The next item is a debate on petition P-05-826: 'Pembrokeshire says NO!! To the closure of Withybush A&E!' I call on the Chair of the committee to move the motion—David Rowlands.

Motion NDM6797 David J. Rowlands

To propose that the National Assembly for Wales:

Notes the petition ‘P-05-826 Pembrokeshire Say NO!! To the closure of Withybush A&E!’ which received 40,045 signatures.

Motion moved.

Diolch, Dirprwy Llywydd. I’m pleased to introduce this debate on a petition that seeks to protect the provision of accident and emergency services at Withybush District General Hospital in Pembrokeshire.

This is a major petition, both in terms of its importance to people in the local community and the number of signatures gathered. In total, the petition received 40,045 signatures. I understand that this is the largest single petition the Assembly has received since the formal petitioning process was introduced in 2007. The level of support for the petition was borne out when it was delivered to the Assembly in July, accompanied by a significant number of supporters who had travelled from Pembrokeshire. I want to acknowledge the support enjoyed by the petition and the commitment of those who have campaigned to gather the signatures.

I will now turn briefly to some background before addressing the matters raised within the petition. On 19 April this year, Hywel Dda health board launched a formal public consultation on proposals to change the way health services are provided across the area. This followed an internal exercise that sought to identify the challenges being faced by the health board and the options for change. It is fair to point out that Hywel Dda health board has emphasised that this process was led by clinical staff from the outset.

The public consultation contained three proposals for changes to hospital services. It expressed its overall aim as being to move more services out of hospitals into communities and, where possible, to provide services in patients’ own homes. Under each of the proposals, Withybush hospital in Haverfordwest would be downgraded from a district general hospital to become one of a network of community hospitals. The consultation closed on 12 July. As Members will be aware, the results of the consultation and recommendations were considered at an extraordinary board meeting of Hywel Dda health board earlier today. It has been reported in the media that the health board was asked to approve several clinical recommendations. These include the development of a new model at pace and a revised version of option B from the consultation.

Option B will mean, amongst other things, the closure of A&E departments at both Withybush and Glangwili hospitals and the construction of a new hospital between Narberth and St Clears. It is intended that both Withybush and Glangwili will be repurposed as community hospitals. These proposals were approved by the health board with the next step being a draft health strategy to be considered in November.

The Petitions Committee acknowledged the level of support for the petition when we discussed it for the first time just prior to the summer recess. The committee was also conscious of the time-sensitive nature of the issue. In light of this, we agreed that it would be appropriate to immediately refer the petition for a debate in Plenary. The committee is grateful to the Business Committee for agreeing to schedule this debate at the earliest possible opportunity. It is obviously of considerable regret that, despite those efforts, this debate is nevertheless taking place after the health board’s meeting this morning.

I am also disappointed that information the committee received from Hywel Dda was incorrect. It indicated that a consultation closing report and proposals would be presented to a public board meeting tomorrow, on 27 September, rather than today. Nevertheless, I am sure that the health board will wish to pay close attention to the matters raised during the debate this afternoon and to the views expressed by Members.

I will move on now to the concerns expressed within the petition. These focus on the effect that removing A&E from Withybush hospital will have on the distance that many people would need to travel to reach their closest A&E department.

Under the plans, Withybush will host a minor injuries unit.  However, the petitioners believe that the change will result in travel times of an hour or more to A&E for people living on the western side of Pembrokeshire. They also express a concern that this time could be much longer in reality for patients who require an ambulance to take them to hospital. We all know the value that local communities place upon their health services, and how emotive proposals to change them can be. That is, of course, not an argument for never making changes. However, it should be an argument for ensuring that as many voices as possible can be heard and for taking concerns extremely seriously.

In this vein, I also wish to note for the record that the Petitions Committee has recently received a petition in relation to proposals contained with the same consultation for changes to be made to the services delivered at Prince Philip Hospital in Llanelli. The committee will be considering this in the near future.

Dirprwy Lywydd, I am sure that the points raised here today will be of great interest to the petitioners. It is also clear that the decisions taken by the health board earlier today will be a major disappointment to those who signed this petition and to a number of people in Pembrokeshire and west Wales more widely. I am also sure that a great number of Members here today wish to speak on this subject, and I will leave it to others to expand upon the principles and arguments that lie at the centre of this issue. It only remains for me to say that the Petitions Committee will return to consider the petition further in the future in light of the discussion here today, and that the various contributions we hear will greatly support those considerations. Diolch yn fawr.

Thank you. As has been indicated, there are a number of people who wish to speak, and so can I just say to you all: it's not me you're hurting when you go over time, but you may stop one of your colleagues from speaking. So, if you just bear that in mind, please. Paul Davies. 

Diolch, Diprwy Lywydd. I’m pleased to take part in this debate. I’d like to, at the very outset, place on record my thanks to the petition organiser, Myles Bamford Lewis, and the countless number of local activists who have gone out of their way to campaign to protect services at Withybush hospital.

Today's a very dark day for the people of Pembrokeshire following the disastrous news that Withybush hospital will lose its status as a round-the-clock district general hospital, and at the outset I ask the Cabinet Secretary for Health and Social Services to urgently intervene on this matter and take immediate steps to protect our local services. Indeed, the very fact that just over 40,000 people have signed this petition just shows the strength of feeling about health services in west Wales and makes it abundantly clear that the people of Pembrokeshire will not give up their services without a fight.

As Members are already aware, this is a campaign that I've proudly supported for years, and in my role as the local Assembly Member I will continue to do everything in my power to oppose any plans that will result in services being removed from the hospital. It’s my view that the downgrading of services at Withybush hospital will not result in making services safer or more sustainable in the future.

