Questions now from the party spokespeople. Plaid Cymru spokesperson, Helen Mary Jones. 

Diolch, Llywydd. Does the Minister agree with the statement made by the First Minister yesterday in response to questions from Adam Price, when talking about pressures on the ambulance service? And I quote:

'The problem is not one that is soluble in the hands of the ambulance service alone...It is a whole-systems issue, in which we have to...clear people through the whole system so that, when the system comes under pressure, as...over the last few weeks, there is room at the front door.'

And does he further expect us to believe the First Minister when the First Minister told Adam Price that:

'we have resolved the problem...and the situation is much better than it was when I started as health Minister'?

Because I would submit, Llywydd, that is not the experience of my constituents who are served by Betsi Cadwaladr and by Hywel Dda health boards.

Yes, I think the First Minister properly describes it as a whole-systems issue; it certainly is. That's been reinforced to me on the visits that I've had through the start of this winter period, in this calendar year already. And that's a change from just a few years ago, to go into emergency departments and not to have people saying, 'We need more consultants', but actually saying, 'We need more investment in social care.' So, it is definitely a whole-systems issue.

But also, I think when you look at where we are, then actually yes we have. If you look objectively at where we are in terms of delayed transfers of care, we are better now than when the First Minister started his time as the health Minister. We have a number of things that have improved within our system. Our challenge, as ever, is the rate of improvement we make in our health and care systems, and the ever-changing rate and nature of demand and need. And that is the constant challenge that we face in the health service, and it goes back into the questions and conversations we had yesterday around the transformation fund in its broader sense around healthcare. 

I'm grateful to the Minister for his response. I wish I could characterise it as adequate; I'm afraid I can't. I have been looking back at the Minister's statements around winter pressures over the past three years, and he always says the same things. He always talks about norovirus and flu, and he says the same things when you have a really challenging year, when you actually have lots of norovirus or flu, and he says the same things when, as in this year, in fact, the situation is not that challenging.

Now, he may be right that there are some aspects of the service in unscheduled care that have improved since the First Minister's time, but one thing that has not been solved is the interface between health and social care. Now, Llywydd, we all know that the portfolios for health and social care have been held in our Parliament by Welsh Ministers for the last 20 years. Can the Minister tell me, can he reassure us today, that we will not be having this same conversation in another year's time, let alone in another 20 years' time?

Well, I don't expect to be having this conversation in 20 years' time; I hope my life will have moved on to a different point by then.

But in terms of some of the things that you said, when you describe it as not being challenging, actually, the context in which we deliver health and care is challenging. And it isn't just related to the circulation of flu or norovirus or the weather; it is the changing nature and mood of our population. And in the statement that I issued earlier today, the fact that we've had a 23 per cent increase in red ambulance calls during that period—the sickest, the most unwell people—an increase of that nature from one winter to another, that is the sort of trend you'd expect to see over several years, not over one winter. So, the context is different. The increase is different. And it's not just me saying that; any and every part of the national health service in each of the four countries in the UK is describing the same ramping up in challenges and pressures.

And in terms of the staff that I've met, they understand very well the nature of those challenges they see coming through the door, and they don't describe it as, 'It's just the same as previous winters where the system can't cope.' So, you go back to the challenge about the interface between health and social care. And, again, we've made real progress. When you look at the work that partnership boards are doing and the way they used money, not just this winter, but the improvement in relationships—. It is because of those improvements and the interface between health and social care that we're seeing flow restored, that we see flow continuing in different parts of the country, in and out of the hospital. And we are more successful than ever at keeping people in their own home now as well.

But it's still, 'How do we get even further ahead?', and that's why we're looking over not just this winter, but into the next winter, about how we get further ahead and actually spend more, not just money together, but more to stabilise and improve the services on that interface between health and social care, to keep people in their own homes more successfully, and on the ways to get them out of hospitals, which is no longer the right place for their treatment.

Well, the problem, of course, is, Llywydd, that nobody disbelieves the Minister when he's saying these things, but the problem is that he's been saying a variety of them, and his predecessors have been saying a variation on a theme. It may very well be, and I'm not questioning his figures, that we have, for example, had an exceptional number of vulnerable patients, but that begs the question about why those patients are becoming so vulnerable, why they're not receiving the care in the community that they ought to be receiving, and it brings us back to this whole issue of an abject failure to deliver the whole-systems approach.

We need to be very clear, Llywydd, that this is not an attack on the staff. We know that staff are doing excellent work. We also know that, in some places, local authorities are co-operating well or less well with their local health boards, and that where they are co-operating well that that is delivering change. But my question would be: where is the national leadership to scale up that change? Now, the Minister will no doubt talk again about the transformation fund, but I would again remind this Chamber that he or his party have been in charge of this for 20 years, and I am no more reassured by what he said this afternoon than I have been about all the other things that he's said over the preceding years. 

