The next item, therefore, is the statement by the Minister for Health and Social Services on the task and finish group on critical care, and I call on the Minister to make the statement—Vaughan Gething.

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

Diolch, Llywydd. Members will recall that, in 2016, we created a parliamentary review of independent experts to examine health and social care in Wales, and that review, of course, had cross-party support. The report of the parliamentary review described the increasing demands and new challenges that face health and social care in Wales. These include greater care needs as more of us can expect to grow older, and increasing public expectations of new and emerging medical advances. These challenges have been acutely felt by critical care services in recent years. It is clear that there is a significant strain within critical care services, and this has been increasing in recent years. Despite this, people who require critical illness support continue to receive high standards of critical care, thanks to the dedication of the many expert members of staff who are working in what is a highly pressurised environment.

As set out in 'A Healthier Wales', hospital-based services such as critical care remain an essential and visible part of our future health and care system. As with other healthcare systems, we need to speed up the pace of change within critical care, including the model of provision across Wales, to ensure that we have the right services in the right place for those who are critically ill. That is why, in July last year, I issued a written statement announcing a nationally directed programme to look strategically at the issues and challenges for our critical care services. In that statement, I said that our approach to critical care will build on the work already being taken forward with the implementation of the delivery plan for the critically ill. We are now taking a more central hand in directing this work at a national level. I established a task and finish group, which was chaired by Professor Chris Jones, the deputy chief medical officer. It comprised seven work streams looking at: the mapping of service models, demand and capacity; workforce requirements; outreach; post-anaesthesia care units; long-term ventilation; patient transfers; and performance measures.

Following the recommendations of these work streams, immediate progress has been made. This includes: critical care becoming a strand within the 'Train. Work. Live.' recruitment campaign; highlighting the existing opportunities to work in critical care in Wales; and critical care activity now being included within the unscheduled care performance dashboard. This helps health boards to manage their services more effectively.

I am pleased today to publish the task and finish group's final report. The report is honest about the challenges facing critical care, and provides a strategic view on the steps necessary to ensure services for people who are critically ill are fit for the future. In addition to the main report, the reports from each work stream have been published as annexes, setting out more detailed recommendations. The report concludes that, unless admission and referral practices change, which the group felt there was little scope for, the increased future demand can only be met by an increase in total critical care capacity. The task and finish group are clear that Wales does need additional capacity. However, this must be in combination with improvements in critical care pathways, such as post-anaesthesia care units, otherwise known in the service as PACUs, long-term ventilation, critical care outreach teams, and improved efficiencies, including reducing delayed transfers from critical care and utilising the skill mix of our staff more effectively.

We do need to address existing workforce issues of skill mix, recruitment, retention and training, as well as increasing the numbers of appropriately skilled healthcare professionals to meet both current and future need. The task and finish group acknowledges the national programme is ambitious but, if fully implemented, will help to ensure that Wales has a critical care service on a par with the best in the UK. Critical care staff throughout Wales work in a highly pressurised environment, and the lack of capacity across the system has exacerbated this. The task and finish group hopes that both staff and patients will see this as a clear commitment, backed up by robust recommendations and additional funding to help deliver a phased improvement programme.

To help implement the task and finish group's report, I have already announced that an additional £15 million of recurrent funding will be provided. The funding will be used to support a number of national priorities. such as the establishment of a transfer service for critically ill adults and a long-term ventilation unit. Local priorities, including increasing critical care capacity, workforce, outreach and the establishment of post-anaesthesia care units, are also being supported.

We need to be clear that this additional funding must have a significant positive impact on the service and that our systems improve as a consequence of the investment and service redesign. To support this, a new set of performance measures linked to the investment will be implemented and we will track performance on delayed transfers of care. This nationally directed work has important links to other developing areas of specialist services. These include major trauma, treatment following an out-of-hospital cardiac arrest, and vascular surgery. It is important that this investment is seen in that wider context.

Finally, I want to end this statement by expressing my gratitude to the members of the task and finish group as well as the healthcare professionals and managers who are working, and working together, to bring real and meaningful transformation to our critical care services.

