Item 6 on the agenda this afternoon is a statement by the Minister for Health and Social Services, an update on the 'Train. Work. Live.' campaign. I call on the Minister for Health and Social Services, Vaughan Gething. 

Thank you, Deputy Presiding Officer. 

The Welsh Government commitment to our NHS workforce was set out clearly in our programme for government, where we pledged to recruit and train more doctors, nurses and other healthcare professionals. Last summer, I published our long-term plan for health and care, 'A Healthier Wales'. It emphasises how fundamental our workforce are to delivering successful health and social care in Wales. Planning for a skilled and sustainable workforce has never been more important than in recent times.

The most recent official workforce statistics, published last week, show there are now more staff working in NHS Wales than ever before. That reflects our ongoing commitment and investment in the NHS workforce, even against the backdrop of ongoing austerity, now going into its tenth year. But success is not always about adding more. In line with prudent healthcare principles, it is vital that NHS Wales makes effective use of the skills of each profession in the role that they are qualified to undertake, supporting staff to work at the top of their skill set, and working as part of sustainable multidisciplinary teams.   

For the fifth consecutive year, funding to support health professional education and training in Wales has increased. In this financial year, we will invest £114 million, an increase of £7 million available from 2018-19. That will support a range of education and training programmes for healthcare professionals in Wales. This is a record level of funding, and will support the highest ever number of training opportunities here in Wales.  

Following the publication of 'A Healthier Wales', Health Education and Improvement Wales is developing one of the key actions, which is a national workforce strategy for health and social care, to be completed later this year. This will provide a more strategic framework for planning and developing the workforce, including, of course, recruitment and retention.

Alongside our continued investment and longer term priorities through the workforce strategy, our flagship national and international marketing campaign, 'Train. Work. Live.', has been supporting health boards, trusts and Health Education and Improvement Wales in their activities to attract additional staff to train, work and live here in Wales. The campaign is supported by a range of stakeholders. It has put Wales on the international recruitment map for healthcare professionals, showcasing the benefits of training, working and living in Wales. The campaign has targeted a number of countries through digital marketing, featuring images and personal stories of healthcare professions working within our NHS, many of whom have relocated to Wales and put down roots here.

As part of our actions to support general practice and primary care, GP training has been incentivised through two schemes, which are already proving to be successful in attracting doctors into areas of Wales where there have been vacancies for a number of years previously. Since the launch of the medical phase of 'Train. Work. Live.', the number of doctors choosing Wales to undertake GP speciality training has increased significantly. In 2017, we overfilled our allocation with the 144 places filled. Last year, we had 134 from 136 places filled. Health Education and Improvement Wales has already begun to introduce measures to enable an increase in the number of GP training placements advertised in 2019, with the increase in advertised places greatest in areas of Wales that, until recently, have had the most pressing issues with GP training capacity.

As a result of a combination of these actions, I am pleased to be able to confirm to the Chamber today that following only the first of the three recruitment rounds for GP speciality training in 2019, we have filled 131 places—28 more doctors than at the same stage last year. I am also pleased to confirm more positive interest from doctors applying through the round 1 re-advert recruitment window in 2019, with over 50 per cent more applications received than at this stage in 2018.

I have agreed further funding for Heath Education and Improvement Wales to enable them to offer additional places above the allocations where we are able to capitalise on this increased level of interest and secure additional GP trainees in 2019. This is in line with my long-standing commitment to ensure that we could accommodate additional trainees where it was possible to recruit them and not be constrained by fixed targets. In autumn, once this year’s specialty training recruitment rounds are all complete, I look forward to providing further positive news about the total number of doctors appointed to GP speciality training.

I have also asked Health Education and Improvement Wales to undertake a review of GP training schemes to establish whether the current arrangements are fit for purpose in terms of their size, location and quality to deliver an increased number of GP trainees in Wales and meet the future needs of our model for primary care. Their advice will inform my future decisions, including long-term investment plans in this area.

