Questions now from party spokespeople. Plaid Cymru spokesperson, Helen Mary Jones. 

Diolch yn fawr, Llywydd. I'd like to turn to the subject of the performance of our emergency care system, and it's been highlighted that the performance of two out of the three of the accident and emergency units in hospitals in the Betsi Cadwaladr region has been so bad that it's dragged the average Welsh figures substantially down. The First Minister acknowledged last week that this level of performance was unacceptable. Now, given that the Minister is, through special measures, directly responsible for this performance, can he account for the factors that have led to it?

I won't rehearse the challenge about whether I'm directly running the health service in north Wales through special measures or not; we keep on coming back to this. But the reality is that the performance within emergency care in north Wales is not acceptable, and that is the direct message that the health board have had. In terms of the reasons for it, and factors within it, some of the factors are that, despite the fact that we've had better weather this winter than last winter, actually the flu season is slightly worse this winter, and, unusually, in January, there are more major incidents than minor incidents compared to last year. But, essentially, the challenge is actually about how the system in north Wales, in particular in two of our major sites, is not able to cope in the way that the rest of the country is able to, and that's complicated. It's about relationships between health and social care, it's about clinical leadership, and it's actually about leadership across the board. And there's a challenge about understanding that in other parts of Wales—there is significant pressure on our system at this time of year, which we understand—performance standards are better. So, it isn't just about saying, 'This is unacceptable, sort it out'; it is actually about working with our staff, because the worse thing I think I could do is to simply say, 'It's unacceptable and I want people to go down the road.' Actually, we need those staff within our system, their compassion and their commitment to deliver. We need to keep the staff with us whilst we understand, and they understand, together with their clinical colleagues and peers, how they can actually improve the service that they want to provide with their colleagues and for the people that they serve. It's also why the post of the unscheduled care lead, an emergency department consultant herself, is actually really important, to have that clinical credibility to deliver the improvement that all of us wish to see. 

Well, I'm grateful to the Minister for his answer, though slightly puzzled by it. I thought that the whole point of special measures was that the Government was taking some responsibility for what was going on. But putting that to one side, and be that as it may, I'm also slightly surprised to hear the Minister say that factors are complex and, by implication, they don't know exactly what's going on, because in response to my colleague Adam Price last week, the First Minister asserted that there was no need for an in-depth inquiry into the state of A&E in Wales. That is, of course, something that's being called for by your Labour colleagues in London, though, in fact, the English system, unfortunately, is outperforming the Welsh system on average. One of the reasons, of course, that the First Minister gave for not needing an inquiry was, he said: 

'We know the things that need to be done.' 

That's exactly what he said, and: 

'The job is to get on and make sure that the general improvements are shared elsewhere and everywhere'.

Now, I'm sure I and everybody in this Chamber would want to associate ourselves with what the Minister has just said about the excellent work that front-line staff do, in sometimes very, very difficult circumstances. But either the First Minister is right and we know what needs to be done, in which case, I'd suggest that the Minister and his officials get on with it, or we don't know, in which case, we need to find out. 

Well, that isn't quite an accurate reflection of what I said or what the First Minister said either. I certainly never said, 'We just don't know what's going on within the emergency care system.' We do know that there's a challenge about clinical leadership and engagement and buy-in. And, actually, if you look across north Wales you can't really distinguish the take that comes into Ysbyty Gwynedd compared to Glan Clwyd or Wrexham Maelor to explain the differentials in performance. So, there is a challenge about how we have a positive perspective with our staff that doesn't simply say, 'You are not doing your job properly'. That is the worst possible message. So, it is about the engagement we expect to have. That's why the clinical leadership, from a national lead, really does matter—somebody with credibility with that workforce, to understand the specifics about each site, but then the broader points about clinical leadership and behaviour within our system. And all the things that we are doing across this winter, about making sure we don't have people going in unnecessarily, having more ability within our primary care service, they matter in every part of our system. But we do recognise the specific challenges and problems within north Wales in particular, and that is a focus, of course, for our whole system.

