The following amendment has been selected: amendment 1 in the name of Rhun ap Iorwerth.

We now move on to item 6, which is a debate on the chief medical officer’s annual report for 2015-16. I call on the Cabinet Secretary for Health, Well-being and Sport to move the motion—Vaughan Gething.

Motion NDM6175 Jane Hutt

To propose that the National Assembly for Wales:

Notes the Chief Medical Officer for Wales's Annual Report for 2015-16 ‘Rebalancing healthcare—working in partnership to reduce social inequity’.

Motion moved.

Thank you, Deputy Presiding Officer. I’m happy to move the motion on the order paper and at the outset confirm that the Government is also happy to support the amendment tabled.

Now, each year, as Members will know, the Chief Medical Officer for Wales sets out an independent overview of health and well-being issues facing the nation. I’m pleased to lead this debate to mark the publication of the very first annual report from our new chief medical officer, Dr Frank Atherton. It’s been written jointly this year with Professor Chris Jones, the deputy chief medical officer.

This annual report traditionally sets out an assessment of where Wales stands with regard to health and well-being and I hope that Members have noted that, in this report, the chief medical officer has actually given us a different feel to those previous reports. Now, it builds, of course, on many of the messages of his predecessors, particularly in relation to prevention and timely intervention. But the new chief medical officer has chosen to view things in a slightly less traditional manner. He’s not simply added a section on the social gradient, he’s focused the whole report specifically on the social gradient and how people from disadvantaged groups experience higher levels of ill health and poorer life chances.

I welcome the direction of this report. It challenges all of us here in this Chamber, as decision makers and scrutineers, and it should drive our choices in the future and I hope it will inform the future debate of health and well-being in Wales. It provides recommendations on how we make our services more effective, accessible and sustainable for all.

The social gradient affects everyone and all our public sector organisations must think and act differently if we are to tackle the inequalities that exist within communities in a meaningful way. These are inequalities within each community and between different communities. Whilst these inequalities are not unique to Wales and they are seen in other countries across the world, they do, of course, have a uniquely Welsh dimension, in terms of history, culture and geographic location. It’s the understanding of people and the communities that they live in, in which their everyday life takes place, that will help us to work together to ensure the most appropriate response for those circumstances. Because all of us know that the national health service faces a continual struggle to meet the demands caused by ill health—demands that we recognise as rising, year on year.

An overreliance on services and outdated clinical custom and practice can cause huge amounts of activity in the system, but do not always meet the needs of those who are worst off. I’m pleased to highlight here the work we’re already doing in trying to reform the out-patient system. We know it drives huge inefficiency into our services. It does not make the best use of clinicians’ time, or, indeed, make the best use of patients’ time, all the time; it is really a point of activity that can have huge savings for our health service and much greater value in terms of what we deliver afterwards.

The chief medical officer’s report quite rightly asks what the NHS can do to address this situation, by, amongst other things, unlocking the power of the individual and community involvement in creating a shift away from ill health to well-being. Now, ultimately, this should reduce demand on services and make them more sustainable. By looking at health outcomes through the lens of the social gradient, we can observe a higher prevalence of lifestyle-related and social harms, illness, and early death in the more economically disadvantaged groups. So, the report seeks to set out what we understand by the social gradient in health and it shows that it is as unambiguous here in Wales as it is elsewhere. Health gets progressively better as the socioeconomic position of people and communities improve. The report also examines how the social determinants of ill health, from a difficult early-life experience during foetal life or in the early years, poor education, housing, unemployment, or the impact of poverty, each one, can impact on our health and well-being in the longer term, and how the national health service and other public bodies can intervene to influence or mitigate some of those negative factors. The report reinforces what we’ve learnt and know about how best to tackle the social gradient: that is, through universal services that respond to the level of need, which differs in different parts of our country.

Now, our free-at-the-point-of-use NHS, with its worldwide reputation for excellence, has done much to prevent health inequalities, but this report asks questions about how we use the NHS resource here in Wales to its best effect, how the NHS must be organised to further reduce, not increase, the social gradient, and about how best to embrace our prudent healthcare principles here in Wales and provide more equitable services to be genuinely co-produced with the individuals and communities that they serve. I think here is the point that the amendment is seeking to focus on as well. We recognise that there is a leadership responsibility for people like us, politicians, and for people in health boards and other organisations leading and running organisations. But, as well as that leadership, we won’t be truly successful unless we’re able to work with different communities and individuals, not simply to tell them what they must do. At each interaction with health and care professionals, and with peer support and peer challenge as well, we recognise that we can help to inform people to make genuinely informed choices. We do know that the more informed patient tends to make better choices.

