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

Item 7 on the agenda this afternoon is the Welsh Conservative debate on NHS capacity. I call on Angela Burns to move the motion. 

Motion NDM6829 Darren Millar

To propose that the National Assembly for Wales:

1. Expresses concern at the capacity of the Welsh NHS to meet demand for services throughout the year, not just in the winter months.

2. Notes that year-round pressures hinder the ability of the NHS to provide consistent and equitable access to out-of-hours, critical care and ambulance services.

3. Calls upon the Welsh Government to develop a comprehensive national plan to address pressures on out-of-hours, critical care and ambulance services to ensure that patients receive timely services which meet their needs.

Motion moved.

Diolch, Dirprwy Lywydd. I'm pleased to open the Welsh Conservative debate tabled in the name of Darren Millar. We want to express our concern at the capacity of the Welsh NHS to meet demand for unplanned care throughout the year, and not just in the winter months, which is often much discussed here, because the truth of the situation is that pressures may look marginally different in winter, because there are a greater number of young children with bronchiolitis or frail people suffering from falls and chest conditions, but the hard reality is that these pressures are year-round, and a constant failure by the Welsh Government to tackle this challenge severely hinders the ability of the NHS to provide consistent and equitable access to unplanned care. 

In the last 12 months, nearly 1,400 days—that's one thousand four hundred days—of extreme emergency pressures for Welsh NHS hospitals were recorded. Our hospitals operated under extreme pressure on 1,395 days over a one-year period in 2016-17. The pressure on the service, on staff and on patients is intolerable and cannot go on. Sickness rates in the Welsh ambulance service run at a staggering 8.8 per cent and, in 2015-16, the NHS in Wales lost over 948 person-years of work due to staff being absent with stress-related sickness. Therefore, we call upon the Welsh Government to develop a comprehensive national plan to address pressures in out-of-hours, critical care and ambulance services in order to ensure that patients receive timely services that meet their needs.

Now, it seems to me that improvements in these key areas depend on ensuring that people do not end up relying on those vital services because they're unable to access care in the local community in which they live. Getting a community-based model of care right is vital, especially as Government and health boards are seeking to transform the provision of secondary care. When areas such as west Wales see the delivery of healthcare being changed in a way that doesn't match the availability of services in the community it begs the question: how can we stop putting pressure on critical care, on out-of-hours services and on ambulance teams throughout Wales?

We've heard time and again that those of us who are lucky enough to live longer—and, with luck, to do so in our own homes—often struggle to get the appropriate support, usually because of a lack of resource available from social services. Whilst the aim of this debate is to draw attention to the Government's lack of integrated planning for unplanned care, I do accept that amendments 2 and 3, tabled in the name of Rhun ap Iorwerth, bring to the table a vital element, and we'll be supporting his amendments.

Deputy Llywydd, I can't take the Government's amendment with any degree of seriousness. Let me read this bit out:

'Calls upon the Welsh Government to support the implementation of a Healthier Wales to address pressures on out-of-hours, critical care and ambulance services'. 

Now, you may recall that 'A Healthier Wales', the Government's much vaunted vision and action plan, flowing from a parliamentary review, firmly puts social models of community-based health and care at the centre of health service delivery. The underpinning cornerstone of this direction of travel is to anticipate health needs and implement sustainable prevention and early intervention strategies in order to reduce the impact on poor health and the need for interventionist models of social care. The ambition is that people will only go to hospital when it is essential. Services will be designed to reduce the need to access hospital and to spend time there. 'A Healthier Wales' specifically states that there will be a 'shift in resources to the community', and this is good news if it enables pressures on the ambulance service and on out of-hours care and critical care to be reduced. So, the plan is to signpost people away from hospital and to community services. However, without the community services in place, people will still need their hospital, and, this year, some hospitals in Wales experienced their worst performances on record in the provision of emergency services.

Welsh Government is failing to strengthen the foundations of the NHS. We cannot build up a community-based model if we do not have 24-hour, 365-day responsive, preventative primary or social care provision. And how can that be built when spending on primary care by health boards decreased by 5 per cent in real terms from 2010-11 to 2017-18? This deterioration in services affects much of the patient experience and creates huge delays for people.

Cabinet Secretary, the most basic requirement for unplanned care is that it must be able to provide care quickly to people with urgent and emergency needs, and, as I've already said, the community will continue to rely on that. A 91-year-old constituent of mine fell and broke his hip in three places in a mental health unit located across the road from Withybush hospital in Haverfordwest. Staff at the unit were not allowed to get him up off the floor until medical professionals arrived. Cabinet Secretary, those professionals took five hours to arrive, and the poor chap was left lying on the floor for all of that time at 91 years of age. Fortunately, he eventually was collected by paramedics and was taken the staggering 380 yards across the road. It is only by chance that he lived through the experience given his age and the severity of the injuries. Now, we can and we must plan for our health services, but we must also have the flexibility to react to out-of-the-ordinary circumstances such as this, because I believe this story highlights that it's becoming increasingly challenging for Wales's emergency services to cope with winter pressures, summer pressures, and, indeed, all-year-round pressures.

Last year, the Welsh Government provided an additional £50 million to ease winter pressures and opened an additional 400 beds across Wales's NHS to ensure our services could cope with demand. Fellow Assembly Members, that is the equivalent of a general district hospital. However, there's been no indication that the Welsh Government will reallocate this funding this year despite demand for services growing throughout the year. Bed occupancy remains consistently above the recommended 85 per cent occupancy level, which means that patient safety standards are being compromised. In 2017-18, average daily occupancy was at 87 per cent within the Cardiff and Vale health board, reaching over 88 per cent at some times, and in Welsh Government-run Betsi Cadwaladr, it reached almost 88 per cent. That's a staggeringly high figure.

