The next item is a statement by the Minister for Health and Social Services on unscheduled care winter delivery. I call on the Minister to make his statement—Vaughan Gething.

Thank you, Llywydd. I am pleased to update Members on the delivery of unscheduled care services this winter. I'd like to begin by paying tribute to the hard work and dedication of thousands of our health and social care staff this winter. I've had the opportunity to see front-line staff across Wales delivering services for people whilst under pressure. I've talked previously about the planning process for this winter, which included leaders from local health boards providing assurance to the Welsh Government about their readiness. The local plans were agreed in partnership between health and local government. I've supported local organisations through an extra £39 million, provided earlier than before, based upon findings from our 2017-18 review and feedback from clinicians.

I'm pleased to report improvements have been made following this additional investment and lessons learnt from previous winters. I am confident that, without these, the winter we have experienced so far would have been much tougher on staff and had a negative impact on patient and staff experience. Emerging evidence tells us that the number of lost hours for patients waiting over an hour for ambulance handovers decreased by 30 per cent, comparing December 2018 to December 2017. 

The Deputy Presiding Officer (Ann Jones) took the Chair.

Hospitals across Wales reported considerably less time spent at the highest levels of escalation in December 2018 and January 2019 when compared to December 2017 and January 2018 respectively. When hospitals did experience those increased pressures, this winter they recovered and de-escalated quicker, and that is a real indication of improved resilience of front-line services.

Hospitals have admitted fewer people over the age of 85 as emergencies this winter, compared with the previous two winters. The average length of stay for patients admitted as emergencies in December 2018 was at its lowest for over six years. There has been a continued reduction in the number of delayed transfers of care, and improvements have been made in waiting times; the number of people waiting over 36 weeks for elective care at the end of November 2018 was 41 per cent lower than November 2017, and now all health boards are in a better position than they were last year. 

I'm also pleased to update Members on a number of collaboratively delivered initiatives between the Welsh Government, local health boards, the Welsh ambulance service and third sector organisations that are already making a positive impact for people this winter. The Welsh ambulance service has collaborated with St John's on a falls assistance initiative, responding to 773 people who have fallen this winter. Over 85 per cent of those calls included patients over the age of 65. Patient feedback indicates 94 of people were satisfied with the response provided.

Since mid December, local health boards have been working with the British Red Cross to support over 14,000 patients in eight emergency departments across the country. The pilot aims to improve staff well-being and patient experience. It supports patients and their families in emergency departments and transports patients home. The home transport includes helping to resettle patients by connecting them again to community services. That has been especially helpful for lonely people. 

The Hospital to Home pilot, delivered in collaboration with Care and Repair Cymru, is focusing on improving housing quality to support reductions in delayed transfers of care, prevent admissions and reduce readmission rates. Collaboration and integration with the third sector is a key facet of 'A Healthier Wales', and I'm encouraged to see further progress being made here.

We're also trialling new integrated models of care this winter by deploying pharmacists into emergency departments. Again, early indications are positive. Dedicated pharmacists are now working as part of a multidisciplinary team, with some hospitals already reporting seeing up to 100 patients a week, to help support the safe and efficient delivery of care to patients in the emergency department.

However, this winter has also been difficult for services and staff across health and social care. There have been occasions where patients have waited longer for advice, care or treatment than we or health and social care staff would like. Winter stomach bugs such as norovirus place additional strain on our NHS, and since October 2018 there have been 103 gastrointestinal outbreaks in hospitals and care homes across Wales.

Members will be aware that the last flu season saw the highest number of GP consultations and flu cases in hospitals since the 2009 pandemic. We've increased testing following the roll-out of Welsh Government-funded rapid flu tests for patients in emergency departments across Wales. This winter we have seen a higher number of flu cases confirmed in hospitals compared to the same time last year.

Despite a record number of attendances at major emergency departments, performance against the four-hour access target improved at seven out of 13 hospitals. However, it is clear that performance in particular at three sites is simply not good enough, and that has affected the national overall performance picture.

