2. What action has the Welsh Government taken following the decision of Hywel Dda University Health Board to cancel in-patient operations on Monday 6 January 2020 at Bronglais, Glangwili, Prince Philip and Withybush hospitals? 375

Thank you. I'll just start by reiterating my thanks, together with those offered by the First Minister yesterday, to our staff right across the health and social care system in a period of truly exceptional pressure. Every winter provides difficulties, but we have seen exceptional pressures across our system at the end of the festive period and into the start of January. Without their dedication, we would not be able to provide the level of care that is still being provided across Wales. 

The decision to postpone inpatient operations within Hywel Dda was an operational, clinical decision made by the health board to ensure that patient safety was not compromised. My officials have been in regular communication with the health board to ensure that they're implementing all necessary actions to enable them to de-escalate as quickly and as safely as possible. 

I thank the Minister for his answer. And, of course, I'm sure we would all agree with his comments about the excellent work that the staff are undertaking under very difficult circumstances. But I wonder how he would respond to the Royal College of Nursing's call to him yesterday to get back in the room, and to start talking about the extent of these pressures. I wonder how he would respond to Dr Philip Banfield, from BMA Cymru, saying— and I quote—that they are really concerned about the impact of current workload and workforce pressures on the NHS staff. He goes on to say that there is seriously a real chance of lives being needlessly lost.

I'd also be interested to know what the Minister would have to say to my constituents, and those of others here, who have had their operations postponed. We know—and I should be clear, Llywydd: I'm not criticising the decision that the health board has made; if the services are not safe, they didn't have a choice. But I wonder if the Minister would wish to join with me in expressing his regret to patients that their operations—some of which they've been waiting for for a very long time, some of them are in very severe pain—have had to be postponed. I'd be grateful if the Minister can let us know what the situation is with regard to Betsi Cadwaladr University Health Board, because my understanding is that they've postponed some planned operations today. It's also been suggested to me that, in fact, Betsi Cadwaladr has not got an agreed plan with the Welsh Government to deal with winter pressures. And I wonder if the Minister can tell us whether that is or is not the case, and whether, in fact, they have got their share of the additional resources that he has put in.

The Minister talks about exceptional pressures, and I would once again put it to the Minister that winter comes every year, so does norovirus, so does the flu. These things are entirely predictable. The First Minister, questioned on these matters yesterday, described the arrangements in place with the health board as 'resilient'. Well, I would like to suggest that he comes to the Hywel Dda health board area, and explains that to my constituents, because this doesn't look like a set of resilient or acceptable arrangements to me. And, most importantly, perhaps, Llywydd, what assurances can the Minister give us that the kind of all-systems approach that the BMA are asking for—? We need to see an urgent increase in the number of beds. Longer term, the message remains the same—we've got to increase staffing levels in healthcare settings and in communities. I wonder what he can do to reassure us that we will not be having this same conversation, in this Chamber, this time next year. And more importantly, what can he do to ensure those front-line staff that he speaks so warmly of, and patients, that they will not be in this position?

Well, there's a wide range of questions in there, Llywydd; I'll try and deal with the points as they've been provided. The starting point is that, of course we know there's extra pressure that comes over winter, and that the start of January is the most difficult time of all, with the pressure that comes in from the end of one festive period, people have put off care, people have gone home in the middle of that, who then require further treatment. It's not just in our hospitals either—this is a real challenge in primary care as well. And what we see in Hywel Dda, with the cancellation of inpatient activity, is a symptom of that whole-system pressure. And in terms of describing the whole-system pressure, nine out of the last 11 months in 2019 that have been reported on were record months for activity—nine out of 11 reported months. That's the scale of demand that is coming into our system. And, with respect, last winter, no-one in this room would have predicted that that is the activity that we would have seen.

