border and reciprocal healthcare arrangements that we currently enjoy with our European neighbours. This healthcare is provided under the same conditions and at the same cost as people insured in that country. Under the proposed terms of the transition agreement, EU nationals currently in the UK and UK nationals living in the EU will be able to continue to live abroad and have the same access to healthcare as they do now. However, the future axis of those reciprocal arrangements is not yet guaranteed as they are subject to the outcome of the negotiations between the EU and the UK Government. But one thing I can make clear: access to NHS Wales operates on a residency basis. That means that free healthcare is provided to people who are ordinarily resident in Wales. Health boards in Wales will not refuse treatment to EU citizens who are ordinarily resident in Wales if there are any difficulties regarding their right to live in this country during the transitional period.

The Brexit risks for health and social care are obvious and critical. If unresolved, they will have real and lasting consequences for our services, for individuals, families and communities across Wales. The Welsh Government will continue to make the case for these to be addressed in any deal to leave the EU. No-one should be in any doubt that leaving the EU without a deal is the worst possible scenario for health and social care in Wales.

Thank you for your statement today. I think you're absolutely right to raise the challenges that we all face, whether we're in Wales or in the UK, in regard to leaving the EU under terms of an agreement that are satisfactory to all of us. However, I do think that there's a degree of mischief making in this statement because this is still a negotiation, as you well know, and I do want to reiterate very clearly that the UK Government does not want or expect a 'no deal' outcome. So, the question I would like to ask you, Cabinet Secretary, is: if faced with Hobson's choice, a bad deal or no deal, which would you prefer? Because I personally would not like to sign Wales and the UK up to something that is utterly untenable. You have said again and again in this statement that a 'no deal' would be awful, and I agree with you; I want a deal that is good for Wales and good for the UK. But I'd like your clarity, where you stand, on the difference between walking away from something that's awful and just going for it.

The second point that I would like to ask you about is that you very clearly state in here, and you have in previous commentary, that you are, or your officials are, very actively engaged on groups that have been established with both the UK and Scottish Governments to discuss all the various implications of us leaving the European Union. Could you please give us a little bit more detail about those groups, what they sit on, what they're looking at, and how they are contributing towards this debate, so that we can be assured that we are actually making our voice, as Wales, heard in the right place and we are having an effect on the discussions that are taking place at present?

Given that your officials are actively engaged on these groups, you do raise a serious number of questions that we already know some of the answers to. On assurances that health and social care staff currently working in Wales would be able to stay in the UK, the Government have very, very clearly said that; they've laid out very clearly that European people who reside in Wales, and in the UK, will be able to stay, and vice versa. They've talked about the healthcare, the pension rights, and they've talked about the recognition of qualifications—again, another point that you raise in your written statement that you issued earlier on today. Absolutely valid things to ask, but my question back to you is: if you're not clear on the answer to these, then what groups are your officials working on? Because I would've thought that you would have known that all of this had been discussed, that these points had been raised, and you would know how far down that particular direction of travel we already are. Because you're absolutely right, Cabinet Secretary; it is vital that our friends and our partners in the European Union understand how much we value them, and that those who work in our NHS, and in our social care, and, indeed, in any part of Wales, understand how vital we think that their input is in our country. So, I do not quarrel with you on that, but I do not wish to see any form of frightening people when things have already been discussed and agreed. So, I'll be interested to understand your take on this and why you feel that those assurances that have already been agreed, and have already been put out into the public space, are not acceptable.

Regulation of medicines: I've raised this here myself, with you and definitely the First Minister—with you in a speech, but with the First Minister directly—because I think that's incredibly important, and I'd like to understand if your groups have been working on that, and what progress you've been able to make on this.

I would like to finally end by saying that this is for negotiation; it is still ongoing. Seventy-five per cent of the outstanding issues were agreed at stage 1 of the negotiations between the UK Government and the European Union. Much has already been agreed in stage 2, and I just wonder if you would like me to send you a copy of the joint statement from the negotiators of the European Union and United Kingdom Government on the progress of the negotiations dated 19 June of this year, because I think that would actually very clearly lay out the position.

