Item 7 on our agenda this afternoon is a statement by the Minister for Health and Social Services: update on NHS planning. And I call again on the Minister for Health and Social Services, Vaughan Gething. 

Thank you, Deputy Presiding Officer. I am pleased to provide Members with an update on the progress being made to strengthen integrated planning across NHS Wales. We're all aware of the challenges that face our NHS both now and in the future. We continue to see increasing demands and pressures on services that are managed day to day by our committed front-line staff. This is within, of course, the context of great uncertainty in relation to Brexit, 10 years of austerity, and the need for us to ensure that quality, equity and prosperity continue to drive what improved population outcomes should result.

I firmly believe that a collaborative NHS Wales, which plans in an integrated manner with its partners, particularly at regional partnership and public services board level, is well placed to meet the challenges that lie ahead. The NHS Finance (Wales) Act 2014 is now five years old. Since its implementation, we have seen the evolution of the planning system here in Wales. Today, that system is more mature and robust. This has been demonstrated by the number of organisational plans that I was able to approve this year, increasing to seven in the last planning round. This included the Cardiff and Vale University Health Board, which received plan approval for the first time in three years, and the organisation was then de-escalated from targeted intervention following sustained improvements in performance and finance.

Looking ahead to the next round, I'm looking forward to cluster-level IMTPs informing overarching organisational IMTPs. This will strengthen and enhance collective understanding of population health and the required service provision even further. Those IMTPs—I should say integrated medium-term plans—are central to our approach to delivering services in a planned health and care system. These are rolling three-year plans that require health boards and trusts to plan and deliver services for their populations that are high quality, sustainable, deliverable and financially balanced. The system is complex and we should acknowledge the progress made to planning in an integrated manner across Wales.

We have made real strides forward but continue to see variation in the maturity of plans. Notably, we have seen those organisations with approved plans being better able to respond. This year, we saw a greater emphasis within plans on a number of key areas, including providing care closer to home and the implementation of the primary care model for Wales, collaboration and relationships with regional partnership boards that are driving integration and transformational projects, and organisations demonstrating their commitment to the Well-being of Future Generations (Wales) Act 2015.

I am particularly encouraged by the integrated planning commitment from supporting organisations in Wales, including EASC, WHSSC, the shared services NHS partnership and NWIS—I should say, in terms of all the different initials within health, the Emergency Ambulance Services Committee, the Welsh Health Specialised Services Committee and the NHS Wales Informatics Service. They are not covered by a statutory duty to develop IMTPs, but nevertheless they've fully embraced the requirements and spirit of the Act. They play a key role in enabling and joining up the system. Health Education and Improvement Wales, as a new strategic health authority, is not currently covered by the duty, but chose to demonstrate its commitment to planning by submitting an integrated plan in its first year. So, HEIW is playing a key role in working with health boards and trusts to address key workforce and training challenges in partnership and collaboration. This is key to ensuring that our services can deliver effective care and treatment when required.

I look ahead, now, to the next planning round, for the period 2020-23, when I expect to see further steps made to improve our approach to integrated planning. To support this aim, I have brought forward the publication of the national integrated medium-term plan by four months. The development of a national IMTP was one of 40 commitments I made when publishing 'A Healthier Wales'. The national IMTP will help to make a further contribution to strengthening our integrated planning system. The intention of this inaugural document is to look back and reflect on the outcome and impact of the last planning round. I am also clear that my intention for the document was to set the tone and direction for the next round. The early issuing of the national IMTP has meant that we commence the next planning round with greater clarity and direction, which has been welcomed by the service.

The national IMTP found evidence of organisations making good progress in areas such as primary and community care, mental health, innovation, collaboration, and research and development. Whilst improvements were made in these particular areas, there is still a need to ensure improved grip around commissioning arrangements, a wider focus on prevention and a stronger approach to regional planning for health services. By issuing the national IMTP, I have reaffirmed a clear strategic context for the next planning round. 'Prosperity for All', supported by 'A Healthier Wales' and our unique and groundbreaking suite of Welsh legislation, creates the framing for the integrated planning system in Wales. We will continue to use this context to embrace change and create resilience and sustainability for patients throughout Wales, wherever they live.

