Questions now to the Minister for the party spokespeople. Plaid Cymru spokesperson, Helen Mary Jones. 

Thank you very much again, Llywydd. 

Minister, we were discussing in committee this morning the ongoing concerns on some of the issues around Brexit and the healthcare system, and you'll be aware that on 17 November the issue of The British Medical Journal starkly stated that patients will die if we can't maintain the medicine supply chain. Can you update us on the contingency plans that your department is putting into place to ensure the supply of medicines, particularly medicines with limited shelf lives that cannot be stored in the event of a 'no deal' scenario, which, of course, we're all hoping may not occur, but is becoming increasingly a risk?

Thank you for the question. As you know, I've made statements in this place before about our preparations for any form of Brexit, but in particular a 'no deal' Brexit. I've set out the range and the seriousness of my concerns about the impact of a 'no deal' Brexit. And the undeniable truth is that if we crash out without a deal at the end of March, it will have a real and almost immediate impact upon people's health and well-being. The reality is that if we have challenges about trading arrangements, not simply about whether people do or don't wish to continue to supply a range of medical devices, equipment and medicines, then there will be an impact.

I have a further meeting with the health and social care stakeholders in Wales, focusing on Brexit, tomorrow. Myself and the Deputy Minister will be attending. We'll continue to outline with them the current state of our preparations, both within Wales and, indeed, the measures we are seeking to take together with partners across the United Kingdom. I may well be in a position to update this place with a further statement on our preparations for, and the impact of, a 'no deal' Brexit within a very short period of time. 

I'm grateful to you for that, Minister, and I think the whole Chamber will look forward to that update. As I've said, it's a situation that we're all hoping will be avoided, but does seem to be becoming more of a real threat. I'd like to give you a specific example to illustrate the dangers that we face, which I'm sure you're very well aware of. The radioactive isotope technetium is used in about 850,000 scans in the UK for a whole range of conditions, including heart disease and cancers. This product has a half-life of just 66 hours, meaning that it can't be stored and stockpiled. Currently, the UK as a whole relies on a continuous supply of this product from France, Belgium and the Netherlands, and that supply is governed by the Euratom agreement. The nearest potential non-EU suppliers are in South Africa and Ontario in Canada, and obviously couldn't be useful to us in this situation. And, obviously, this is only one example, because there are many types of isotopes that can't be stockpiled. We know that even under the existing arrangements Northern Ireland had problems twice—in 2009 and 2013—due to the logistical challenges of getting this product in time. Can you explain how hospitals in Wales will be getting these types of products in the event of a 'no deal' Brexit?

In the event of a 'no deal' Brexit, it will be virtually impossible to continue supply chains in exactly the same way as now. Much of this comes on road freight and the undeniable reality is that if there are problems in road freight that affect our ports, as you'll have seen from the exercise undertaken recently and reported in the Financial Times—hardly an organ of fearmongering or left-wing conspiracy theories—it demonstrates the significant and quite shocking impact of minor delays for all freight transport coming into the country. The alternative plan, which is not a secret, is about, if that were to be the case, whether medicines with very short half-lives before they're no longer useful—and I've regularly talked about nuclear medicine and radioisotopes in the past as well—for those to be flown, and that would undeniably provide an additional cost, and it may affect the supply. But the additional cost would then have to be borne by the taxpayer. So, there is, undeniably, a challenge, and I've also regularly talked about the challenge for insulin that is made for type 1 diabetics. We make nothing like enough insulin for type 1 diabetics to cover our own population. And, again, in a 'no deal' Brexit, that is one of the very real risks to directly affect people's health and well-being almost immediately.

Thank you, Minister, and perhaps you can give us some further information following the stakeholder meeting about the precise arrangements if we do face the issue of having to fly medicines in.

