Party leaders to question the First Minister next. The leader of the Welsh Conservatives, Andrew R.T. Davies.

Thank you, Presiding Officer. If I may, with your permission, put on the record my sincere thanks and my group's thanks to the Commission staff over the events of the period of mourning, and in particular the extensive preparations that went into the King's reception here last Friday? If I could also thank the First Minister for the civil servants who put a huge amount of work at very short notice into the arrangements around Llandaf cathedral, and the generosity that the First Minister extended to party leaders and others to attend events in London as part of the Welsh delegation? I'd just like to put my thanks on the record for that, First Minister. 

First Minister, there is a cost-of-pain crisis within our NHS. Many people, sadly, in orthopaedics are waiting for procedures for a considerable amount of time, some as long as two years and more. We heard from you in July that there was to be an orthopaedic summit held by the Minister in August, but we've had no update as to any positives that might have emerged from that summit. Could you now update us as to what exactly has happened from that summit and what we might see as we go into the winter months so that people can have confidence that they will get the procedures that they require?

Llywydd, the health Minister will be very happy, I know, to provide Members with an update on the more detailed results of the summit. In general, the leader of the opposition is right to draw attention to the pressures that the health service is under and the very hard work that is going on to try and recover the ground that was lost during the pandemic. Very long waits in the Welsh NHS continue to fall. Activity in our NHS continues to recover. In the last month for which figures are available, we are back to 97 per cent of all out-patient activity, compared to the month before the pandemic began. And in planned operations, we're back to over 80 per cent. Now, that means there's still ground to go. The COVID issue that Joel James raised is still part of that picture. A thousand staff in the NHS in Wales are not in work today either because they have COVID themselves or they've been in direct contact with somebody who has. So, a huge amount of work is going on inside the health service to try and recover ground and to be able to deal with people whose operations are outstanding. The context remains a challenging one.

I appreciate the context is a challenging picture, to say the least, First Minister. Other parts of the United Kingdom have managed to bring the extensive waiting lists that they had for the two-year period down and, in fact, in some cases, eliminated those waits. In Wales, we see in excess of 60,000 individuals on those waiting lists. I had hoped that I would have heard something more tangible about the summit that you yourself referred to in July that was happening in August around orthopaedic services. Surgical hubs have been talked of at length in this Chamber by me and you in questions, but also the Royal College of Surgeons have pointed out the benefits of dedicated surgical hubs in bringing waiting times down. Now, I appreciate that surgery happens at all district general hospitals, but the definition of a surgical hub, as defined in other parts of the United Kingdom, allows for all of the procedures to take place in a secure setting, and ultimately a secure staffing base, to allow the processes to continue to bring those waiting times down. Can you update us today as to the roll-out of surgical hubs here in Wales, and what resources has the Welsh Government made available to health boards to allow for those establishments to be created within our district general hospitals?

I thank the Member for that question, Llywydd. Very long waits in Wales continue to fall as well. They were 4 per cent down in the last month for which figures are available. A word of caution about assuming that everything is fine in any other part of the United Kingdom in relation to the NHS, and some of the claims that are made: when you look at the exceptions that lie behind them—'We have achieved this, apart from this, apart from that, apart from the other'—I think the figures are not to be taken just at the headline value. 

As for surgical hubs, we have indeed discussed them here before. The leader of the opposition will know that there are particular geographical challenges in Wales in identifying any hospital as being given over entirely to planned surgery, because those hospitals continue to provide necessary emergency responses as well. Nevertheless, there are efforts in different parts of the NHS in Wales to try to concentrate more planned surgery on a smaller number of sites in order to be able to protect the resources—the theatre space, the ward space—to allow planned surgery to go ahead.

At the orthopaedic summit, a whole range of these issues was discussed. How can we, in orthopaedics, make better use of things that prevent people from needing operations in the first place? If you are waiting for an operation, what more can be done to make sure, through physiotherapy and so on, that you can be looked after while you are waiting? As we emerge from the COVID experience, what more can we do to return theatres to the level of productivity that they were able to manage before the additional cleaning regimes became necessary to prevent the spread of the virus? All of these things were discussed and the Minister, as I said, will provide more details of it.

In parts of Wales, as I said—in Hywel Dda, at the Prince Philip Hospital; in Swansea bay at the Neath Port Talbot Hospital—dedicated protected space is being provided. They are not surgical hubs in the way that that definition is used elsewhere, but they perform the same function.

I take from your answer, First Minister, that we do not have dedicated surgical hubs here in Wales. I appreciate that you identified three, I think it was, hospitals there that have areas identified for specialist surgery, but they wouldn't fall under the criteria of surgical hubs. Is it your Government's ambition that, should people find themselves on a waiting list for a considerable period, it should be able to actually offer a second offer, so that they could go to an alternative establishment and have that procedure undertaken, as happens in other parts of the United Kingdom?

Indeed, previous Welsh Governments have made this available to people who have found themselves, in their own locality, having inordinate waits placed on their procedures, which, as I said, does give a cost-of-pain crisis to that individual, whether that be emotional, whether that be a monetary loss, because they are unable to work, or whether that be a whole host of other issues that compound that individual's ability to get on with life. Would it be the Welsh Government's ambition to create a second-offer scheme that would allow patients to access that ability, where those facilities exist, so that they could get that procedure done in a timely manner?

Well, I thank again the leader the opposition for that. I am very familiar with the second-offer scheme that we had here in Wales over a decade ago, having been heavily involved in it at the time. We already use capacity outside the area in which somebody lives in order to be able to accelerate treatment wherever we can. We are using capacity in the not-for-profit sector. We are encouraging health boards to make sure that if they are able to, they work collaboratively together, so if there is capacity in a neighbouring health board, that becomes used for patients as well. 