The Government’s commitment to sustainability and de-carbonisation is an area that NHS organisations are embracing, and the impact of change can already be seen. Innovative schemes are being implemented that address climate change challenges and also bring health and well-being benefits. Swansea Bay’s focus on de-carbonisation and biodiversity has seen it become the first health board in Wales to develop a green growth project. I am keen for sustainability to be an area of focus in the next round of plans to maximize the use of our finite resources. We will address this as a matter of urgency and show leadership in this area from the health service.

Plans are, of course, required to be financially balanced. I am pleased to note the continued reduction of financial deficits across NHS Wales. At a time when we are still having to do more with less, that positive trend must continue. I expect to see further reductions in the overall deficit in the coming years.

The Welsh Government continues to work with all health boards and trusts, particularly those in escalation, to provide the advice, challenge and support they need to work towards achieving approved plans. Quality remains central to the health and care system in Wales. I am determined that we continue to raise the bar for everyone to ensure equity, reduce health inequalities and deliver the vision set out in 'A Healthier Wales'.

Finally, I want to reaffirm my commitment to the NHS planning agenda in Wales. I have invested in developing and strengthening planning skills through the new planning academy. The new diploma in healthcare planning starts this month and the programme includes a range of peer-to-peer learning opportunities.

My five priorities for our healthcare system are: prevention, reducing health inequalities, delivering the primary care model for Wales, timely access to care, and mental health. Achieving the vision I set out in 'A Healthier Wales' will deliver those priorities for the people of Wales. Looking ahead, I want to see the population at the heart of our integrated planning systems. Placing people at the heart of an integrated planning system is an essential building block to the progress we all want to see. Just as this Government wants to see people benefiting from a more equal, prosperous and greener Wales, I want the same for our NHS and for the people we serve. Diolch.

I thank you, Minister, for a copy of your statement in advance. I was very interested to hear your references to the success of the integrated medium-term planning system. I know that, certainly in terms of a number of NHS organisations, they have been living within their means and they were successful in developing three-year medium-term plans that seem to have been largely on track. But, of course, that can't be said for a number of health boards, which, unfortunately, are not yet in a three-year planning time frame, and, of course, those include the Betsi Cadwaladr University Health Board, the Hywel Dda health board and the Swansea Bay University Health Board, none of which have had any integrated medium-term plans actually agreed.

That concerns me, because, obviously, we're a number of years away from the point at which the legislation giving them a statutory duty to have those plans in place was introduced, and, of course, certainly in the case of two of those health boards, they are spending significantly beyond their means and have been for a number of years. I think that it is necessary to look at the capability of some of those health boards to actually meet the financial challenges that they face. I know that you put some additional resources into Hywel Dda a number of years back, and that was extremely welcome, I think, because there was a structural deficit that that organisation inherited when it was founded. I think the same can probably be said, actually, about the Betsi Cadwaladr University Health Board, and perhaps you could tell us whether you're considering taking a similar view in terms of the structural deficit that I believe underlies the Betsi Cadawaladr health board's finances to see whether there is something that can be done from the Welsh Government's side in order to assist that health board so that it can not completely switch off from making proper financial judgments, but that it can focus perhaps more on some of the performance issues that also are besieging that particular health board in question.

You made reference to the fact that there's no statutory duty on some of those other NHS organisations that have been developing their own plans, including NWIS, WHSSC and the Emergency Ambulance Services Committee. I think it's very commendable that they are working in the same planning framework as the other NHS organisations, but perhaps you can tell us whether you will have plans at some point in the future in order to bring a statutory responsibility onto those other NHS organisations that aren't boards or trusts, because I think it may be useful, actually, in getting this NHS-wide approach, so that everybody's working in concert.