Thank you for your comments. All of the issues that I have mentioned are being discussed between Governments within the United Kingdom. So, there is a constructive conversation taking place, but I think it's important to set out the range of risks that do exist before we reach a final deal. And on the issues that I have mentioned thus far, none of them have been bottomed out in terms of post transition; that's the challenge. In particular, for example, you mention longer-term residency; there's an agreement up to the transition, but there isn't an agreement after that. So, I think it's entirely proper to raise that these are matters that do need to be resolved in any final deal and have not been resolved to date. This is not a matter of mischief making; I think we just need to be honest about the range of risks that we carry if we don't have a good deal and information that people are not commonly aware of on the detail of each of these areas.

You asked a question about a bad deal—no deal or a bad deal. The problem is that the worst possible deal is no deal. That is the worst possible deal, and so there is a challenge here about being honest with each other about that, and the difficulties we have with the position being taken in negotiations. For example, the role of the European Court of Justice is a red line at present for the UK Government. That's problematic because of the range of issues that we talked about where there is co-operation across Europe, currently overseen by the ECJ. Now, other countries that have arrangements with the European Union sign up to formally agree how that oversight operates. If there's to be no oversight, then the default position is that we'll fall outside the arrangements that I know that you value, and, actually, I think the UK department for health values as well. So, the challenge is whether we can inject a dose of reality into the discussion, the debate and the negotiations.

From my point of view, when you talk also about things that aren't finalised, like the equivalence of qualifications, well, that isn't finalised. There is absolutely not a finalised position on that, and the points that I have made today are underscored, supported by and amplified by a range of other commentators within the field of health and social care, not party politicians. I'll give you some examples: the NHS Confederation working together with social care partners, the Academy of Medical Royal Colleges, the Royal College of Nursing and, indeed, the BMA as well. So, this is not an area where there is mischief making; this is an area of real, clear and present concern that has to be managed not just between health departments within the UK agreeing what we think matters, but actually it's for the UK Government to deliver a deal on Brexit and not to make sure that people who voted to leave or to remain are subjected to wholly unacceptable risks to their health that nobody voted for two years ago.

Thank you, Cabinet Secretary, for your statement today. It's a long list, isn't it, of things that, without question, pose a threat to the delivery of health and social care post Brexit. I was reading a Welsh NHS Confederation policy forum briefing earlier today, bringing together some of their main concerns: supply of workforce, the need for continued recognition of professional qualifications, protection of employment rights and patient rights, the need to continue to participate in EU collaborative programmes, making sure that regulatory alignment continues for the benefit of patients and the public's health, preserving reciprocal healthcare arrangements, ensuring robust co-ordination mechanisms on public health—it's a long, long list of areas and we couldn't possibly address all of them here today.

I don't know if you, Angela Burns, want to accuse me of mischief making also for being concerned about these areas, but coming off the back of Andrew R.T. Davies, the Welsh Conservative leader's totally inappropriate comments yesterday on Airbus, accusing them of making threats, you are doing yourselves a disservice and the Welsh public a disservice by being so blasé about the biggest threat that we have faced in modern times here in Wales.

Let me turn to a series of question to you, if I can, Cabinet Secretary. First of all, on the transport of medicines under Euratom and associated agreements, there are clearly two differing interpretations here. The first interpretation, held by the Association of the British Pharmaceutical Industry and also others working in the NHS, is that a 'no deal' Brexit is highly dangerous for patients, given the short shelf lives of the products we're talking about, making the need for seamless transport across borders essential. This makes it impossible to stockpile medicines and so on. The second interpretation held by the UK Government is that the nuclear safeguards Bill passing through Parliament now means that there is no problem. So, which interpretation do you agree with and what are your contingency plans for a 'no deal' Brexit if you agree with that first interpretation?

Secondly, turning to access to research networks and funding, what proactive steps—proactive steps—has your Government taken to ensure that our universities and our life sciences sector can continue to participate in these networks in the event of a hard Brexit? Or perhaps your Government is content to let the UK Government take those proactive steps. 

On staffing, one issue that's particularly concerning to us is the fact that we have no data on the social care and independent sector workforce, and how that will be placed at risk through a hard Brexit. So, what steps are you taking to collect and evaluate this data? 

Finally, my fourth question: we have to look at the indirect impact of things on the NHS; do you think that there's a threat to the NHS from different outcomes in trade negotiations, for example?