Now, in opening this debate, the Chair highlighted the consultation launched by Hywel Dda university health board on its proposals for changing the way health services are provided across the health board area, and confirmed that, under all three proposals, Withybush hospital would be downgraded from a district general hospital. In other words, the people of Pembrokeshire had no choice in this consultation as the decision had already been made to downgrade the hospital to a community hospital. Surely that is no consultation.

In Pembrokeshire, we have suffered in the past from a lack of transparency, openness and confidence in our health board, and that has certainly had an impact on the way that these latest proposals have been received locally by people. Local people remember the rural health services strategy, 'spend to save' plan document that was leaked to the press and subsequently withdrawn, which talked about the centralisation of services away from Withybush hospital. That document made it clear that the only core services the health board wanted to deliver from Withybush was an urgent care centre: no A&E, paediatric assessments with pending transfers to Glangwili, short stay elective surgical services, low-risk obstetrics, and midwifery-led care. Well, fast-forward to 2018, and that's almost exactly where we are.

The health board's current consultation is simply the latest in a long string of attempts to continuously remove services at Withybush hospital in recent years, and, to be perfectly frank, the local people are sick and tired of having to fight to maintain essential services at their local hospital. In recent years, we've seen services such as orthodontic services and the special care baby unit closed and centralised away from Pembrokeshire, and we've seen full-time paediatrics downgraded.

This continual erosion of services has a subsequent impact on the sustainability of other services. For example, the continual downgrading of full-time paediatrics naturally has an impact on the A&E department at Withybush hospital, particularly given that 25 per cent of admissions to an A&E department are children. Indeed, the fact that the health board is even remotely considering downgrading the A&E department to a minor injuries unit only serves to prove the point made by those at the time that the downgrading of full-time paediatrics would have an impact on the sustainability of other services. This is what people like me and others were saying a few years ago, and I'm afraid we've been proved right. At the time, we were accused of scaremongering.

Let's also remember that the health board's proposals mean that patients will now have to travel further for essential services in a part of Wales where the transport network presents a number of challenges. Little attention has been given to the tired transport network of west Wales, which will have to cope with more and more people travelling eastwards from Pembrokeshire. Once again, this shows the level of priority attached to delivering health services in west Wales, and the Welsh Government must now put a stop to the health board's plans and send a clear statement that the constant removal of services away from Pembrokeshire will no longer be tolerated.

Deputy Presiding Officer, we also know that by downgrading and removing services, Hywel Dda health board and the Welsh Government have done nothing to help attract doctors and medical staff to the area, which, in turn, does nothing to protect the current provision of services. Now, more than ever, it's absolutely crucial that the Welsh Government intervenes and puts an end to the health board's catastrophic plans once and for all.

Therefore, in closing, Deputy Presiding Officer, can I once again reiterate my support for this petition and reiterate the views of the people of Pembrokeshire on this matter? The message is quite clear: stop downgrading our hospital. This is a message supported and advocated by representatives of all political parties and at all levels of government. Indeed, it is very much a team Pembrokeshire campaign, led by local people who care passionately about local health services.

I’m pleased to able to make a contribution as a member of the Petitions Committee and Plaid Cymru’s spokesperson on health. I’m going to talk about the principles of downgrading and losing emergency services.

This petition, of course, which we’re discussing today, is a reflection, once again, of the concern that arises regularly when we talk of reorganising hospital services, and particularly the recommendations that have been causing concerns in this part of Wales for many years. Concerns are often ignored by politicians who say, 'Well, we have to go through a process of change. We have accept this.' And perhaps we will hear rhetorical references today to the parliamentary review of healthcare in Wales in the future, but before you go and search yourselves, I can tell you that there is no reference in that report to anything that is akin to the reorganisation being recommended here for the Hywel Dda area. Believe you me, it is important that we do listen to the petitioners and the protesters, because I think that people do have a right to crucial services within a reasonable distance of their homes, and an emergency department in a hospital, surely, is essential. 

I’ve called in the past for the development for frameworks within the health service noting which services should be provided at what level, that is, some services within your community or close to your community—your GP, for example, pharmacists, and so on. We should note that there are some specialist services that we have to travel for, and I would include in that—I’ve been convinced of this—the emergency trauma services, specialist trauma services. And I will note here that it reflects very poorly on historical decisions taken that patients in north Wales have to travel to Stoke for some of these trauma services, rather than investment having being made in developing those services to serve north Wales in Wales. But you can’t develop those services easily now.

But, looking at emergency services generally, I looked at a recent report published in Health Services and Delivery Research, which was a study comparing outputs between areas that have seen A&E services centralised and other areas. And that study doesn’t demonstrate any benefit of centralisation. Some good news for you: in centralising, there was no great increase in the number of deaths, but that was because mitigating steps had been taken. And, yes, there was an increase in the risk of death following centralisation, but, generally speaking, things weren’t much worse as a result of centralisation, if you can take some comfort from that. But, there was evidence of pressure on the ambulance service as a result of the centralisation of services, and it’s worth noting too that the areas looked at as part of that study were less rural than this particular part of west Wales.

I also think that it could be useful to look at the findings of the Sheffield University study, which looked in 2007 at 10,500 emergency cases and found that 10 km further in distance from an A&E department corresponded to a 1 per cent increase in mortality. And the figure was worse, then, for people with respiratory conditions. So, distance from A&E does have an impact on outputs and outcomes.