Now, I know that, clearly, there are still many challenges ahead. Obviously, I've looked at the priorities that you've got set out in your planning framework, going forward. You touched on workforce earlier on, and, of course, there are huge challenges in terms of making sure that we've got a workforce that can meet the demands being placed upon it across the country. I wonder if you could give us a little bit more detail about the work that Health Education Improvement Wales is actually doing, and how that ties in with the work of individual health boards to make sure that they are working together to address these issues more widely.

Capital and estates, of course, are very important in terms of being able to deliver improvements in healthcare, and one of the concerns regularly raised with me when I visit different health boards across the country has been the delay in decision making over estates. Now, I know we've got a finite sum that we can invest in capital infrastructure, but, clearly, if many of the improvements in healthcare are absolutely linked to investment in estates, then I think it's only right and proper that people are able to get on and crack on with investing in new buildings, or extensions, or refurbished buildings in order to make those things happen. Perhaps you could tell us what work the Welsh Government is doing in order to improve its decision making on capital, going forward, so that we can get decisions out more quickly.

In addition, you made reference in your document to timely access to care, which, of course, is very, very important to patients across Wales, as is equality of access in all parts of Wales. Now, one thing that we do know is that performance from one health board to the next can be very significantly different, and I would like to know to what extent within those three-year plans, those intermediate plans, you are expecting to see some levelling up, if you like, to the best performance across Wales, and how you're expecting those plans to actually show progression towards a levelling up, so that we're not losing out on momentum for improvement going forward.

Just finally, if I may, one final question, and that is about the diploma in healthcare planning. I'm very pleased to see that going forward. Obviously it's important that people are able to access that diploma and training in that diploma in all parts of Wales. Can you tell us whether that is going to be possible, to make sure that people are able to do these things alongside their day job, as very often that can be quite difficult? What resources are you making available to encourage people to take up that opportunity to be trained in that way? Thank you.

Thank you for the range of questions. I'll deal with your last point first. I made the decision to invest £0.75 million over five years to create the new postgraduate diploma and it will support 25 students a year for five years. It should enable people to cover those modules over an 18-month period, so it should mean that there is cover for them to do their job as well as undertake the new qualification. We should then have a new generation of planners within the service for people to develop their skills at different levels within our organisations.

On your point about timely access and equality of access, of course we do consider those performance aspects as well as finance when we look at whether a board has an approved plan, whether it will continue to have an approved plan, and what that means in terms of escalation status. So the performance of those organisations definitely makes a difference. You'll have seen that in terms of the escalation choices we've made about a number of organisations, because in some of them it has been absolutely the performance issues that have been a significant factor in them either going into a different stage of escalation, up the ladder, but also, in Cardiff and Vale's case, it was a significant factor in them moving down the escalation to normal status. It was the same with the Welsh ambulance service as well in their journey. Of course, you started by talking about the progress that has and hasn't been made. The Welsh ambulance service is a good story in this sense, because they were in a very difficult place, a very difficult performance; they're in a different position now, their performance has been improved and sustained, and they have an approved plan. Five years ago, when I had the opportunity to join this department, you would not have thought that they would be one of our higher performing organisations, not just within Wales, but within the family of ambulance trusts across the UK.

We have now seven organisations with approved plans compared to four when the NHS Finance (Wales) Act was introduced. You also mentioned the NHS funding formula, and whether this was an issue in particular in relation to Betsi Cadwaladr. In the coming months I'll be coming back to make some choices about the future NHS funding formula. You'll be aware—well, you may not be aware, because you're no longer on the health committee, but I have indicated to the health committee that we're revising the formula, that is, looking at the current funding requirements and the needs basis for doing so, and so I'll be able to make a confirmed announcement on what that means for each individual organisation and how that revision will be implemented.

I will take the point about special health authorities and three-year plans, but some of the bodies that are mentioned, of course, are conglomerates of organisations that are working together. So, WHSSC is health boards acting together and the emergency ambulance services committee is actually health boards working together to commission the Welsh ambulance service to undertake its function. So I'm not sure that introducing a statutory duty across all of those bodies is the right thing to do, but I'll take seriously the point that you mention.