You see, Llywydd, I am struggling a little bit with this, because, on the one hand, the Minister is telling us that there is no substantial difference between the effect of what's going on in Ysbyty Gwynedd and what's going on in the other two accident and emergency units, and, on the other hand, he's telling me that the factors are different, and we need to take them into account. Now, I am certainly not suggesting that anybody on the front line in those services is not doing their job properly. We might ask ourselves if there are persons in this Chamber who, in this regard, may or may not be doing their job properly, but I don't want to get to that level, necessarily. It is clear that, in relation to accident and emergency, and these two particular hospitals, whatever the Minister is doing under special measures, as it stands, is not working, because otherwise they would be learning from the good practice that he rightly highlights elsewhere in Wales. Does the Minister accept that it is now time, given the powers that he has under special measures, to do something more radical, that we need a root-and-branch look at the whole system around those two hospitals, looking at what's going on with admissions and unnecessary admissions, right through to what's going on to people unnecessarily being kept in hospital? It cannot be the case that Ysbyty Gwynedd can manage, and these two hospital cannot manage. It is time, I think, for the Minister to step in and look at this in a radical and consistent manner.

Again, I don't think that's a fair reflection on the fact of what I've set out. You need to understand what is specific to each particular site to address, but, actually, there is nothing that explains the significant difference in performance between the three sites within north Wales, and, actually, when you go beyond that, then, the differences in different parts of Wales too. That's why we do have a real focus on clinical leadership. For the third time I'm going to say: clinical leadership matters, and performance, and that can and will make a difference. Our job is to be able to encourage and support those people to be clear about the expectation for the board, and their point in accountability and achievement—and they will be held to account, and, actually, the chair has taken some personal ownership and responsibility for the mission of improvement within this area—to understand the 90-day turnaround and improvement plan, to let us see what has changed, and what needs to change further. Because simply saying, 'Do something radical and different, Minister'—well, that isn't an answer. That is the easiest thing to say, but it is not an answer to address performance and the sort of service that our staff want to deliver, and our public expect. I'm determined to do the right thing—that is about listening to our staff, looking at the evidence, and making sure the right thing is actually done. And I fully expect to be held to account, whether we do well or not.

The Conservative spokesperson, Janet Finch-Saunders.

Thank you. I think my questions are—thank you. Diolch, Llywydd. May I welcome you to your first questions, I believe, Minister? I look forward to working with you, as we go forward, in this portfolio. I know, from my time with you in committee, that you're very genuine in your working.

Right, there are at least 370,000 carers in Wales, which is more than the population of Cardiff. And around three in five of us will become a carer at some point in our lives. For many young people, however, this point comes far too early. Indeed, as you will be aware, we have a selfless army of carers aged under 18 years old across Wales. Now, last week saw Young Carers Awareness Day, and many of us as Welsh Conservatives strove to raise awareness of this, and the vital role that these young champions play in supporting their sick and disabled family members. One major point of concern is the fact that some young carers are unable to continue in education or apprenticeships, because of a fear of losing their carers' allowance. Will you therefore endorse, support and ensure that we bring about a policy that we want to introduce, and that is a £60 a week young adult carers futures grant?

I thank Janet Finch-Saunders for that welcome and very kind words. In response to her comments about young carers, we're absolutely committed to supporting carers of all ages, including young carers and young adult carers. We do think that education in the school setting is one of the key areas to identify and help young carers and I'm aware that the financial situation of young carers is often a matter for concern, and her proposal is something that we can look at.

Thank you, that's very encouraging. Thank you, Deputy Minister. I believe that our grant would go a long way in helping to ensure that young carers can continue in education. This is key, but there is more still that we can do. Indeed, it is a frightening fact that YoungMinds suggest that 68 per cent of young carers have been bullied at some point because of tackling their home responsibilities. So, they've made clear signals that professionals, particularly in schools, are not yet able to spot and identify training needs, not just for the carers themselves, but for their peers. How can you be sure that the identity card will reach all carers and that adequate training is given to adults working with young people, so that we can identify our carers much sooner in the system and give them the support they need?