The messages in the report regarding a more sustainable healthcare system and the need to manage demand are challenging, but essential. NHS Wales is a busy system. It’s our largest public service. It consumes 48 per cent of our resource, and, indeed, our spending on health and social care is now 7 per cent higher per population than that in England. The most recent OECD report, which reviewed the quality systems operating in the four United Kingdom health departments, was complimentary about much of what we are already doing in Wales, but felt we could do more to achieve our ambitions. That means moving away from treating ill health and towards ways of supporting people to make the best of their life chances, when, in many cases, good health will follow.

The messages in this chief medical officer’s report about new models of care, such as social prescribing, for example, and the need to better understand the challenges faced by communities in order to find solutions, are timely and welcome. The pivotal role of health professionals is also important and chimes with similar best practice for all of our public services in terms of culture, leadership and behaviours. Generally trusted and highly valued, with access to our population at key junctures in their lives, we need to maximise the ability of our workforce to intervene with individuals within their communities and employ shared decision making in order to improve those outcomes for individuals and families. Of course, that also supports the aspirations set out in our Well-being of Future Generations (Wales) Act 2015.

The Llywydd took the Chair.

The eight recommendations in the report, aimed at NHS organisations, their partners, and the Welsh Government and education providers, reflect a life-course approach, with the latest research, including Welsh publications and evidence, and that emphasis on prevention and early intervention. They also call for innovation and the need for ongoing research into new models of care. There are many challenges set out in the report. I look forward to hearing what Members have to say in today’s debate.

I have selected the amendment to the motion and I call on Rhun ap Iorwerth to move amendment 1, tabled in his own name.

Amendment 1—Rhun ap Iorwerth

Add as new point at end of motion:.

Believes that the prevalence of ill-health in poorer communities, identified by the report, is caused by wider environmental, social and economic conditions and cannot be blamed solely on poor choices made by individuals, and that public health policies should reflect the responsibility of government to tackle this rather than merely focus on lecturing people.

Amendment 1 moved.

Thank you, Llywydd, and I move the amendment, which concentrates on one element of the report, if truth be told. The chief medical officer’s report reminds us again that the poorest communities pay a significant price in terms of their health, simply because they are poor and live with others in poverty. There is too much focus on occasion, I think, on the lifestyle choices made by people. It is true, of course, that smoking and obesity are more prevalent in the poorer areas, but we should be guarded always against creating a narrative that the blame for ill health should be placed on the individuals themselves, or that it’s always the case that it is poorer people who have the poorest health behaviours.

There are many people on low incomes who live a very healthy lifestyle, but still have to deal with the impact of poor housing, uncertainties in terms of employment and so on and so forth. Also, bear in mind that Welsh survey data show that drinking alcohol at harmful levels is worse at management level than among others within the workforce, and I am sure that there are some middle-class managers who would be willing to admit that they could do with losing a few pounds. So, I am pleased that the chief medical officer’s report does cover these factors, which can’t be disregarded or put down to poor behaviour in one way or another.

We have highlighted, on several occasions, the links between poor housing and poor health, between homelessness and ill health, uncertainties in terms of employment and unemployment and the relationship with health, and none of those could be considered as lifestyle choices. It’s also true that improved education and access to greenfield sites and more secure employment have a positive impact on one’s health.

The chief medical officer reminds us specifically of adverse childhood experiences and the importance of the first 1,000 days. He notes that evidence shows that investing a little over £100 in preventing ACEs during childhood would lead to savings of over £6,000 across public services over the first five years of life. That is an investment rate that is far better than you will get in many other areas—apart from putting a bet on Leicester to win the premiership, possibly. That’s quite a good return. We could find similar evidence across other public services. Improved housing would prevent ill health, creating green spaces would improve health, and so on and so forth.