Minister, thank you very much for bringing forward your statement on this report. I think this report is very good. I was really pleased to see that it's clear, it's concise, it's got a very well defined set of objectives, and it actually talks about how we can monitor it and measure the outcomes. It is a rare jewel, and I'm delighted to be able to ask you a few questions on this. 

It talks about the fact that we have the lowest number of critical care beds per head of population in relation to most other areas, and I wondered if you could perhaps outline how you see the development of those additional critical care beds and how will you ring-fence them so they don't become post-operative anaeth—. I can't say the word; I'll just call them PACU beds. Because I notice that it's quite clear about how many beds should go to what area, which health board, but, again, it's about making sure it actually happens. If I was to read this whole report, very simply I would say, 'Great report, really good analysis, but how will we make sure it actually gets delivered, when we know the health boards are under immense pressure and when we know that targets and objectives are shifted around, are moved about, and that statistics can say pretty much anything?' Because, if this could be made to happen, it would be an enormous step forward. 

I note that the task and finish group have suggested that, once this comes to being and it moves forward, they should step down and that it should be left to the critical illness implementation group to measure. But, of course, one of the great criticisms of the critical illness implementation group in 2016 was the fact that they were struggling to offer sustainable solutions, and that they hadn't brought into the whole system the organisational commitment that's required. So, I'd like to know what you will do to ensure that the make-up of the critical illness implementation group is capable of monitoring this ongoing work, because I think it's just telling that we've had to have a task and finish group to tell them what they should do, when, to be frank, they should have been able to come up with this under their own steam. 

Will you please just give us a quick overview of where you see the money sitting, because it says very clearly here that funding will be allocated to health boards in their capacity as commissioners, and yet they need to then immediately go and use that money to start building these additional beds, to start putting together the adult emergency transfer system that they're talking about? How will they apply for that, and who will make the decision whether or not their business plan is actually fit enough to be awarded the money to carry on and try and achieve these objectives?

Is there going to be an element of ring-fencing around it? Transparent reporting of critical care outcome measures with robust escalation arrangements: will you, as the health Minister, also be keeping a weather eye on this, or will you be pushing this out to the critical care implementation group to monitor? Because I'd like to think that, actually, this report doesn't just disappear into the ether, but actually you keep, or the Government keeps, tabs on it to make sure that these things happen. My overwhelming fear is that a lot of these really, really excellent recommendations simply will not happen because either the funding isn't in the right place, the skills aren't in the right place, the right people who know how to make change happen, and make change happen successfully, will not be able to carry this out, particularly at a time when we're asking health boards to try to transform the entire way they operate, to follow through on the vision for health, which I think is a particularly good way forward.

I think my final question will be about how the remaining funding is split between Aneurin Bevan, Betsi, Cwm Taf, Hywel Dda and Swansea Bay. It talks about areas of agreed priority for critical care services, and, again, who will have the final say on what those agreed priorities are and whether or not the business case then stacks up. 

Thank you for the series of questions, some of which I think have overlapping themes. I would say I think there's a central point that you're making about whether the report will be delivered and whether the money will deliver against the objectives and how that will be tracked and monitored. Well, I've been clear that the suggested allocation of resource comes from the task and finish group and it's something that we've endorsed. The Wales critical care and trauma network will be involved in looking at the delivery plans from health boards, because it isn't simply a question of saying, 'Please go ahead and do this' to health boards. Actually, we'll need to see those delivery plans to deliver against the increases in capacity that the report has suggested we need to make. So, the money is there, but they need to have proper delivery plans for that to come in. And that will be overseen. The Wales critical care and trauma network will have a view on that as well, the Government will take a view, and it will be on the basis of those delivery plans that the money will actually be released to health boards to deliver against that increase in capacity. So, there is going to be a more central hand. I announced, when I issued a statement last year, that this would be a centrally directed programme of activity, and now we're still making sure that that will be the case. So, it won't disappear into the ether. It will be something where there will be performance measures and outcome measures to understand what's really happening. And, yes, I do expect that the Government will be informed on what is happening there and it won't simply be left to health boards to, if you like, mark their own homework.