On HEIW, their strategic overview is the work that they're undertaking. I've mentioned this before in statements, and I will come back when we talk about the workforce strategy, and of course they're working together with Social Care Wales to do that.

On the final point I think I need to deal with, and that's on capital and your point on whether there's a need to improve Welsh Government processes: actually, we need to look at the whole system, because it just isn't fair to say that delays happen because the Welsh Government doesn't make choices. Often that's back and fore between Welsh Government officials and health board or trust officials with plans that they've submitted, and there are Members in this room who will have their own frustrations about that planning process, and that is part of what we're trying to address, to improve the capacity to deliver business cases and to plan appropriately for the service. So, actually, I think there's a whole-system issue and not simply one part that we need to improve.

Can I thank the Minister for the statement on NHS planning? Obviously, NHS planning—any planning in the NHS—is a huge arena that both goes down to the micro level and, obviously, macro, future, blue-skies thinking. Can I start first of all—? My first point is on the new planning academy, which I think is a concept that is greatly to be welcomed in terms of improving the quality of administrative planning that happens. I would ask for a bit more detail. Some of us would like to think that we can entice and attract more clinically qualified nurses and doctors to be administrators in general, and particularly when it comes to the planning of services, because they tend to have an idea of what needs doing. But also they're not administrators, so they also need to be qualified. But in terms of how we're going to attract more clinically qualified administrators and perhaps a novel concept of actually having them combine their clinical responsibilities with their administrative responsibilities as well, so they don’t completely lose sight of their staffing and resourcing issues.

It’s very much to be welcomed what you were saying about the access, again, to care closer to home. Even with all the new gadgets that we have at our disposal, there’s nothing like the human contact in somebody’s home. But that is a specific workforce plan in the communities. So, could you update us on the work that’s happening as regards primary care and backing up all the innovative things we've been saying about having care in people’s homes, close to people’s homes, so that they can stay where they want to in the community for as long as possible and possibly forever—never having to darken the doors of a hospital at all?

The second point is about ambulance response times. As you’ve said, over recent years, there has been a turnaround in events with the ambulance service with all the planning and winter planning that’s going on. I still do get calls from constituents about big delays, though, in individual ambulances arriving at an individual case, so there is still work to be done. But in terms of winter NHS planning, you published a recent written statement on winter planning as regards the ambulance service, and you confirmed plans as regards the amber review to introduce new call-to-door measures for ambulance response to strokes specifically—speaking in my role now as chair of the cross-party group on stroke. As you will be aware, the amber review committed to a measure of the whole episode of patient care, which, clearly, does not end at the door of the hospital. Now, my understanding is that the call-to-door measure is only stage 1 of introducing this new measure, and that a stage 2 will involve measuring the time it takes patients to get treatment once in hospital, because, obviously, as regards stroke, that is fundamentally an imperative. It’s not good enough just to deliver people to the door, we need them treated as well. So, could you confirm that it is the Welsh Government’s intention to fully implement both stage 1 and stage 2 of the new measure to meet the commitment contained within the amber review and the winter planning aspect of the NHS planning?

Staying with ambulances, although moving on to our world-leading, emergency air ambulances—our air ambulances that are flying around all the time. We justly celebrate—although, sometimes I think we could justly celebrate a bit more—the phenomenal achievements of our relatively new emergency air ambulance, our flying helicopters that are like flying A&E departments, really. They’re amazing, absolutely amazing, innovative and they save lives now at the scene of a dreadful accident where lives before were not saved, and that was as little as five years ago. Our emergency air ambulance service has totally transformed the scene, particularly of rural healthcare, and in emergency healthcare, not just in isolated, rural spots, but in taking people to the best part within minutes. That, possibly, can transform the whole way we think about NHS planning on the ground, vis-à-vis the provision, say, of district general hospitals, tertiary centres, what is required everywhere, because quite often we forget about our world-leading, emergency air ambulance service. That is incorporated sometimes in the small print of all NHS planning, but I think it justifiably requires just celebration.