That’s why the chief medical officer recommends that the NHS must work with other public services—the fire service, financial services and housing support—in trying to create sustainable health for Wales for the future. I would go further, and the report does highlight that cutting public expenditure, as we have seen from the Conservative Government in England, has been an example of a false economy on the highest possible level. It’s the most vulnerable who suffer when public expenditure is cut. It is as simple as that.

At the heart of this problem we are considering here is inequality. Last week, research showed that those at the lower levels of the hierarchy in the animal kingdom have poorer immune systems as a result of their low social status, and many academics who specialise in health inequality have noted the relevance of this study to humans too. Inequality itself is the problem. The book ‘The Spirit Level’ summarises much of the research on this. Countries with less inequality tend to be significantly healthier, they have lower crime rates, and better social mobility and so on and so forth. That is something that we should consider very carefully when we discuss the huge amounts of money that we spend on dealing with the effects of inequality. We need to tackle the problem at source, not deal with its symptoms. Plaid Cymru believes that if the Government was more proactive in creating a healthier environment, then better lifestyle choices would inevitably result. To recognise that, I urge you to support this amendment.

First of all, I’d like to very much welcome this report from the chief medical officer, and I’d like to thank Dr Frank Atherton and Professor Chris Jones for the work that they’ve put into it. I think this report very much demonstrates that a one-size-all-fits approach does not work for the Welsh health service. As Rhun ap Iorwerth has talked about the social gradient, I’d just like to make a quick comment that we’ll be supporting today’s amendment.

It is interesting to note the harm that badly applied or thought through interventions can cause. As the report puts it, health interventions that do not reach those at the greatest risk are likely to increase the inequality of health outcomes. So, Cabinet Secretary, in the past your department has been reluctant to put key performance indicators into place to effectively manage or measure the outcomes of policy. With this statement, you must see the danger an ineffective policy can directly have on health. Will you therefore commit to producing key points of measurement to ensure the effectiveness of the policies that have been introduced?

The report also goes on to highlight that to provide NHS services without regard to the social gradient has the potential to increase the inequality. So, on this basis, would you also, Cabinet Secretary, give consideration to providing more power to community pharmacies to undertake some of the more minor roles to enable GPs and other healthcare professionals to focus on more detailed work and those more in need?

I recently visited the excellent Eastside Dental practice in Swansea, which is one of only two practices in Wales trialling the new prototype of providing a more holistic approach to dealing with their patients. This arrangement allows much more work to be done with dealing with prevention rather than just trying to fix the problems as they’ve arisen in terms of dentistry. The report talks of working with partnerships to reduce social inequality. So, Cabinet Secretary, I wonder whether you would have a good hard look at this prototype that’s been trialled in Swansea and see whether this might be a model that we can roll out throughout Wales, because preventing people from having bad teeth in the first place not only helps with their mouth hygiene and health but actually helps with their overall health as well. This is yet another example of where co-production can really work.

Recommendation 5 in the report, I feel, addresses the crux of the matter. Cabinet Secretary, could you please outline what discussions you’re having with your Cabinet colleague to ensure that the revised planning framework requires organisations to plan for equitable health outcomes for their populations and focuses on reducing demand? I think that that would be really key to being able to move forward on the health inequality aspect that’s covered in this report.

There are two other points that I do want to quickly make. It was really brought home in this report the effect that an adverse childhood experience can have on the life outcomes of another person. I think that, for those who would wish to read this report, I would recommend that you have a good long look at figure 7 on the long-term effects of adverse childhood experiences. People who’ve had four or more adverse childhood experiences might, for example, be 14 times more likely to have been a victim of violence in the last 12 months, and 16 times more likely to have taken crack cocaine or heroin. And if we were to prevent ACEs—adverse childhood experiences—for these young people, then we can really reduce some of the appalling outcomes that we do see within the health service. So, if we were to look at the heroin and crack cocaine use, for example, we could reduce that by 66 per cent. This is a really, really telling table.