There were downsides to the second-offer scheme that those of us involved will remember. Many patients are very reluctant to travel long distances for treatment. What they look for is effective treatment as close to home as possible, and not everybody is resourced—not simply in monetary terms, but just in terms of having somebody who can go with you. Our second-offer scheme paid for you to be accompanied by a family member or a friend if you were going a long distance for an orthopaedic operation, for example. Not everybody's in a position to be able to find somebody in a position to do all of that, so what you found was that some people were able to take advantage of the second-offer scheme—not always the people who were in greatest clinical need—whereas other people, their circumstances simply meant that the scheme wasn't useable by them. So, a simple return to a scheme of the sort we had before, I don’t think that is what we will be looking for. But we do expect the health service to use every available piece of capacity, and not simply to expect that people will use the capacity directly available in their own local health board area.

Plaid Cymru leader, Adam Price.

Diolch, Llywydd. Prif Weinidog, Governments all over Europe are asking urgently what more they can do to help their citizens with the cost-of-living crisis, and with the rising cost of fuel, making public transport more affordable has become a key theme. Spain has announced free rail journeys from September until the end of the year. In Germany we've had the highly successful €9 a month ticket trialled over the summer, which will now become a €49 a month scheme for the whole of next year, following agreement with the Länder regional Governments yesterday. In Austria, we've had the climate ticket, which works out at €3 a day, and the Republic of Ireland cut fares by 20 per cent in May.

These policies do two things at once: they push money into people's pockets and they pull pollution out of their lungs. Do you see the merits of this kind of approach, and will we see it being implemented here in Wales?

Well, I'm aware of the schemes, and I'm aware of the two merits that the Member mentioned, Llywydd. They do a third thing as well: they reduce the revenues available to those companies that provide those services, so lowering fares leaves a gap that has to be filled. The leader of Plaid Cymru will be aware of the tens and tens of millions of pounds that the Welsh Government has had to provide to bus services and train companies in order to make good the collapse of the fare books as a result of coronavirus. So, yes, I'm absolutely aware of the schemes, I see their merits, they do not come cost free, and the Welsh Government's budget today is worth more than £600 million less in purchasing power than it was in November of last year, when the comprehensive spending review set it. So, while I see the merits, I'd need to understand better where the leader of Plaid Cymru thinks the funding for such schemes is to be found within the Welsh Government budget.

Reductions in prices for public transport fares actually don't automatically, inevitably lead to that kind of revenue reduction. It depends on the elasticity of demand for public transport. This is the case that the rail unions have been making, that, actually, if you reduce fares, you increase patronage, and of course you have a situation at the moment that, still, train journeys have only returned to around 50 to 70 per cent of pre-COVID levels. So, I think the First Minister is wrong in his analysis there.

Now, generally speaking, fare increases in rail transport in Wales follow the retail price index in July, which would mean an increase of 11.8 per cent for next year. Can the First Minister at least say that we're not going to see that? Scotland and England have announced a freeze in fares until at least March next year; in Northern Ireland, rails fares have been frozen since 2019. If the First Minister's not prepared to say he'll reduce fares, can he at least commit to the kind of fare freeze that we've seen introduced elsewhere?

Well, it's an interesting argument that the leader of Plaid Cymru makes. He wants to persuade us that elasticity of demand for public transport could be affected in the way that he suggested, and yet he has to tell me at the same time that patronage of the rail industry is nowhere near what it was prior to the pandemic, despite the over £100 million that the Welsh Government has spent in keeping fares at a level that would not have been beyond what they were previously. So, I'm afraid it is simply not a basis on which public policy could responsibly be conducted to say that we could take a punt on the idea that we could reduce fares and it would pay for itself. Unfortunately, I'm afraid the real-world experience is that that is not the case, and the Welsh Government budget—. Although, I'm very happy to take advice from Plaid Cymru on this. If you're prepared to tell me where the money could be taken from in order to mount such an experiment, I'd be very pleased indeed to look at that.

I'm aware, of course, of the way in which fares are calibrated through the consumer price index at the level of inflation at a point in the month, and the Welsh Government is looking, with those who provide our transport services, at what the impact of that will be on fares for next year and what we might be able to do to respond to that dilemma.

I have to say that the argument you're making is directly in contradiction to what Labour-affiliated unions like ASLEF are saying, that, actually, a substantial reduction could help us increase a modal shift that will create a new habit of using public transport, which will actually have benefits in terms of revenue generation.

Let's move from rail to buses. The Labour mayor of the north-west of England, Andy Burnham, has capped bus journey fares in Greater Manchester to £2 for adults and £1 for children, and, indeed, the UK Government now is going to follow that for England in January of next year. Why don't we do the same in Wales? Capping it to £2 would halve, pretty much, the average cost of a single journey in Swansea. It would address the huge increase we've seen in Arriva bus fares in north-west Wales. Are you comfortable, First Minister, with a Labour regional mayor in England and a Conservative Government in England doing more for bus travellers at the moment than a Labour Government here in Wales?

Well, Llywydd, the leader of Plaid Cymru has had three opportunities this afternoon to explain to people in Wales how he would fund the proposals that he puts in front of us. Every time he gets to his feet, he spends more money. Every time he does it, he can't offer us a single suggestion—not a single suggestion—as to which Welsh public service would have to be reduced in order to fund his latest wheezes. Now, I think Members here might understand that unions affiliated to the Labour Party are a little bit more likely to talk to us than they may be to talk to him, and I can assure you—[Interruption.] You may not like it, but it turns out to be true. And I can assure you that, when we talk to them, they understand the limitations of what Welsh Government budgets can do, even if he doesn't.