And when it comes to the point about whether the money will really get to deliver against the objectives, well, I've been clear in the past, when we've had sums of money that have been earmarked for a particular purpose, that it does need to deliver against that purpose. If you take the example of the performance funds we've had in the last few years, where health boards haven't delivered against the plans they've provided, I've been prepared to claw that money back. So, I am clear that this money will be used for the purpose, and not disappear into a general pot of money. It must be used for the purpose. 

And some of the building of capacity is, of course, in staff, so the work around workforce is important not just to understand what we need know, but also in the future. The recruitment activities are already ongoing, the further advice from Healthcare Inspectorate Wales about the groups of staff we'll need, because, actually, the biggest limitation in increasing capacity isn't the bed itself—it's all the staff around it for the different tiers of service that are required—because at the highest level of care, we're talking about one-to-one nursing care and the rest of the team around that person as well. So, staff, actually, are what we do need to invest in in terms of training and upskilling, as well, of course, as the numbers of staff to deliver the additional capacity that the task and fish group recommend and I've accepted we want to try and create. 

When it comes to the point about transfers, though, that is something that will go into the emergency ambulance services committee mechanism, working together with—[Inaudible.]—to look at the experience that already exists there. So, you will have an oversight there about what's being commissioned, how it's going to be done, and, again, a specific sum of money to go into delivering that improvement, because if we improve the delayed transfers of care it won't simply be that I or the Deputy Minister will be able to stand up and say, 'Look, delayed transfers of care have improved', but, actually, have a much better and efficient use of our resources across the system. It means that people that no longer need to be in critical care can be moved down to where they need to be, and that will often be closer to home, especially if they move from one of our tertiary centres. But it will also mean that somebody that does need to have that place in critical care will be more likely to be rapidly in the right place, because we do recognise not having the flexibility, the efficiency and the capacity does mean that some people are not in the optimal place for their care. So, it's the whole system. The delayed transfers make a difference to the top level of care, but also to people moving through in the right direction, whether they're up or down in the system. So, I do think we have the right sort of recommendations so that it will now be about the delivery.

I'd like to thank the Minister for his statement and for the additional information he's provided in response to Angela Burns. Like Angela Burns, I was struck by the very high quality of this report and, as the Minister and others have said, we're very grateful to the task and finish group for all the work that they've put in and, indeed, for the staff who work in very high-pressured environments, as the Minister has said. 

If I can return to the questions about the budget—this is an additional £15 million, very welcome, but not a great deal to tackle what are obviously some big issues that need to be tackled. Can the Minister let us know today from where that £15 million has come? Is that additional money into the health budget from somewhere else, or has it been reallocated from somewhere within his current budget, because these are obviously very difficult priority decisions to be made, and I think it would be helpful for us to know where that money has come from, particularly? 

I'm very interested in the points he made in response to Angela Burns about delivery plans, but he didn't quite answer her question about whether or not the funding will be ring-fenced. And our experience is that the Minister can sometimes have expectations of local health boards that they don't always fulfil, so I'd like to press him a little harder on what the consequences will be if they take this money and spend it on something else. I'm not suggesting for a moment that they will, and the report is really clear and it sets out what needs to be done so they shouldn't feel the need to do that. But I am concerned, because this is a very specific amount of money to do a very specific job, that we wouldn't want it to get lost. 

In the context of the investment issue, what discussions has the Minister or his officials had about specific investments in services in the north, where we know some of the biggest problems lie—an ongoing poor A&E performance that knocks on into a lot of other parts of the system, too many critical care cases that are actually outsourced from Wales altogether, including to Stoke, and that's not long-term acceptable, and it's not long-term good use of resources either? So, can the Minister tell us today what specific investment will go into the north to address the issues that the report highlights?