I am pleased to say that we're seeing improved fill rates in the other medical specialities too, which have featured as part of the 'Train. Work. Live.' campaign, including core psychiatry and core medical training. Final preparations are under way to launch the pharmacy phase of 'Train. Work. Live.' to ensure that Wales remains competitive against a backdrop of increasing competition amongst UK organisations recruiting pre-registration pharmacists. This action will ensure our ongoing commitment to support multidisciplinary team working in general practice and primary care more widely. The marketing activity for the pharmacy phase, supporting Health Education and Improvement Wales and health boards, will launch at the British Pharmaceutical Students' Association later this month.

In May, the third year of the nursing campaign will launch at the Royal College of Nursing congress in Liverpool. The campaign is having a real impact through raising awareness of the career and lifestyle opportunities that are available here in Wales. Plans are also under way to further extend the campaign to include allied healthcare professionals. The campaign will promote the role of allied health professions, in particular as part of multidisciplinary teams in primary and community care. And I look forward to keeping Members updated.

Thank you very much, Darren Millar. 

Thank you, Deputy Presiding Officer, and thank you, Minister, for your statement. I'm very pleased to see that there's been some increase in GP recruitment over the past 18 months or so, but I have to say it is a case of too little too late. We have known for a very long time that we have had significant shortages of individuals coming into the GP workforce and, in fact, the unions and the Royal College of General Practitioners were warning as much as a decade ago that we were not training sufficient numbers of people to replace those who were leaving the profession due to retirement. Whilst I commend the efforts that are being made belatedly by the Welsh Government and I'm pleased to see that there are some increases, I still don't think it's going to be sufficient to be able to plug the gap that's been caused by those who are leaving the profession at the moment.

Of course, the 'Train. Live. Work.' campaign, which is a commendable campaign, is responsible for securing some of these increases in interest in coming to live and work as a GP here in Wales, yet you fail to recognise the significant damage that has been done to that campaign as a result of your announcement yesterday, on April fool's day, of all days, in relation to the GP indemnity package, which you have decided to launch unilaterally without the agreement of the GP workforce. Because we know that that GP workforce is very, very unhappy indeed with what you are proposing. You're proposing, of course, to top-slice from the general medical services contract the £11 million or so that you need to be able to fund this indemnity scheme, at a time when GPs over the border in England are getting increases in the funding that is available to them in their surgeries.

Now, this is isn't me that's saying these things. This is stuff that can be visible for everybody to see on social media, including from Dr Dylan Parry, one of my own constituents, a GP in Old Colwyn, who fronted the 'Train. Work. Live.' campaign, who's now saying he feels as though he is sort of selling a false story about the hope and the goodness that can come from relocating to Wales. And I don't want him to be in that position. I want him to be able to sell Wales as a place to come to live and work, with your family, and to be a GP and to have a successful career in the NHS. But this indemnity insurance scheme, which you announced yesterday, without the backing of most GPs or their representative bodies in Wales, I think, is very, very shameful indeed. You're reducing the amount of funding that is available for GP practices here in Wales. It's going to have a significant impact, particularly on those practices that are just about managing at the moment, and I would urge you as a Welsh Government to reconsider your position on this, to get back to the discussions with the BMA and the Royal College of General Practitioners and others, in order that we can resolve this in a satisfactory way, which is fair to GP practices across Wales and doesn't penalise them for the fact that they've been trying to work with you in order to secure the right results.  

And I would just remind you about the current state of play in terms of GP practices. Between October 2015 and January 2019, we saw 24 GP practices close across Wales. We saw 29 enter into management by their local health boards because GPs gave the keys back, effectively, to their practices. We're told by the BMA that, according to their heat map, there are 85 practices that are at risk of closure. Now, your announcements on indemnity insurance yesterday are going to tip even more into those situations, and more and more patients are going to have their GP services impacted as a result.

Now, you referred to the increase, Minister, in the number of GP training places. Can you explain to the National Assembly and to the medical committees across Wales why it is that eligible individuals who want to come and live and work and be trained in Wales, which is what the aspirations of your campaign are, are being turned away when they actually make applications? Why is it that 50 per cent of eligible applicants in north Wales, for example, in the last two years have been turned away at a time when GP practices are closing the doors because they cannot recruit? Why is it that you haven't found sufficient capacity within the system to help to train sufficient numbers for the needs of our national health service? And when can we expect you to ramp up those training places in order that it can be more attractive to come to train, live and work here in Wales?