What is being done is a plan for winter within each health board. I have no idea where the idea that there is somehow no plan for Betsi has come from, and it's rather difficult for me to deal with works of fiction and imagination. But there is absolutely a winter plan across north Wales—it has been agreed, not just within the health service, but direct matters under the health service control, and their share, which every health board, including north Wales, has received of the £30 million winter moneys, but the joint plan undertaken by the regional partnership board for what to do across the whole system. That does include extra bed capacity—and I announced before the break that that amounts to about 400 additional beds across the system. That's the size of a large district general hospital of additional capacity that's been put into the system. That includes additional capacity within Hywel Dda.

In terms of the conversations taking place with staff, the BMA made their comments on the way to a clinical summit that my officials are holding today—which includes the RCN and other stakeholders—to examine the reality of where we are, the response, and what more is possible at a national level. And, in terms of where Hywel Dda are, they are in a position now where they are seeing more progress being made on discharging patients to at least three of the four sites, because of the work they're doing and because of the implementation of the winter plan, but more than that, because of the relationships that exist between the health board and local authorities. And without those relationships being in a much better place than in previous winters, we'd be unlikely to see those discharges taking place.

It is a whole-system problem and it is a whole-system response in the here and now, and the continuing reform that I've regularly spoken about that is required to make sure we have additional capacity, and domiciliary and residential care, which includes health and social care working together to provide that. And it is also about how we choose to use the system as we continue to see more demand driven into our system. We need to look again at how we deliver and how we design it. And given all the peaks and troughs of activity, we need to recognise that we're unlikely to see a significant fall-back in demand. It's about how we deal with that demand to make sure that patient safety isn't compromised, and that is exactly why it was the right thing for Hywel Dda to do, with all of the different risks involved, to make sure that they prioritise people with the greatest need first.

Wow, where to start? We talk about the word 'safety', which has been used a couple of times, but let's be clear, the beds in Hywel Dda—the operations have been cancelled because the orthopaedic ward at Prince Philip Hospital has been closed to orthopaedic, to elective surgery, and they're putting medical cases in there. That takes care of an enormous number of the problems with the elective surgery. There is a lack of clarity from Hywel Dda management, who I've spoken to today, as to why the operations were cancelled in Bronglais, in Withybush and in Glangwili hospitals, but there's a real clarity about why they were cancelled in Prince Philip. Prince Philip's elective surgery wards are being used for medical cases, because they say that they've had a greater increase in medical cases.

Now, when I spoke to the chief executive earlier, discussing this with him, one of the things that I felt very strongly was that I accept that there are winter pressure plans in place with all of the health boards, but I do not think that they are imaginative enough or building enough contingency. We know what the trends are doing; we know what the trends are doing throughout the year. You tasked them, Minister, with coming up with winter pressure plans. You gave the extra £30 million. But listening, and carefully, I listened, it seems to be that there was a real 'I don't know what the pressure is' in terms of whether they felt that they didn't have the funding to do it, or whether it was 'let's produce the winter plan we had last year. Dust it off, increase it a bit and redo it'. But it comes down to—an awful lot of it—a lack of contingency planning, that extra fat in the system, where we've had to go away and close down entire elective wards.

I would be very interested in understanding from you what can be done to ensure that there's a real analysis of the data. Because, again, when I spoke to the chief executive, he said that they would be looking into what's happened—they would be looking into why this situation's been caused, but somebody's just made the decision to stop the operations on Monday and on Tuesday and again today. So, somebody already knows that data. So, I'm at a loss to understand why that data isn't currently available as to what is the absolute crux.

I wonder if you could look to encourage the health board and indeed now, Betsi Cadwaladr, to ensure that there is a really strong programme put in place to catch up with elective surgery. And let's be clear, folks: we're not just talking about hips and knees; in Hywel Dda, there's a 19.4-month waiting list already for that. So, imagine if you thought you were going to have your knees done, and puff, you've got to wait again. But it's ventral hernia surgery, bariatric surgery, reflux surgery— all manner of elective surgeries have been cancelled with waiting lists of up to 15 months. So, we're going to make our waiting list problem longer. So, Minister could you look at what might be done in the health boards, where they have had to cancel operations so that they can accelerate a catch-up programme so that our waiting times have an opportunity to improve rather than lengthen?