And the picture's even grimmer in the occupancy rates for acute medical beds. Within Abertawe Bro Morgannwg University Local Health Board, for example, it hit over 93 per cent. Already, we are rendered as some of the worst critical care services in Europe, and it's becoming increasingly the case that critical care beds are being used inappropriately and hospitals are having to cancel operations to ensure that these critical care beds can remain unused.

The Royal College of Emergency Medicine is calling for an additional 250 beds and funding that is specifically used to tackle delayed transfers of care. This would free up beds within hospitals and allow for a flow in the movement of people throughout the system. So, we're back to the crucial issue of funding. I'm not calling for more and more money, but for the money that is deployed into the NHS to be used more creatively. Every year, we get to a point where the Government says, 'No more money'; every year there's a volte-face as the pressure builds up. The problem is that this cycle is not sustainable, it doesn't allow for coherent planning and it means that funds inevitably get thrown at short-term problems, which makes for highly marginal short-term differences rather than a sustainable change. We need money, fundamental change, new outcomes, not pressure, money, pressure, money, pressure, money, or the picture will never change.

There's little transparency around the deployment of these funds. We cannot tell if the quick-fix delivers: were they value for money? Are we able to identify what they were used for? Whilst health boards may have been able to drive it through to the front line, the reality is it's probably just plugged financial holes, because to deploy effectively at the front line, you need human resource, and that cannot be switched on and off like a tap. And, ultimately, fixing the problem in the hospital is all about dealing with the rising demands in services, a lack of staff, the loss of too many beds, the lack of resources in the community and a diminishing level of proportionate funding for primary care. The very same GPs you asked to deliver an overstretched out-of-hours service, having allowed their funding to drop in real terms by 5 per cent, a service that should play an integral part in relieving pressures on emergency and unplanned services—it's not possible. There's no consistent access to out-of-hours services throughout Wales. 

In ABMU last year, 19 per cent of all out-of-hour shifts were unfilled. Hywel Dda cannot fill some 1,500 hours of GP-led out-of-hours. On 12 separate occasions, Cardiff and Vale had no GP cover across the whole health board for a period of time, and in Aneurin Bevan, that situation occurred on 27 different days. In January of this year, almost 14 per cent of shifts were unfilled in Betsi Cadwaladr. You can see it's across the whole of Wales, and I merely illustrate that this is the very tip of the iceberg. When we have the Royal College of General Practitioners saying, and I quote,

'weaknesses in the system across the country are compromising patient care and increasing pressure on emergency departments', then, surely, that is the time for the Welsh Government to realise that the situation in out-of-hours provision is critical.

Out-of-hours, ambulance services, critical care, unplanned pressures exacerbated by near collapse in social care. If you as a Government really want to cleave to the ambition set out in the parliamentary review, if you as a Government really want to transform services—as your fine words in the vision for health indicate—if you as a Government really want to deal with this never-ending pressure on our emergency services, on critical care, on out-of-hours or our ambulance services, then you need to look at the other end of the telescope, shift a measure of resources to primary and community care, fund and staff social care, and either support people appropriately in their homes or ensure that quality residential beds are available that match an individual's needs, invest in preventative care, respond to the dynamics of our population health trends, and focus on the integrated well-being of the people of Wales.

This is the hardest of choices for you, for the NHS and social care sector, and, truthfully, for us. You're obliged to meet the needs of today while planning, resourcing and funding the needs of tomorrow, but, at this rate, you'll spend the rest of your time as health Secretary firefighting, and you'll fall between two stools. You'll neither sustain our current systems adequately, nor will you affect the transformation that you seek and that we share with you. 

To quote the parliamentary review:

'Unless faster, more widespread progress can be unlocked, access to and the quality of services will decline in the face of predictable pressures.'

This is why the next five years will be a crucial test. It's about priorities, Cabinet Secretary, it was always going to be about priorities, and I commend this motion to the Chamber. 

I have selected the three amendments to the motion. If amendment 1 is agreed, amendments 2 and 3 will be deselected. So, can I call on the Cabinet Secretary for Health and Social Services to move amendment 1 formally, tabled in the name of Julie James?

Amendment 1—Julie James

Delete all and replace with:

1. Recognises the work that is being done to build the capacity of the Welsh NHS to meet demand for services throughout the year, not just in the winter months.

2. Notes that year-round pressures need to be recognised and understood to support the ability of the NHS to provide consistent and equitable access to out-of-hours, critical care and ambulance services.

3. Calls upon the Welsh Government to support the implementation of a Healthier Wales to address pressures on out-of-hours, critical care and ambulance services to ensure that patients receive timely services which meet their needs.

Amendment 1 moved.

Formally. 

Thank you. Can I call on Rhun ap Iorwerth to move amendments 2 and 3, tabled in his own name? Rhun.

Amendment 2—Rhun ap Iorwerth

Add as new point after point 2 and renumber accordingly:

Notes that financial pressures that lead to poorer social care services contribute to increasing pressures on the NHS.

Amendment 3—Rhun ap Iorwerth

In point 3, insert 'social care,' after 'pressures on'.

Amendments 2 and 3 moved.

Thank you, Deputy Presiding Officer. I move the amendments tabled in my name. It is encouraging, I think, that we appear to be moving towards having a more sophisticated understanding, now, that the NHS is facing year-round pressures, not just winter pressures, when extreme weather can generate pressures in the emergency care system. Now, the implications of this realisation are very clear—the NHS needs to plan for seasonal pressures, but what needs to be understood is that seasonal pressures are something that can happen across the year. Yes, there is winter every year, but it's highly likely we'll have spells of high temperatures more frequently in the future too, and we know that high temperatures can put a great strain on health services.