Can the Minister say a little bit more about how confident he is about the success of the recruitment campaign, basing that perhaps on how the previous campaigns have gone for other specialities? I'm really pleased to see that this is going to be included now, and it will be interesting to hear what sort of expectations the Minister has of its outcomes.

A slightly specific question: the group's report has highlighted how changes to pension and tax arrangements have created some challenges for workforce planning in this area and, no doubt, how it affects other departments too. Can the Minister tell us a bit more about how he proposes to ensure that health boards respond to those challenges, because they're clearly not going to go away?

And finally, could I just ask the Minister for some clarity around the time frame, the timescales for the implementation? I did take it from what he said that there's a certain amount of urgency in this work and that he expects the health boards to respond quickly, but I'd like to know when he feels he may be able to report back to this Chamber as to the progress that's been delivered against the report's aspirations.

Thank you for the series of questions. In terms of the new resource, it is a central resource. It's not about reallocating budgets that already existed within health boards, but there is something about how health boards use the resources they already have available to them as well. This isn't simply saying that extra capacity will only be provided by additional money from the centre, but the £15 million is money from the centre, and Members will recall that the Faculty of Intensive Care Medicine expressed concerns about critical care capacity last year, and I asked the chief executive of NHS Wales to meet them, and that's helped to inform some of the work that we have actually undertaken since then, and members of the faculty have, of course, been involved in the task and finish group. And that comes back to the point you later made about north Wales. The additional capacity we're talking about—seven extra beds—comes from work streams that they've endorsed as well. That's the additional capacity that the finance should release, but it is on the basis that there are proper plans about how they'll do that, how they'll scale that up and make sure that the capacity is there to deliver. But that, in itself, as I've said in response to Angela Burns, must come together with more efficient use of resources and, in particular, as I said in my statement, delayed transfers of care, an area where we could make better use of what we already have as well as the additional capacity that we're looking to create.

I think I dealt with the point about what will happen if people try to spend money in a different way. I've been clear that money can be clawed back in other areas. Health boards will be managed. In this area, it's a nationally directed programme, and I expect the money to be spent that way, and health boards won't be able to find a different way to spend money inappropriately. The set of recommendations are relatively tight and clear as to how money will be spent, so there aren't lots of opportunities for money to leak into other areas of the service.

On your point about what will happen with recruitment activity, well, we actually have a good record through ‘Train. Work. Live.’, and it's come on the back of working with service areas, working with representative groups within that service area, about what is currently attractive for the way in which we deliver our service and what would make that service more attractive. And, actually, having a view on the longer term future for the service is something that staff should find attractive. And, of course, this is informed by the recommendations from a group of clinicians working in this service area at present who recognise the pressures that exist but also how there could be a better service to deliver both for our patients but also, of course, for our staff—a better place for them to do their job. And we have success in terms of psychiatry, GP training places, pharmacy, nurses and therapists in the ‘Train. Work. Live.’ programme, so we have got some reasons to be optimistic about our ability to do more in this area as well.

I expect to have plans provided in the autumn, and I expect to see progress within the next 12 months or so. But some of this, as I see it, is about skilling up the staff we currently have as well as the additional staff we need to bring in to deliver the capacity that we want to deliver. So, I'm not going to pretend that this will be a quick fix. We do have clarity about how the money should be spent and the benefits that should be gained.

Thank you for your statement, Minister, and for providing us with a copy of the task and finish group's final report. I would also like to thank members of the task and finish group for their work in helping us transform health services for the critically ill in Wales.

The conclusions of the report are welcome, with the objectives being clear and concise, along with excellent recommendations. As the group rightly points out and the Minister acknowledges, there is considerable strain being placed upon critical care services and how this strain will intensify in future years due to demographic changes. And, as stated, it is important, as with other healthcare services, that we speed up the pace of change within critical care, including the model of provision across Wales, to ensure the right services are in the right place for those who are critically ill at that time. Workforce issues appear to be the biggest barrier to increasing critical care services, and recruitment and retention of staff are still major factors across the NHS.