Finally, I think the elephant in the room is that social services need to be on call seven days a week all year around, like our health services. On call in terms of being able to do delayed transfers of care, because, again talking to the health board, what they're saying is that they can't get people out of hospital, because, although they have great relationships with social services, during periods such as Christmas and new year and bank holidays, people rightly, of course, have time off. No-one's saying, 'Gosh, you've got to work all the time', but we have to have a system in place where there's cover so that the ordinary business of discharging people, which in turn would free up beds to enable people to go into hospital who present at the front door, could carry on apace. Because, again, what I've been told is that part of the problem is they cannot get people out of there. That needs to be part of the winter planning that actually has a few more boots on the ground in terms of social care to get people out. I'd be very interested to know your thoughts on that.

And, finally, I would like to add that I think the staff have done a wonderful job and I'd like to say that the chief executive was absolutely crystal clear, in my conversation with him earlier on, that staff have come in, they've come in on their days off, they've worked overtime, they've cut short holidays in order to try to help this. So, this is not about the front-line effort and commitment and dedication, it's about the planning side of it and the contingency planning side of it being smarter and more agile in order to prevent this happening next year. 

Well, I understand why a range of questions have been asked by Angela, but I think a number of the conclusions she reached are significantly unfair and I think she should return again to them. I'll happily go through why I think that is. It's very easy to say this is all about planning and about the inability to deliver and the plans aren't imaginative enough. Actually, I think that's significantly unfair, because, if you look at the plans for this winter, they are different, they have learnt from last winter. Planning for winter started in spring last year to learn the lessons—what had taken place last winter, what had been successful. That's why this winter we've increased capacity in a number of areas. It's why we've rolled forward the Red Cross commitments, it's why the Care and Repair scheme has carried on as well. It's also why they've built in deliberately additional capacity together with partners across local authorities. The easiest thing to say is, 'You can be more imaginative and you could do more'. Actually, there's a finite number of things that you can do with a finite list of resource, and that isn't just money, that's people.

And, actually, in terms of your comments about social care, social care already works seven days a week. And, actually, the period between Christmas and new year isn't the particular problem period, because we already see hospitals seeing people leave over that period of time, and the challenge is at this point in the next two weeks. And, actually, the challenge really is about capacity within the wider social care system, in domiciliary care and in residential care. In west Wales in particular, but in other parts of the country—not just Wales but across the rest of the UK too—the fragility of parts of domiciliary and residential care is a real problem and a real limiting factor in being able to get people out of hospital and into their own home, whether that home is a street in a community that you or I live in or it's a residential care facility as well. So, there's a real challenge about how we do that and that's why the longer term reform is so important for the future, because, in terms of coming back to next year, that is about how successful can we be to commission capacity that is sustainable and of the quality that all of us would wish for our own families when we're providing for the wider public.

That is also why, though, I think it's entirely right that the health board have announced that they're going to do an objective deep dive into the decisions taken over this weekend and in the last few days. That doesn't mean to say that those decisions are wrong on the information available, but it is about wanting to learn in the here and now and not wait to review this in six months' time, but to learn, with a small bit of distance, objectively how were those decisions taken, are there things we could have done differently, so that actually it's not for next year, but for next week and next month to learn that. And that is absolutely the right thing to do. In fact, if they weren't doing that there'd be criticism in this Chamber for not undertaking that process at a near point to the events in time. 

I think the leadership of the health board, together with front-line staff, are doing the right thing. And it is an exceptional period of time with an exceptional response from our staff. I look forward to a de-escalation taking place and you and others being able to look at your constituency and see that elective surgery has returned to more normal levels. But I'm not going to criticise the health board for errors where I don't think it's fair to criticise, and that's why I don't agree with the range of conclusions that Angela Burns has reached. 