Cabinet Secretary, one of the areas that have been highlighted recently is the sexual abuse and harassment that young girls and young women face in school. They put up with levels of sexual abuse from young men who haven’t quite understood what the game is all about, and how you respect each other—levels of abuse that we would not expect to put up with in our workplace, but young people do have to put up with it. May I draw your attention to the select committee report from Westminster that looked at all British schoolchildren and girls? Over two thirds of girls have put up with sexual abuse in school. And may I ask you to talk to your colleague, the Cabinet Secretary for Education, about how we might prioritise sexual health within our curriculum, so that we can teach our young people how to be more respectful and better able to handle the abuse within relationships? Because, when we look at this list of adverse childhood experiences, a whole load of them do come back to those formative years and the relationships between men and women. And prudent healthcare is the other matter I would like to have raised, but I will perhaps write to you on that one.

I, too, think this is a really excellent report, because it sets out so clearly the challenges that we face in Wales, not just within the health service, but across all public services. So, I really would like to congratulate the authors on it, as I think it provides loads of food for thought.

It's perfectly clear from this report that the NHS can't tackle health inequality on its own, and the future generations Act requires all public bodies to operate together to tackle these issues. I suppose one of the most interesting graphs is the one around the outcomes for cognition in children with high and low socioeconomic status and how they diverge over time. It's clear from that graph that dim rich kids overtake the bright poor child by the age of five, and the only way in which we can counter that tendency is by having really good quality comprehensive childcare and early education, because it has been shown in other studies that that is the way in which we beat that particular aspect of deprivation.

But I think that, looking at the obesity figures quoted, you know, one in seven children in Merthyr is overweight or obese, compared with one in 14 in the Vale of Glamorgan. Clearly, there is a link with deprivation, but we have to also look at the converse presentation of the facts, which is that six in seven children in Merthyr are not overweight or obese, and that’s to be celebrated. It indicates that it isn't a given that those who live on lower incomes are necessarily going to be obese. It is absolutely incorrect that good food costs more money than food that is low in nutritional content. One of the most important points in the report is the correlation between fast food outlets and areas of deprivation, and it refers to an English report that says that you're twice as likely to be obese if you live close to a fast food outlet. I don't think this applies just to England, because I attended an Asian caterers’ event recently at the Cardiff City Stadium, and it was made perfectly clear there that if you live or work close to a fast food outlet, you are twice as likely to be obese. It is that stark. So, it is not the fact that you are living on low incomes; it is the behaviours that lead you to go to a fast food outlet, rather than to make food from scratch, which is obviously the way in which you avoid the harmful things that are added to processed food in order to make a profit. So, I would be keen to hear the Cabinet Secretary for health’s views on the importance of the food that we give our children in school and whether he thinks that this is an aspect where we can ensure that all children, regardless of the habits of their parents, can taste and experience good, plain food, to enable them to grow up having a healthy diet.

I recently visited one of the schools in Flintshire, which are all following the Food for Life programme, and they have doubled the number of children taking up school meals, which the headteacher said most definitely reduced the number of children bringing in inappropriate food in packed lunches, which means that those children were not actually getting any nutrition during the school day. So, I would be keen to find out what the health Secretary thinks is the role of local authorities in promoting not just the ‘Appetite for Life’ guidance, but the ‘Good Food for All’ guidelines, which ensure that freshly prepared, locally sourced food is served on a daily basis for all our children. So, I think this is a really excellent report, and I think we should listen to the words of Dr Mair Parry, who’s from the Royal College of Paediatrics and Child Health, who says that Wales continues to have the worst rates for childhood obesity in the UK and that clearly more needs to be done to address these shortfalls. Concerns still remain over the number of children who eat fruit and vegetables every day and who do exercise, and there’s clearly something very important going on here.

I’ve run out of time, but I suppose the other really stark thing is how little poor communities use dentists and opticians. Of course, these are the two health services—compared with GPs, which they’re using much more in deprived areas—these are the two services where you actually have to pay for it. This is obviously one of the things we need to reflect on. What it tells us is that poor people are not able to access dentists or get glasses when they need them, and that is a very significant matter that—it would be useful to know what the Cabinet Secretary thinks.

I’d like to thank Dr Atherton for his report, and record my thanks to Professor Jones for holding the fort following Dr Hussey’s retirement. Dr Atherton makes it clear that the biggest health challenge facing our nation is tackling the health inequalities between the richest and poorest in our country. The fact that the gap in life expectancy between those living in our most and least deprived areas is growing should shock us all. We cannot stand idly by when the poorest in Wales can expect to live 11 years shorter than the most affluent.