Thank you for all the questions. I want to reiterate that the Welsh Government continues to support our life sciences sector, research and innovation and we're working practically to see how we can participate in the future rounds of collaboration across Europe. That's a really significant risk for us. We're actually doing very well in terms of research collaboration at present and the amount of funding that UK-based organisations actually win. That is one of the biggest risks that we face if there isn't a sensible agreement, and that will require the United Kingdom to pay into those research and collaboration pots to be able to continue to participate in them. So, we're making our views absolutely clear on that, and the scientific community across the UK, not just in Wales, is nearly unanimous in its view of the essential nature of continuing to participate in those networks and the loss of people that will take place if a deal does not agree to do so.

I want to deal briefly with your point about the social care workforce, then I'll come back to trade, customs and Euratom at the same time, if I may. We recognise we have got a weakness in understanding our data about the current social care workforce and the number of non-UK workers, both European Union workers and those from outside the European Union too. That's why my officials are already working with Social Care Wales on a bid to the European transition fund to have a further amount of research to give us a fuller and more accurate picture of the workforce we currently have in the social care sector and, indeed, where they have come from, and, indeed, more recent trends of people who are and are not coming into that sector in the more recent past since the vote two years ago.

But I think your question on Euratom mirrors a number of points that I've made in other fora about the real risks of a 'no deal' arrangement. If there are barriers to trade, that will affect a wide range of things, so medicines, but Euratom is particularly important, and it's also one where both trade arrangements that are tariff free and a customs union really do matter. Any delays in the ports don't just affect perishable goods in the food supply, but, actually, radioisotopes are hugely important. Nuclear medicine and the ability to diagnose and to treat a range of conditions are hugely important to a modern health service. We import nearly all of the radioisotopes used within the health service right across the United Kingdom. Coming out of Euratom was not something that I ever heard in any part of any debate during the referendum two years ago, but apparently the United Kingdom Government are saying that that is what they wish to do. Well, coming out of that, given that we are less than a year away from EU exit day and transition, would be disastrous. In terms of nuclear medicine, it would have huge problems. It simply could not be replicated; we could not replicate the ability to supply and create those radioisotopes within the UK within that period of time, and the ability to transport them from elsewhere is limited. Because of the half-life of the radioisotopes that are created, actually, you have a limited period of time to make proper use of them.

It's one of these areas where there's got to be a dose of reality about what 'no deal' means. It means if you sign up to a no deal, you are basically saying the NHS, for a significant period of time, won't undertake these treatments. That would be wholly unacceptable in any and every part of the United Kingdom. So, it is yet another area where current United Kingdom Government red lines need to give way to reality and common sense, and our responsibility as elected representatives is to serve the best interests of our people and not to pretend that we aren't on a guaranteed crash course to do the very worst thing for health and social care here in Wales and, indeed, right across the United Kingdom.

Like the majority of the UK voting public, I voted to leave the EU, and my opinion hasn't changed. Our NHS was created long before the EU and will be here long after we leave. Are there risks? Yes, but no-one really expects that these risks won’t be addressed in a future deal.

We are leaving the EU, not Europe. Our continuing co-operation with European nations will continue, and I expect some will be strengthened. I agree that we have to ensure that medicines, equipment and staff should be free of restrictions wherever possible.

People are predicting that Brexit will lead to the collapse of our NHS because we will lose doctors and nurses. But let’s not forget that just over 2 per cent of NHS staff come from EU countries and just over 5 per cent of our doctors and nurses come from the European Union. The vast majority of our foreign-trained doctors come from the Indian sub-continent, followed by Egypt and Iraq. Cabinet Secretary, what discussions have you had with the UK Government about making it easier to recruit non-EU foreign-trained doctors and nurses following Brexit?

Cabinet Secretary, have you considered the risks to the future of health and social care in Wales of the UK remaining in the EU? After all, if it had been up to EU negotiators, our NHS would be at the mercy of large American corporations as a result of the transatlantic trade and investment partnership.

We need to be looking outward and not inward as we go forward. We live in an age where collaboration is taking place on a global scale. Science doesn’t see borders and if we are to tackle big challenges to our health and well-being, we have to co-operate on a global scale. The EU alone won’t tackle antimicrobial resistance. The EU alone won't combat cancer, heart disease or the obesity crisis. We have to work closer with all nations—EU and non-EU countries—to face these challenges. So, Cabinet Secretary, do you truly believe that it's in the EU's best interests to isolate the UK in the way you highlight in your statements? Although we have different opinions on Brexit, we do need to work together to ensure that our NHS and social care sectors do not suffer as a result of Brexit. I don't believe they will, unless the EU takes a political decision to punish the UK. So, it is in all our interests to ensure that this doesn't happen. Thank you.