But I want to bring us back to a specific. So, the Minister has just acknowledged, as the First Minister said, that one of the issues around discharging patients from ambulances into hospitals—one of the reasons for the pressures—is that there is a need for a whole-systems approach. So, I'm a little bit surprised in that regard that the Minister has decided to set up yet another task and finish group to review the ambulance service. If the problems are not in the ambulance service but are actually in social care, in delayed transfers of care—and I would argue in the capacity that's been stripped out of the system—why is it going to be helpful to have yet another review of the ambulance service, which on other occasions he's told me is perfectly all right? I am somewhat at a loss. 

I'm not particularly interested to hear what the Minister says to defend the decision, to be completely honest. But what I would ask him factually is: who are the members of this task and finish review going to be? He's told us who the chair and the vice-chair are going to be—or joint chairs, I apologise. Well, who are the members of this going to be? How is the voice of patients,  and particularly the most vulnerable patients like older people and people with learning disabilities, going to be heard in this review? And when does he expect it to report? Because I think we're all losing patience with task and finish groups and reviews. What I would like to see is a health Minister who's prepared to make a decision. 

I make decisions every single day in this office. I've made a number of decisions about directing the future of the service, not just the overarching 10-year plan in 'A Healthier Wales' but many more, as the Member knows. I appreciate there's a sense of theatre to this, but every now and again we should try and deal with some of the more realistic elements of what we're dealing with in the service. 

When you talk about why are patients so vulnerable, we know very well why lots of our patients are more vulnerable now than in previous years. It's part of our success story of keeping people alive for longer. It's also partly about the challenge of the burden of ill health and disease that is not a part of the natural ageing process. So, the Member knows that very well.

When it comes to capacity being stripped out of the system, we haven't stripped necessarily capacity out of the system. Our challenge is our ability to increase it across the whole system to the extent that it is then properly sustainable to deliver the care that we need. And, actually, if you looked at any objective commentators about where that capacity exists, then I don't think they share the Member's analysis.

And when it comes to the task force that I have set up, you know very well who the chairs are, and I'll announce all of the members who are taking part in that in due course. I expect them to report to me to make early suggestions before the end of this winter period, so before the end of March. I expect to have the full measure of that within a period of three months or so. I have not set something up to take six to 12 months to avoid the challenge. I am interested in some advice and some challenge about how we do this across the whole system.

I think the Member has misunderstood this about just being focused on the ambulance service. It's actually about improving ambulance availability, and that requires a look at the whole system. I look forward to being able to report back on that properly to Members once that advice is available to me.

Conservative spokesperson, Janet Finch-Saunders.

Diolch, Llywydd. There is absolutely no doubt that we have a selfless army of 370,000 unpaid carers in Wales. In November 2017, the Welsh Government announced that one of its priorities to support the delivery of the enhanced rights of carers under the Social Services and Well-being (Wales) Act 2014 was to support life alongside caring. 

On Carers Rights Day 2018, the Welsh Government announced a £15 million investment in preventative services that support adults with care needs and carers who need support. On Carers Rights Day 2019, your Government announced that you will be developing a national action plan this year to strengthen the national co-ordination of support for carers. Evidence has emerged showing that 59 per cent of carers in Wales stated that, over the festive period, they really struggled, and 45 per cent are struggling even to make ends meet.

The director of Carers Wales has commented that carers across Wales sacrifice so much looking after a loved one, yet their contribution to society goes largely unnoticed and under-appreciated.  What actions are you taking, Deputy Minister or Minister, to ensure that the new national action plan you're going to be working on will address this?

I thank Janet Finch-Saunders for that very important question. I think we all appreciate the huge contribution that carers make—the 370,000 that she referred to—and we want to make their lives as easy as we possibly can.

She mentioned that one of the Welsh Government's priorities was life alongside caring. It's also to ensure that carers can identify themselves as carers and that we know them as carers, so that any help that is available they can access. And we also want to be sure that there is advice and information available for them. And those are our three priorities, and we have supported those priorities through a series of funding initiatives, and we have also re-emphasised the ministerial advisory group—the group that is advising the carers group.

I'm also aware that the Health, Social Care and Sport Committee has had an extensive investigation into carers and have 31 recommendations for the Government, which we will be responding to shortly. So, I can assure her that carers are very much on our minds and that we are addressing their issues.

Thank you, Deputy Minister, I do appreciate your efforts in this regard, but we have to face facts: more than any other nation in the UK, Wales is very dependent on its carers. The percentage of adults who have been carers during their adult life was found to be 63 per cent in England, 65 per cent in Scotland, 66 per cent in Northern Ireland, yet 70 per cent in Wales.