The reasons for the existence of the social gradient in health are complex, but contributory factors include poor diet; a greater prevalence of smoking and alcohol misuse in our most deprived areas; poorer housing conditions; high-rise flats with no garden for children to play in, getting the much-needed exercise; damp conditions leading to respiratory problems; and also high unemployment rates in poorer areas. People in our most deprived areas are twice as likely to smoke as those living in more affluent areas of Wales. We need collaboration of services and partnerships to help with these inequalities.

While we are making progress in reducing the numbers of smokers overall, tobacco control measures have been more successful in reducing uptake than in encouraging existing smokers to quit. Children with at least one parent who smokes are 72 per cent more likely to smoke in adolescence, and if both parents smoke, children are four times more likely to start smoking than if neither parent smokes. Therefore, we must redouble our efforts to encourage parents to quit smoking.

A study for the British Medical Journal found that smokers underestimate the risk of lung cancer, both relative to other smokers and to non-smokers, and demonstrate other misunderstandings of smoking risks. This is put down to the fact that, as a species, we’re not very good at evaluating future risk. Telling someone that they may develop cancer in 30 or 40 years unfortunately doesn’t motivate them to quit smoking. However, we are much better at evaluating risks to our children. Telling a parent that their behaviour is encouraging their children to smoke may have the desired outcome.

We have to accept that many smokers find it nearly impossible to quit. Research by the UK Centre for Tobacco and Alcohol Studies found that approximately one in three smokers in the UK currently attempts to quit each year, but only about one in six of those who try to quit remains abstinent for more than a few weeks or months. Most smokers who try to quit do so without accessing professional help, and those who use over-the-counter nicotine replacement treatments appear to be no more likely to quit than those getting no help.

However, those who switch to e-cigarettes are far more likely to quit tobacco. The Royal College of Physicians states that

‘in the interests of public health it is important to promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK. ’

Public Health England advocate the use of e-cigarettes as an alternative to smoking and issue guidance to employers stating that they may consider allowing people to use e-cigarettes at work if it is part of a policy to help tobacco smokers kick the habit. The Medicines and Healthcare Products Regulatory Agency has approved a brand of e-cigarettes to be marketed as an aid to help people stop smoking.

As the chief medical officer says in this report, the NHS should not make the social gradient worse. I therefore urge you, Cabinet Secretary, to adopt a similar approach to England when it comes to e-cigarettes and their role in reducing harm from tobacco. We should be encouraging those smokers who are unlikely to quit to switch to e-cigarettes, highlighting the fact that e-cigarettes are 95 per cent safer than tobacco products, rather than focusing on the potential harms of vaping. Thank you. Diolch yn fawr.

I think this is an excellent report. I think the way it’s presented is very clear and it clearly shows the way that we should go. I particularly welcome the emphasis on health inequalities and the social gradient because the evidence is absolutely clear that there’s a higher prevalence of illness and early death in more economically disadvantaged areas. We know in Cardiff itself the difference between two wards, where perhaps you can get to them within 10 minutes, is nine to 11 years of longer life in the more affluent area. That cannot be acceptable. It also can’t be acceptable the number of childhood deaths that take place in disadvantaged areas compared to those more affluent areas. Again, that is something I think that we have to work at and we have to challenge.

So, I welcome the emphasis on the health inequalities. I also welcome the very clear priority on the first 1,000 days of a child’s life and of those days being absolutely crucial. I think that is an area where we have to put our emphasis on. The information about adverse childhood experiences I think should really dictate how we carry on our policy in this Assembly, because the evidence is so strong about what happens later if you do experience, say, four or more of those adverse childhood experiences. So, I think all the information is there on how we need to move. Obviously, establishing good, healthy eating habits and exercise very early on is very important.

The only thing I was surprised that wasn’t in this report, and I may have missed it, but I don’t actually believe I saw any reference to breastfeeding at all. I do actually think that that is one of the crucial areas that we need to take into account because, if we just look at the overweight issue, we know that there’s evidence to show that children who are breastfed are much less likely to have overweight children. We know that the World Health Organization recommends breastfeeding exclusively for the first six months, and there’s also evidence to show that breastfeeding decreases the risk of babies getting infections. For the mother, there are health benefits too, including reduced risk of breast cancer and ovarian cancer and osteoporosis. It’s absolutely vitally important. So, I am surprised that there is nothing in this report, unless I’ve missed it, that says, when we work really hard at the first 1,000 days, ‘Breastfeeding is one of the paramount things’, because it builds the bond with the mother, and we do know, looking at health inequalities, that breastfeeding is less taken up in areas that are poorer. It is absolutely vitally important that we put an effort in to ensure that mothers can be encouraged to breastfeed.