Thank you for the comments. I'm not surprised that you haven't changed your mind on leaving the European Union, but I would have thought that there would be a dose of reality, again, on what that actually means if we leave with a no deal or a hard Brexit. Look, on the workforce for the health service outside of the European Union, we've had a long and spirited correspondence and conversation between officials, with the United Kingdom Government, and, indeed, every organisation representing health and care staff right across the UK has called on the UK Government, for a long time, to change the environment or to change the rules around people being recruited into our health service. So, I welcome the u-turn announced by Sajid Javid to lift the tier 2 restrictions. That was a positive step forward, and that was always within the gift of the United Kingdom. It was the madness of having the Home Office say to the health service, 'You can't restrict the staff that you need, who you could recruit to meet our health and care needs, because we put an artificial cap on the numbers that can come in.' So, that's nothing to do with the European Union.

I just think, in terms of your suggestion that this is about the European Union punishing the United Kingdom, this basically comes down to, if you leave a club and you say, 'I don't want to play by the rules; I want all the benefits, but I'll then decide what else I want to do as well', then that is absolutely where we can't be. We have to have a range of measures that deal with the reality of European Union-wide institutions and rules, and if we want to benefit from those, then we will need to act in a way that is consistent, and have agreement about doing so.

On your point at the start of your speech, saying nobody wants medicines and equipment to have any restrictions—of course we want to be free of restrictions, but that requires us to have systems that allow us to do so. So, that is why arrangements around customs and trade do matter: 47 million pharmaceutical products each year go into the European Union, and about 39 million come back the other way. There's huge trade going on here between us and the rest of Europe, so the customs arrangements and trade arrangements really do matter in this area of activity too. They're underpinned by EU-wide systems in terms of how medicines and how equipment come into use within Europe. And there's a common centrepoint here: we either want that to continue, or we're prepared to bear restrictions that will cause real harm to people in our country. My view is we should not countenance that possibility. We should not wish to say it is acceptable to have an average six-month delay for new medicines to become available, as is directly the case now in Switzerland. I do not believe that would be acceptable. The Welsh Government does not believe that would be acceptable either.

Can I thank you, Cabinet Secretary, for this statement setting out clearly the potential risks to the NHS in Wales that Brexit presents? I have to say, I don't agree with Angela Burns that this is about scaring people. I think it is about facing the reality and preparing people for it, and I think not to do so would be irresponsible. I certainly don't want our Government to be as complacent about this issue as, clearly, the UK Government, the Conservatives and UKIP are.

Rhun is absolutely right: there is a long list of issues that we've got to face here, and he mentioned one in particular that I think carries one of the most significant risks from the uncertainties surrounding Brexit, and that is the UK's participation in the hugely important, European-wide clinical trials, the science and research, and the potential impact that that's going to have on the growing life sciences sector in Wales. I know that you did touch on that in your reply to Rhun, but I think it's worth noting that this has also been highlighted by a number of organisations, not least of which is the Academy of Medical Royal Colleges, who identified that the UK received something in the region of €8.8 billion in EU research funding between 2007 and 2013, despite only contributing €5.4 billion ourselves. So, the UK research funding was a net beneficiary to the tune of €3.5 billion, and €40 million of that alone went into cancer research.

So, given that continued access to EU research and development networks must be a key outcome of the Brexit negotiations, can you say a bit more about the steps that Welsh Government is taking to ensure that the UK Government includes that specifically in the final Brexit deal? If that is not achieved again, how specifically are you planning to militate against this, particularly given your indications that officials are engaged in discussions around the potentials of a 'no deal' scenario?

Thank you for the questions. It comes back to the challenge of how responsible the United Kingdom Government are prepared to be, both in the negotiation on the terms of a deal to leave the European Union, but also about what then happens afterwards with the way that funding is used within the United Kingdom.