Part 3 of the Social Services and Well-being (Wales) Act 2014—and I sat through the scrutiny of this—placed a duty on a local authority to offer an assessment to any carer. When considering the data for the number of assessments undertaken, it would seem that there is a positive trend, with the numbers going up from 6,178 in 2016-17 to 7,261 in 2018-19. This isn't good enough. Looking at the situation in some detail, I have found that the number of assessments in Wales has actually fallen in seven local authorities. 

When considering Carers Trust findings that the number of carers will increase in the UK by around 60 per cent by 2030, we should actually be seeing an increase in these assessments, not a decrease. So, will you, as Deputy Minister with responsibility for this, investigate why this is not the case in almost 40 per cent of our local authorities, and ascertain whether some carers are missing out on what is, in fact, a statutory right for their assessment?

It was groundbreaking, in the Act that Janet Finch-Saunders referred to, that carers had a right to a carers assessment, and we want to ensure that as many carers as possible get access to that right. That's why one of our priorities is identifying carers and for carers to self-identify, because many people carry out the role of caring for a loved person and don't identify themselves as a carer. So, I think it's very important that we emphasise who is a carer and what help is available. And of course, I think we have to accept as well that some carers don't want an assessment. But I accept what she's saying and I think we've seen from all the reports that have come from the Carers Trust and from other organisations that there are people who are not getting the service that we would wish, as a Government, for them to have. And that's why we are putting more resources into projects related to caring, and the sustainable social services grants that will be announced fairly soon give significant funding to carer organisations, and we do intend to increase our support.

Thank you. I'd just like to emphasise once again that it's the number of assessments—when carers do present and want those assessments and they're not able to access them. Since the Social Services and Well-being (Wales) Act 2014, I think it's even more important that your Government isn't failing on those.

Now, social care demands such as providing support for carers and looked-after children and meeting domiciliary care needs are placing local authorities under huge financial pressure. For example, it is partly because of social care and children's services demands that Monmouthshire local authority is facing a £4 million deficit this year. Conwy County Borough Council, my own local authority, is forecasting a financial deficit of £12.5 million for the next financial year. Whilst the draft budget allocates £40 million via a special grant to local authorities to address pressures in social care in 2020-21, the £30 million allocated via grants to local authorities last year did not succeed in addressing these pressures in social care. So, I suppose it's a really obvious question on my part: why do you think that £40 million is going to be enough to actually help these local authorities meet their duties, especially including those owed to carers and looked-after children? 

Certainly, the £30 million was used very effectively by local authorities. The decision as to how it was actually used was left largely to the local authorities, because they are closer to their needs. But certainly, we know of the sorts of issues that they used that £30 million for: nine local authorities utilised this funding to support adult and older people's services; eight local authorities used the funding to support domiciliary care for older people; and eleven local authorities used a portion to increase wages across the sector which, of course, is an issue—the wage levels that exist in the social care sector. And so, I'm very pleased that we've been able to give an extra £10 million to local authorities for them to use in these sorts of ways I've described, and in any other ways that they feel are going to help, because we absolutely accept that there is pressure on the social care sector.

It's crucially important to the people of Wales that we are able to provide them with adequate care when they need it, and that's why we have a whole variety of initiatives to try to tackle these issues. We've mentioned the transformation funds and the integrated care fund, and all those are used to have integrated working to help the social care sector. And I absolutely acknowledge the issue about children, and that is one of the reasons why we are working to try to keep children at home with their families, where we put in extra support to try to help them stay there rather than have to go into care. So, we have got a whole host of initiatives, but I absolutely accept that there is more that we need to do. 

Brexit Party spokesperson, Mark Reckless. 

Diolch, Llywydd. 

Minister, I wanted to enquire about the thinking behind how our pay scales for hospital doctors differ from those in England, and the impact that this has on recruitment and retention. I note that, for the first-year foundation doctors, our scales are between £1,300 and £1,500 higher per year than in England, but don't doctors look through that and see that at the end of that foundation year as they go into the second foundation year, in England they get approximately a £2,800 increase compared to only £700 in Wales? That then leaves them around £600 per year less than equivalents would get in England. And that continues to the specialty registrars, where they start about £600 less than in England, and then at the top of the highest pay point, it's about £1,000 less than in England. When I speak with doctors in Wales, I often find that their perception of the difference between the pay scales and an idea that somehow pay is significantly less in Wales is out of all proportion to the   relatively small amount of those differences I've just described, and I wonder if, therefore, there may be a negative impact on recruitment and retention, which is out of all proportion to the modest amount of savings made by the lower pay scales I've described.

