The following amendment has been selected: amendment 1 in the name of Paul Davies.

The next item on the agenda is the Plaid Cymru debate on NHS privatisation. I call on Rhun ap Iorwerth to move the motion—Rhun ap Iorwerth.

Motion NDM6303 Rhun ap Iorwerth

To propose that the National Assembly for Wales:

1. Supports the principle of the Welsh National Health Service being kept in public hands.

2. Is concerned about the budgetary and cross-border implications for health services in Wales in light of the creeping privatisation of the National Health Service in England.

3. Believes that any future UK trade deals must be subject to the consent of this Assembly, where those deals affect devolved policy areas such as health.

Motion moved.

Diolch, Llywydd. It seems remarkable, in a debate such as this, that we’re going to have to go over some of the basics of how the Welsh Government receives its funding and why the decisions of how England chooses to run its national health service are relevant to both the financial and workforce decisions that are possible in Wales. So, for the benefit of people who perhaps don’t recognise or realise the relevance, in simple terms, it is this: the available budget for the NHS in Wales is highly influenced by overall public spending in England. So, if a UK Government cuts the NHS budget there, then the Welsh Government would either have to cut the budget of the NHS here or cut another budget to break even. If the UK Government decides to increase the budget of the NHS in England, and doesn’t cut other relevant departments, then the Welsh Government can also make that decision. But the key factor is always the decisions made about spending levels in England. It would be effectively impossible for England to have an NHS with a substantially smaller budget and for Wales then to maintain a higher budget. This is why spending decisions for NHS England, and the nature of that spending and the structure it falls into, matter to us. If the NHS in England is likely to be spending substantially less money, then Wales has less money to make a different decision.

There are other implications too: if the NHS in England cuts services used by Welsh patients, for example; if the standards of training for the workforce drop because companies providing services start de-skilling in order to maximise profit, and, conversely, hyperinflation for senior management salaries—a predictable consequence of private sector growth—would inevitably lead to an effect here.

The Deputy Presiding Officer (Ann Jones) took the Chair.

But it isn’t just on the alleged privatisation and austerity where there are concerns due to the political structure of Wales being overly dependent on decisions made by politicians in London. The transatlantic trade and investment partnership talks that were ongoing a couple of years ago attracted major concern because of the effects that such a deal could have on the NHS. Had TTIP been signed in one of its early forms, certainly the NHS would have had no choice but to open up provision to the numerous private health companies lobbying for such a deal, remember. Indeed, some opposition to TTIP was publicly expressed by the Eurosceptic movement as a way to bring people to an anti-European position. But I would argue that we are now perhaps in even greater danger from such an agreement being pursued by the UK Government, unilaterally with the United States. At least the EU has strong internal political pressures to maintain public health systems. It’s naivety of the utmost, I think, to pretend that the emboldened Thatcherites likely to resume control of the UK Government are going to have the interests of the NHS at heart when negotiating trade deals. I’d even add that many may see this as a way of pushing through their long-term agenda of NHS privatisation, and being able to avoid blame by subsequently blaming an unintended consequence.

With that I turn to the final aspect of this debate. Yes, the NHS is in danger of privatisation. I’m aware that the Conservatives are now downplaying the extent to which private providers have actually taken over the running of NHS services since the 2012 Health and Social Care Act in England, but the facts do show a growth: slow-release privatisation has seen the percentage of the health budget finding its way into private hands rising from 4 per cent in 2009-10 to 8 per cent in 2015. The slowness, incidentally, of this growth actually reflects some inconvenient facts. It’s actually pretty difficult to make money from some parts of the NHS, so why would a private sector provider want to run it? You can only really start a significant privatisation, you could argue, by allowing providers to turn people away for treatment if they can’t pay.

Finally, the bigger danger to core services isn’t so much from obscure commissioning rules and contract design, it’s from continual poor performance, leading to people perceiving that private health insurance, or the private healthcare route, is essential in ensuring that they get prompt diagnosis in treatment. I’m sure I’m not the only Member in this Chamber who’s been approached by constituents who say they have been encouraged and advised by GPs or hospital consultants to seek private treatment because that would get them that treatment quicker. Those constituents tell me that they have felt they have no option. Private providers can only really start to make money if health insurance grows, therefore they need waiting lists to get longer, to the extent people fear for their own health.