Looking forward to the medium term, we're overseeing a number of programmes to support the sustainable delivery of unscheduled care services. The new primary care model will provide a 24/7 response, with the 111 service being a key component. As the 111 service rolls out over the next two to three years it will improve access through better signposting, clinical advice and treatment using a free-to-call number and other digital opportunities. There'll be greater regional and national working to meet the demand for critical advice and treatment at peak times, and 111 will be available nationally by 2022.

The amber review implementation programme, which I've highlighted to Members in a previous statement, is well under way and expected to run until November 2019. I will update Members on progress on that programme over the summer. A quality and delivery framework for emergency departments is under development and includes the piloting of new measures developed alongside clinicians over the past year. This'll be the first phase of wider work to develop clinical outcome and experience measures across the unscheduled care system.

Building on an in-depth review into how we discharge people with complex needs from hospitals, we will substantially increase focus on preventing unnecessary admission and reducing delays in hospital transfers of care for older people in 2019-20. I will also provide an update on this ‘home first’ approach in the summer. This reinforces our need to work across our whole health and social care system.

And finally, we will launch a policy framework for unscheduled care to describe our policy expectations for local health boards and NHS trusts in the summer 2019. I will, of course, provide further detail upon its release.

Thank you, Minister, for your statement and for the advance copy that you provided to my office.

Clearly, there has been progress in some areas, and I’m very pleased to see that, because, my goodness, we needed some progress on this very important matter. Because, as you quite rightly said, whilst performance against the four-hour target has improved at some hospital sites, at others it is woefully inadequate, including, most seriously, in north Wales at two of the hospitals, which are at the bottom of the league table in a health board that, of course, is currently in special measures and under your direct control.

Can I give you an example of the sort of care that is being provided at Glan Clwyd Hospital? This is from an e-mail that was sent to me by my constituent, John Cook, about his son Gareth Cook, who, unfortunately, had occasion to need some attention in the emergency department there back in November. He attended three times in a single week, largely because, at the first of those attendances he was turned away inappropriately, and at the second attendance he was also turned away inappropriately, because of bed pressures in the hospital. He comments, and I quote:

'I have mentioned the lack of basic hygiene, privacy and respect for patients arising from the appalling conditions. To illustrate this point, I refer to patients vomiting within touching distance of one another. Gareth recounts an experience of sharing a four-chair bay with three others. Included in this group were an elderly blind person and a younger man who was an alcoholic and clearly disturbed. In the middle of the night, this alcoholic introduced a pair of scissors and was prodding the blind man awake.' 

In addition to that, there are scenes described of two elderly gentlemen, one 94 and the other in his 80s, spending days—not hours, days—on chairs, sharing a single one-bay bed with three others, all, again, within touching distance of one another.

Now, clearly, these are unacceptable descriptions of the sort of care that both you and I and anybody else in this Chamber would want to be seeing provided, but I am very concerned that that’s the sort of care, unfortunately, that many people are witnessing in our hospitals, particularly in north Wales. But I know that those sorts of scenes are not confined to there, and I want to know what you're doing to address those sorts of concerns, because it seems to me that a large part of the problem is the bed capacity in our hospitals, which is keeping too many people in our emergency departments for too long.

Because we know that the figures on the 12 plus-hour periods that people are spending in our hospitals are actually getting worse. They got worse in December, and they were worse in November than they were 12 months previously. So, whilst I appreciate that there is progress being made in terms of transfers of care, and that there has been some progress in terms of some of the other targets, clearly, people should not be spending more than 12 hours in an emergency department unless there is an exceptional circumstance that requires them to be in there.

You made reference to the extra cash that has been invested this winter. I’m pleased to see that cash going in. I’d be very grateful to know, Minister, how that cash was divided by health board area, because it seems to me that it’s not always been targeted at the level of greatest need, where the biggest problems are manifesting. So, it would be interesting to know if you could give us a breakdown in your response today.