There are two points that I think I should make. The first is that, in the thinking that lies behind the pay arrangements, that's a matter of negotiation between the Government, NHS employers, and the recognised trade union, the BMA, so, there's a range of things to take into account with that. Obviously, from the industrial side, you expect they'll want to get the very best possible deal for their members, but also there's the balancing of what the system can afford and there's what that does in terms of recruitment and retention. And there is some sensitivity about differential scales, potentially, on either side of the borders. There's a bit of divergence, obviously, at the junior end of the scale because of the contract that was imposed in England. And, actually, in our very direct engagement with the BMA and their juniors' committee, they were really clear that they thought that we'd done the right thing in not following suit.

We've agreed, as part of the normal way, that we will continue to negotiate both the longer term challenges about consultants' pay, where I think it would be preferable to take a multi-nation approach, but that's something to discuss and to talk about, together with a review on the juniors' contract position here in Wales. There's certainly no agenda given to try to somehow save a small amount of money and to risk recruitment and retention, because, actually, doctors look at a much wider suite of things: they look at training, they look at excellence, the future of the services and whether they believe that that's somewhere they actually want to work. That's why we have a campaign, 'Train. Work. Live.', because all of those aspects make a difference to where a whole range of health professionals choose to locate themselves for their careers.

I thank the Minister for his reply. If I may turn to the particular issue in light of that of pensions, I think it was when the Minister was standing in for the First Minister at a previous First Minister's questions that I asked him about what had happened in England to pay those extra costs that doctors were finding and would we be doing similar in Wales. I see that we now are doing so; there's been a ministerial direction for that to happen.

But I just wondered if I could highlight a key difference between what we're doing in Wales and the position for the UK Government for England, as I raised with the Finance Minister earlier in committee, in that, for the UK Government, it is essentially an accounting transaction between the NHS for England and the Treasury. Whereas, for us in Wales, don't we face the same cliff edge that doctors face themselves, and they choose not to take on extra sessions, because the impacts on their pensions of those extra sessions are so much greater that it costs them money to do so? And the marginal costs of those sessions are huge because of the way that they interact with the pension system. Isn't that also the case for Welsh Government if they choose to pay that tax? And is it a cost-effective way, certainly, of anything beyond the very short term, of our spending Welsh taxpayers' money on these very substantial sums to pay pension tax to UK Government when we're only getting modest increases in the number of sessions delivered by doctors out of that?

I think it's a very real problem and it certainly hasn't been resolved. In the context of pressure across every single UK nation and the national health service in winter, it's an exacerbation of that because some of the people we're talking about work at the front of the hospital system together with people who work in general practice as well, whether in in-hours or out-of-hours. So it affects the whole system and there are other groups of staff, clinical and non-clinical, affected by the same issue.

So, the choice made in England, I would say that it was pretty extraordinary to do so in the middle of an election campaign and to do so without any contact with the other Governments within the UK as well. I don't think that was particularly well reflected in the way that lots of healthcare staff, regardless of their views on how to vote, felt about that choice being made, and there is a real need to go back to look at the direct impact. The impact upon staff on the cliff edge that some face is potentially having in-year bills that are the same or more than their rates of pay or significant sums of money that they just haven't provided for and can't plan for, and you couldn't reasonably expect them to do so as well.

There's also a challenge about the long-term effects of the pension scheme. If you get your higher earners and higher contributors coming out of that scheme and not making contributions, that affects everyone who's in the scheme. But more than that, these are UK rules, and they're UK rules designed and delivered by the UK Treasury—they affect all of us. And I certainly hope that, in the UK budget coming up within the next coming months, they resolve the problem that they have created. Because it will cost more money to resolve it  otherwise, because we'll do that in the sense that the arrangement we've already had to work around now; we'll do that by paying more for activity, probably in the independent sector, to recover activity that won't take place within the national health service. But, more than that, we are bleeding away the goodwill of staff who are directly affected, and some of those staff who come and work additional hours within the national health service, to undertake waiting list initiatives in every one of the four UK countries, may decide not to come back, and we may find that we need to recruit, train and retain even more of those staff in the future, with even more cost to the taxpayer and the national health service to do so.

I think it is a self-defeating measure. I've written or I'll shortly be writing again, and I'll happily make Members aware of that when I do, to the UK Government asking them to, again, have an attack of common sense, to look again at the rules, and to do the right thing by the national health service, because all of us will pay if they don't do so, and it's literally affecting thousands and thousands of episodes of patient treatment and care. That has to be the wrong choice to make, and I certainly hope that the UK Government do the right thing and then they can all argue about who should take credit for it afterwards.