I think part of the challenge is that there's a question about money. There's also a question about knowledge as well. So, we do overachieve, from a United Kingdom point of view, in a way that research moneys are allocated, and I think it would be incredibly difficult to replicate that sum of money without a UK Government willingness to put extra funding into the research community here. Thus far, it's been difficult to persuade the United Kingdom Government to give any sort of commitment on those terms, let alone for the Governments of the United Kingdom to have a role in helping to design that framework. But, actually, I'm just as worried about people who are mobile and who are sought-after and desirable people when it comes to other countries as well, and the opportunity to carry on working in your chosen field or speciality, the real expertise you can have, and for people to go to other parts of the world. We actually attract people into this country because of the research expertise that we have. And those people: there is every prospect that we will lose some of them and the knowledge that they have—not just the money, but the knowledge that they have—to other countries. In particular, of course, the irony is that many of these people actually come from within the European Union to come to institutions here within the United Kingdom. So, we should not assume those people are guaranteed to stay regardless of what happens in terms of the deal, regardless of the funding.

I'll make one further point about what you mentioned about clinical trials. The European Union is about to have a European Union-wide framework of clinical trials, where people enter from different parts of Europe to make that collaboration easier. The United Kingdom helped to write the rules for that. We help to design that framework to make it easier to do so. If we then place ourselves outside it, we make it even more difficult to take part, even less likely we'll be able to take part, and that will disadvantage people here in Wales and the rest of the United Kingdom. That's why I say there has to be a dose of reality and some honesty about not agreeing a deal, and what that means, because, very quickly, we will see the suffering that we will cause, and it's all wholly avoidable.

Thank you very much. We have had one speaker from each of the parties, and therefore I have three more speakers. So, I'm going to ask you just to give a brief introduction and one or possibly two very short, succinct questions, please. Suzy Davies.

Diolch, Dirprwy Lywydd. Thank you for your statement. I think it might have been just been a little bit more balanced if you had mentioned the £1.3 billion innovation fund that was mentioned by the UK Government. There are other ways of dealing with some of the challenges that you raised here without being quite so gloomy about it. What I wanted to ask you specifically was: this is 'Brexit—the Risks for the Future of Health and Social Care in Wales'—I can't really see anything in your statement about social care, and I'm hoping that this is not going to be a recurring theme when we're talking about the integration agenda. So, I'm wondering if you can tell me particularly which of the current European programmes to which we might have access after Brexit you might like us to buy into, which might be of advantage for social care innovation and knowledge, and, secondly, whether you can give us some indication of how you've reached the figure you think that we have for the number of EU nationals currently working in social care. I appreciate that, because we don't have registration, that's difficult, but I'm quite curious to know where you got the figure from because a simple extrapolation from a UK figure won't be accurate, bearing in mind that 12 per cent of the EU national care workforce works in London, and only 2 per cent works in the north-east of England, for example. Thank you.

I've already said in answers to other questions that we are reviewing the workforce data here because we want to more easily understand the number of European Union nationals who work in the social care workforce here. But you and I will know, if you visit a range of residential care facilities in particular, you will meet people from across the globe, and lots of European Union nationals are undertaking that. That's why we're undertaking the research to understand and have a more accurate picture. Indeed, when it comes to the field of research, we are talking about health and social care research as well. So, that knowledge is shared because we want to see a developing area of social care research.

At present, Health and Care Research Wales is deliberately going and choosing to look at social care priorities, and as you and I both know, from a health and social care point of view, a range of these challenges don't neatly recognise the boundaries that we currently draw in the way that health and social care work. So, in almost all of those fields of activity and expertise you will see a social care contribution that is potentially lost in not having a similar expertise to be shared within Europe. But I really do think that it's something of a stretch to say that this would cast any doubt on the integration agenda in the plan that we have actually set out for the future of health and social care in Wales. We are taking that forward with vigour and with real positivity from our colleagues in the social care sector. We're going to take a series of meetings with health boards and local authorities together through the rest of the summer. 

I thank the Cabinet Secretary for his statement today, although I am surprised that, in his statement, there's a failure to refer to the potential risks of international trade deals should we leave the European customs union. Surely the biggest threat facing the founding principles of the NHS as it approaches its seventieth year is that of new international trade deals led by Dr Liam Fox.

In the last few weeks we've seen the President of the United States openly state that his aim in trade talks with the UK will be to impose higher prices on drugs in order to slash prescription prices in the US and put 'American patients first'. So, future trade deals, if we're dragged out of the customs union, will have an enormous impact on Welsh patients, and if the President of the United States has his way, will put huge pressure, I believe, on the free prescriptions policy we are rightly proud of here in Wales. That's not scaremongering. I think that's a simple, logical fact.