So, there are risk factors inherent in these proposed change, and people, therefore, have a right to be concerned. And, of course, we don’t have the details that we need at the moment to make a full evaluation of what is being proposed. There is no recommendation on out-of-hours care; no significant increase in social care; no plans to invest in the ambulance service, and so on and so forth. Rather, what we have is the bait of a new hospital, and I can tell you that everyone that I’ve spoken to is very suspicious as to whether that can be delivered: £350 million in investment—all of the capital expenditure in a single year in Wales. What we need to do, of course, is to improve those elements of the service that will make a real difference to people: we need to strengthen primary care; we need to invest more in medical training; we need to tackle recruitment problems, and so on, and retain staff in that way.

To conclude, removing crucial services from large areas of Wales is not going to improve our health service, I’m afraid, and I’m very grateful to the petitioners for ensuring one of the highest numbers of signatures on a petition to be considered by our committee, because you represent not only the people of the Hywel Dda area, but people the length and breadth of Wales who treasure their local health service.

This is clearly a difficult issue, confronting the mechanics of change. The case made by the Hywel Dda health board is for the sustainability of services, not now, but in 10 years' time, and we already see that our hospital services are struggling under the extra demand and the implications of an ageing population today. There are already shortages, on many weekends, of out-of-hours care in the units associated with the hospitals alone, let alone the pressure on the wards, where the average age of a patient in Prince Philip is 82 years of age.

Clearly, these changes in society need to be reflected in the way that we run and organise hospitals. I think there's a broad agreement on that. The difficulty comes from the politics and engaging with the public and the patient on the implications of that for our local hospitals. That, clearly, is not easy, and I have been critical of the way that Hywel Dda engaged in that in trying to control the debate, not engaging in public meetings, putting out an almost impenetrable public consultation document. So, it is imperfect, the way that they have run the consultation, but the fact that change needs to be confronted, I think, is without argument. But, of course, we want to see change for the better.

I am pleased with the announcement this morning that option A has been taken off the table. I do not think that with a population the size of Llanelli, given the role that Prince Philip plays within the Hywel Dda ecosystem of hospitals as a training centre, it would have been in the best interests of the health board, or in the interests of the people of Carmarthenshire, for that to be downgraded to a community hospital. And, I'm pleased that the health board has listened and engaged patiently with the arguments that were put, not just by me and by Nia Griffith, my colleague, the MP, but also by the responses to the consultation, where their own staff said, in response to the consultation, that option A was not acceptable, and that option B was a better solution. So, to that extent, I am relieved that the outcome has been as it has. As David Rowlands said at the beginning, there's a petition from the SOSPPAN campaign, the save our services campaign, pending before the Petitions Committee—a 13,000-strong petition that has yet to be heard.

Looking at the result of the decision this morning by the health board, there are a number of things that they have agreed to in response to the consultation that I think are encouraging, but we need to watch carefully. One is recommendation 7, which is the development of a detailed plan to address the significant concern heard about access. In particular, they are going to work with the Wales ambulance service to look at patient transport—looking at new models for getting people around. This, to me, is the Achilles heel of the change. When 25 per cent of people do not have access to a car, and those who do have access to a car are an hour away from a hospital—. Constituents of mine will be closer to Morriston; they'll be closer to the Prince of Wales; they'll be as close to the Heath as they will to the hospital in Whitland. So, clearly, the access is going to be the key for making any changes work.

The other recommendation, 8, is the use of technology, which I think was profoundly underdeveloped in the proposals put out by Hywel Dda. I heard on the webcast this morning Dr Alan Williams, who is the cluster lead for Llanelli, say that their plan to maximise the use of technology, which was illustrated in the slides by an iPhone—. He said that the reality in the NHS today is not that this will be involving an iPhone; the reality is that this is going to be involving a fax machine. We've discussed in this Chamber before the reality of the state of digital in the NHS today. Given the pace of change that the NHS Wales Informatics Service has been able to deliver to date, even though this is 10 years ahead, there has got to be some doubt about whether or not they are going to be able to deliver it as currently structured and resourced. So, clearly, that has to be put right, because the potential for cutting down the need to travel in the first place by using digital, so that people can access services without needing to go to a hospital, is huge and is not being capitalised, either by the Hywel Dda plans or by the NHS in Wales more generally.

There are still some causes for concern in the response from the point of view of my constituents, and levels of trust are low. They say there will still be comprehensive—. Even though acute services will remain in Prince Philip, there will be comprehensive reviews required in this planning of the service change to ensure that acute medicine is going to be available in all hospitals. So, having said on the one hand that acute medicine will be preserved in Prince Philip, there is that slightly sinister warning that there could yet be battles ahead, and I will certainly be keeping a close eye on it. Diolch.   

I'd like to thank the Chair of the committee for putting this forward in such a measured and balanced way. We are talking about 40,000 signatures. Behind each and every signature is a voice. We are talking about 40,000 voices who have been striving to be heard for over a decade; 40,000 tired and very frustrated voices, who live in constant fear because they never seem to be able to impact successfully in any way at all any of the plans that others have about their lives.

This is the third consultation in my Assembly life as the Assembly Member for Carmarthen West and South Pembrokeshire. I came in on the back of the 'Designed to Deliver' document, which was a complete disaster. There was some nonsense of a consultation about five years ago, which bit the dust as it deserved to, and now we have this one.