I’m very keen also to hear a little bit more about these collaborations that the NHS is developing with the Red Cross, St John’s Ambulance, and Care & Repair Cymru. It’s wonderful that those collaborations have started. I know that patients, certainly in my neck of the words, really value very much the support that the Red Cross have been giving, and I think that’s working extremely well. But, clearly, I think what we need to know is: are these going to be permanent features within our health service in the future and, if so, are appropriate regimes in place to ensure that there's proper scrutiny of those new systems and arrangements, and are they being properly paid for?

Can you also tell us what the situation is in terms of the take-up of the flu jab by front-line healthcare workers? You made reference to the flu season in your statement, and we know that it started a little bit later this year than it has in previous years and, of course, there's always the opportunity that it will gather momentum again. Now, we've had just around half of our front-line healthcare workers in the past actually receiving their jabs. That's clearly not good enough. We need to get a higher take-up rate amongst front-line health professionals, and I'd be grateful if you could tell us whether you're going to introduce new targets, new measures that can prompt and encourage people to take the opportunity to protect themselves in order to protect other people.

And just finally, can I ask you on the whole subject of the ambulance service and its targets—? We know that there have been some welcome changes in terms of the intelligent targets that have been set now for the ambulance service, but one thing that rings in my ears on a frequent basis is the concern that some people who show symptoms of a cardiac attack, a heart attack, are not being regarded as the top category of calls, and don't stimulate an ambulance to be able to respond to them within the eight-minute call time. I think that is a concern for a lot of people. Some people, sadly, have lost partners, lost family members as a result of that target. I'd be grateful to know if you could tell us what you're doing to review that particular arrangement in terms of the cardiac care in the future. Thank you.    

Thank you for the series of questions. I'll begin with your last point, because it was covered in the amber review. There was a review of the conditions in the different categorisations, in red, amber 1 and amber 2, and your personal view is not supported by the clinicians who undertook the review. We're taking a proper evidence base as to the categorisation of healthcare conditions, but also to look at improvement within the amber category in any event. And as I said in my statement, I'll be reporting back to Members this summer on the progress being made in delivering that and, of course, I'll expect to report again at the end of the implementation period for the recommendations made in that review. As I indicated in my statement, that work is due to carry on until November of this calendar year.

On your broader point about the flu jab, again, I expect that, as part of the wider review into this winter, we'll look again at the overall success of persuading the public and our staff to take up the opportunity offered by protection from the flu jab. We'll look again at the most successful parts of our system, both for employees as well as the ability to persuade people to take up their flu jabs, whether at GP surgeries or at pharmacies. In fact, this morning I had to call into my own general practice, and the wall was plastered with posters about getting your flu jab for those people at increased risk. So, certainly, the information being provided there in both languages was very, very visible, and I know that it's something that has been discussed and will be discussed again with employers about the success, or otherwise, of persuading staff to take up the flu jab in each part of our system. And you'll know that this winter, of course, we've rolled out the opportunity for staff in residential care to receive the flu jab from the health service as well, so I'll be open and transparent about success and what measures we propose to take at the end of this winter as well.

On the Red Cross, I'm glad that there's broadly a welcome for it, and it's been very, very warmly welcomed by staff and by people who are engaged in the service themselves as well. It is a pilot, and it's a pilot that is due to run at the end of March, and we will then evaluate it to understand the impact that it has had. We will then—I will then have to make a decision about whether to recommission that, whether it will be a regular recommission, whether it will be a seasonal recommission if the evidence supports it in winter, or whether it's a regular part and feature of our system. We will need to understand from the Red Cross about their ability to supply that service, should the evaluation show that it's of the sort of value where we would want to sustain it. 

On your broader point about money, I confirmed in a previous statement that of the share of the money that's gone out, north Wales had the highest share of the moneys announced. I'll happily recirculate to Members the share of that between different health boards and their partners.