I could go on with more and more statistics, but I'm not going to. What I will simply do is this, Minister, and this is my parting plea: listen to the voice of GPs. They're very unhappy at the moment. They're warning of an exodus from Wales into other parts of the UK, particularly to England from border parts of our country, because of this indemnity scheme that you have announced yesterday. Think it through. You're doing the wrong thing, and you need to back up now.

I thank the Member for his series of questions and comments, and I hope that, assuming Darren Millar is genuinely interested in where we are and where we could be, he'll be interested in what I hope will be a helpful correction on some of the points that he's made.

I'll start by saying—you know, it's good to see you recognise three years of real progress in terms of GP recruitment and GP training. The choices that we have made—and this is a difficulty across the UK and, actually, compared to other UK nations, we are doing better in terms of our GP fill rates over the last three years, and that's a real cause of celebration. It's the Government, the health service, and doctors themselves working together to attract people into the country, and that is a real success story that we should be proud of. And that includes filling and overfilling where possible. Your point about north Wales—I actually made sure that, where there were people who wanted to go to north Wales to do their training in the last year, there were places available for them to go rather than the simple targets that were in place for each of those training schemes, and we were able to overfill them where that capacity was possible. That's the point about the review, which I referred to in my statement, that HIW are undertaking, because they're going to look at where we are with the training places and the capacity across the whole system. You can't simply decide to over-flex the system if there isn't a capacity from the training practice that exists to actually train people here in Wales. So, it's about our whole system and a way that is sensible and managed, as opposed to simply being led by whatever demands are made by an angry and ill-informed commentator.

Now, we'll have more places this year as well, Deputy Presiding Officer, because of a choice that I've made and referred to in my statement, and I'm optimistic about our ability to fill those places. Most of the questions and comments, of course, referred to the ongoing contract negotiations with the British Medical Association General Practice Committee Wales, and I should point out you referred to negotiating with the Royal College of GPs. We don't negotiate the contract with the royal college because it's a trade union matter, hence why we're negotiating with the General Practice Committee of the BMA here in Wales.

The indemnity scheme is a positive step forward, and it's a positive step forward in every part of the United Kingdom, including here in Wales, where we've introduced a new state-backed scheme because one of the big issues that was threatening the future of general practice was the rise in indemnity insurance, and in the last few years, those premiums rose significantly. So, what we have done by introducing the scheme from 1 April—it means that those premiums will not be rising year on year and threatening general practice here in Wales. So, actually, there's widespread agreement that that's been the right thing to do, and, actually, having access to a scheme that's funded in a way that the Welsh risk pool recognises too places GPs on a par with their colleagues in secondary care, and that's broadly recognised.

We're still negotiating with the BMA about all aspects of the contract, but I should point out a couple of facts about where we are: (a) the negotiations aren't complete,(b) the proposals are along the same principles as agreed in England—the idea that there is an entirely different approach in England is simply not true, and, in fact, as we know, we have made a more generous offer here in Wales compared to that in England. Now, that's where we are, but it's entirely appropriate for the trade union side to say during the negotiations they haven't agreed the current offer that's on the table. That's the whole point: it's a negotiation process that we are involved in. But I would say that it is not just the fact that in the last few years we have delivered a consistently more generous offer in the contract of GPs in Wales—that should provide confidence to Members here in every party, as well as GPs—but the fact is we are sitting down again with the BMA next week to go through this negotiation, and the only reason we're not sitting down this week is about the availability in people's diaries on the negotiating committee. Now, that's a matter for the BMA. I'm happy that we'll be sitting down again, and I'm confident we'll reach a deal that when GPs look at it and compare it with their colleagues across the border, they'll recognise that there's a better deal on offer here in Wales. This is a moment for calm and for trust and good faith between partners to find that agreed way forward, and I look forward to reporting back on those negotiations to the Chamber in due course.

But I fully expect we can continue to make progress to de-risk the future of general practice, to reduce insurance premiums with the indemnity offer we have made and implemented, to make progress on the last GP standing challenges, to improve access, which is a key issue for the public, and to continue to invest in general practice. And I think that that is a message the public will welcome, and I hope at the end of these negotiations we can all reflect on where we've got to and recognise general practice has a Government that is definitely on its side here in Wales. 