It always focuses on Withybush being downgraded—one of Wales's furthest flung hospitals, serving one of Wales's furthest flung populations: a population that is disproportionately elderly compared to the Welsh national average. What do elderly people tend to have in common? They don't tend to be hugely IT literate. They often don't have access to their own vehicles. They find public transport difficult and exhausting to use. 'But, hey, guess what, all you dear old folk of Pembrokeshire? We're going to move your hospital further away from the kinds of services that you might need.' It's a population with also a high number of disadvantaged people, poor people, living in Pembrokeshire—a population that already struggles to recruit and retain GPs and nurses, allied healthcare professionals and hospital staff. And those first three—GPs, nurses, allied healthcare professionals—are all vital if we are to build up these community services that we speak of. But I say to you: cart before the horse? Because we should build up those community services before we even start having a conversation about these hospitals.

This is a population that has the largest GP practice in Wales, with over 25,000 patients and almost double the national average of workload for each GP involved in that practice—a population that's constantly seeing services dragged eastwards. And I can remember, over my 11 years as an Assembly Member, various chief executives, various chairmen, phoning me on my mobile to say, 'Angela, I want to give you a heads up. We've got a problem in haematology. We've got a problem in this, histopathology. We are going to have to take it away from Withybush, only for three months—oh, four months. Oh, we haven't quite been able to get it back again'. Again and again and again—it's a death of a thousand cuts.

This is a population with really poor transport infrastructure: small roads, an A477 that had yet another disastrous crash on it last week, an A40 that's not dualled—and I listened to the health board today when they did their big meeting in Carmarthen town hall, or county hall, and one of the independent members said, 'Oh, we need to dual the A40'. Well, good luck with that. I think we've said that a few times, have we not, Paul Davies? And I've looked at the transport plan for the Cardiff bay city region: there's nothing in the 2015 to 2020, there's nothing in the aspirational 2020 to 2023, on the dualling of the A40.

This is a population served by dedicated staff in a much loved local hospital, but a hospital that doesn't have a 24-hour emergency medical retrieval and transfer service, doesn't have a 24-hour chart, so, guess what? If you happen to be in the wrong 12-hour cycle, you could be in a spot of bother trying to get to any other service.

And now, A&E: this is something that Paul Davies and I have raised again and again and again here, about the fact that, as soon as paediatrics left Pembrokeshire, A&E would be hard on its heels, because paediatrics makes up 25 per cent of A&E admissions. Without paediatrics—if you don't service paediatrics, you don't get to have your A&E, and we're not having our A&E. We're told it's all about clinical safety, but it does seem to be all about Withybush. Are hospitals in the poorly performing, highly overdrawn Betsi Cadwaladr in the firing line? Do all the discussion and plans ever drawn up ever talk about the politically protected Bronglais or Prince Philip?

I was going to finish by saying that my depression over this intensified when I looked at the final document that the board considered today. And, in that final document, apparently, a separate group of stakeholders and staff that had not been involved in the development of the options looked at where they would rate the criteria. So, quality and safety: 18 per cent, absolutely. Acceptability to the general public: 7 per cent. That's the lowest criterion for why we should keep Withybush apparently a fully functioning district hospital. Those 40,000 voices are blowing in the wind.

A view from outside the area, but a view from somebody else who was on the Petitions Committee: one thing we know from the petition is that there are a very large number of people who want an A&E service at Withybush. A petition of 40,045 signatures is unprecedented. You actually need 5,000 signatures for the Petitions Committee to ask the Business Committee if we can have a debate on it. We could have eight debates on this, because it beats it by more than eight times. I think it does show the amount of interest there is and the amount of opposition there is to the idea of closing A&E in Withybush. And I can understand it. The idea is that there will no longer be a functioning A&E department within Pembrokeshire; it'll be replaced by a minor injury unit on the Withybush site. In doing so, patients requiring emergency care in Pembrokeshire will be facing a substantial journey. And I speak as somebody who quite often travels to north Wales, because my daughter is at Bangor University, and I know that, in 2.5 hours, I can get to Machynlleth, or, in 2.5 hours from where I live, I can get to Birmingham. I know which is the furthest away, but, if anybody can manage an average speed of over 40 mph in rural areas, I congratulate you, and can you explain how you manage it? The tractors—ambulances haven't got an ability to fly over tractors, have they? The problem you get with Mansel Davies lorries—no offence to Mansel Davies, but your lorries do clog up the road—and trailers, especially in the summer, when you've got lots of caravanners moving caravans. The road network is appalling. To Angela Burns—and Paul Davies will bear this out—you're not the only people who've been asking for the A40 to be dualled. I've asked for it, I've written about it, I've called for it. [Interruption.] Certainly.

Can I just point out the irony? You've just delivered a speech on the mitigation of climate change, and you're now arguing for the dualling of a major road.

Yes.

Friendly fire. [Laughter.]

I know Lee Waters doesn't accept this, but improved roads can reduce emissions. If you've got to make a journey to a hospital, how else do you suggest that people make it to A&E—by cycle or walking to A&E? 

Pembrokeshire lives at risk—. Providing healthcare in rural areas is difficult, but it is not impossible. Other people do it. 

We also know that a similar petition regarding A&E in Llanelli has been received, and I'm sure that Lee Waters doesn't want to close some of the dual carriageways around Llanelli in order to reduce—[Interruption.]—in order to reduce the amount of emissions.

I do not believe that Hywel Dda works as a health board. I've said it many times. I do not think Hywel Dda works as a health board. The area covered is too large. In ABMU, travelling between Morriston, Singleton and Baglan is relatively easy for most people. You can travel by bus—not necessarily very easily. You can travel by car relatively easily. Travelling around the four main hospitals in Hywel Dda is very difficult by car, and, in many cases, I would suggest, close to impossible by public transport. If Powys can have its own health board, why cannot Pembrokeshire? Powys was a 1973 invention, while Pembrokeshire has existed for centuries.