We know that health professionals are under pressure and it takes time and effort to try to help mothers to breastfeed, because sometimes it’s not easy and you need to spend time with new mothers. I know that there’s also evidence that shows that young mothers in particular—the breastfeeding rates for young mothers is lower than the average. So, I think, again, that is something that we need to tackle. In Wales, the highest breastfeeding rates are in Powys Teaching Local Health Board, at 72 per cent, and the lowest are in Cwm Taf, at 50 per cent. Looking at the babies leaving the neonatal units, I met, as I think others did, with the Royal College of Paediatrics and Child Health, and they highlighted the different rates of breastfeeding across the UK when women leave the neonatal units. The highest percentage was 85 per cent, and the lowest was 43 per cent, and Wales was at 43 per cent. So, I don’t want to take anything off this report, because I think it is a brilliant report, and I think this is the way that we should be tackling these issues, but I do think that breastfeeding is a bigger mission, and there’s no emphasis on breastfeeding in the report. It helps, at the earliest stage possible, to establish that bond—and we know the value and the nutrition of breast milk—but you do have to make an effort to make it happen, in some situations, and I think we should be putting more resources into that. And I know that it is difficult, sometimes, for particularly young mothers to feel able to breastfeed when they feel there is a social stigma. Only recently, in my own constituency of Cardiff North, there was an incident in a local cafe—we keep hearing about them every so often, this sort of thing happens—where somebody was abusive to someone who was breastfeeding. So, that climate is still there. So, it is an area we need to work at, and I think it is an area where we can make a difference to the long-term chances of children.

I, too, welcome the CMO’s report and its emphasis on creating a health service, rather than an illness service, which is something we’ve spoken about for quite a long time, and also its emphasis on socioeconomic status, which again is something that’s been debated and discussed for quite some time, but perhaps with a new emphasis in this particular report. It also emphasises the importance of lifestyles to differences in life expectancy and healthy life expectancy, and I think there are a number of things that Welsh Government can do to help address those issues and their socioeconomic bases. For example, there’s a lot that can be done to encourage healthy eating. We could have a traffic-lights system of food labelling, for example, I think, to inform people far more clearly as to what are the healthy foods and what are not. We could have a sugar tax, or a fat tax, for example. Obviously, there are issues about what’s devolved and what’s not devolved, and some of it, no doubt, will be a matter of trying to pressurise UK Government, but some of it may be looking to further devolution and, indeed, what we might be able to do within current powers.

I think it’s very, very important, as we often talk about, Llywydd, that we instil good attitudes and behaviours in our young people as early as possible. I very much agree with the emphasis on the first 1,000 days, and I know there’s a building amount of evidence as to the importance of those early years. We’ve got healthy school networks, of course, and I think there’s some very good practice there. We have new opportunities, I think, to drive improvements to physical literacy, following Tanni Grey’s report, and around the curriculum review, and I very much hope that we take those opportunities.

I would like to say a little bit about what we’re doing locally in Newport, Llywydd, which I have mentioned more than once before. I think we’re making progress in pulling together some key players in public health, from the health board, Aneurin Bevan; Newport Live, the providers of leisure services; the sports clubs; Newport City Homes, and other housing associations; Natural Resources Wales—a host of players have been meeting locally for quite some time to discuss how we get a more physically active population and how we get healthier behaviours more generally. We have made progress. Organisations have committed to a day a month of staff time to pursue this agenda. They’re looking at actions they can commit to and how they can do one more thing. They’re looking at examples from across Wales and locally in terms of how you get change on a wider scale, rather than something that’s very localised. So, I do believe that we are trying to do something important locally in terms of the issues highlighted in the CMO’s report, and I hope as well that other areas in Wales look at how we can build the partnerships, bring key players together and have new collaboration. So, I do hope, Llywydd, that Welsh Government is looking carefully at what’s happening across Wales and also looking carefully at how it might support these initiatives, perhaps through some pilot schemes, for example, which could support, build and strengthen the work that’s taking place. I hope that the Minister can address that in his closing remarks. Diolch yn fawr.