And with that, can I welcome the phenomenal commitment of NHS staff and social care staff on the ground to make sure that what NHS plans we have in place are brought to fruition? Thank you.

Thank you for those points. I'll start with your first point about the planning academy. It's being developed in conjunction with Cardiff business school and I'm happy to say that the programme for learning does seek to reach a broader range of professionals within the national health service. 

I think it's fair to point out that this year is the first year we've had primary care clusters developing their own IMTPs, their own plans, and that's actually a significant step forward, which tells you something about the developing maturity of those clusters. But also we're expecting that within those plans there'll be a variance in what they have in them. Some of that will be about understanding the needs of local population; some of that will be about the varying levels of maturity and ability to forecast and plan for the future. But I think it's really important we've had those as the next stage in the development of clusters, but equally they're going to underpin, and they're being provided now to help inform the health board level IMTPs as well, rather than trying to do them at entirely different times. It would have been a nonsense if you'd had a cluster IMTP coming in after the health board had already published what it said it was going to do for the next three years anyway. So, we're trying to get our system lined up in the right sequential order to take advantage of that and to see the improvement that we'll need and want to make.

On your point about the amber review, I am committed to coming back to Members to update on progress made on the amber review, and that will include the unfinished work that is going on with stakeholders about measures around stroke units. It's not complete, but I'll happily make sure that I update Members when there is a proper update to give. So, it certainly hasn't been forgotten or wished away. 

I'm delighted that you mentioned what was initially called, for a while, the Wales flying doctors service. Of course, it's more than just doctors. We have a range of different professionals who go up in helicopters, but also some of the all-terrain vehicles we have access to as well for the emergency medical and retrieval service. And it has been a real success. It's helped us to recruit and retain staff here in Wales. People have made a definite move to come here to Wales because of that service. I've met a number of those people who would otherwise not be here. And it is helpful both from a research and improvement point of view in any event in terms of our access to emergency care in particular. But I think the point you make is about faster access to better care, because it's not just having lots of gadgets, it's about getting people to the right care, getting the right care to them initially and then getting them to where the right care is, whether that's a district general hospital or a tertiary centre, whether it's Morriston if someone requires the burns unit, or indeed in the future when people are going to be taken to the major trauma centre being developed in Cardiff. So, that is definitely part of the planning that already takes place now, and I'm delighted that you've raised the real success story that NHS Wales should definitely celebrate.

Thank you for your statement, Minister. I too would like to thank all the staff in the NHS who work under difficult conditions to carry out their duties. In order to ensure our NHS survives the long-term challenges it is facing, we need to implement long-term planning in health and social care, and planning that has to date, I'm sorry to say, been piecemeal. Proper planning doesn't just mean setting financial plans for a couple of years, we need full-on horizon scanning of future advances and challenges. We need a whole-system approach to workforce planning that anticipates future demographic changes, advances in medicines and health technology, and provides a workforce with the right skills to address all these challenges. 

I welcome the opportunity for people to study for the diploma, because encouraging participants makes them feel valued, and this investing in their future will give them pride to carry on and hopefully have a long-standing career with the NHS.

We also have to ensure that solutions to address these challenges do not take years to implement. For example, the revolutionary 111 service was carried out in my region, it was piloted some three years ago now, but it won't be rolled out all over Wales for another two years. I think this is quite frustrating because it is a successful arrangement here. So, when we plan improvements to health and social care services, it shouldn't take six years to implement them, when they've already achieved best practice status.

So a lot of work needs to be done also on ambulance response times, because I am having a lot of people contact me regarding these response times and also the amount of time it takes for a patient, once they are admitted to the hospital, to eventually have a bed on a ward. It's 10 to 14 hours of being stood in a side ward. So, Minister, how will your planning academy ensure that future challenges are anticipated, and how will you ensure that all these challenges are going to be met to the very best of their ability?