The Llywydd took the Chair.

More often than not, it’s not the number of people who turn up at A&E who cause the winter pressures; more people attend A&E during the summer months. Of course, it’s not much use or help when many people who don’t necessarily need to be in A&E do turn up with a heavy cold, or because they’ve drunk too much. But, even if we prevented that kind of access to our A&E departments, then the winter pressures still exist, because the winter pressures relate, if truth be told, to the kind of patients, those patients who need to be there and come through our hospital doors because, usually, they are older and they suffer multiple conditions simultaneously, which, as a result, causes more complex cases. It takes more time and more expertise to deal with those illnesses. It’s more complex to treat them successfully. People like these need a longer period in hospital, and, very often, they can’t be released from hospital because of a failure to put social care packages in place that are appropriate.

Of course, the winter does make it more likely that a patient will be taken ill because of cold weather. When it’s slippery outside, it’s more likely that an elderly patient may slip. There are also additional problems caused, for example, by low-quality housing during the winter months. But warmer weather can also have an impact on these patients, by causing ill health, causing dehydration, sunstroke and so on and so forth. So, in the midst of these seasonal pressures, what we have, if truth be told, is a kind of patient who is more vulnerable, and understanding that means that we can understand which policies will, hopefully, be put in place in order to help the NHS to plan for the changes in patterns of usage—and that’s where our amendments come in.

Incredibly, we still have to highlight social care through our amendments, and highlight its importance in helping the NHS. It’s incredible that the Conservatives seem to be wedded to the idea that it’s possible to safeguard the NHS budget on the one hand, and to cut expenditure for social care on the other, without there being any sort of impact. I think failing to include social care in the original motion slightly dents your credibility in this regard. We will be voting against the Government amendment, because it would delete our amendments and makes the same careless mistake of failing to address the importance of social care.

To conclude, a few other policies that would be of assistance: investment in services to keep people healthy and out of hospital in the first place—that's preventative services, through social care services, medical care, out-of-hours care, which could assist people to receive treatment earlier when they’re ill, flu jabs—we know that there are current problems with the provision of flu jabs—and, as I mentioned a few minutes ago, low-quality housing. We need to think across all Government departments as to how we create a more robust population. There are things that we can look at in terms of flexibility and increasing flexibility among staff in hospitals in order to ensure that periods of bad weather don’t have such an adverse impact on staff ability to get to work, and through monitoring need in real time and defining that need in a more considered way than simply through figures alone, then we could respond by shifting staff and sharing facilities and so on and so forth.

Without doubt, preparing effectively for seasonal pressures is something that should be commonplace, and we, I believe, must see an end to the excuses that we hear annually, and we must be in a situation where we don't have to return to the same topic year on year.

In seeking to delete our motion, which reflects the concern expressed to us by staff and patients throughout the year about the capacity of the Welsh NHS to meet demand, the Welsh Government is recycling lines that we have heard so often before. I've participated in similar debates throughout the last four Assemblies, and each time the Welsh Government has dodged responsibility by asking us to recognise the work that it is doing to build the capacity of the Welsh NHS. So, let us be absolutely clear: NHS Wales has been led by Labour health Ministers in Labour-led Governments since 1999.

Referral-to-treatment targets continue to be missed and the accident and emergency waiting times target has not been met in 10 years. Betsi Cadwaladr university health board has been under Welsh Government control for three and a half years. Welsh Government figures showed last month that Wrexham Maelor and Glan Clwyd hospitals had achieved the worst A&E performance for Welsh hospitals since records began.

A fortnight after writing to the health board about a constituent who had waited three years for a knee operation and who is in constant pain, we only received an acknowledgment from the health board yesterday, after having to chase this with their new chair. A constituent who spent three hours with a neighbour who subsequently died while he waited in the snow for an ambulance following a stroke, then suffered six months of procrastination and misinformation after complaining to the Welsh ambulance service. Only my intervention with the chief executive secured an apology and a response half a year later.

This summer, more than 5,000 hours were lost because ambulances were delayed handing over patients at north Wales hospitals. Bed occupancy rates consistently exceed the recommended 85 per cent occupancy level to maintain patient safety standards. Over the last two years, almost 75,000 NHS Wales patients had their operations cancelled for non-clinical reasons. It is now clear that unscheduled care services are not just under extreme pressure in winter, but all year round.

This is why our motion calls on the Welsh Government to deliver a comprehensive national plan to address pressures and ensure that patients receive unplanned and critical care services that meet their needs, including preventative services such as community and out-of-hours care. As the WLGA Conservative group leader Peter Fox said last week, in a document supported by local government leaders from all parties, with £370 million of new moneys arriving from Westminster, an imaginative approach to funding preventative services to keep people out of hospitals is needed.

On a frustratingly regular basis I've also raised in this Chamber cases of third sector bodies providing effective preventative services that have lost their funding because of dumb commissioning that is adding millions to the cost pressure on statutory health and care services. At the request of campaigners I formed CHANT Cymru—Community Hospitals Acting Nationally Together—in the second Assembly, to campaign against the Labour Welsh Government's community hospital and bed closure programme. We promoted at national level the role of community hospitals in providing quality accessible local healthcare and reducing pressure on our general hospitals. After 2011, Labour pushed ahead with the closures, with the inevitable consequences we warned of.