I was going to say that no-one sees Dyfed as a unit for service delivery anymore, but I will not say that, because I know one person, probably the one person in Wales, who does. I'm afraid that very few people living in the area see it as a sensible unit for service delivery. I ask any other Members representing the area covered by Dyfed—if they see a sensible area for service delivery, please get up and correct me.

Will you take an intervention? You and I represent the same area, in which Morriston Hospital is found. Do you share my concerns that, if all these services keep being pushed east, then they'll get as far as Morriston, which is already overloaded by other demands made on it? While it's great that we have things, hopefully, like thoracic surgery coming to us as a specialism, when you've got emergency services then you need to be near the place where the emergency occurs. 

I agree entirely with that, and that takes a large part of the next bit of my speech. But the one thing I will say, before I finish, is that there are things that work. The hub-and-spoke model for renal services, which those areas in Hywel Dda and those areas in the rest of ABMU benefit from—I've talked about that for seven years, and the growth in hub-and-spoke service models in terms of service delivery have been nowhere near as fast as I, and probably most other people, would like. 

The ability to access an A&E department is something that people want as close to their homes as possible. Requesting one in the ancient county of Pembrokeshire should surely not be too much to ask.

Much has changed in public life in Wales since I last spoke on a health issue here in this Chamber. Some things have not. One thing that has not is the simple fact that many in communities in the west do not have confidence in the Hywel Dda health board, do not trust it to act in their interests, and do not believe that, when it consults on proposed service changes, it listens to them and responds to them. Hence the petition that has triggered this debate today, and, like others, I'm grateful to the Petitions Committee for bringing this forward. 

Another thing, of course, that has not changed is the Welsh Government's habit of distancing itself from proposed changes, even though the health boards are entirely accountable to Welsh Government and it is the Welsh Labour Government policy that is behind this drive to centralise services. 

Yet another thing, of course, that has not changed is the rather unedifying spectacle of politicians elected in the name of the Welsh Labour Party persisting in campaigning, and sometimes leading campaigns, against the proposed service changes driven by their own Government's policies—baffling, absolutely baffling. Faced with the current proposed changes, Plaid Cymru, as my colleague Rhun ap Iorwerth has already said, has sought to take a responsible approach. We have developed and presented alternative proposals following consultation with community members and professionals in the region. And I will, if time allows, refer to some of the specifics of those proposals in a moment. 

It is vital, Dirprwy Lywydd, as others have said, that we acknowledge that the concerns raised by those supporting this petition are genuine. They are based on the past experience of service changes at Withybush hospital over the last 15 years—changes that have led to real tangible problems—and it's important to reflect on the lessons learnt from that reconfiguration. We know that, if essential consultant-led services are removed or relocated, it is crucial that effective risk assessments are undertaken and mitigation measures are put in place to ensure that the right patients get to the right place to be treated in the right settings, and these measures must be robust.

The Cabinet Secretary will recall that in some tragic cases, following, for example, the changes to maternity services, this did not happen. He will recall the ombudsman finding in 2016 that a baby had died following poor care and a failure to properly assess the risk level during pregnancy, with the patient's request to give birth in a more specialised setting at Glangwili ignored. Now, I trust that the lessons from this individual case have been learned, but it is vital that we remember that this case forms part of the background to the community concerns about further proposed service changes that have led to this petition. I hope that the Cabinet Secretary and the health board will treat these justifiable concerns with the seriousness that they deserve. Sadly, given past records, I am not sanguine.

Plaid Cymru do not believe that the health board's proposals will address how services will be improved in the short to medium term. They make reference, for example, in their statement today to the need to work more closely with the local authorities, but it says nothing about how. And I would agree with what others have said about it being important to wait for the detail, but surely we don't have to wait another 20 years for the detail of this. It says nothing about how, and, frankly, we have heard it all before. We are unconvinced that the proposed new superhospital would solve all the problems that the health board hopes that it might, and we are far from convinced, frankly, that it will ever be built, much as some of us might hope that it will be.

Time does not allow me to set out our alternative proposals in detail, and I am conscious of instructions from the Dirprwy Lywydd. We will, of course, be happy to share these proposals again with the health board and with the Cabinet Secretary. One thing is crucial: reconfiguration of acute services must not be made until such a time as the envisaged changes and developments in community services and working practices are in place, and the new acute services are in place. We must have new approaches to joint working between the health boards and the local authorities, and we must have integrated, holistic health and care provision delivered locally, with a single line of management and accountability. And we must ensure that, if we are transferring patients from hospital settings to emergency settings, the proper provision is in place. We need a trauma stabilisation unit in every hospital, in every setting, in which a patient might find themselves, and we urgently need sector-wide recruitment and development plans across health and social care. It is beyond me that, in a country the size of Wales, we cannot properly plan our health and social care workforce, and I would argue that we need, for example, to double the number of medical students training in Swansea, because we know those students stay in west Wales.

Dirprwy Lywydd, no-one in Plaid Cymru is suggesting that health services should not change; I don't imagine there's anybody in this Chamber who is suggesting that. It is true that we have, to a certain extent, a twentieth century pattern of services that do not meet twenty-first century need. But, in delivering that change, we need to build the trust in the communities that those services are there to serve, and we cannot do that if we dismiss their legitimate concerns. The health board and the Welsh Government need to listen to the concerns raised by those who have signed this petition. No further changes should be made to services at Withybush or elsewhere in this region until effective alternative services are in place. Diolch yn fawr. 