On your broader point about the experience of care when you started off your contributions and comments, I would not try to say that the picture that you paint from your constituency is one that I would wish anyone to have in any emergency department in any part of the country. And the challenge for us is not just understanding that that has taken place, but our ability to do something different about it. Now that, for me, isn't just about the front door, and we regularly rehearse this—it isn't just about ambulances and the front door. And actually, it isn't always about bed capacity. And one of the interesting things about the conversation with the college of emergency medicine has been their focus on, yes, wanting more staff, but actually, their other big focus has been about wanting more resource to go into social care, because they recognise that the medically fit people within any of the hospitals almost always equal the pressure they have at the front door, and actually being able to get those medically fit people out of the hospital requires the support of social care and the third sector for that to be able to happen.

Now, for me, the frustration is how fast we're able to move, bearing in mind the demand that we continue to see coming through our front door. We know that we have managed to support more people outside of emergency departments this winter. If we hadn't taken those measures, we'd have more people in our emergency departments. We need to do progressively more each winter just to keep pace with the demand that we know exists in our whole system. But it isn't just emergency departments that see that pressure, our colleagues in primary care do as well.

So, if you want to provide me with the details from your constituent, I'll happily make sure they're looked at, but the focus will be on the whole system and, in particular, how we support people to leave a hospital and be supported, so they're not readmitted and they're not returning to hospital without having had the appropriate support and care outside of our hospital system.

I'd like to thank the Minister very much for his statement and, in doing so, join him in valuing the excellent work that our staff are doing, sometimes under very difficult circumstances. I'm sure that we all appreciate the efforts they make, often under very difficult circumstances, as I've said.

It is, as Darren Millar said, positive to see some trends. I'd like to ask the Minister for a little bit more detail about some of the headlines that he mentions. So, the statement mentions that hospitals across Wales reported considerably less time spent at the highest level of escalation in December last year and January this year. That's obviously good to hear, but I'd appreciate some more detail from the Minister. Perhaps he could write to Members, because 'considerably less time' is quite a vague term and it would be interesting to know whether that improved performance was consistent across all the hospitals in Wales, were there variations, and if there were variations, what accounts for them and how those might be addressed.

So, a further question of detail around delayed transfers of care. Again, it's very pleasing to hear that there has been a reduction, but it would be helpful, from the point of view of scrutiny, to know a reduction from what to what, and again, whether that performance is consistent across the whole of the service or whether, as we might suspect, there are substantial differences. And again, if there are differences, what accounts for those. And I should stress, Dirprwy Lywydd, that I'm not expecting the Minister to have all of this at his fingertips, though I'm sure he will have some of it. But it would be useful to have that level of detail.

I also welcome the engagement of the third sector, where it's appropriate, to help in this area of work. I would, though, put it to the Minister that it's very important that we ensure that these third sector services once—. As I appreciate the Minister said to Darren Millar, some of these are pilots, and we need to see whether they're working and then whether Government wants to commission them on an ongoing basis. But it is very important when we are engaging with the third sector that it's done on a sustainable basis and that the funding pattern is enough for the organisations to be able to sustain themselves as well as to provide the particular service. I have, for example, been in some discussions with a hospice at home service in my own region where the funding that they're being offered from the health board is on a standstill basis, despite the fact that nursing salaries are, rightly, being increased. So, I think it would be helpful for the Minister to take a look at how the service as a whole is engaging with the third sector and is it doing so in a way that makes those services, which are much appreciated, as Darren Millar has said, truly sustainable.

The Minister's statement made references to the accident and emergency situation, but it's at a fairly broad level, though I appreciate we have discussed this already. But the reality is, isn't it, that we had almost 4,000 people—3,887—waiting longer in major A&E centres last December, and that was more than in previous years. The Minister rightly highlights that the figures are skewed by particularly poor performances in particular places—Darren Millar made reference to the north—and I'd be grateful if the Minister can say a bit more today about what he and his officials are doing to address that performance in those three centres where we know that there are really serious issues.