You mentioned in your response the additional cost to the NHS. As part of the potential 'no deal' Brexit preparations—. I must say that I have some frustrations with Members there; I'm sure that you will have opportunities to respond to these points to the Minister, but it's very difficult to have a sensible conversation about these issues when people are making comments from a sedentary position.

Minister, have you made any assessment of what these potential extra costs might be, and how is that being built into your contingency planning? I realise that these potential costs are, at this stage, theoretical, and hopefully that's an issue that we won't have to face, but I'm sure that you would agree with me that it's crucial that, in terms of planning for the worst-case scenario, you have some clear idea about what those additional costs you may need to face are.

Yes, there's a challenge about theoretical costs, but costs are actually being soaked up now. For example, there's the additional cost that the health service across the four nations of the UK is undertaking to increase storage capacity, and the costs that we are spending now on planning for potential scenarios, when we know that at least one scenario is not going to be—well, more than one scenario is not going to be the reality where we find ourselves at the end of March. Every Government within the United Kingdom is having to run through this particular challenge. Officials regularly speak to each other, as well as our individual conversations within each of the four UK nations. I do hope to be in a position to provide more information about cost, about the arrangements that we are undertaking. I also hope that there will be a positive response from health Minister counterparts across the UK—four health Ministers of different Governments and different political backgrounds—to nevertheless have a constructive and upfront conversation about what we can do to support each other, and the risks that we each recognise exist, depending on whatever form of Brexit occurs, should we leave the European Union, and the impact that would have on our health and social care system. I know that my colleague in Scotland is equally keen to have that meeting with our counterpart in the United Kingdom Government and whoever would attend from the Northern Ireland Government—whichever official that may be.

The Conservative spokesperson, Darren Millar.

Diolch, Llywydd. Minister, can I ask you why it's taken you so long to intervene in the situation in Cwm Taf university health board?

It hasn't taken a long time at all. I've kept this Chamber updated at all points on the intervention around the initial issue around maternity care, and, indeed, following the very recent tripartite meeting between the chief executive of NHS Wales, Healthcare Inspectorate Wales and the Wales Audit Office, I made an early choice—as you will have seen from today's written statement—to change the escalation status of Cwm Taf from 'normal' to 'enhanced monitoring'. And I of course will be answering a topical question on this matter in a few minutes' time.

It was on 4 October, Minister, that concerns about maternity services were first exposed at the Cwm Taf university health board. Your statement today refers to non-compliance with health and safety and radiation regulations, quality of governance and serious incident reporting arrangements, the lack of action and response to healthcare inspectorate reports, and staffing shortages also in that health board being problematic. Many people in that health board area will be wondering why on earth it's taken three months—more than three months—for the Welsh Government to escalate the situation there in order to secure some improvement.

Of course, Cwm Taf is not the only health board that is currently in escalation measures. Five out of seven Welsh health boards, supporting 2.4 million people in Wales—three quarters of our population—are currently being served by health boards that are subject to intervention. Does that not concern you, in terms of the speed of the response, because it certainly concerns me?    

Well, I would hope there would be a more rational and factually founded response on these matters. Trying to conflate the issue of maternity services with the areas that are outlined in my written statement today simply does not stand up to honest scrutiny. On maternity services, we acted properly and promptly, with the conversations that took place between the chief nurse's office and the health board, and the decision that I then took that the review jointly by two royal colleges should be undertaken independently, with the Government actually being, if you like, the sponsoring organisation, rather than the health board. I expect to have that report available in the spring. So, these matters are being addressed appropriately and are being addressed speedily by the Government and the broader health service. I look forward to being able to provide more facts on this matter as that report is provided, as indeed I expect to have more to say on the actions that will be taken by the health board in response to my decision today to change the escalation status of Cwm Taf university health board. 

The situation, of course, should have been escalated from day one as soon as the maternity situation had been exposed in that particular health board, and I'm sure that many people will have been disappointed with the speed at which the Welsh Government has acted.