I thank the Minister for his statement. It's good to hear some positive progress—always ready to acknowledge that—but there are a few particular issues that I'd like to raise with him and I would also like to follow up on some of the points Darren Millar has raised.

If I can begin by looking at the issue of agency working. Now, we know that there are real challenges and I've certainly—I don't have the statistics, but it's certainly clear from my correspondence that there are medical professionals and nursing professionals who are choosing to move away from full-time salaried posts in the NHS and into agency work. Now, some of the reasons that are being given to me for that are issues that could have been quite simply settled, for example particularly nursing professionals asking for flexible working arrangements in their ongoing posts, being refused those flexible working arrangements, going to an agency, and on a number of occasions returning to exactly that post on an agency basis, at obviously greatly increased costs to the service and particularly potential risks to instability of service to patients. What steps is the Minister taking with colleagues across the NHS in Wales to address some of these inflexibilities that are forcing particularly nursing professionals, but other professionals too, out of our full-time salaried service and into agency work? It's been put to me that in some sections of the NHS, there's quite an old-fashioned idea about what commitment is, that unless you're prepared to be full-time, you're not sufficiently committed. I'm sure the Minister would agree with me that this isn't accurate at all, so I'd like to hear from him what steps are being taken to address this, because it is, I believe, a growing problem.

If I can return to a couple of issues, then, relating to general practice, and the first I want to raise with him is the issue of accuracy of data. Now, the Minister will of course be aware that StatsWales has not provided the full-time equivalent numbers of GPs. They can tell us how many GPs there are, but they can't tell us how many full-time equivalent GPs there are. They haven't been able to do this for about five years because they're investigating the quality of the data. Now, obviously, Dirprwy Lywydd, the Minister is unable to make accurate assessments about what needs to be done if he doesn't have the accurate data available to him. So, I ask the Minister this afternoon why is this investigation taking over five years? And it's surely the case that if we don't know the number of full-time equivalents, we don't know the number of posts that we may need to fill. It is certainly the case that there are more and more people wanting to work, particularly women, wanting to work part-time in general practice, and that's very welcome, but it's normal in a workplace to calculate your number of full-time equivalent posts and then to break those down to reflect the flexible working that you can offer. So, I'd like to hear some more from the Minister about how confident he is of the accuracy of the statistics that he's put before us this afternoon, whether he acknowledges that there is an issue around the accuracy of those statistics and how that might be addressed.

Now, the Minister's statement notes that we've overfilled a number of training places for GPs in some circumstances, and that is obviously positive, and it proves there is the demand out there for people to undertake the role, to study for the role. But you'll be aware, for example, that around the time of the 2016 election, the BMA said that we needed about 200 GP training places annually. I'm finding it hard, and I hope, Dirprwy Lywydd, the Minister will forgive me for this, but I'm finding it hard to get excited about the filling of 136, when what we actually need is 200—though, of course, we then have this issue of the accuracy of the data. Does the Minister acknowledge that there is a gap there? I welcome what he has said about that 136 not being set in stone and there may be opportunities to expand, and that's really positive, but does the Minister acknowledge that there is that gap there, and what plans does he have to fill it? Because it rather feels to me as if he's asking me to be excited about the filling of the minibus when what the journey really needs is a coach.

I'd next like to turn to the issues that Darren Millar has already raised with regard to the global sum. I think Darren Millar was right when he said that perhaps we should hear the voices of GPs, and with the indulgence of the Deputy Presiding Officer, I want to quote very briefly from some correspondence I've received on this issue. And this reflects the number of e-mails that I've received this weekend—I'm sure I'm not the only one. This senior GP says to me, 'The state-backed indemnity scheme has come into force, which is a positive step'—that supports the Minister's position. He goes on to say, 'However, currently it is proposed that this will be followed by 3.2 decrease in our global sum funding. As things stand, this means that the only group benefiting from the state-backed indemnity who will be contributing to the cost is GP partners.' He goes on to state that this isn't the case in other countries, and he goes on to say—and I'm summarising because I can see the Dirprwy Lywydd looking at me sternly, which is always a scary experience—he goes on to say that there's uncertainty regarding the contract, not just the indemnity scheme: 'This uncertainty is extremely detrimental to Welsh primary care services at a time when many practices and GPs are struggling to maintain the service. Many, including my own practice, are having to carefully consider plans to recruit additional staff.' He goes on to describe the effect that that's having on him as an individual.