I think where we are is that we've had a consultation document, we've had proposals and we've had petitions, with people clearly expressing concerns about those proposals. I live in Haverfordwest. I know perfectly well where Withybush hospital is, and I also know the strength of feeling and the fear that exist in people who might need to access A&E quickly. I think that, moving forward, as has just been said in the lengthy six-plus-minute speech by Helen Mary, we recognise the need to change the current configuration of health provision to meet the future demand that will be placed upon us to deliver that. And there are many, many changes that will have to be made, with a systematic approach, to meet those challenges. 

And the biggest challenge of all—. Well, there are two challenges, but if we focus on the people we are trying to serve, we have an ageing population—lots of people have said that—when they present to hospital, they have multiple needs, but it doesn’t always mean that there aren’t opportunities along the way for those needs to be addressed before we get into the hospital setting and for them to be looked at once people leave those hospital settings. And it seems to me that, wherever I’ve spoken to people, the one real fear they have is about the provision of community beds, or beds in the community, so that they can visit elderly patients and also keep them closer to home, because those patients will do particularly much better if they’re in a setting where others can come along and support them.

The other big challenge that we are facing in an evolving medical setting is the staff to deliver it. What we have at the moment, clearly, are large-scale shortages of medical staff at every single level. That isn’t unique to Wales, to Pembrokeshire, to Dyfed or anywhere else. It is the case right across the country. We cannot pretend that Brexit isn’t happening, and nobody’s mentioned that, actually, today, and the pressures that that could further place on us accessing—

Will you take an intervention?

—not at the moment, no—us accessing the highly trained medical staff that we need and the experiences that those staff might gain from other parts of the world. So, I’m going to bring that into the mix, because it is very definitely in the mix at the moment.

What I think we need out of this consultation at the moment is some real meat on the bones. What really does it look like? When we talk about community hubs, exactly what are we talking about? Where are they going to be, and what is it that they’re going to deliver for people that is different to now? Is that also going to help with retaining and gaining GPs in our communities, which is also another huge, huge challenge? Do we need to go to hospital all of the time for all of the appointments that people go for at the moment and travel the miles that they do at the moment? I think we need a reasoned debate here in looking at the genuine reconfiguration that has to happen.

And the other question that I ask is this: should we, without thought, be turning down what could be an absolute opportunity to build a hospital in west Wales that might solve all of the problems and bring massive investment in the change that people will need in 10 or 20 years' time that will last for the next, maybe, 30, 40 or 50 years, when, probably, a lot of us in this Chamber won't be around to see that change? We need to think now, clearly, for the people who will need us to do that now, to be a little bit brave, but at the same time to ensure that there is no change at the moment to services before there is an opportunity to take advantage of the new systems in place.

I agree with Joyce Watson; we do need to have a reasoned debate about the health services, and I believe that this debate has been reasoned. There have been some passionate speeches, of course, inevitably, because people do feel very, very strongly that, in Pembrokeshire in particular, they are forgotten, neglected and abandoned by the health service and that their needs are not being properly looked after now, let alone in the future if ever these plans are put into effect.

Nobody denies the intractable problems that the health service faces throughout the whole of the United Kingdom—funding is a problem everywhere and needs, as we know, are growing. We have a national health service, but the national health service is nothing if it's not also a local service. You've only got to look at a map to see the geography of the Hywel Dda area. Pembrokeshire sticks out into the sea, and I think that the people of Pembrokeshire feel as though Hywel Dda are actually digging a great big moat between Pembrokeshire and Carmarthenshire and Ceredigion and that they are drifting further and further from the centre of operations. Nobody can underestimate the degree of genuine feeling of alarm and fear that is represented by this unprecedented petition that we are debating today.

The fundamental problem that we are facing here is that the health service is totally undemocratic, and the major decisions are taken by technocrats who are not elected and we can't dismiss, and are ultimately not accountable. The community health councils are not elected and they can easily be stuffed with compliant members who won't live up to the expectations of the people who they are there to serve. This exercise in consultation that we're looking at today is, I think, an example of this also. Lee Waters referred to it as an impenetrable document and I absolutely agree with him—I've got it here. You only have to look at it to see that the decision, effectively, had been taken even before the consultation was started. It's no surprise that in paragraph 1.106 that the conclusion is that public support for what the health board is now going to endorse was driven by location. Well, what would you expect? People want hospital services that are close to where they live. I mean, it's the most obvious fact that you could imagine; you don't need a consultation with all its cost in order to arrive at this conclusion. Just a few paragraphs before that, the health board says: 

'It is important to recognise that there is very strong public support for another alternative across many parts of Pembrokeshire'.

In other words, 'none of the above' is what people in Pembrokeshire want—that's just not on offer. If this was a true consultation, there would've been the alternative that might've been acceptable to the people of Pembrokeshire. What an extraordinary consultation that it's proved to be. It's a 'nonsultation' as far as most people in Pembrokeshire are concerned, and that, I think, is totally unacceptable. 

I totally agree, also, with what Rhun ap Iorwerth said on behalf of Plaid Cymru. The people have a right to expect that their main services that they're going to need, particularly in rural areas where transport links are poor, poverty levels are higher and the age of the population tends to be in the higher regions as well—they have a right to expect that their main services can be accessible within a reasonable distance. 

And I agree, also, with what Helen Mary Jones said, and others have alluded to also, in that we mustn't put the cart before the horse. We mustn't plan to close down major facilities that are fulfilling a vital need until we have got the building blocks in place for what is going to replace them. So, this, I think, has been handled in a most insensitive way.