You failed to respond to the fact that five out of seven health boards are currently in escalation intervention arrangements of some form and that three quarters of the Welsh population are being served by those health boards. Doesn't that tell you, if five out of seven health boards are currently in escalation arrangements—many of them have been in for a long time, including the Betsi Cadwaladr health board, over three and a half years to date and no sign of it being taken out of special measures yet—doesn't that tell you that you are a failing Welsh Labour Government that's failing to get to grips with the problems in our national health service, and that you are not acting swiftly enough to remedy them? 

Well, it is much easier, as the Member demonstrates, to chase headlines than to deal with the facts in front of them. It would have been entirely wrong—it would have been entirely wrong—as the Member knows very well, to have intervened in October on the very first day when concerns were raised about maternity services. I am doing the right thing by the country and by the people served by these individual health boards and indeed by the staff who deliver those services. I expect there to be proper scrutiny of the choices that I make and of the conduct of each and every health organisation within the country. An escalation, of course, has taken place for different reasons in different health boards and I look forward to organisations reducing their level of escalation as well, as I expect will happen at various points over the next year and more.

We are planning for the future, and we are delivering that future, and, indeed, the people of Wales have great faith and confidence in our health service, as every single recognition of people's experience of healthcare demonstrates. The future for health and care services is a difficult one. We face a rising tide of demand, fast and rapid technological change and, of course, as we all know, a period of continuing austerity. Regardless of that, we have planned for the future. We have a long-term plan—a joint plan—for health and social care and I look forward to the United Kingdom Government catching up and having a joint plan—

He should put his money where his mouth is.

—to deliver health and care together.

UKIP spokesperson, Neil Hamilton. 

The Minister may recall that last October I raised with him the non-availability for patients of GPs in north Wales of the internet tool myhealthonline for making appointments. He kindly wrote to me subsequently saying that this wasn't a policy decision, but sometimes this system wasn't available because it was impossible to match patient need to GP availability in practice, in particular where there were large numbers of locums. The implication, of course, being that there are periods of time when it's not possible to access the service. Is he aware that there have been successful trials in London of this tool in GP practices, whereby administration has been cut and efficiencies have been improved? In one particular instance, GP waiting lists were cut from four weeks to just one day, and 25 per cent of 2,500 patients needed an appointment, so 75 per cent were able to be dealt with without taking up GPs' time in the surgery, with many other advantages as well, and GPs processed 30 online patient queries in the time it took otherwise to see 18 face to face. So, clearly this is an important and useful tool, where we're constantly facing the problem of matching needs to means. So, can the Minister assure me that he will pull out all the stops to ensure that this internet tool is available as often as it is needed, not just in north Wales but throughout the NHS in Wales?

I think that the challenge that you've set out is not how we simply continue to deliver what we have now, but what the future looks like and the necessary reform to get there, and not just in the area of making better use of technology. In the long-term plan for health and social care, you will see a significant section on making better use of technology and, in particular, digital technology.

That's partly about access, and the examples that you gave are about access, and I don't think it's just about one particular tool. A range of different computing tools, as it were, are available to try and enhance and make better use of staff time in doing so. It's also about then having the staff who are able to operate that system, and not just to operate the system as a digital technician but then to provide the clinical support to enable the system to work properly. So, there's more that we could and should do, and we expect to do, in local healthcare but also in hospital-based care about access, about diagnosis and treatment and making better use of technology that should ultimately mean that it's a better place for our staff to work as well as a better experience for patients when they do need healthcare themselves.

I thank the Minister for that response, and, of course, he makes some very important and sensible points in response to my question. He'll be well aware of the problems that we had faced in Wales in the NHS Wales informatics systems, and the Public Accounts Committee published a report a very short time ago that says that we believe that NWIS is primarily focused on running outdated IT systems, and that at a time when the potential of digital healthcare is capturing the imagination and improving patient outcomes, just 10 per cent of NWIS's activities are focused on innovation. 