Now, I have heard, absolutely, what the Minister has said and, indeed, what the First Minister said earlier to Paul Davies. I appreciate that with any trade union negotiation, the timing of that is not always in the hands of the employer, but I wonder if the Minister can tell us this afternoon, to give us an indicative timescale, about how soon the issues around the contract will be resolved, and whether or not he intends to maintain the position, whereby the funding for the indemnity is coming out of funding that would otherwise be there to provide services. If he needs to do that, Deputy Presiding Officer, then that is understandable at a time of austerity, but let's have some honesty and clarity about this. Can he provide that GP, and others who have written to me, and others in this Chamber, with some reassurances that this uncertainty with regard to the contract is not going to go on too long?

I'll deal with the points about the contract at the end. On your practical points about flexible working and a potentially inflexible approach, it would help to have some specific examples, because, really, that should be taken through not just individual employment relations, but, actually, at a strategic level in the partnership forum, where Government, NHS employers and trade unions across all sectors actually sit down. It's exactly the sort of thing they should discuss. If there is an individual issue, it's for the individual employer and their workplace, but, actually, if it's suggested that there is a more strategic challenge, then that's the place at which it should be addressed. And I expect it to be addressed, because it isn't just women who are opting for part-time careers, actually, more and more men do as well. Were I not in this job, it's entirely possible that I would be working part-time and my wife would be carrying on working full-time, and I'd be happy to do that, and there are many, many more men in that position through their careers, for a variety of reasons. So, it's an issue about the workforce and it's part of what should make a career in the health service an attractive one.

Of course, when it comes to the costs, we've rehearsed in this Chamber and in committee before the positive effect on the NHS of actually introducing an agency cap in rates at the time, and also the work that we're trying to do around locum. And, actually, the locum register is part of that. We want to make sure that, actually, taking on a permanent post is attractive, and that's some of the work we're doing alongside different professionals.

On the data accuracy, I hope that'll help to inform the HIW review, because I'm confident in the figures that I've given, because we're comparing like with like over the last few years, but I want to be assured that the data is properly accurate and does take into account variances in work patterns. On the HIW review, I'm not wedded to the figure of 136 forever more; that's why there's a review. I recognise the potential to overfill from our training places. That's why, as I've pointed out in my statement—in response to Darren Millar as well—I made a decision to flex upwards the training places that are available, because there's capacity in the system to do that. The figure of 200 that's been proposed I don't think is one that has lots of evidence around it about it being the right figure. There's a general acceptance, though, that we have some capacity to train more, hence my decision to be able to do that, but more so, to have a better understanding of where we could and should be, that will definitely be considered within the HIW review, as I said—the numbers, the location and the quality of that training experience. And, of course, I will keep Members updated about the advice I receive and any decisions I make, or that HIW make, about the future training capacity and nature.

Now, on your point about the contract negotiations, of course, I've been very well aware of the voice of general practitioners over the weekend, expressing their view on where we are in the negotiations. I will take some care in what I say, because what I don't want to do is to have those negotiations in public, because I don't think that's appropriate. And, as I said at the end of Darren Millar's series of questions, this is a time for calm and trust and good faith on all sides, and that means that I have to wear some of the flack that is flying around, because the negotiators need the time and the space to sit down and reach an agreement. The update letter that GPs have received puts the trade union side and their take on negotiations about where we are, and I've been a trade union negotiator in giving messages to people that I represent, and it's not always a view that the employer has agreed with, but you reach the end point of a negotiation to try and find a place where everybody thinks there's a good agreement for them, and, crucially, in this place, a good agreement for the public. So, there are a range of different issues within the negotiation. 

I do want to be clear, though, about the indemnity proposals. The one-off adjustment to take forward the state-backed indemnity scheme is exactly the mechanism that is being used in England as well—exactly the mechanism that is being used. And, in fact, in the adjustment that is being proposed, I don't just think it is proportionate, but it is a better offer than is on the table and has been agreed in England. There's something here about some honesty in our conversations about this, but the conversation is not complete. So, I'm certainly not looking to have a new area of disagreement with the BMA; I'm looking to find a point where we can all agree on having a good deal for general practice and more investment into general practice. And that's the message that I hope GPs can hear loudly and clearly from me, and, next week, negotiators will sit down again. And, when we are at an end point where there is agreement, I will be more than happy to update Members on the agreement that I am optimistic that we will still reach.