I absolutely agree with the Member that there is a lack of awareness of the issues of young carers and it's really important, particularly in schools that there is a much wider awareness, and that is something that the Government certainly wants to work on. 

The proposal for a young carers ID card is actually being worked on at the moment by officials here in the Government and they're working with Carers Trust Wales to consider the proposals for such a scheme and working also with the education department. There are already a number of carer identification schemes in place in local authorities in Wales, and I think what we've got to do is to investigate how they are working, but what we would want to do is to introduce a national ID card for young carers. But, obviously, you can introduce the card, but you've got to make sure that people understand what the card means. So, I'd like to reassure the Member that people in the Government are working at the moment on this issue, and I think this is something that young carers themselves would welcome.

Thank you, again. One aim of the Social Services and Well-being (Wales) Act 2016 is to improve the well-being of carers who need support. Following this, a carer of any age has the same rights to be assessed for support as the person they care for. These assessments are undertaken by social services. However, the total number of social service staff for children and young people has not really, in any real form, improved since 2014-15, especially when one takes into account the high levels of sickness and stress that actually exist within those very departments. Therefore, what measures are you taking to ensure that young carers are able to fully receive their needs assessment—and this is a genuine assessment—and then to receive the subsequent support that they need and that they receive it promptly?

It is absolutely vital, as the Member says, that correct assessments are made for young carers, and the social services and well-being Act does require that, but I am aware that many young carers have not had assessments and I know that there is variability of how the assessments actually apply. So, the Government is looking at this—looking at how to improve this and is looking at it through the ministerial advisory group for carers and in other ways. But I do think that it's absolutely crucial that young carers do get assessments, because one of the things that you have to look at in an assessment is how being a carer is affecting the ordinary, everyday life that a young person needs, and the assessments really need to take those into account when they're made. So, the assessments are crucial, but we do need to ensure they're more consistent and more widespread.

The UKIP spokesperson, Neil Hamilton.

Diolch, Llywydd. The Minister will be aware, from the auditor general's report on NHS Wales's expenditure on agency staff that the amount of money that is being spent has gone up by 171 per cent over seven years, and amounted to £135 million in 2017-18. This is a very expensive way to recruit staff. In Betsi Cadwaladr in 2017, they were spending 7 per cent of their total staff budget on agency staff, and in Hywel Dda it was 10 per cent. The latest figures show that Betsi is spending £30 million on agency staff, and Hywel Dda £23 million. The response that I've seen so far from the Welsh Government is this: that this report will inform future activity in strengthening leadership to steer work to deliver future efficiencies and develop a single source of data collection. Will the Minister agree with me that, rather than just management speak, there should be some practical action to get these figures down so that the money could be spent in other ways that are more beneficial to patients in the health service in Wales?

Actually, if you look at what we've done over the last two years, we have made real inroads into agency and locum spend. I made a choice to introduce not just a cap on rates, but a range of other measures that the service had offered in terms of some policy choices. That's meant we've spent at least £30 million less on agency than in the last financial year, but we know that we need to do more. And actually, there's a challenge for all of us: if we really do want to see a reduction in agency and locum spend, then we need to change the way that we deliver care. That means the current way in which we deliver care will need to change to make it more attractive to recruit permanent staff within the service. And, of course, Members across this Chamber are regularly put under pressure to support keeping the way that services are delivered, even when those services rely on high degrees of agency and locum spend. So, actually, changing services isn't just about driving the financials down; it's actually about delivering better care, with permanent members of staff who are permanently on the care team.

Of course, some health boards in Wales are doing very much better than the boards that I've just quoted. In Cardiff and Vale, for example, only about 1.5 per cent of their staffing budget is spent on agency staff. So, if they can do it, why can't the other health boards? This is largely going on medical and dental staff, and nursing and midwifery. Again, in Betsi, 65 per cent of the money they've spent on agency staff has gone on medical and dental staff—that's £19 million. But Cardiff and Vale, by contrast, spent only £360,000 on this in the latest year. What accounts for these disparities? It clearly can't be pay as the cause, because pay rates are pretty much nationally set. Here is a case again where political leadership is absolutely necessary to solve what is a substantial problem that adds to all the other burdens on the health service.