So, I think we’re probably not going to get to a stage where a mainstream political party advocates fully a privatised system. It will be pursued, I think, through stealth, by the few true believers, and emerge slowly as a result of a thousand decisions made by pragmatists operating within constrained financial circumstances. The perception is that offering services for competitive tender brings efficiency savings or better care. This will happen alongside the removal of any free treatment for things deemed by some to be luxuries or lifestyle treatments—IVF, perhaps; gender identity.

So this is the risk of the Conservative NHS: in the long run, their NHS will be shrunk and become like the UK version of Medicare. If you’re lucky—[Interruption.] I will certainly give way.

Do you share my concern that the percentage figures you’re quoting include things like community hospices, Marie Curie, Macmillan—these sorts of bodies? The NHS, which we support, taxpayer funded, free at the point of delivery, should be asking how they could help them deliver more for the patients for the resource available.

The figures I quoted were of the money going into the private sector, which I admit is growing slowly, but it’s exactly this ‘death by a thousand cuts’ that threatens the future of the NHS. [Interruption.] From a sedentary position, the Conservative health spokesman asks if I’m going to talk about Wales. This is the context in which the future of the Welsh NHS will try to survive. In the meantime, the job of each successive Welsh Government to maintain and improve a public NHS will get harder in this context. That’s why it’s important that we defend Wales and have a strong Plaid Cymru voice in Westminster.

Thank you very much. I have selected the amendment to the motion. I call on Angela Burns to move amendment 1, tabled in the name of Paul Davies.

Amendment 1—Paul Davies

Delete points 2 and 3 and replace with:

Acknowledges the collaboration between Welsh and English health services and the dependency Welsh patients have on specialist services in England such as transgender services, acute neonatal services and child mental health services.

Amendment 1 moved.

Thank you, Deputy Presiding Officer. I’m pleased to move the Conservative amendment, tabled in the name of Paul Davies. The motion tabled by Plaid is clearly politically motivated and designed to scaremonger about the future of our NHS. For the avoidance of doubt, my party wholeheartedly believes in the Welsh NHS being kept in public hands. In fact, I believe every party in this Assembly supports the principle of the Welsh national health service being kept in public hands.

During this general election period, where Plaid are obviously struggling to connect with the Welsh public, many cases of fake news like this will no doubt be trumpeted. The reality is that there are already elements of private providers in the NHS, and I would like to draw attention to the figures shown in the NHS Wales summarised accounts for the last two financial years, which highlight the expenditure on healthcare from other providers. The column representing private providers has risen from £43,015,000 in 2014-15 to £49,732,000 in 2015-16. I would be interested to hear from the Cabinet Secretary, who was only this week on tv slamming my party for NHS privatisation by stealth, to explain this expenditure and enlighten us as to exactly who or what private providers are.

Point 3 of the motion tries to link Brexit and new trade deals to the provision of health. I would point out to the Plaid spokesman that the European Union that they so passionately supported was responsible for the TTIP trade deal, and now we’re on our way out of Europe, this perceived threat is no more. I have every faith that our Prime Minister will get good, sound deals—[Interruption.] no, I won’t, actually—will get good, sound deals for the whole of the United Kingdom and that, where required, devolved administrations will be consulted.

None of us have a crystal ball, but it is our duty as a country to enter the negotiations positively and strive for the best possible outcome for all of us. I don’t see that support from the Plaid group, who seem to be wishing the talks to fail. Instead of casting suspicion on the way in which cross-border health services are provided, our amendment aims to delete yet more nationalist scaremongering and highlights the important role that provision from across the border plays in providing treatment for Welsh patients.

I want to briefly touch on a couple of the services raised in our amendment, which help to demonstrate the importance of collaborative working between the two NHS services. Acute neonatal—a report by Bliss last year highlighted evidence from neonatal units, neonatal transport services and parents across Wales showing worrying shortages in the nurses, doctors and other essential health professionals that premature and sick babies need. This puts neonatal units under severe pressure; it leaves them unable to meet national standards for quality and safety, or support parents to be involved in their baby’s care. The report found that only two out of 10 neonatal units had enough nurses to staff all of their cots in line with national safety and quality standards, over half of units did not have enough medical staff to meet national standards, and none of Wales’s neonatal intensive care units had enough overnight accommodation for parents to meet national standards.

We should be thankful that NHS trusts in England are able to receive emergency cases and provide the cots that aren’t always available in Wales. I know constituents whose babies would no longer be with us if they were not able to make use of some of the amazing NHS services in England, such as the paediatric intensive care unit at Southampton General Hospital. I know that I, as a parent, would want the best treatment for my child, wherever that was available.