Minister, the task and finish group point to the impact recent pension changes are having, given the reliance on consultants doing additional sessions. So, what discussions have you had with the UK Government regarding the impact tax and pension changes are having on our NHS? I've been told that recent changes are discouraging more and more doctors from conducting extra sessions across the NHS. It is clear that we need to recruit more staff for our critical care service, but these personnel will not appear overnight, and, therefore, Minister, what steps are you taking to ensure critical care services do not deteriorate further until we have sufficient staff to meet current and future demand? Importantly, Minister, is funding ring-fenced?

Minister, I welcome your national approach to critical care. Given the roll-out of the major trauma network, what steps are you taking to ensure we have sufficient patient transfer capacity going forward?

Finally, Minister, I also welcome the emphasis given to reducing delayed transfers from critical care. However, we still have issues of delayed transfers throughout the system and I recently learnt of an instance of an elderly stroke patient being sent home without any care package in place. What discussions have you had with colleagues in local government about increasing social care capacity, given the impact this has upon services such as critical care? Because this 85-year-old gentleman waited nine hours in A&E for a bed, how will you, therefore, ensure there are sufficient beds for people, as his local hospital was also full to capacity? Thank you, once again, Minister, and I look forward to working with you to improve critical care services for patients in Wales.

Thank you. On workforce, of course, in terms of stabilisation of the workforce now, we invested £5 million in this particular area over the last winter and that was deliberately to try to stabilise this particular part of the service whilst we're looking to the future. On your point about delayed transfers, it's quite interesting, actually, because, when I've gone through a range of different hospitals across the country, as every health Minister gets the opportunity to do throughout the year and in particular through winter, our emergency medicine consultants are actually quite an honest bunch, and they'll tell you what they think works and what they think doesn't work. What's been really interesting for me is that they have not made a bid for an extra amount of beds within the hospital in general. And we often argue about bed numbers in this place, in saying, 'You've cut too many bed numbers out of the system over a long period of time', but, actually, their bigger ask is for there to be greater capacity in social care. I had a very interesting couple of conversations through the winter where they said, 'We've got a challenge at present, but I don't think having an extra 20 or 30 beds in the hospital over and above what we already have is the answer'. They were saying, 'We want there to be more capacity in social care to release people out of the hospital', because they all knew of the large numbers of medically fit people who existed within the hospital, and that was the challenge about the whole system not being able to move people around to where they needed to go.

I have raised these issues and have discussions with health boards and local government together on delayed transfers. I've recently concluded a series of meetings with each regional partnership board, health and local government leadership, and I've always, since—. Well, following my first discussions about delayed transfers of care, where I talked individually to local authorities and then their health board and finding out that they broadly said it was the partner who wasn't in the room who was responsible, I've always had joint meetings. It's been a much better way of understanding what progress could and should look like. And everyone understands this is a priority for the Government, but, equally for them as well, whether in health or local government, and we are in a much better position with delayed transfers at historic record lows, whereas, in England, the position is going in the other direction. So, we're getting some things right, but it's about how much more we need to do.

And then your point about pension changes: well, this is a big challenge for the health service, not just in this area, but a much broader challenge, and it's not just a challenge for Wales. It affects every single UK nation, every single partner of the national health service, and it is poisoning the well of goodwill that exists from our staff who are prepared to do additional work within the national health service, including waiting list initiatives in evenings and weekends, and they're now finding significant and unexpected tax bills arriving on their doorstep. It's a problem that's been created through a change in Treasury rules and the risk is that we will drive NHS workers out of the health service—not just doctors, but other staff too—and we'll then have to buy those services and it will cost us as much if not more than what we would otherwise pay to NHS staff. The other risk is, of course, that, if we drive high earners out of the NHS pension scheme, then we potentially undermine the scheme for the future. So, I've already had correspondence with the UK Government on this point; there is due to be a formal consultation in the imminent future. But I do hope that the Treasury are prepared to listen to every part of the national health service and to do the right thing by our NHS, or we'll all pay a price if they refuse to do so.

Thank you very much, Minister. Thank you.