And then, of course, we come to the elephant in the room in the form of the health Secretary, because ultimately, Hywel Dda is now under his supervision, just as Betsi Cadwaladr is in north Wales, and the Welsh Government can't simply wash its hands of responsibility for what's happening here. Ultimately, it's the responsibility of the Welsh Government to provide the funds for each of the health board areas, and I don’t underestimate the problems that the finance Secretary has in making his numbers add up. It’s impossible to do everything that people expect and want from the health service. Socialism is the language of priorities, as somebody once famously said a long time ago—indeed, I think, if I remember correctly, the man who actually founded the health service, Aneurin Bevan. Well, the people of Pembrokeshire expect that they will be a priority of the Welsh Government and if they are abandoned by the health Secretary, then he will go down and be remembered not as Aneurin Bevan is remembered today, as the saviour and founder of the health service, but he will go down as the Pontius Pilate of the health service, who ultimately failed the people of Pembrokeshire.

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

Thank you, Deputy Presiding Officer. Members will be aware that it was only earlier today that Hywel Dda university health board presented the outcome of their recent consultation on transforming clinical services, and they confirmed their recommended way forward for changes to services across the health board area. The recommendations were presented by clinicians who work in west Wales, and those clinicians are making a case for the future of healthcare in the communities that they serve, and I think that they deserve our respect. Regardless of our view on the future, they deserve our respect for making a case for change in a difficult and highly contested environment.

You will also be aware that the proposals that the health board has only just confirmed are not the end of the process. The arrangements for proposing significant changes to health services in Wales are set out in the guidance for consultation on changes to health services, and that guidance clearly sets out my role in the process, including that I may be called upon to take final decisions on a health board's plans if agreement cannot be reached locally. You will, therefore, appreciate that, despite all of the kind and gentle—and less kind and gentle—urgings, I won’t comment specifically on any of the proposals that Hywel Dda university health board has confirmed today, as doing so may prejudice any future role that I may have to play in the process.

So, my comments this afternoon will be restricted to reminding Members why services across Wales must change—

Will you take an intervention? 

—no, I’m carrying on with my remarks—if we are to provide the health service that the people of Wales need and deserve, because service change requires maturity and leadership from all of us. The challenges facing health in Wales today are well known. They include a rising elderly population, enduring inequalities in health, increasing numbers of patients with chronic conditions and, of course, a challenging financial climate. The adage 'If it ain’t broke, don’t fix it' could not be more inappropriate, because, in healthcare, waiting until 'it' is broken means waiting until real, avoidable harm is caused and no public servant should contemplate doing that.

It's widely accepted that there are UK-wide shortages of health professionals in certain specialities, which is causing difficulties in recruitment, as was mentioned in the debate. We also know that where more specialist services are provided, doctors need to see a minimum number of patients to maintain their skills and expertise to meet care quality standards. There is a wealth of evidence that shows that concentrating some specialist services in fewer centres improves outcomes for patients. Don’t take my word for it: that is one of the clear, unambiguous messages from the independent parliamentary review that enjoyed cross-party support.

So, these are Wales-wide challenges, and I’ve repeatedly been clear that I want to see an increase in the pace of reform in Wales, because there is simply no avoiding the reality that there will always be contentious choices to be made in every area of Wales. So, we either engage in that debate now and confront some of those challenges and then help to make clinically led choices, or we put that off and make it even less likely that change will happen until a point of crisis and a service collapses, and I do not think that is a responsible thing to do. And, again, that’s a very clear message from the independent parliamentary review, which told us that our current system is not fit for for the future. [Interruption.] I’m happy to take Nick and then Angela.

I’m sure you do, in your position, have to make difficult choices, but would you agree with me that, aside from whether it is right to reform the services in the way you’re proposing or not, there is a bigger issue that was raised by Neil Hamilton amongst others—that you’re not carrying people along with this process, hence we have this petition, which has been given in with all of these signatures, hence we're having this debate today? In south-east Wales, the area I represent, we’ve got Gwent Clinical Futures, which has virtually unanimous support across Gwent, without these sorts of complaints. So, surely, even if you think you're right with the decisions you're taking, the health board is taking, what has gone wrong with this process and why are so many people not trusting your Government?

Well, this isn't a choice that the Government is making. The broad choice is for us to reform or not. I'm clear that our health and care system needs reform. The parliamentary review told all of us our health and care system needs reform. Staying as we are is not fit for the future. In Gwent I made a decision to enable a new hospital to be built at the centre of that reformed system of health and care. There are different conversations taking place in different parts of Wales. You can't simply impose the way people do it in one part of the country on another. But key to this all has to be engaging our staff and engaging the public. We need to be honest enough to say that people won't necessarily all agree at the end of it, but a decision still needs to be made.

I'll take Angela's intervention and then I'll move on and make more progress.

Thank you. It was actually just a point of clarification, because I can accept, in a way, your commentary that you say that you don't want to comment on these detailed plans because you might have to make a final decision at some point in time. That's on the one hand. On the other hand, though, the health board will not be able to proceed with their multimillion pound—Rhun said £350 million, they've told me £500 million—new hospital without having additional funding, which will have to come from the Government. So, how can you square those two if you've got to keep independent, but actually then decide whether or not to commit to that plan?