The clinical trials that I mentioned a moment ago in London were carried out by a medical software company called EMIS, but that has now lost its preferred vendor status as a result of a decision of NWIS here in Wales. So, here we've got, first of all, a damning report of NWIS's activities in recent years and the failure of their attempts to modernise the NHS computer system, and yet, on the other hand, they're taking away provider status from a company that has been successfully providing exactly the kind of services that we need. So, can the Minister tell me what he is doing to ensure that we don't get the kind of administrative crossing of wires that this kind of thing seems to have brought about in this instance?

With respect, I think they are two different points. The first is about our system that we wish to have here within Wales and our strategic oversight, and about the level of resource that we could and should commit to maintaining our current systems. That is, in itself, a significant undertaking in addition to our ability and the resource that we put into reform and innovation. Of course, we'll respond to the PAC report and I expect that to be a regular topic of conversation now and in the future.

The point about EMIS is not so much that this is an example of people who have great innovative ideas who have been taken out of the system and that there is a disconnect, but actually what took place with EMIS and GP systems is that there was a tender exercise and they chose to submit a bid that did not comply with the basics of the tender. That decision not then to allow them to nevertheless carry on as a potential supplier was not simply made by the Government; it was actually supported by the general practice committee of the British Medical Association themselves. A representative group of doctors agreed that, given that EMIS had refused to comply with the tender, they should not therefore be rewarded in any event and be allowed to come back into the system. And unusually—because there were questions in the Chamber at the time from people from more than one party—since that time, there has not been a significant amount of complaint about it because we provided the support that we said would be made available, and broadly the GP community have accepted that we made the right choice in not allowing EMIS into the system when they'd refused to comply with the tender details.

The chairman of the Royal College of General Practitioners, Dr Rebecca Payne, said at the time that she was very concerned about the potential impact of this on practices in north Wales, because 89 out of 118 practices were with EMIS. It's hard to see how we have the clinical staff in Wales to mitigate the potential problems that might arise. But going on from that to changing IT systems, obviously it has the potential to create all sorts of practical difficulties when it sometimes has to happen, of course, because existing systems become outdated or technology moves on. There are many people who think it will take three years before all patient records will have settled down on replacement systems, and patients need medical record integration between primary and acute settings, and current circumstances in north Wales are not producing this. So, can the Minister tell me what specific measures we're taking in north Wales to minimise both patient suffering and lost opportunity to deliver improved patient efficiency in this region?

I think the first point I'd make is that the now past chair of the Royal College of General Practitioners in Wales, Dr Payne, did raise concerns at the time, as did a number of other stakeholders, but, as I say, the representative body of general practitioners who are involved and engaged in actually assessing the responses to the tendering exercise agreed with and positively supported that choice. David Bailey is many things but he's certainly not a patsy for the Government, and he supported the choice that was made not to provide EMIS with an opportunity to try and be a supplier, having failed to deal with the tender.

On the broader point about people's access to records, it's not just within the health system; we've had a challenge of joining up records, say, within a pharmacy setting. That's what Choose Pharmacy is allowing us to do—so, a version of the GP record being available and to make entries into, but also doing more about making records available within that community pharmacy setting as well. But on access between the emergency ambulance service and between general practice, and indeed hospital practitioners as well, we've actually made real steps forward within the last few years here in Wales to do so. But there is always more to do, including the continued roll-out of the Welsh community care information system, which means that we can actually share information between health and social care.

Now, there are a range of parts of Wales where that has been rolled out and, in virtually every area where that's taken place, practitioners in health and social care recognise it's been an improvement. It means they spend less time on chasing information, and they believe that not only is their job better because it's less frustrating, but that they are providing better care for the citizen.

So, yes, there is more to do, and I accept there will be always other ideas about what we could do to improve, but this is not an area that is marginal. It is core business for health and care services, and I expect to answer more questions on this now and in the future.