Let’s look at transgender services and mental health services. Two years ago, this Chamber voted to explore the possibility of opening the first gender identity clinic in Wales. Wales is currently the only one of four countries in the United Kingdom that does not have a gender identity clinic, meaning trans people have to travel to England. Figures from 2012 estimated there are over 31,300 trans people in Wales, but no dedicated centre, and I would be keen to learn from the Cabinet Secretary whether we’ve made any movement on this issue, but, again, stress to the Plaid spokesman that whilst the service isn’t available in Wales, it is the English NHS stepping into the breach, and the same goes for elements of the provision for child mental health services. The English NHS is our top-up and support.

In bringing my contribution to a close, I urge Plaid to think again about this motion. We need to be considering what is best for the patient, and not what best fits into Plaid’s narrow, ideological view of the world. As the Welsh Affairs Committee in Westminster concluded in their report of 2015, cross-border movements have been a fact of life for many years, and it’s no less the case for health services. For those residing in immediate border areas, the nearest health provider may not be in their country of residence, as you, Deputy Presiding Officer, will well know, representing a northern constituency. So, I would urge Members to reject the motion and back our amendment. I do hope the Welsh Government will not be tolerating this form of nonsense.

I’m pleased to take part in this debate on the NHS in Wales, and pleased also to celebrate the achievements of the NHS in Wales. This is, obviously, from the vantage point of having been a doctor in Wales since 1980. Working in the NHS has been exhilarating, challenging, and fulfilling—sometimes all at once—despite all the governmental and managerial upheavals and reorganisations that have been hurled into my path down the years. It’s a tremendous bond with people. I have grown up with people in Swansea. Patients who were children when I started are now grandparents. It’s been a privilege to have been a constant thread in the lives of so many people. It’s a strength of trust and respect—mutual—as people recognise the tremendous commitment and skill of the staff of the NHS.

Now, the NHS is not without its faults, of course. That very human resource can also err, and there is never enough money for the latest technologies and drugs. But here in Wales we have an NHS—yes, under strain every day, yet still remarkably a public service in public hands that engenders phenomenal levels of loyalty and respect from the patients of Wales. And because it’s not private, no money changes hands during the consultation. People know that the advice I give them is what I would give my own family, untainted by finance skewing the management. With free prescriptions, I can recommend long-term preventative medication, life-saving tablets like statins and high blood pressure tablets and asthma inhalers, safe in the knowledge that people will take them, and not be swayed by having to pay over £8 per item for them, as in England.

I am proud of the innovations in health here in Wales. Our two excellent medical schools are at the forefront of world-class research and treatments, involving patients from both inside Wales and beyond. Exciting immunotherapy for mesothelioma, as we heard in the cross-party group on asbestos last night: immunotherapy for mesothelioma in Cardiff, and patients coming from all over. Cutting-edge surgery in Cardiff, and, in Swansea, Morriston’s advanced burns and plastic unit—that covers the south-west of England as well as the whole of south Wales. That burns and plastic unit is truly phenomenal. Similar high praise comes in the way of cardiac surgery in Wales, too. Lives are being saved that would not have been saved a generation ago, and I am proud to be associated with all of that. And organ donation: the new opt-out system, pioneered here in Wales, is transforming the renal transplant scene in the United Kingdom. This Assembly should be justifiably proud of its role in bringing this about, providing inspiration throughout these islands, and additional organs for transplantation across these islands and across Europe.

Ours is a collaborative, human NHS, and any dependency works both ways, as I’ve already indicated. Yes, there are specialised units in Liverpool and Manchester serving the people of north Wales, but they are dependent on the 600,000 north Walians to make their specialised units viable, in critical mass terms. Without those 600,000 people in north Wales, those units in Liverpool and Manchester also are not viable. The dependency bit works both ways and all along Offa’s Dyke around 15,000 people in England are registered with GPs in Wales, and around 13,000 people in Wales are registered with GPs in England, to be fair. But mature human consideration and altruism mean that the care carries on regardless of geography. But we live in uncertain times. Brexit has imperilled our NHS and care staff. Voting for a hard Brexit brings other Tory ways of dealing with public services too, like insidious privatisation of the health service as in England. Commissioning groups there have to commission from outside the NHS. They have to privatise; they have no choice. Division and competition are rife; non-regulation and secrecy supreme; and a Tory health secretary in England who has provoked junior doctors strikes for the first time in over 40 years. Wales—different. No, defend Wales and defend our NHS. Diolch yn fawr.