I call on the Cabinet Secretary to reply to the debate.

Thank you, Presiding Officer. I’m grateful to Members for taking part in today’s debate—a very consensual debate in many ways, with similar concerns and an expression of similar challenges that we know that we all face in different communities in pretty much every part of the country.

I want to start by dealing with issues raised in the amendment and in the contribution from Rhun ap Iorwerth, but every Member mentioned lifestyle challenges. I think there’s a challenge for us here in not confusing blame and responsibility. It’s right that we don’t blame people, but we do have to find a way to have a conversation about people taking more personal responsibility and how we get alongside them to help them to make different choices, and that’s got to be a conversation that we are prepared to have in our own roles, as well as expecting healthcare and other services to do so as well. Of all the different challenges that we recognise in public health—diet, exercise, alcohol and smoking being the big four—in each of those, people make choices. It’s how we equip people to make different choices and then how we equip people and empower them to make more healthy choices later down the line if we can’t prevent them from undertaking risky behaviours in the first place. In fact, alcohol, as Rhun mentioned, is the one example where you can demonstrate that, actually, it’s more middle-class people who have a problem with drinking—not so much binge drinking, but regular overuse of alcohol.

I recognise a number of the points that were made and I’ll try and deal with them before I conclude, Llywydd. A number of interesting questions and points were made by Angela Burns. I want to start by saying that I would be very happy to have a grown-up conversation about what we measure and why within our health service—the different measures that we have, the way that they’ve been generated and whether we can have something sensible, like is what we’re measuring sensible, is it helping to drive the right behaviour and whether it’s telling us something useful about the performance of our health service, but also about the way in which the public engage with the messages from that health service as well. We can look at things like the public health outcomes framework development, looking at outcomes and not just activity, and I do hope that, through the parliamentary review process at the end of that, we can continue to have that debate in the part of this term when, frankly, we can have it, because I don’t think we can have that same debate in the last 12 months of this term, if we’re being perfectly honest.

I’m pleased to hear you make mention of the dental process of contracts; I’m actively interested in them and I’m looking forward to the learning we get from those pilots and to look at what we could potentially adopt system-wide. Actually, oral health is an area in which we’ve had some success here in Wales. Designed to Smile has been successful. It isn’t the only thing to do and we do recognise that in general dental services there are still challenges for us to address and deal with. I think there’s a link here between dental services and pharmacy services, because there’s something not just about rewarding activity and volume, but a thing about how you reward quality. Because in pharmacy, which you mentioned, and I know other Members have mentioned in different debates here in the past—I think there’s a really exciting time in community pharmacy here in Wales, not just because we’re investing in an IT platform to enable pharmacy to do more, not just because our partners and colleagues in the British Medical Association are actually in a different place; it’s about recognising the value of pharmacy as part of that wider primary care team. The opportunity is there to try and understand what more pharmacy can do to take people away from general practice when they don’t need to be there, to be part of the team, but also to look at quality payments for the future, not just about volume and activity in dispensing, but, equally, I think there’s a really important piece of work already in place on the hospital discharge process. There’s much more we could do for community pharmacy, the individual and the hospital pharmacy service as well.

Would you take an intervention? Thank you, Cabinet Secretary. Of course, the other thing is that a lot of the people we’ve talked about today who struggle to access a number of these services do go to the chemist. They go to the chemist on a regular basis to get the medicines that they’ve been prescribed because of their lifestyles, and that gives us a really great chance for the pharmacist to perhaps get hold of them and to help them make better decisions about their way forward. So, we can use the pharmacist as a consultant in terms of lifestyle and behaviours.

It’s exactly the reason why we’re investing in our community pharmacy network, and it’s why we’re rolling out extra investment in that IT platform and expecting them to do more. Now, that’s an open conversation we’re having and I’m generally pleased that there’s not just a pharmaceutical committee, but the role of Community Pharmacy Wales being genuinely open-minded about the future. It’s a real positive, and it’s a helpful contrast between Wales and England. I think everyone in every part can take some real pride that we’re taking that approach here in Wales.