The first thing I want to do is to thank all the staff who are working incredibly hard to give dedicated support to those who need it and to recognise that they are completely driven to attend to the needs of their patients. I want to start there because I feel that's of importance and reassuring to those that we recognise that. I've read the e-mail from Dr Philip Banfield of BMA Cymru and the concerns that he's raised, because he's sent that, I would imagine, to a number of us. But I'm also aware of the distress that will happen for those patients who've been waiting for a procedure, whatever that procedure might be, and that people get anxious and then it is cancelled. So, I want to put on record that I recognise that; I'm sure everybody in this room does. So, what I'm interested in now is trying to move this forward, and there were a few suggestions that have come out of Dr Phil Banfield's statement. And he calls for an urgent need to expand the capacity of beds that are available as one possible solution to move people through the system. I don't know what your thoughts are on that, but I'd be interested to hear them. 

I know that you've made extra capacity available in Hywel Dda, as you have across Wales, and again that is welcome news. But I think the one thing—and where I agree with Angela—is that, those people who've missed out this time on their procedures, they don't somehow get pushed back to the back of the list but they stay where they were, at the forefront. And if there's any way whatsoever that we can, in Wales, wherever that might be, bring these procedures forward or at least offer that possibility to the individuals so that they do see an end to what it is that they're hoping to resolve in their care package and their care procedure—. 

So, those are the questions that I would like to know and I do understand also that there's going to be a joint meeting between yourself and the Deputy Minister for Social Services to look at moving forward perhaps more quickly and more carefully the domiciliary care challenge that we know is out there and also has been somewhat exacerbated by lots of the individuals who are working in that sector feeling unwelcome as a response of the Brexit. So, we are now even more short-staffed than we were before. 

It's a fair point that Joyce Watson makes about the reality of wanting to recruit staff and people working in both domiciliary and residential care, and we do rely on a range of people from outside the UK to do so. So, any barriers to recruiting those people, who are often under the Government's proposed immigration cap, is a real problem for all of us in every one of the UK nations. If we were having this conversation in England, Scotland or Northern Ireland you'd find providers and elected members expressing exactly the same concerns about the practical impact on health and care services. 

In terms of what we are in control of and what we can do, I'm happy to confirm to Joyce Watson that people who have had their operations postponed by the health service will be informed of a prompt early date for that operation to be re-arranged. The operations haven't been cancelled and moved to the back of the queue. It's part of what we do when the health service does say that it needs to put off an operation; they will automatically be offered a new and a prompt date. And, of course, I want to highlight, as the health board has done, that I'm really sorry and I understand the impact upon individuals who have been looking forward, often with a degree of anxiety, to a surgery, to then have that put off. That is not a pleasant position to go through, and yet we also know that objectively the people that are having emergency care and having cancer surgery—if we were not prioritising those people we would rightly be criticised for failing to do so across the system. 

On the challenges and the potential answer that Phil Banfield has suggested—he said is a possible answer—more beds is often a seductive answer. We have surge capacity, so, as I've said earlier, 400 extra beds right across the health and care system—beds or bed equivalents. The challenge is that if we want to permanently increase capacity we need to understand what that's for, how we staff that so we have the permanent staff to be able to do so, and yet, actually, when the Royal College of Emergency Medicine talk about what they want to see to release what they refer to as exit block, they are not just talking about more consultants—and everybody typically asks for more of their own members—but they're saying they want to see investment in social care and in the social care system, because they recognise this isn't just a problem at the front door of the acute system in our hospitals, it's a challenge about people being kept at home safely, but also about being able to go to their own homes with a package of care and support. You'll have seen in the draft budget that, yet again this year, the health budget has put a deliberate sum of money into social care. I've increased that sum of money within the budget. It's also about why we put money into regional partnership boards that require health and social care to work together with other partners, and that is the system reform we need to see continuing at pace to try to make sure that we can deal with these problems as effectively and as quickly as possible, because they're not going to disappear.

We have these heart-searching sessions so often because of extraordinary pressures on the health service, but that indicates that the extraordinary pressures have in some ways become routine and that's the systemic problem that we've got here. Operations have been cancelled now for the third consecutive day in Hywel Dda and people might be forgiven, therefore, for thinking we should change the name of the health board to Hywel Ddim Mor Dda—you know, Hywel Not So Good, as a health board.