The Welsh Government's policy of strengthening primary care and community based settings is not being matched by resource allocation. If patients are to receive care closer to their homes, it is imperative that general practice is properly resourced. In 2014, the Royal College of General Practitioners warned that the share of Welsh NHS funding for patient care in general practice had been falling for years. A BMA survey in 2016 found that 82 per cent of GPs were worried about the sustainability of their practice in Wales. In 2016, the vice-chair of the north Wales local medical committee stated, 'I cannot stress enough how near the edge things are, and how the time for action is now or never.' In 2016-17—the most recently available figures—Welsh general practice received the lowest share of NHS health spend in the UK, despite a rise in patient demand. Last week, BMA Wales figures showed that 21 GP practices have closed since October 2015, with a further 82 at risk and 29 now health-board managed, with the largest number in north Wales.

In pursing this agenda, some might say that the Welsh Government had been putting ideology before patients, where BMA Wales also provided evidence that managed practices do not provide value for money and that health boards are actively seeking to return them to independent GP contractors. Well done, Minister.

In my opening remarks and in direct response to the Conservative Members opposite, and particularly the remarks in Mark Isherwood's contribution, I ask whether they feel that the £4 billion extra that Welsh Government could have had if the block grant had kept pace with the growth in the economy since 2010 might have been one useful way for Wales and our health and social care service system to respond to some of the pressures that they describe. And in exactly the same way, whether they think it would be useful to know exactly how much money Wales is going to be getting from the Prime Minister's recent unfunded NHS birthday pledge, or how much extra money Wales is going to get from the end of austerity, as the UK Prime Minister now leads us to believe is about to happen. Because even though the Welsh Government and partners are well advanced with planning for the winter ahead, they do so without certainty as to when the extra funding is becoming available from the UK Treasury.

Last week, the party of austerity were calling for more money for local government services. Now they want more spending on capacity in the NHS. I don't think the irony of this going to be lost on the people of Wales.

I'm very grateful to you for taking this intervention. You will surely recognise that the situation that the Conservative Government inherited back in 2010, in terms of public finances, was absolutely horrendous. Gordon Brown brought our country to the brink of bankruptcy, and this responsible Conservative Government has turned that situation around.

Well, of course, Llywydd, it is only the Conservatives that still believe that lie, but there we go. So, as the debate—[Interruption.] So, as we debate the issues here, and quite rightly focus on the responsibilities of our Welsh Government, I for one am not forgetting the responsibilities of the UK Government in funding Wales correctly. And if you don't like it, let me ask the former leader of the Conservatives or the current leader of the Conservatives if they can show me the letters that they've sent to the UK Government demanding more money for Wales. And I bet they don't exist. 

But to turn to NHS capacity—

Andrew R.T. Davies rose—

I'm not taking another intervention. To turn to NHS capacity—[Interruption.]

She's not taking interventions. Dawn Bowden, you can carry on.

To turn to NHS capacity, the response that we need to make, as recognised by the new national plan for health and social care, is a whole-system response. And that recognition is entirely missing from the Conservative motion. It's worth remembering that, here in Wales, we already treat the health and social care services together, and that 'A Healthier Wales'—the Welsh Government's long-term plan—will accelerate progress in that area, backed by the £100 million transformation fund.

By contrast, England has pretty much ignored social care, which has meant that, when pressure is increased, the strain is heaped on the NHS there, with no capacity to get people out of hospital. And while the Tories continue to criticise Wales's successful ambulance response model, and say that we are moving the goalposts to achieve better target outcomes, it's interesting to note that both England and Scotland are now replicating it.

But a whole-system response will go beyond out-of-hours, critical care and ambulance services, as is mentioned in this motion. It also needs to focus on the role of social care and on strengthening primary care. And in Wales, thanks to Welsh Labour, we have a planned health and care system that allows for that type of response. We know that in successive budget rounds, this Welsh Government has provided money to help with the integration of these vital services, and, thankfully, our services have not been broken into bite-size chunks, ready for privatisation. So we have the potential to make further improvements.

As a member of the health committee, I've read with interest the work of bodies like the Royal College of Emergency Medicine. In a report on their UK-wide winter flow project, they've highlighted the fact that we do need to focus on the care needs of patients who've been medically optimised and are fit for discharge back into the community. The royal college describes this as the exit block that we can open through further strengthening our social care packages. While we've made some progress with this in Wales, clearly there's a lot more that can be done, and of course we all know that being able to move patients out of hospitals as quickly as possible also improves patient outcomes. 

From evidence that we've heard in the health committee across a range of issues, I believe we also need to continue to address the variations in practice and performance between health boards. I think, Angela, that was the point that you were making, because I do find it simply unfathomable that when a health board establishes a successful work practice, for example, the Cwm Taf discharge from ambulances at the front door of the hospital, why that isn't quickly replicated elsewhere. Likewise, I think the systems of triage need to be backed more robustly. For example, if someone is in accident and emergency and that's not the service that they require, we should enable hard-pressed NHS staff to more firmly signpost them out of that part of the service.

I understand that the royal college is asking for an increase in bed capacity, and that's for the Government to consider as part of the new national strategy, but the royal college also focused their advice on optimising patient flow, on reactive steps to help capacity, on engaging and empowering the wider system, and on a workforce strategy. So, whilst the motion is useful, it is in my view too narrowly focused, which is why the amendment, I believe, presents a better picture of the response that we can make in Wales to meet the demands of our health and care services, and why I will be supporting the Government amendment and voting against the original motion.

I would certainly like to support our own proposals to establish a national plan that aims to deliver a more sustainable out-of-hours critical care and ambulance service that will meet the needs of the Welsh people. Under this Welsh Labour Government, the NHS in Wales has increasingly continued to underperform. These issues have been particularly acute in Betsi Cadwaladr board, which covers my own constituency.

Betsi has seen significant issues with the performance of A&E departments. A Statistics for Wales report on A&E waiting times, published in 2018, shows 68 per cent of patients waiting more than four hours to be seen, going worse in August 2018. Two hospitals in north Wales achieved the worst A&E performance for a Welsh hospital since records began. Wrexham Maelor saw fewer than half its patients within the Welsh Government's own four-hour target time. Ysbyty Glan Clwyd had a rate of 52 per cent.