Finally, Deputy Presiding Officer, it is fairly obvious to state that winter does come every year, and yet we do seem to hear that we are to be surprised by certain things like influenza and norovirus, and I wonder if the Minister can assure us—and I look forward to seeing the policy framework for unscheduled care, because I think it's very useful to have a national policy framework—. But will the Minister ensure that, in that framework, we take into account the fact that these pressures do come every year? Some years, they're worse than others; some years flu is worse, some years norovirus is worse. But we do need to understand that there will always be those additional pressures. So, can the Minister assure us that that policy framework will take into account that variation in pressure so that we're not looking for emergencies when, in fact, what we've got is just the weather and this being Wales? Thank you.

If I can deal with your last point first, we recognise that this being Wales and the weather vary in terms of the pressures that they drive. Cold weather tends not to produce a big spike in admissions at the time; it's actually roughly a week or so later when the cold weather produces the impact in terms of the additional number of people going in. We know that the first week of January is almost always a point of really large pressure right across primary care and the hospitals. There are parts that we really can predict and those that we can't accurately. We know that, as more of us live longer, we can expect there to be more pressure across the whole system and, in particular, through winter. That's why one of the encouraging things with the difference this year is the number of over-85s falling in emergency admissions terms, and that's really positive, but it does show that we need to do even more to support people in their own homes, and it's why there is such an understandable, not just direction of policy but a range of people across primary care and social care who are saying that they actually need to not just talk about the way we want more to be done there but how we actually resource those teams to deliver the care that we want to see delivered locally and sustained locally as well.

On your broader point about the three centres with particular challenge, there is a mixture of support and challenge. The support that is provided, not just in monetary terms but actually in advice from officials here has to be complemented with challenge at board level, and that absolutely happens. It's part of the conversation I recently had with health board chairs and trust chairs and chief execs last week. We went through their emergency department performance and in particular focusing on those areas where they recognise they have real and significant challenge, and there is the peer leadership and clinical leadership as well. There is a limit to what politicians demanding answers can actually do to help practice on the ground and indeed the broader whole system about how effective relationships are between health and social care and the third sector, because actually getting those relationships right is just as important as the clinical leadership in any emergency department.

So, there is never one single answer to resolve all of these issues, but you raise a point about the third sector, and actually the sustainability of those services, of course, matters to us as well as the third sector. When we're commissioning a service from the third sector, we want to know that the organisation is robust and able to deliver its service. We have key indicators about the service so they understand we're spending public money wisely, and the third sector don't take issue with that. They want some certainty about the future, and there's a limit to how much certainty we can provide. When you're living year to year on budgets in national Government, it's hard to give people the longer term funding cycles that they would want themselves, but actually we had a very constructive conversation with the third sector in Wales on exactly this topic around health and social care just a few weeks ago when I and the Deputy Minister met with the group convened by the Wales Council for Voluntary Action to look at all those people engaged in delivering and working around the health and social care sector.

And the encouraging point for the third sector to take is that, when you look at the way that 'A Healthier Wales' is not just written and what's in the language in it but actually the WCVA, the Welsh Local Government Association and the NHS Confederation here in Wales—the three key partners who co-produced that strategy—. So, they're absolutely at the start of the conversation, not being tagged on at the end. And they are also part of our regional partnership boards across the country. There's always third sector representation there. So, it's never a perfect point in time; there will always be a need to challenge and discuss what we're doing, but they're absolutely part of the conversation and part of the future as well.

On your two more detail points—on delayed transfers of care, yes, there are variations between health board partnerships. We publish those with the figures on a regular basis. I can say that the last two years have had the lowest levels of delayed transfers of care in the last 13 years since we started collecting these figures, and 2018 had a third lower delayed transfers of care than in 2006. So, actually, we are making real and sustained progress, and there's a positive comparison for Wales compared to England, where delayed transfers are moving in the opposite direction.