Nobody questions, I think—I certainly don't—the commitment of the staff and the management in Hywel Dda to make things better, and they've been working very, very hard since the change of regime to improve things and have met with a great deal of success, I think. There is obviously still a long way to go, but there is a systemic problem, not just in Hywel Dda. Figures published last month showed accident and emergency performance at hospitals throughout Wales was at a record low for the third month running and the Welsh ambulance service failed to meet its response time target for the first time in four years.

Dr Banfield, who's been mentioned several times in this session this afternoon, has said that there isn't one person to blame for this. He said this is an issue within the system. And he says:

'We're hearing reports of cancer surgery now being cancelled as well throughout different hospitals in Wales.'

I hear what the Minister said about the beds question a moment ago, but, again, Dr Banfield does make what I think is the elementary point, that surgical beds are full of medical patients and that puts the wrong type of patient in the wrong hospital bed at the wrong time and they're clearly not getting the care that they should do.

Nobody expects anybody in the health service to have perfect foresight and things will go wrong, often for adventitious reasons that nobody could have predicted, so we have to be reasonable about this. But, as Helen Mary Jones said right from the start, we do know that winter takes place every year and that there are extraordinary pressures that are likely to hit, and I heard the First Minister yesterday saying, 'Well, we knew this was coming anyway. That's why we didn't have operations planned for last week.' Well, in which case, surely we could have perhaps been a little more accurate in our predictions as to the kind of pressures that would be added on top of what was in the system anyway.

The Minister comes here so regularly now he just has a sort of look of resignation on his face at the points that we all have to make. And if he were in our position he'd be making them in the same way that we have, I have absolutely no doubt. Again, I don't doubt his commitment to improving the health service in Wales at all, but something has to be done.

More money somehow has to be provided as well as some sort of improvements at the micro level within each of the health boards that is suffering from these kinds of systemic problems. Hywel Dda has been in a difficult position, it has been making improvements, but clearly there's a long way yet to go. I hope that the Minister will do his best to ensure that Hywel Dda is given the resources that it needs to cope with the pressures that it has been enduring. 

Well we've provided significant support as a Government to the health and social care system, sustained investment over and above consequential sums of money. So, in terms of financial support, this Government has absolutely—. And that's objectively undeniable: the Treasury's own figures show that we continue to put more money into our health and health and care system than England, and we've sustained that investment for a deliberate purpose.

It's not just the money. As I've said on several other occasions, it's about how the health and social care parts of the system work together. The BMA and the RCN recognise that it's complex. It's not as simple as saying, 'Provide more money and just try harder and everything will be fine.' It is about the level and the nature of the demand, and one of the best examples of how that demand has increased in complexity is that the red calls that the ambulance service respond to—. When I made the decision to change the red call status, there was some criticism—there's still a bit of it every now and again—to try and suggest that that was really about changing the figures to suit me. It actually came because of a clinical review, supported by our front-line staff, supported by every medical director in Wales. We have a new category, a new definition to get to the sickest people. That's why there's a new red category. And yet, now, we have 15 per cent more red calls to the ambulance service than last winter, and over the last three months there have been record volumes of red calls. These are very, very unwell people who do require hospital care. So, the demand profile has changed since last winter.

So, all the measures we took last winter, the additional measures we've taken now, and our ability to get people out of the hospital system and into social care is the nub of the challenge. That's why the fragility of domiciliary and residential is such a threat and a problem, which is why we look at health and social care more and more closely together. And I'll say it again, without the improved relationships and the steps that local government must take side by side with the health service—those things are taking place now, as I speak, to get more people out of hospital—this problem would be significantly worse.

But, it is not finished. I'm certainly not complacent or satisfied, because I recognise that means that the experience of some people is not what it should be. And the small number of planned operations that were due to take place but have not—that is the system planning for what it can expect to see. But, these are still, nevertheless, acceptable beyond the planned-for activity. So, the deep dive that I've referred to, that Angela Burns referred to, will take place. That will be useful not just for Hywel Dda but for other parts of our system as well. And I look forward to answering probably similar questions next week when I make a statement on winter pressures.

Thank you, Minister.