Pressures on the ambulance service have been compounded by system blocks at our hospitals causing significant delays in ambulance handovers. Almost 5,000 hours were lost to handover delays as Wrexham Maelor, Ysbyty Glan Clwyd and Ysbyty Gwynedd between April and June of this year. These figures come after the north Wales senior coroner and assistant coroner recently highlighted concerns regarding ambulance waiting times in their regulation 28 notifications.

Further—[Interruption.]—GP-led out-of-hours services, which are an integral aspect of relieving pressure on emergency services, are also under pressure. It woke the Cabinet Secretary up, I think that did. The Wales Audit Office's 2018 report on the state of out-of-hours services states that such services are not meeting national standards due to morale and staffing problems. Research from BBC Wales and the Wales Audit Office shows that the Betsi board could not fill 2,082 hours of GP out-of-hours shifts. This means that 462 individual shifts were empty, escalating pressures on A&E services, especially for non-urgent cases.

Whilst those who work in out-of-hours critical care and the ambulance service continue to provide a fantastic level of care to patients, and we salute them all, these figures clearly show that they are simply failed by a lack of leadership, and I tell you: that lack of leadership comes from here. My constituents are fed up with a severely underperforming health board that has seen standards fall continuously, and a health board in special measures for three years.

It is not just our constituents who are fed up. A former senior manager in the Welsh NHS, Siobhan, is now leaving Wales following several failings in the care of her husband, and I didn't like the way that her arguments were dissed in this Chamber earlier. She argues that there is a void in Welsh Government and that health boards are not being controlled by this Government, nor are they accountable to people. This is happening because of the failings of your Government—leaderless, incapable and incompetent. That is the legacy of this Welsh Labour Government.

It is, however, encouraging to hear of the Prime Minister's recent commitment to invest an extra £20 billion a year in real-terms funding into the NHS. This means that the Welsh Government will get a funding boost of £1.2 billion a year. Long-term funding must now be invested wisely by the Welsh Government, particularly into critical care and ambulance services. Therefore, I urge the Welsh Government to work with health boards to develop a comprehensive national plan to address the issues currently experienced by the critical care and ambulance services. I also urge the Government to commit more resources to preventative services to reduce unnecessary attendance at emergency departments whilst the £100 million transformation fund is being implemented.

Cabinet Secretary, it is not the first time I have almost pleaded with you and begged for you to actually show some mercy, really, on the many patients who depend on our hardworking nurses, consultants, doctors, general practitioners and our care-in-the-community workers. The fault lies here—not in this Senedd, but with you, the Welsh Government, here in Cardiff. Please, Cabinet Secretary, I ask you again, not only for the sake of my constituents in Aberconwy, and your patients, but for all of the patients across Wales and their families.

Thanks to the Conservatives for bringing today's debate. UKIP supports their motion today. Like them, we acknowledge the problems with capacity in the Welsh NHS. Like them, we acknowledge that the pressures on the NHS are year-round pressures that do not just hit patient care in the winter months. And like them, we acknowledge the need for some long-term strategy, which here they're calling 'a national plan', to address these problems, rather than the sticking-plaster solutions that we seem to get year after year from the Welsh Labour Government here in Cardiff Bay.

We also support the Plaid Cymru amendments, which state that we also need to have a long-term strategy of funding social care, because if we keep on with the firefighting approach to health and social care, which Rhun ap Iorwerth referred to earlier today at health Minister's questions—I prefer to call it the sticking-plaster approach, but it's essentially the same thing—then that will also lead to increasing pressures on the NHS.

We acknowledge that the Labour Government have a plan, which they refer to in their amendment, but time is rather against their arguments now. They've had control of the Welsh NHS for the past 19 years, and health outcomes for many people in many parts of Wales still appear to be getting worse. The Labour Government have been plagued by public dissatisfaction over their running of the NHS since the very first term of the Assembly, and they're still facing essentially the same problems that they did then. As we know, and as has been mentioned, today we still have several health boards in special measures and targeted intervention.

The Welsh Government is now spending approaching 50 per cent of its budget on health. The upward trend surely cannot be allowed to go on indefinitely. We do need to move towards more preventative spending, as has been advocated by the future generations commissioner, among others. There was a proposal that she put forward that, in the long-term interests of the Welsh public, we needed to ring-fence at least a certain amount of the health budget and say that that was to be set aside for preventative spending. So, it had to be investment, for example, in promoting activities that might prevent obesity from occurring, rather than spending it on dealing with the effects of obesity.

The idea of preventative spending seems to me like a good one, but putting it into practice has proven difficult. We've ended up with an argument over what exactly constitutes preventative spending, so we now need to come up with a definition for this before such a policy can take shape. I don't want to get into the mechanics of what is and what isn't preventative spending today, but I feel that we must move towards a more strategic and more long-term approach, and I'm not convinced that the Welsh Labour Government is moving in that direction. So, that is why UKIP today supports the motion and the Plaid amendments and opposes the Labour amendment. Diolch yn fawr iawn.

If we are to relieve the pressure on our NHS, we must address the issue of support and resources for preventative services. One such service is out-of-hours care. The fact is that GP-led out-of-hours services are vital in relieving pressures on emergency services in Wales. The Wales Audit Office recently produced a report and a survey that found that nearly 700,000 people contact the out-of-hours service each year in Wales. Of the staff who responded to the survey, 66 per cent said that services are not flexible enough to meet the peaks and troughs in demand. Forty-six per cent disagreed or strongly disagreed that morale was good. It is clear that while out-of-hours services are appreciated by patients, national standards are not being met due to staffing issues and poor morale.