I think it’s absolutely appropriate that some services are provided in England and that is where rare, specialist services can only be provided in Wales if there are sufficient numbers of patients with that condition to underpin the clinical excellence that all patients seek. So, I agree with Dai Lloyd that some of the specialist services on Merseyside and Manchester are dependent on the numbers of referrals from north Wales, but the same applies to people in Lancashire that applies to people in north Wales. Everybody wants an excellent service and that means you have to have a throughput for clinicians to be able to maintain their clinical excellence.

But, I disagree with Angela Burns. It’s not fake news to worry that the consequences of outsourcing health spending in England do, indeed, potentially pose a threat to the global sums in the block grant that will be coming to Wales and we can’t ignore that. We just have to acknowledge that and badge it up as a real issue for concern that some people may wish to take into account when they’re casting their vote in the general election.

I think that we all subscribe to the NHS being both free at the point of delivery and that nobody’s misfortune to fall ill should be used as a way for someone else to make a profit out of them. I hope that we can all subscribe to that, but I think that the situation is more nuanced than perhaps the motion makes out. For example, all GPs are independent contractors, as Dai Lloyd knows, and whilst the vast majority are completely committed to serving patients on their list, it has been known for some GPs to adjust their activity to chase particular financial incentives, either through the quality outcomes framework or by having an inappropriate relationship with a particular pharmaceutical company in order to promote a particular medicine over another cheaper one. We cannot get away from that. It is well documented and that is one of the realities that we have to bear in mind. It’s also been suggested that a hospital may be keen to prescribe medicines before a patient leaves hospital because they can make money out of the transaction even where the medicines management would be better done by the patient’s GP or local pharmacy. These tensions exist and they need managing. Hopefully, the current integrated structure of healthcare that we have, with seven health boards responsible for delivering both primary and secondary care, ought to make it easier to squeeze out such inappropriate practices. But we have to acknowledge that doesn’t always happen.

Part of the prudent healthcare principle is that services should be delivered by the person who is qualified to deliver that service and no more. That could, in principle, be delivered by a private sector organisation in some cases. Yesterday, I visited the multidisciplinary panel that is working on how to manage frequent attenders at A&E in Cardiff and the Vale. One individual had used out-of-hours, A&E or the ambulance service over 50 times in the last month, all because they’d been waiting 18 months to be seen by a psychiatrist. Another reported self-harming, including the swallowing of sharp objects, apparently to avoid having to meet his probation officer. These cases do exist, and we have to be imaginative in the way we deal with such challenges.

In some cases, those who are depressed, isolated or addicted individuals may be best served by confidence-building courses, living life to the full courses, which bring them back into the community, because their depression is related to their isolation. Those services are currently being provided by Communities First but could, in theory, be provided by a private sector company. I’m not saying they should, just that we need to at least discuss it. There have always been private companies involved in delivering mental health services in the NHS. However, there are structural drawbacks, for example, instability—the organisation may move out if their profits drop; cost—they may have to pay their shareholders; the transactional processes involved that ought to be avoided when we’re discussing the holistic provision of services by public servants; and then there’s the lack of accountability that we should all worry about. But the NHS would fall apart without private companies’ input. They provide all the equipment, build the hospitals, make the drugs and, in the IT world, the whole of primary care IT is privately run. So, there is ample evidence that alternative providers can challenge state delivery, and occasionally improve ideas, vision and relationships with the users of services, and so we have to have a broader approach to this matter.

I want to focus on the integration of social care and health, and the problems that creating a more and more patchy system would create if we were to move towards using more and more private contractors.

We’ve discussed the need to integrate health and social care on a number of occasions. There are a number of problems caused as different institutions argue over the different elements involved—for example, administrative and bureaucratic battles as to where responsibility for a patient lies and is passed from one institution to another, patients who can’t be released to the community because of a lack of facilities and community-based health services to enable people to live independently, and arguments as to who should pay for what.

Now, we more or less all agree that we need to integrate more of this and that we need an urgent debate on the issue, but one thing that would make integration more difficult would be more competitive tendering and more providers competing for profitable contracts, whilst leaving crucial services that aren’t profitable in the hands of a system that is being bled of investment. That is the risk and that’s what could happen in Wales if the UK signs trade deals that require our health and care services to open their doors to private providers.

Some people will raise the point that many private contractors already provide health and care services, but that is exactly the problem: contracting services, or tendering them out to providers of low-quality has led to a social care workforce that isn’t sufficiently remunerated, and suffers from poor working conditions. In turn, that leads to a lack of status and respect for the care sector. If we are forced to open up our health service to private providers because the English Government is ideologically committed to the private sector, and is signing trade deals on behalf of Wales, then there is a very real risk that we will lose more skills and that standards will fall further.