And on your point about the highest level of escalation, well, for those who aren't health geeks, we have four levels of escalation: level 1 being the lowest, level 4 being the highest—you may know this, others may not. And for the time we spent at level 4 for this January compared to last January, there is nearly a 12 percentage point difference. And, equally, when departments have been at level 4, they have de-escalated down to level 3 or lower on a much quicker basis as well. So, that is something that isn't because the Minister has said, 'You must do this', it's actually because there is greater grip and performance, and that is because our staff are in a better position, and it's also because the whole system in those areas is in a better position to deliver.

Could I echo both the words of the Minister and others who've contributed so far in response to this statement about the incredible work that people do in different disciplines, both within health and within social care and third sector partners as well? And it's to one of those particular organisations that was mentioned in the statement that I want to address some questions and some remarks. And that's one that began, actually, in my own area in Bridgend, back in 2013–14, I think it was, which is the Bridgend care and repair support that was given to the hospital to home initiative. And it proved its worth very, very quickly way back then—the ability to have much more rapid discharge from hospital to a safe, secure environment with wraparound care, but also to prevent too early readmissions as well by providing that right support of wraparound care at home. Now, of course, as the Minister mentioned, it's having some interesting pilots now—it's been extended well beyond that area to six different areas in south and west Wales, and we're waiting to see the results. But I will just draw the Minister's attention to the performance report of April 2017 to March 2018, which looks at some of the quite compelling results already at that point: around about 1,500 referrals that have been through this particular initiative. Within that, one of the notable successes of the service, even in that early period, was the speed of that service to respond quickly to referrals from health professionals, accessing the service, particularly for discharge. The average speed of the service was one day from referral to completion of work in order to rapidly get somebody back to their home environment. But in addition to that, of course, it's the other services that come with it, including not only the full home assessment visits and the falls risk assessments, using the FRAT tools, the healthy homes check, but a full welfare benefits check as well. Over 230 patients had their weekly income increased during that: a total increase for the whole cohort of £657,000 in that one year's annual report. So, the impacts are massive, and when you hear the health professionals' testimonials about what this is doing—from occupational therapists, from physios and others—the impact on people's lives, as well as preventing early re-admissions, as well as early discharge, is significant.

So, could I ask the Minister—in this quiet revolution that we're trying to do within health and social care, and all the partners within it, which needs, I would say, to be a continual revolution, constantly seeking improvement—how do we move from pilot funding? This was originally the integrated care fund, now it's got some transformation funding and so on in there—if it proves itself, does he agree with me that what we then need to do is make this normal, make this part of core business? If this sort of approach we see here in front of us works, and saves money by being more preventative, then, surely, that should be part of the core business of our health and social care and well-being services. And, secondly, perhaps I could ask him, and I'm sure he'd be up for this, at an appropriate moment, would he accept an invitation to come and see the work that is being done by Bridgend care and repair in their hospital to home service? Because I think he, like me, would be simply blown away, not only by the results but by the professionalism and the commitment of these people. They've been doing it for a long time—they know their stuff. So, please, come and see it; they'd be delighted to see you and to see first-hand the results that they're delivering on the ground and the quality-of-life improvements they're making for their clients as well.

Thank you for highlighting the success of that particular area of work, and, again, the ideas come and they are supported, but, actually, people need to deliver them and to make the difference. And it is encouraging to hear to hear the level of detail and the numbers of people that are benefiting and benefiting rapidly from the new service—that point about a rapid discharge and supporting people to leave, but then the support they need to stay in their own homes safely and securely and as independently as possible. And I just want to pick up that this is about partnership between third sector, housing and different groups of staff who occasionally get talked about, particularly the therapists—occupational therapists and physiotherapy support as well. It is absolutely my ambition to understand which models of care and support have the greatest prospect of making the greatest difference, and the ability to be scaled on a much wider level. I've been really clear that I don't want to keep on funding micro projects that are not transferrable to other parts of the country. I'm interested in a broader not just debate, but a broader change in practice and to take on best practice so that it becomes standard practice—not something you point to that stands apart from everything else, but, actually, that is the way to deliver business on a standard basis to make the sort of transformation that we all wish to. In principle, I'd be very happy to take up his offer, and, if he'll write to me, I'm sure that we can sort out a convenient time and date in the diary.