My own local health board, Aneurin Bevan, could not fill about 2,300 of GP out-of-hours service shifts. On no less than 27 separate days, there was no out-of-hours cover across the entire health board for at least 30 minutes. In the six months between October 2017 and March 2018, there was no GP out-of-hours cover across the entire region for over 53 hours. For a five-day period in February, more than half of the GP out-of-hours shifts were unfilled.

The Royal College of General Practitioners has published an action plan for this service. This action plan calls for steps to be taken immediately to address the crisis. They say that weaknesses in the current system across the country are compromising patient care, and increasing pressure on emergency departments. The college outlined that they called for five essential and achievable steps to help turn around GP out-of-hours care in Wales. These include addressing the vital issue facing general practice in the current climate.

In spite of Labour manifesto commitments to improve GP access, it is becoming increasingly difficult for patients to access their GPs. A BBC news investigation earlier this year found that the patient can only see their GP later in the evening in two Welsh health board regions. Across Wales, in seven health boards, only a quarter of GP patients were offered appointments up to 6.30 p.m. in the evening twice a week, and only 20 per cent of Welsh GP surgeries were able to offer early-morning appointments before 8.30 a.m. at least twice a week. No wonder that the chair of BMA Wales's GP committee said, in his words, 

'With the lack of resources and no new investment in out-of-hours services, it is no surprise that GPs are feeling too exhausted to work out-of-hours.'

The pressure on GPs is now acute. The number of new GPs joining the workforce in Wales is now at its lowest level for a decade. Just 129 GPs were added to the workforce in 2016-17. The number leaving the service is now at its highest level in the last two decades; 212 left the service over the same period, which is much more than actually came in.  

Presiding Officer, this motion calls on the Welsh Government to develop a comprehensive national plan to address pressure on out-of-hours care, critical care and ambulance services. I believe such a plan would deliver significant improvement for patients in Wales, and deserves the support of this Assembly today. I hope that the Minister is listening. Not everybody in this Chamber, but at least this side of the Chamber we are all looking forward to seeing a better health service in this country. You've got more than one third of this budget, but where are the services to the people? I have yet to see them. Thank you. 

It's a pleasure to take part in this debate today on the capacity in the NHS here in Wales. Of course, as has been said, the health service here in Wales is under great strain throughout the year. In my practice in Swansea, we have a couple of hundred phone calls from patients every morning of the week, and there was one Monday a couple of months ago when we had 700 calls. Then, as GPs, nurses and so forth, we have to cope with that great burden, in a situation, of course, where we have a shortage of staff and also a shortage of resources to look after these people.

Of course, under these circumstances, staff in the NHS, as we’ve heard already, do excellent work under very difficult circumstances, which are complex, and they are so very busy, it’s very difficult to be able to convey how busy we are, often, to people who don’t work under those conditions.

So, there are three things to say about this debate on capacity in the NHS. Yes, there is a staff shortage, in the first place. If you name any profession working in the NHS, you need more of them—nurses and GPs. We’re short of about 400 GPs here in Wales. There are about 2,000 GPs in Wales and there should be about 2,500, and we have fewer doctors per capita in Wales than in the majority of other countries in Europe. Among our specialists in hospitals, about 40 per cent of consultant posts are vacant posts in our hospitals here in Wales.

So, of course, with such a busy system and a staff shortage, of course we’re going to have waiting lists, people having to work far too hard and so forth and so on. That’s why, as a party, we want to open a new medical school in Bangor. We have to train more doctors in the first place. We have to develop more of them, because we don’t produce enough doctors at present, and even if everyone who graduated these days stayed to work in Wales, we still wouldn't have enough doctors in Wales to serve our population.

Another element of the capacity is a shortage of beds, which has already been mentioned. There are several royal colleges that say this, and sometimes it’s not fashionable to talk about bed shortages, because over the last quarter of a century we’ve lost several thousand beds in our hospitals and in our care homes here in Wales. Why is that important? Well, with an ageing population, there is a range of people who are too ill to stay at home, even with whatever intensive package you have supporting them. But despite the fact that they’re sick and they’re so vulnerable, they’re not seriously ill enough to take a bed in an acute ward in a general hospital like Singleton or Morriston. There’s always a range of patients who fall between those two stools, and we can’t deal with them very well these days in the absence of beds in our community hospitals.

The final point that I’m going to make about capacity, of course, is the fact that the majority of capacity here is outside the health service. I’m talking here about social care. The social care situation in Wales, as in the rest of Britain, is very vulnerable at present because of significant underfunding over the years, which means that there is a very high threshold for you to be able to access services from social services. But, basically, if there is no social care, there won’t be a health service. That’s why, in the first place, we need to tackle social care. Time is short now, because we can’t offer any kind of support to a great deal of our population at the moment. That’s how serious the situation is. And that’s why, as a party, we’re looking to reconfigure, radically, the social care system by creating a national social care service that will operate like our health service, and alongside our health service. We have to do that, because, at present, we can’t offer care to our most vulnerable people who most need that care, and the resources are just not available. The time has passed to just take small measures at the margins; we need a radical solution, and a new national social care system that befits our country. Thank you.

I'd like to thank the Welsh Conservatives for bringing forward this important debate today. Our NHS is facing unprecedented demand. In the past 12 months, there were well over a million visits to A&E departments around Wales. Over four in 10 of us find it difficult to make a GP appointment and operations are routinely cancelled due to a lack of beds. While the Choose Well campaign is a step in the right direction, it is going to take much longer to totally re-educate the Welsh public. It is so ingrained in the public’s mindset that when they get ill they need to see a doctor that convincing them that, sometimes, a community pharmacist is a much better option is going to take a long, long time. When you couple this mindset with the fact that it is getting harder to see a GP because of underfunding and over work, it is no wonder that people inappropriately turn up at the A&E department.