I think you should listen to your colleague Nick Ramsay, because across Gwent there was agreement, on a cross-party basis again, cross-community, on a new plan to deliver health and care. That was agreed before the Government said there was definitely x sum of money to deliver a new hospital at the heart of it. I think I was the fourth or fifth health Minister to be confronted with that choice, and I made a decision. I'm keen that we make choices to keep our system reforming and confronting the challenges we face today and the challenges of the future. So, I see no challenge at all in not making a comment on the detailed choices now, but I also give the assurance that, of course, for any Government initiative—it might be me, it might be somebody else who is asked to make a choice on any capital expenditure and support for the final delivery of that plan. Because change will happen across health and care. We either let that change happen in a chaotic, crisis-led manner or we empower our NHS, our staff and the public to take ownership of the future. Because there is no easy way to have a conversation about transforming our NHS. There'll always be a view—and an honest view, I accept—about why a change, in particular on a local or individual level, should not happen in any and every part of the country where change is proposed.

Our long-term plan for the future of health and social care in Wales, 'A Healthier Wales', describes how we will implement the review's recommendation. It sets a vision for the future and explains how we should adapt to meet future challenges to transform the way that we deliver health and social care. That means evolving traditional ways of working to provide a more proactive approach. That should get patients young, old or frail, and everyone in-between and around the services they need, when they need it.

There will of course be occasions when changes are proposed to hospital-based services, and I know this is about much more than buildings. People have powerful emotional attachments to the venues in which healthcare is delivered, but it is about investing in communities, attracting doctors, nurses, therapists, scientists, by operating a modern healthcare system to make the best use of digital technology and to keep hospitals for those who really need it. That's why we need to build capacity in primary and community care, to provide more care closer to home, in genuine partnership with social care and the third sector. An excellent example of this is actually in eyecare, which is particularly relevant as this week is National Eye Health Week. The NHS Wales eyecare service enables optometrists to provide local, accessible, high-quality care and to reduce the number of patients being referred into hospitals. I had the pleasure of visiting a high-street practice today.

I'll try to draw my remarks to a close, Deputy Presiding Officer. To meet the challenges confronting Hywel Dda, the health board began engaging with the public on a transforming clinical services programme last year. The consultation received over 5,000 questionnaire responses, 275 submissions, and had over 160 face-to-face events. Five petitions were received, including the one of today's debate. But following that process, the health board has been through another process of reconsideration. The full range of views and implications have been assessed with other options put forward, and that outcome has been put forward to the health board today. But, as I said earlier, this is not the end of the process, and in light of the role that I may still have to play, which I outlined earlier, as Members know I cannot and will not comment on the decisions that the health board has made today.

Thank you. Can I now call David Rowlands to reply to the debate?

Diolch, Dirprwy Lywydd. I shall endeavour—. First of all, I shall thank all those who've taken part in this debate, and, clearly, there are some very serious passions involved with regard to this debate, so I'm going to take a little time and try to repeat some of the things that people have been saying. 

First of all, Paul Davies asked the Cabinet Secretary to intervene and oppose the closure of the A&E department at Withybush, but the decision had already been made, so this could not be a consultation process. He also remarked about the continual erosion of services in Pembrokeshire, and that this could not continue. Rhun ap Iorwerth reiterated Paul Davies's assertion with regard to the downgrading of services, also noting that emergency services are critical to every community. He also mentioned the pressure on the ambulance service due to the centralisation of hospital services. Again, he pointed out a perceived lack of alternative contingencies.

Lee Waters spoke of Hywel Dda's consultation process, and he was pleased that option B was taken rather than option A. Access was key to make any changes work—that's access to hospitals is key to make any changes work. He spoke of using digital communication as offering some solution to increased travel. Angela Burns spoke of the frustration of the 40,000 who signed the petition at not being taken notice of by Hywel Dda over the various so-called consultation processes. And she also spoke of the closure of the A&E at Withybush as being inevitable. 

Mike Hedges spoke of great opposition to the closure of A&E, and pointed out the difficulty of travel in rural areas, especially in Pembrokeshire in the summer months. He also voiced his concern over the sheer size of the area covered by Hywel Dda.

Helen Mary Jones pointed out that there were many who had no confidence in the Hywel Dda board, and spoke of the failure of past promises not being kept, and that her party had alternative proposals that should be looked at before any further actions were taken by Hywel Dda. 

Joyce Watson spoke of the fear of the people affected by the changes, particularly the proposition of community beds. She mentioned shortages of clinical staff as being part of the mix. Do these changes planned make recruitment of doctors and nurses more difficult, and the possibility of having a brand-new hospital in west Wales?

Neil Hamilton mentioned the importance of these matters being comprehensively debated, with the general mix of clinical services moved from east to west, and criticised the complexity of the consultation document. There was no proper alternative to the closure of A&E at Withybush, and no real infrastructure being put in its place.

If I come to the Cabinet Secretary and his response, he says that Hywel Dda deserves respect for their attempts to change the health services across the board, and he spoke of the need to centralise specialist services and specialist clinical staff. And he insisted that there is a need for reform, and that there will be people who will always disagree with what's being proposed. He spoke of the need to have care closer to home and, if possible, in the home.

I think that I've comprehensively covered most people's comments on this, so, again, I thank the Members for their contributions. I promise them that the Petitions Committee will return to consider the petition again at a future meeting, and in doing so we will seek to consider the petitioners' reaction to the points raised today. We will, of course, be giving consideration to the decisions taken today by Hywel Dda health board. So, on behalf of the Petitions Committee, I'm grateful to all Members for their contributions and for the opportunity to debate this matter today. Thank you.

Thank you.

The proposal is to note the committee's report. Does any Member object? No. The motion is therefore agreed in accordance with Standing Order 12.36. 

Motion agreed in accordance with Standing Order 12.36.