A number of people mentioned education and the importance, not just of the new curriculum and the health and well-being aspects of that, including relationships, but this whole point about childcare and early years education. I know Jenny Rathbone mentioned this as well. It’s definitely part of the agenda of this Government not just to improve our childcare offer, but to think about how we add a real quality element to this, so it’s not just volume but the quality of that intervention too. Because we do recognise that talent is not the reason why wealthier communities outperform poorer ones, both in terms of educational outcomes and indeed economic ones at the end of it as well. There is much more to it than that. I’m happy to recognise the points that both Julie Morgan and Angela Burns made about adverse child experiences and their impact on people’s outcomes later in life, but in particular the really important ones are the first 1,000 days, and the priority that we pay to that as well.

It isn’t explicitly mentioned in the report, but as part of the Healthy Child Wales programme and the focus on the first 1,000 days, there is no letting up on the importance of breastfeeding as well. There’s something about: is the message still ‘breast is best’ or ‘breast is normal’? Because actually we need to renormalise breastfeeding because, you’re right, there are still far too many examples of the way that people react poorly or offensively when someone is breastfeeding. It’s an entirely natural process and it’s good for the child and the mother too, as you’ll recognise there’s a lot of research for that as well.

I’m glad to hear that John Griffiths didn’t miss the opportunity to tell us about the Newport update as well, but I want to address perhaps one of the points that Caroline Jones made. In the report, we recognise the differential rate of smoking and its real impact on health outcomes. I don’t quite share your enthusiasm for e-cigarettes as the way forward as almost a panacea for smoking. There is evidence that is contrary at present. Some of the proponents of e-cigarettes as an alternative, there’s alternative evidence both from the British Medical Association and also the World Health Organization as well. I think we’re doing the right thing keeping an open mind, but a precautionary view on e-cigarettes as a potential tool to help people to give up smoking, but they are not a harm-free substitute for smoking. There is still harm associated with e-cigarettes. We want to monitor and understand that evidence before we reach a definitive conclusion.

On the point that Jenny Rathbone made about obesity and diabetes in particular in children and young people, and the importance of food and nutrition in schools and in wider communities, there’s a real challenge here not just about what goes on in schools, because I’m proud of the work we’re doing across schools right across the country, in having a really clear healthy-eating message and the food that people are provided with in a school setting. There’s more that we can always do, but it has to be working with that whole-school community so that parents and carers understand the choices they make outside the school gates and the impact they have, because actually that message is more important than the one that children get in school.

Llywydd, I’m really pleased with the debate we’ve had here today and the recognition that health inequalities arise because of inequalities in society, both in the conditions in which people are born, grow, live, work and age and in the structural drivers of those conditions—the unfair distribution of power, money, resource and opportunity. Professor Sir Michael Marmot, a recognised expert in the determinants of health and health inequalities made recommendations for action to reduce health inequalities in his report, ‘Fair Society Healthy Lives’. He’s highlighted the majority of steps required to address health inequality and a social gradient to take place outside of the health service.

I’m delighted to have taken part in a helpful and constructive debate and I look forward to working with Members across the Chamber over the next few years as we look to take forward not just the message in this report, but how all of us have a contribution to make.

The proposal is agree amendment 1. Does any Member object? Amendment 1 is therefore agreed in accordance with Standing Order 12. 36.

Amendment 1 agreed in accordance with Standing Order 12. 36.

Motion NDM6175 as amended:

To propose that the National Assembly for Wales:

Notes the Chief Medical Officer for Wales's Annual Report for 2015-16 ‘Rebalancing healthcare—working in partnership to reduce social inequity’.

Believes that the prevalence of ill-health in poorer communities, identified by the report, is caused by wider environmental, social and economic conditions and cannot be blamed solely on poor choices made by individuals, and that public health policies should reflect the responsibility of government to tackle this rather than merely focus on lecturing people.

The proposal is to agree the Motion as amended. Does any Member object? There are no objections. Therefore, the Motion is agreed.

Motion NDM6175 as amended agreed in accordance with Standing Order 12. 36.

Rŷm ni nawr yn symud i’r cyfnod pleidleisio. Oni bai fod tri Aelod yn dymuno i mi ganu’r gloch, rwy’n symud yn syth i’r cyfnod pleidleisio.