We have to be bold if we're going to ensure that ambulances queuing outside our A&E departments are a thing of the past. We have to be bold if we're going to ensure that our hard-working NHS staff no longer feel that they're working in a war zone. And we have to be bold if we're going to ensure our NHS has a future. We know that over a third of those attending A&E would be more appropriately dealt with elsewhere in the NHS, which is why I wholeheartedly support both the BMA and the Royal College of Emergency Medicine, which have suggested we look at co-location of primary care services and the use of front-door physicians. We also have to look at introducing a single point gateway service that can funnel people to the appropriate service. The 111 service is a step in the right direction, but it needs to be rolled out faster and have a much wider remit.

We have limited resources in terms of doctors and nurses, and quite often a patient can be seen faster and receive the same level of care by seeing an allied health professional. Why take up a GP’s valuable time to issue a sick note, when an occupational therapist could deal with this request? Why see a doctor about a cold when the pharmacist can provide you with the best treatment option? As I highlighted earlier, this will require a complete mindset change from the general public, which is why we have to help them make the right choices. Adverts will only get us so far. We have to introduce a system of triaging patients, and I believe that the 111 service has the potential to be that system. Make it a one-stop shop for the NHS and help ensure that patients get the best treatment at the right time by signposting them to the most appropriate service.

Our NHS can’t afford another bad winter leading to a bad spring and a worse summer. We have to act now and take the bold steps needed to relieve the pressures on the system. Diolch yn fawr.

I call the Cabinet Secretary for Health and Social Services, Vaughan Gething.

Thank you, Llywydd. I'm grateful to the opposition for tabling today's debate. The overall sentiment—delivering high-quality services that meet high and increasing demand—is something on which I'm sure we can all agree, but obviously there are points of disagreement within the motion; hence a Welsh Government amendment. 

The parliamentary review, made up of a panel of independent experts that every party in this place supported, described the increasing demands and new challenges that the NHS and social care face: an ageing population, lifestyle factors and changing public expectations. We know that, despite these demands, the vast majority of patients who need NHS services receive care in a timely manner, with high rates of satisfaction. The fact that typical NHS care is effective, timely and compassionate is, of course, thanks to our staff. But, in terms of capacity to meet the demand for services, there is now a record number of staff working within NHS Wales. It is the only public service, in an age of austerity, that has seen an increase in head count, and I will in the coming weeks announce my decision on investing in the future of our healthcare workforce.

I have previously described how 'A Healthier Wales' sets out our commitment to enable health and social care services to meet population need—as I've said before, the first time we have ever had a joint health and social care plan with ownership between health, local government and the third sector. A transformation programme will bring pace and purpose to how we invest in people and how we build staff capacity, and we know that improving system capacity to plan effectively and efficiently is essential. We're delivering on a key priority to work with health and social care organisations and partners to simplify the planning and delivery of our services. Our amendment recognises the comprehensive work of our staff within the NHS, within local government, and wider partners, to plan and build capacity around and within NHS Wales to meet demand for services throughout the year. We, of course, heard some of this, in relation to specific planning for winter, in the earlier comments of David Melding.

We've been open about the challenges felt by out-of-hours primary care, critical care and emergency ambulance services, and we also know that, despite this pressure, the vast majority who require these services continue to receive timely access and high standards of care—once again, thanks to our compassionate and dedicated staff. As an example, the latest available figures show people categorised as 'immediately life threatened' in our red category of emergency ambulance calls receive a response in just over five minutes on average, and Dawn Bowden was right to point out that our model for emergency ambulance services is being copied in Scotland and England. We've been clear about how we're targeting national support for these services, with a clear understanding of demand and how best to manage it. That will help us to deliver sustainable out-of-hours primary care as well as critical care services. I've recently announced an additional £5 million to be made available this year for critical care, which will help us to create the capacity that is required over winter and to create a foundation for sustainable improvement.

We have commissioned an independent review of ambulance services and the amber category to understand whether improvements can be made to the management of patients and, of course, we'll have a statement on that next month and an opportunity for Members to consider that in advance. There is significant work under way in all three areas to focus on the need to recognise and understand pressures and plan to meet them. Our plan is to help support front-line staff to deliver those high-performing services, focusing on experience, outcome and value.

As to developing a national plan to address pressures on services, 'A Healthier Wales' describes our commitment to delivering a whole-system approach, where all services are delivered seamlessly and wrapped around the needs of the individual. It is imperative that we do not consider services in isolation. We should resist the regular calls in this place and in others to create new and piecemeal specific plans, but concentrate on delivering action that we have set out and agreed in our long-term plan.

On bed numbers—a point was made at various points in the debate—we actually have a lower occupancy rate than in England and more beds, proportionately, than the system in England. Now, specifically on critical care, I made reference to the £5 million this year to help support a permanent increase in the number of critical care beds, and that does underline our commitment to strengthening critical care and we recognise that that is necessary, not only for the winter, but in the longer term. That follows my recent announcement of £15 million of recurrent funding from the next financial year for these essential services.

On our emergency ambulance services, we already have a national plan. The Welsh ambulance service trust has an approved plan up to 2021, based on commissioning intentions that are set out by the chief ambulance commissioner. Members will, no doubt, be interested to know that the collaborative commissioning arrangements that we have in Wales have recently been copied in England. We know there are more paramedics working in Wales than ever before, and, since 2014, the number of paramedic training places has more than doubled—not by accident, but by deliberate choices made by Welsh Labour leadership.