Also, what role will Health Education and Improvement Wales play in ensuring that we have sufficient numbers of young people studying for a future career in health and social care? What can be done further to help health boards also who are underperforming at the moment and have financial challenges? How can we get the health boards with the best practice to take on board those that are not achieving their ambitions at the moment? How well is best practice being shared?

And finally, Minister, with all the various strands involved in providing the health and social care workforce, how will you ensure that we have a flexible, adaptable training system that plans for the future whilst meeting, obviously, the significant challenges of the moment? Thank you.

Thank you for those questions. Certainly, on your final point about how we plan for the future, that's part of the reason we created Health Education and Improvement Wales. It's a strategic body to help forecast workforce need and to come up with that national workforce plan that I referred to earlier. And the way that they're working jointly with Social Care Wales—. Because every time we have a challenge on service pressures in this Chamber, we talk regularly about the staff and the staff that we need, and there's mixed acknowledgement of the fact that we can't always simply recruit staff, certainly within the UK, to cover all of those gaps. It's partly about planning for our future workforce, understanding where and how we'll be able to recruit from within the UK, from within Europe and the challenges that Brexit may deliver, and the wider world as well.

That goes alongside our planning on increasing our training places. In the last two years, I've approved, even in very difficult times, real increases in the training of healthcare professionals, and we heard earlier today about the increased number of GP training places and others as well. And that goes on to the second point about the challenges of where health boards act individually but where we've understood that we need to act nationally to deliver the greatest returns. So our 'Train. Work. Live.' campaign has been a good example of having a national approach that health boards have all bought into—not just the common branding and not just the common messaging, but actually how we go about doing that, having a national single point of access for a range of those areas, and it's been successful, in particular in terms of GP recruitment. We've also launched—[Inaudible.]—midwifery to follow nursing and other healthcare professionals as well. So, we are learning from where we've been successful with that campaign recently and, equally, where we know there's still more for us to do.

On your point about integrating planning across the health service and with other services, your point in particular about ambulances and the challenges, this is a whole-system issue—both people who do or don't need to be in an ambulance. Once they're at the front door of an emergency department, it's very difficult for them to be released. Ambulances are held there and waiting too long, and what does that means for people who are medically fit within the hospital, wherever it is, who could and should be released and helped to get back to their own homes? That's partly within the gift of the health service. Not every single medically fit person is waiting for social care, but we do recognise it is, in significant part, about the partnership between healthcare and social care to make sure that people are having the same conversation and a more integrated approach. That underpins our transformation fund and approach, of course, as well.

And I think that goes into the point that you made about future challenges. Well, we already have future challenges that are here today. Telecare and technology-enabled care aren't really about the way to deliver healthcare in the future—they're already happening today. Our challenge is how we take advantage of them to deliver much more consistently across the country. They're not just for rural parts of the country, they're for every single part of the country to improve access and experience. And we're already considering, for example, how precision medicine will change the way we'll need to plan for the service. We may well have expensive new medicines, as we're enabled to have into our system in the new treatment fund, but we could have expensive new medicines of a much more significant initial cost that could be genuinely curative, though, and that would be a very different conversation to have about front-loading the investment you make to actually have a curative impact in any event.

I recognise your point about the 111 roll-out, but I do need to just come back and say we didn't roll 111 out at the same time as they did in England. They took a very rapid national approach, and they had lots and lots of problems within England as a result—very different models, and it was a really big problem in large parts of the healthcare system for staff and the public. We deliberately took more time to understand the model that we want, and the reason it isn't being rolled out at breakneck speed across the health service is because we've taken seriously the ability to get the right staff in the right place at the right time to deliver the right service, because, otherwise, we would simply repeat the mistakes that were made in England, and I'm not prepared to do that.

So, finally, we certainly do take a long-term perspective. Of course, we have a long-term plan in Wales—it's called 'A Healthier Wales'. It's a joint plan across health and social care, and planning more effectively will allow us to deliver the vision that I set out before you more than a year ago.

Thank you very much, and that brings today's proceedings to a close. Thank you.

The meeting ended at 17:36.