Like everybody else, I'd like to thank the Minister for this statement and to express my own appreciation to NHS staff for the tremendous job that they do, often in very difficult and stressful circumstances. And can I start by echoing what Helen Mary Jones said in her questions earlier on, asking the Minister for greater transparency in statements of this kind? I know I'm knew to this brief and therefore don't have the degree of background knowledge that others might possess, but I have found it quite difficult to understand what is actually going on. The statement is fine, as far as it goes—under the emerging evidence section, we hear that hospitals have considerably less time spent at the highest level of escalation; that there are fewer people over 85 treated as emergencies; that the average length of stay for emergencies was at its lowest for over six years; that there's been a reduction in the number of delayed transfers of care. But without statistics, we're not really able to evaluate exactly what these statements mean. And although I've spent a bit of time with my researcher today trying to find out what the situation was last year in detail, I found that some statistics were found on the StatsWales website, others were on the NHS Wales website and others were held by CHC Wales. And sometimes, the tables are not always made user-friendly, forcing the user to create a table for every month within every year, making the deciphering of multi-year trends, therefore, extremely difficult. I wonder if it might be possible, in the digitised version of these statements, to provide links to the information sets that will actually put meat on the dry bone of the generalised statements. I realise that this isn't always possible, but where it is known in advance for some time that there is going to be a statement or a need for a statement on certain areas, it shouldn't be beyond the wit of man to set up a system that enables us to do our jobs better in the Assembly of providing scrutiny, in a constructive way, which is what these exchanges should be about.

I wonder if the Minister can perhaps provide a little more information about some of the statements that were made. In relation to lost hours for patients waiting over an hour for ambulance handovers, it's very good news that there's been a decrease by 30 per cent year on year, but patients waiting over an hour, according to the A&E patient experience review a short time ago, in January of last year, showed that at that stage 30 per cent or so of people were waiting for an ambulance for more than an hour. So, a 30 per cent reduction still means there's a very substantial number of people who are having to wait for more than an hour, and 10 per cent last year had to wait for three hours or more for an ambulance. So, I wonder if the Minister can tell me whether the improvement that is alluded to here has been pretty even throughout the time periods that people have to wait for, or is there still a specific problem in certain areas? Again, fewer people over 85 are treated as emergencies; well, out of 80,000 or so admissions last year, 5,000 of those were over-85s—not surprisingly, it's a significant number. But what has been the pressure this year? Is it related to the weather and perhaps fewer people getting diseases that would otherwise make them have emergency admissions, something over which the Government has no control, and for which they can take no credit, or does it show a real improvement within the system? Again, the average length of stay for patients admitted as emergencies last year, if they were 75 to 84 years old, was seven and a quarter hours, and, for 85 and over, eight and half hours. So, I wonder whether we can show meaningful improvements, because we just say that the average length of stay was the lowest for over six years, but what is the difference that we're talking about here? Is it something that is a very substantial reduction or not? These are all important issues, which are difficult to evaluate in the way in which this statement is made.

I accept that there have been improvements made as a result of the efforts that the Welsh Government has made in the last year; it would be difficult not to, given the extra resources that have been provided, and given the low base upon which we start in many cases. And the Minister, importantly, did say that a small number of hospitals are actually distorting the picture for the whole of Wales. I wonder, therefore, the extent to which Betsi Cadwaladr in particular is still underperforming and dragging the whole system down with it. I note from, particularly, the patient pathways, waiting for more than 36 weeks—in the statistical bulletin that was published last July, about half of those cases were in Betsi Cadwaladr's area. We will need to have Betsi Cadwaladr doing substantially better than the average if we're to make any real difference to these alarming figures. So, I wonder if the Minister is able to tell us whether he thinks that Betsi Cadwaladr is making enough progress towards improving the system for the whole national health service in Wales to appear in a better light. 