Unlike the glass-half-empty position of Darren Millar, I very much welcome the Minister's statement, because I think it gives a clear direction to the workforce plan underpinning 'A Healthier Wales', and I think that's really important. So, thank you very much for your statement. I think you're to be congratulated that we've managed to attract more and more doctors, year on year, to come and train and live in Wales, and that's absolutely as it needs to be. It takes a bit of time to fill the places, and, if we haven't taken on more people, it's because we have to ensure that the candidates we are going to invest in training with are above the line in terms of competencies, otherwise we'd be wasting the investment.

I just wanted to ask you about the specific issues raised by the endometriosis march that I went on on Saturday, because endometriosis affects one in 10 women—it is not a rare disease, sadly—and it's little known about, beyond the immediate families of those who suffer from it. Once you've got it, from about the age of 12, it unfortunately is a chronic and lifelong condition. As a result of people generally not knowing about it, I feel it isn't appropriately resourced, neither in primary care nor in secondary care, because too many people on the march were talking about how it had taken years to get themselves appropriately diagnosed, because their GP simply hadn't thought about endometriosis when they went to the doctor with pelvic pain or other related issues. So, it seems to me that, in this training, we need to ensure that people do know about endometriosis and that, in secondary care, there needs to be at least one member of the gynaecological team who is specialising in endometriosis.

And, in terms of the nursing staff needed, we have an excellent specialist team based in Cardiff and the Vale who provide an excellent service, both at secondary and tertiary level, for people with endometriosis, with a team of three or four surgeons and consultants and just one endometriosis nurse, and she is on the verge of retirement. So, we need to ensure that those who have these excellent skills are able to train up appropriate people to carry on the excellent work. And we clearly need more than one endometriosis nurse for the whole of Wales, if we're talking about one in 10 women. So, I wondered if you could tell me how this work plan is going to ensure that we have appropriately trained people to deal with the sorts of diseases like this that aren't the ones that everybody talks about, like cancer.

Thank you for the comments and the questions. I recognised some time ago that endometriosis was a common condition that is not commonly talked about or recognised. As you say, approximately one in 10 women, we understand, will be affected by it during their lifetime. So, it's not an uncommon condition, and there's a challenge about where we do need speciality and where there's a role for the general service on a condition that is this common. That was one of the reasons why I decided to create the women's health group to look at a couple of particular issues where most of the attention and people affected are women. So, the first two issues that that group's been considering are mesh and tape for vaginal prolapse and endometriosis—those being the first two issues. Now, I take the view that, if conditions that were that common had affected men, they probably wouldn't have waited this long to have been highlighted and had a plan of action. So, I've created the group to bring together appropriate speciality and focus on those issues, and I've just directed that group to also consider the report from the faecal incontinence group—the report of Julie Cornish has been received, and I've directed the women's health group to look at that as well.

It's then about making sure that the learning from each of those areas, including endometriosis, actually leads to improvement across the service, because these are not uncommon conditions, so I expect the service to deal with them—so, a limited number of conditions, to see improvement. But I expect there'll be more areas of activity as we move forward and as I hope we can resolve what looks like a proper improvement plan in each of the three areas that the group is currently considering.

Thank you, Minister, for your statement today. I have four specific questions for you. Firstly, I'd welcome your comments around recruitment to the variety of professions that we need within the Welsh NHS. I recently visited St John's Medical Practice in Aberdare to see their award-winning virtual ward programme, which enables a range of multidisciplinary professionals to work together to deliver improved patient outcomes. How can initiatives like this be used to promote Wales as a place for NHS professionals to work?

In addition, I note your remarks around the pharmacy phase of 'Train. Work. Live.' I know this fits with your previous commitments to ensure that NHS professionals in Wales can fully utilise their skill set. Can you provide any further information about this part of the roll-out of 'Train. Work. Live.'? Linked to this, I've also been very impressed with Cwm Taf's support for career development within its workforce, so I'd welcome your thoughts on how this could best be prioritised and if, in particular, you agree with me that it's important to encourage professionals into areas like mine in the Valleys.