Actually, we know that for a significant part not just of Wales, but across the United Kingdom, some centres are more easy to attract and recruit to than others in different parts of the country. You don't need to take my word for it; go and talk to people who work in those other parts of the health service about the relative ease or difficulty of doing so. Cardiff and Vale, and other parts of the south-east corner, have had a more stable way of delivering and transforming their care. There is a different job of work to be done, for example, in west Wales and in north Wales in transforming the way that care is delivered. If we're unable to do so, then we'll continue to prop up parts of our service with agency and locum and higher spend. That's the unavoidable reality of where we are. So, if Members want to see genuinely a reduction in agency and locum spend, then we all need to have a grown-up conversation about where that care is delivered, to make it a more attractive place for staff to work. If we can't do that, we'll continue to either prop up parts of our service with agency and locum spend, or see those reform and change at a point of crisis, rather than deliberately planning to do so. That was one of the central messages of 'A Healthier Wales' and, indeed, the parliamentary review that every party in this Chamber signed up to.

Of course, the performance of some health boards in recent years perhaps makes it more difficult to recruit staff, in areas like north Wales in particular. Nevertheless, that can't be the whole answer to this difficulty, because the same problem is seen with locums for GPs as it is for NHS staff in other areas of professional activity. For example, in relation to Blaenau Ffestiniog, the Healthcare Inspectorate Wales 2017 report said that GP recruitment there still had significant issues because there was considerable reliance on locums and improvement was needed. Well, on the Primary Care Professionals website today, there is an advertisement for 32 GP jobs in Blaenau Ffestiniog, 22 of which are for locums. So, in 16 months since that healthcare inspectorate report of 2017 till today, there's been very, very little change. On page 39 of that report, it said that the assistant area director of primary care and primary care development manager, by 31 January 2018—that's a year ago—should increase the availability of salaried GPs through recruitment to reduce frequent change in staff and locums available to complete their own tasks. So, when are we actually going to see some significant progress not just in relation to agency staff in hospitals, but also in the recruitment of GPs to serve areas that have relied far too long upon locums chopping and changing? Most patients want to see their regular GP; they don't want to be in a situation where every time they go to the surgery they're seeing somebody new.  

That's true for some patients, and others take a rather different view. If you look at what we're doing and, actually, if you look at the NHS England plan, for example, when they talk about the way that they want general practice to work together, it sounds and looks a lot like clusters here in Wales. They may not give us credit for it, but they're actually copying a number of the things that we're doing because the workforce of the future will be different, and, when I think about agency and locum, I absolutely think about primary care—the ability to recruit enough general practitioners, the training that we have, the achievement over the last two years and doing very well on filling our GP training places, but, more than that, about the environment they're going to work within with different forms of staff.

And there's a different number of GPs working in a different way with other healthcare professionals. That's why the record investment we're making in other healthcare professional training, the £114 million we're investing—. Even in a time of austerity, a £7 million increase in that form of training, for more staff, for the physios, the nurses, the paramedics. That's the challenge that we have to confront. And, actually, our GP workforce are broadly supportive of the direction that we are taking. The challenge, as ever, is: are we able to move fast enough to keep services open, up and running, and to persuade enough people to actually come on board to work in a different way? And, within that, I accept I'm not the most persuasive voice. A general practitioner is more likely to listen to a fellow GP about the way that they have changed their practice, working with different professionals, than to any politician within this place. And, actually, we do have a range of leaders within general practice who are making that bid and showing real leadership with their peers. So, actually, for all the challenge that we have, there is real room for optimism about the path we're on, and, indeed, the flattery of NHS England largely copying significant parts of what we're already doing in Wales.