On primary care out-of-hour services, there's been a significant and collective focus on this area over the past year. As part of our broader plan, work is under way to develop a new model of out-of-hours primary care, modelled on seamless integration with other services through the 111 service. And I'm pleased to hear both in this debate and in recent weeks recognition of the successful impact that the 111 service has had where it's been rolled out. I'd caution Members who would demand an immediate roll-out of that service across the country. Part of the success has been to understand the demand of each area and to build capacity in primary care support and to make sure that we have the right staff in the right place to deliver the quality of service.

Will you take an intervention?

I'll happily take an intervention.

But surely you recognise that having somewhere like Aneurin Bevan health board having no out-of-hours cover for parts of the day on 27 different days simply isn't acceptable if we're trying to take this pressure away.

And that's why we're committed to rolling out the 111 service. We are committed to improving out-of-hours care, just as every Government across the United Kingdom is. We're actually doing something about it. And you will see the 111 service arriving in Aneurin Bevan in the near-ish future.

Now, on staff numbers—[Interruption.] Well, on staff numbers, it's worth reflecting, as I said, that we've continued to invest during a time of Tory austerity, but it isn't just the numbers of staff; it's how they do their job. That's why integrating health and social care services with seamless models of care is a priority for the Welsh Government. Despite significant cuts to the Welsh Government's budget, after eight hard years of Tory austerity—which, Dawn Bowden reminds us, are continuing—we have continued to invest in social services. This is a significant difference to what is happening across the border, where Conservative choices—deliberate choices—have been made to cut and cut again social care in England. Yet, here in Wales, we have had £50 million this year in the integrated care fund, £100 million over two years into the transformation fund, and £30 million next year for regional partnership boards.

There is a radically different story being told here in Wales about our choices in a time of austerity and what is happening when the Conservatives are actually in power. And there is a contradiction in a number of the comments that have been made by Conservative speakers today—on the one hand calling for more money to go into primary care, but, on the other hand, calling for more money to go into secondary care. It simply isn't possible to do both of the things you are suggesting and, at the same time, demand you get more money to put even more money into local government. These are the unavoidable consequences of Tory austerity, and I should remind you of that undeniable fact. The Conservative Party has campaigned for austerity in three successive general elections. You cannot champion austerity at the ballot box and then run away from its undeniable, indivisible consequences. We will continue to prioritise social care as a sector of national importance. It is front and centre in 'A Healthier Wales', our joint plan for health and social care, designed and owned, for the first time, by health, local government and the third sector.

We know the NHS needs to transform to meet the needs and demands of today and the future, but one thing will remain as it always has: the NHS will continue to deliver to meet the needs of the people who need it most, and those people will never trust the Tories with our NHS.

I call on Suzy Davies to reply to the debate.

Diolch yn fawr, Llywydd. Yes, it's always easy, isn't it, to make yourself try and look better just because another Government might be doing worse than they used to. That does not disguise the fact that you are still producing the poorest health results across the UK. Can I thank everyone who took part in this debate, please? I'm sorry I'm not going to have time to respond to it all, because I don't have much time. But this debate was essentially about the difference between a vision, which a lot of us were behind, and that lived experience of our constituents—and, indeed, our doctors, judging from what Dai Lloyd said.

Angela Burns's example of the gentleman who was waiting five hours just to go a few hundred yards is not unique, but it is illustrative of the problems that we were trying to raise in this debate and hoping to get some sensible response from the Government on. Because, Cabinet Secretary, I'm sure you're not thrilled by those out-of-hours statistics either, or the delayed transfer of care statistics, how long ambulances are waiting outside hospitals—I'm not very happy with you pulling your statement on ambulance times, by the way—or, in fact, the fact that paramedics, 8.8 per cent of them, are off sick. [Interruption.] But all this is happening on your watch.

We're all behind you with this parliamentary review direction, following the work that was done on that, towards improved community care—it was a policy direction we were all tending to follow anyway—but we are not feeling it, and that is why your amendment is so hollow. The references to social care we tend to hear here are still feeling like an afterthought compared to the health service. We have examples in my own constituency of temporary closures of services and clinics—temporary that become permanent, because staff get redeployed; that happened in Maesteg. We have new ideas, like the Red Cross's work with individuals who are making a series of inappropriate 999 calls, being trialled at Morriston. Fantastic results—money pulled. And of course, when you're talking about a social model of community care, it's not just about GPs; it's about people like the Red Cross and the paramedics and the pharmacists and the third sector. 

So, I want you to look at community care, if you like, as a sort of preventative flood plain in which care and well-being of our constituents can be better managed. Flood plains don't just alleviate the effects of storm water further downstream; they create a fertile soil. It's where things grow, where things get better, where you get signs of health. If community care is about preventative care producing those valuable results less stressfully and more efficiently upstream, that's where the investment should be. But if you let these storm waters—and they're increasing; they're all-year-round now—just continue to surge across an arid desert, you're going to stay and remain with the results that we have now.

That 5 per cent cut that Angela Burns spoke about—I know you're talking about in-year increases, but that 5 per cent cut is fundamentally undermining the purposes of 'A Healthier Wales' here, and it doesn't do, as Caroline Jones actually mentioned—. If you're not investing in community care, you are not creating trust in a part of the health service where that trust needs to be created in order to persuade people to move away from the 999 buttons on their phone. 

So, I don't particularly want to wait until next week, Cabinet Secretary. I'm sorry you didn't mention this in your response to this debate, but there is a transformation fund—two, in fact; you mentioned it earlier—and I don't see yet how they're contributing to creating the community care that we need to stop the problems from happening downstream.

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

Voting deferred until voting time.

Unless three Members wish for the bell to be rung, I will move immediately to voting time.