Lastly, I know there are particular challenges around out-of-hours GP cover, and, with the success of 'Train. Work. Live.'—and, indeed, I note your previous comments about the programme surpassing its targets—would there be any capacity for overfill of these out-of-hours posts?

On out-of-hours, we've got an out-of-hours reform programme. It's coincided with the roll-out of 111 as well. As we've learnt through the roll-out of 111, we've learnt more about how to support the in-hours as well as the out-of-hours service as well, and so I think in the places where you see 111 staffing, there is a more robust out-of-hours service, and it leads back to your first point about the variety of professionals. People used to refer to out-of-hours as 'GP out-of-hours'. Now, general practitioners are an important part of that team, but, actually, having a range of other professionals, including a nursing professional, including a pharmacist, and, often, I think, we may well see the addition of a mental health practitioner within that as well—so, you'll see that, together with a generalist like a paramedic, being part of a team of different professionals who will be part of that out-of-hours service, and so I do expect that the challenge we see in Wales is reflected across the rest of the UK with out-of-hours services, and that goes back to a previous reform of the GP contract. 

I don't think it's going to be possible, or indeed helpful, to try to say you should force all GPs back into doing out-of-hours as an old contract required them to do. So, I actually think we're building a better service with a that different mix of professionals, and St John's is a good example of the virtual ward—the work that started out in southern Powys, the infamous Brecon virtual ward—and it's a good thing to see that being rolled out, because it is about valuing the contribution of different healthcare professionals and about the fact that it makes the job for those healthcare professionals a more enjoyable one, because they recognise they are providing better care and making better use of their resources. And, crucially, it's really improved team working as well, between general practitioners as well as between the general practitioner and other members of the healthcare team. There's greater appreciation of what other people can do, and that is a positive aspect of coming to work here in Wales, because what I expect is that we will progressively see more and more people describing the way they work in the same way, and it's certainly affected the way people are trained, as well, which is a real positive too.

And, on your point about pharmacists, as I indicated, the campaign will be starting imminently for the pharmacist area. I issued a written statement earlier this week about investing more in pharmacy and looking forward to further discussions with them about their contract, and about the role that they can play and the greater role that pharmacy could and should play in delivering local healthcare. That in itself, I think, will help with the geographic opportunities that exist. A number of doctors have gone out and positively talked about their part of Wales and the opportunity in medicine in where they are, but also the other leisure opportunities that exist in large parts of the country, and that includes the Valleys, just as much as it does north and west Wales too.

Finally, Caroline Jones.

Diolch, Dirprwy Lywydd. Thank you for your statement, Minister. We are three years into the recruitment campaign, and, whilst I recognise and welcome the progress we are making, we still have too few doctors and nurses. I recognise that the problem is not unique to Wales. Last week, the King's Fund, the Nuffield Trust and the Health Foundation launched a joint report warning that the NHS in England is unable to train enough GPs and nurses to meet demand and the situation is at crisis point. They warned that the English NHS would be short of 70,000 nurses and 7,000 GPs in the next five years. So, Minister, may I ask what assessment you have made of the impact that this will have on Wales's ability to recruit sufficient GPs and nurses over the next five years?

Even if you meet your recruitment targets, many of the royal colleges and organisations representing doctors and nurses warn that it will be insufficient. So, what discussions have you had with the Royal College of General Practitioners, the Royal College of Nursing and the British Medical Association about ensuring safe staffing levels in NHS Wales over the coming decade? Bear in mind that many nurses are finding agency work extremely lucrative, and one mentioned to me that in 2.5 days she can earn a week's salary. Many GPs are turning to part-time work, some because of the stress of working full time as a GP and others due to family commitments. 

Minister, according to freedom of information requests by the north Wales local medical committee, half of all eligible applicants were being turned away. Can you confirm that this is the case, and if so, how this can be justified given the massive shortages we are facing not just in north Wales, but across the nation?

There has been a worrying increase in the number of closures of GP practices in recent years. Last year nearly 50,000 patients had to find new GPs after their surgery closed. The Welsh general practitioners committee chair warned that general practice in Wales is truly on the brink of an abyss, with practices serving around one in 10 people in the country at risk of closure. Minister, what assessment have you made of the risk of surgeries closing in the next 12 months and what are you doing to mitigate those risks?