Turning to your final point first, I've been very clear that Betsi Cadwaladr need to do substantially better on both unscheduled care and planned care as well. They make up about half of the numbers of people waiting more than they should do for 36 weeks. Their 26-week percentage isn't where it should be either. The revised plans they've provided me with, with new scrutiny from the chair and the reinvigorated board, give me some greater confidence, but I have made it clear that they will need to deliver the performance improvement they set out before I will come here and give the sort of assurance that you and other Members will look for. And making that difference in north Wales will make a difference to the people of north Wales and the picture across Wales as well. And the same in unscheduled care as well.

And it's about the appropriate balance between support and challenge, because I think, as I said previously, the easiest thing for me to do is to say it is somebody else's fault and I expect them to do better, when, actually, those staff need to be supported as well. And that's why the peer leadership and the clinical leadership really matters, and why the whole system support and engagement matters as well. I want to see people stay within the system, and, actually, I have some more cause for optimism about the next few months and where we'll get to after that, but I'm looking for that to be made real. And I fully expect to have questions to answer about that, not just through the winter, but through the rest of the year, whilst performance figures remain as they are. 

On your broader points about the level of detail, well, we always make a choice about what's in statements. If I'd provided particular statistical figures through the statement that are linked to it, then I'd have been spewing out a range of figures and not giving analysis. There is a balance, and, in an answer to a question from Helen Mary, I gave some more figures, and I have to tell you that, in terms of the length of stay for emergency admissions, there has been a 3 per cent reduction this winter compared to last winter, and, on emergency admissions for over 85s, there has been a 7 per cent reduction—so, a real and material reduction in percentage terms. The challenge is to sustain that, not just through the winter but through the rest of our year, and to do what I said in response to Helen Mary about making sure that we actually deliver on having the adequate resource within primary care and social care to deliver more care closer to home and keep people out of hospital when they don't need to be there. There is more to do in the way we engage professions in doing that, and, actually, the pharmacy pilot is a really important part of this year, not just in the community provision, and actually asking people to go the pharmacy first, but in having pharmacists within the emergency department, because, as we regularly rehearse—and David Melding regularly does when he talks about community pharmacy, and others—a significant number of hospital admissions are about medication errors. So, the more we can do in having appropriate pharmacy support, the better for the whole system. 

And, on your point about ambulance waits, well, I start with the recognition that too many people still wait too long—not just an hour, but there are some waits that are still just too long in any event, on an individual level. But the 30 per cent improvement is real, and it includes Betsi Cadwaladr as well—they have made real improvements in reducing the number of, if you like, lost ambulance hours too. That's part of the challenge about our system, that we're doing better on the ambulance end in a sustained way—that isn't transferring through the whole system, though. There is still more to do, but, again, we should not lose sight of the fact that this is the fortieth consecutive month that the Welsh ambulance service has met its target for red calls, despite there being a larger number than ever of the life-threatening red calls as well. And that is a significant tribute to the ambulance service trust.

And, on your final point about the level of demand that comes in and what that might be, well, actually, this isn't simply about numbers. The portion of numbers changes. We categorise patients who come into emergency departments as either minor, in terms of minor injuries and minor ailments, or major, where they're really significantly ill. And, actually, it's the case that, in winter, we tend to see more people in the major category; they tend to be older. Actually, this winter, the percentage of our major patients, so the people who are most ill, has shifted again. So, we're actually seeing even more people who are actually very, very unwell, and need to be in a hospital for treatment. And, actually, more and more of those are getting there themselves—they actually are either walk-ups or people who are being driven there by friends and relatives—as well as the record numbers that are being transferred by the ambulance service. There is more to do about how we're able to cope with that changing picture in demand. That's the context for us to deliver, but I recognise Members will expect me to be accountable for the whole system, and for the whole system to be able to recognise and address the pressures that exist within our population.

Thank you, Minister.