The Cabinet Secretary will therefore understand my disbelief upon learning that his colleague the economy Secretary has said that he's content with Welsh Government being 'in the room next door' when devolved matters are being discussed in future trade talks. In a letter that I have to the Chair of the House of Commons International Trade Committee, his colleague the Cabinet Secretary says, and I quote, 

'in areas of devolved competence Welsh Government should be part of the negotiations—whether that is "in the room" or "in the room next door"'.

Isn't this a rather feeble position to hold? Surely a Labour Government would be prepared to break down doors to be in talks on the future of the national health service, particularly with the threats that we are facing from a very different agenda in Westminster. So, my question directly to the Cabinet Secretary is this: doesn't he want to be right there at the heart of future trade negotiations when the future of the Welsh NHS is at stake?

I think the key point from the economy Secretary there is that we expect to be involved in any negotiations in devolved areas, and that's the point: we expect to be involved. We expect to have a say with other Governments within the United Kingdom, and it's about developing a maturing relationship here within the United Kingdom as much as anything else.

I would, though, agree—. Look, the point about Liam Fox—when people say, 'You're scaremongering talking about no deal. Of course there'll be a deal', well, actually, he's the Cabinet Minister who was openly talking about the prospect of no deal and the fact that that must be on the table. He's the person who raises the spectre of these deals with other parts of the world that would be wholly unacceptable and damaging to a range of industries here in Wales, and public services, and indeed in our economy. I've also heard comments from not just the President of the United States, but other US officials that he has appointed, on wanting to try and change the nature of the relationship on drug pricing within the United States, and to try and make other people pay more for those commodities.

So, I recognise that there are real risks to other arrangements. I've also set out, in answer to other questions here, about the risks that we face if we are not able to secure tariff-free trade and a proper customs union arrangement.

Thank you. Finally, Joyce Watson.

Diolch, Dirprwy Lywydd. Just for the record, between 2017 and 2018, 3,962 nurses from the European economic area left nursing, according to the Nursing and Midwifery Council's register, and they were replaced by just 805. That is the lowest level of recruitment to date, so I think we need to make it clear that this isn't scaremongering—these are actual figures.

The good news in this is that those numbers have remained fairly stable in Wales since the talk of Brexit, but I think that we really need to make it clear that these threats are real, they are already starting to happen, and that isn't to mention the effects that it can have on doctors, healthcare support workers, catering staff, housekeepers and porters, because they are all part of keeping the NHS going, and each one of them performs a vital role. So, I suppose my question to you, Cabinet Secretary, is: having managed to hold on to our nursing staff so far, how do you think that we can sustain that going forward, especially if we end up with a 'no deal'?

I think you're right to point out the catastrophic fall that has taken place already in nurses from the European Union and wider economic area working here in the United Kingdom. It largely affects England at present, but that's the point: at present. We can't pretend that if this continues, if we don't have a greater deal of sense in the way that our future arrangements work, that we will not be adversely affected here as well.

For all that we wish to do, and we're committed to do, to increase the nursing workforce here—I think there's been a 67 per cent increase in nurse training in the last five years or so, so we're putting our money where our mouth is in training the next generation; and the bursary as well is keeping people here in Wales, is keeping people within the NHS here in Wales after they've completed their training—there'll be an even greater imperative to do so if we end up with no deal, because our ability to recruit European Union based nurses will have been made even more difficult.

I find it really striking that when you go to meet representatives of nurses, whether they're in Unison, the Royal College of Nursing or other trade unions, they're genuinely worried about the prospects for their profession's future if we leave. They see colleagues who are already openly talking about not being welcome and who are thinking that they're going to leave because they're worried about future arrangements.

In England, part of the response has been to change some of the roles. They're bringing in a new grade that they're calling nurses associates. The chief nursing officers outside England think that that is role substitution, and that what they're really doing is trying to take off duties that could and should be undertaken by registered nurses, to be undertaken by people who are not at that professional grade. We have a different answer. We have a proper network of healthcare support workers—someone in this room helped to negotiate that framework for them to have a proper career path as well. We need to continue to do it, to develop our own workforce here, but I couldn't honestly say to anyone in this room from any party that if we leave the European Union with no deal that we'll be able to avoid the consequences of that in terms of our workforce and who we have. It will involve the money that we spend—that we're prepared to spend—and, frankly, the jobs that our people are prepared to undertake within the wider health and social care field.

So, the risks are real. No-one should ignore them. They should recognise that without a proper deal, we will have to face those awful consequences and even more difficult choices.

Thank you very much, Cabinet Secretary.