Finally, Minister, can you outline the additional steps you are taking to recruit sufficient numbers of Welsh-speaking doctors and nurses to ensure that, no matter what part of Wales you live in, you can access services through the Welsh language? Providing services in Welsh is not just a matter of choice, it's essential for some, particularly those suffering from dementia. Diolch yn fawr.

I think, on that final point, you'll have heard the First Minister talk earlier about our expectations that we're able to service the healthcare needs of people and to improve the ability of the primary care team to do so. That requires us to take GPs with us and to help them acquire language skills and value those skills. It's also why we've been interested in investing in specific recruitment and training opportunities.

So, I think I've mentioned here before some of the programmes that we have on recruiting and engaging people from those communities that are not usually going to medical school, and the opportunities are being provided, and a lot of that has been targeted delivery at Welsh speakers, for example. I met a group of people from Blaenau Gwent, Welsh speakers from Blaenau Gwent, who were going to a day of engagement to look at the possibility of careers in medical education on a day run by Cardiff University. So there is real, deliberate engagement looking at the future workforce as well as the workforce we have today. And when we look at the workforce plan you mentioned earlier, actually that is partly what HIW are looking at. They're looking at the workforce plan for the future to help reform what our health boards do and the opportunities to think about what medical education and non-medical education will provide, and the ability to plan that with our higher education sector, together with the training they'll undertake within a professional setting. 

On your broader point about practice sustainability, I've regularly said that we will have a different number of general practices in the future, and if you go to a practice with one person, one doctor partner in there, that is a practice that is unlikely to exist in the future if it remains like that. The days of single-handed GPs are unlikely to return, and actually, going back to the comments made by Vikki Howells and the points you made as well, people expect to see different healthcare professionals in the one setting. So, I don't think a single-handed practice is likely to be robust and sustainable for the future, and some of that change is going to need to be managed and planned properly. There's a challenge about people engaging with their local health board to have that conversation, and crucially to engage with their peers in clusters where they discuss these matters. Actually, clusters have promoted much better working between different general practices, and that was not the feeling that people had at the start of clusters. People viewed them as a bureaucratic exercise to get money, and some people were resentful, and yet now people talk about the opportunities that they deliver because they are used to working with different practices in the same local area, serving broadly the same community. That is a positive step forward.

On your point about understanding the right numbers of staff, well, of course, we have a piece of legislation on nursing in particular that the then backbench Member for Brecon and Radnorshire piloted through the Assembly with cross-party support, and so we'll look at the roll-out for that piece of legislation. But that relies on professional judgment and relies on an evidence base for the difference that nurse staffing numbers would make, and it also relies, of course, on our ability to fulfil the role of that legislation by actually recruiting and training more nurses. And compared to just a few years ago, we train nearly two thirds more nurses here in Wales now who are going through our education system. So we are making real steps forward.

The final point I'll make is in response to, if you like, your opening gambit about the fact that there are too few doctors and nurses. Well, we are recruiting more and we are training more, but not only that, though, we should remember that this is the only area of the public service where there is an undimmed public appetite for more staff and an expectation that those staff will be delivered, and that has a real consequence. We're nearly 10 years deep into austerity. You're about to hear a statement from the Minister for Education, and because we are prioritising the national health service and more staff in the national health service, that means there are even more difficult choices to make in every single other part of our budget and it means there are fewer staff available in other public services. And I have never forgotten that in the budget choices that I then get to make.

So, austerity is, of course, a really big issue, but Brexit is, too. If you look at the number of people who have left the nursing and midwifery register across the United Kingdom, the biggest drop has been in EU nationals who have left the register and returned to mainland Europe. So, actually, the choices we make, the way we talk about Brexit, the way we talk about European Union nationals really matters and it has a real-world impact in every part of the United Kingdom. So, our ability to recruit relies on our standing in the world and our willingness to recruit people and welcome them into our country, not just as health and care professionals, but as citizens of this country. And I do want to reiterate, from the Welsh Government's point of view, European Union nationals are welcome, not just in our health service, but welcome as citizens of our country. 

Thank you very much, Minister.