We’ve already seen the problems of the piecemeal system in England as a result of the Health and Social Care Act 2012. The decision to put public health responsibility in the hands of local authorities has led to an appalling decision by the NHS in England, namely, not funding the drug PrEP, which prevents the transmission of HIV and is therefore seen as a public health issue. Because of that disastrous decision to make huge cuts to local authority budgets in order to protect the NHS, expenditure on public health has fallen significantly. Public health in health systems is dominated by the private sector and that is bound to face underinvestment, because there isn’t money to be made in that area. And in seeing the emphasis shifting to treating ill-health rather than preventative services, that doesn’t make business sense, of course, because it’s more expensive, ultimately.

It is crucial that we maintain the national health service in public hands and that we keep the Conservatives and their trade deals out of Wales. Plaid Cymru will protect the national health service of Wales every step of the way.

I thank Plaid Cymru for tabling this debate today, and I’m pleased to take part. UKIP firmly believe that the NHS should forever remain in public hands and be free at the point of delivery. We’re also totally against TTIP, and campaigned heavily against it. As long as the patient is seen and diagnosed quickly, the outcome is the important factor here, as long as the service is free to the patient. Without the participation of the private sector, large sections of our health and social care sector would not function.

We wouldn’t have the most important tool in our health arsenal, the most used therapeutic intervention: medicines. The majority of our medicines are researched, developed and produced by the private sector, which contributes billions of pounds to the UK economy, employing thousands of people and providing life-saving drugs to NHS patients. In the last three years, the pharmaceutical industry in the UK has paid over £1 billion pounds towards the pharmaceutical payment regulation scheme, which improved the flow of new medicines to NHS patients, allowing patients to get access to treatments that are widely available in other European countries.

The independent contractor model is the cornerstone of our primary care sector. GPs and GP practices are private sector contractors and companies providing healthcare to NHS patients. Without the private sector, social care provision would disappear across large parts of the country, as large numbers of care homes are privately run. Without the private sector we wouldn’t have access to innovative health technologies. A proton beam therapy centre will be opening later this year, giving NHS patients access to this innovative cancer treatment. The centre, just outside Newport, is run by Proton Partners—a private company set up to bring proton beam therapy to the UK. You may have read in the press over the weekend about a new treatment for burns victims, the SkinGun, which utilises stem cells from donor skin and grows a new layer of skin on the patient, ending painful skin grafts and extensive scarring. This technology was developed by a private sector company.

It is clear to me that private involvement in the NHS is not only welcome, but necessary. For the NHS to thrive, it must be a true collaboration between the public sector, the private sector and the third sector. Patients do not care which sector provides much needed treatment, as long as it is the best available treatment and that they don’t have to pay for it. We need to abandon the dogma that equates to public sector is good, private sector is bad. Collaboration is the most important thing and patient outcomes is of paramount importance. Without the private sector our NHS wouldn’t survive, so UKIP will therefore be abstaining on Plaid’s motion this afternoon. Diolch yn fawr.

I want to focus my remarks this afternoon on the implications of new customs arrangements for the national health service and other devolved matters, because whatever our differing views on the decision to leave the customs union and leave the European single market, we can all agree, whether we were leave or remain, or nationalists or unionists, that that is going to have consequences that we haven’t had to consider for some time. It is further complicated, of course, by the fact that if we have a situation where the new UK single market and the new UK customs union is exclusively administered by the UK Government, it is complicated by the fact that the UK Government, of course, acts as the Government of England when it comes to things like health. Therefore, there will be a legitimate concern, I think we can all agree, that a health policy and a health paradigm by the UK Government will also overlap then into future customs arrangements. So, I know we’re all excited with election fever at the moment; I’m going to try and see if we can have some sort of consensus about acknowledging that, whether intentional or not, future trade agreements, if not done concurrently between the Governments of the UK, could lead, inadvertently or not, to devolved public services, including the NHS, being disadvantaged.

When TTIP—that’s been mentioned several times, of course—was being discussed, concerns were raised legitimately then. The NHS Confederation specifically had an issue with the inclusion of controversial investor-to-state settlement mechanisms, which, of course, are normal in trade deals, but the nature of these bodies are crucial in terms of protecting public services. These cases are heard in secret, in private arbitration courts, and allow corporations to sue Governments that are attempting to make decisions based on their own political mandates. Famously, when Australia introduced plain packaging for cigarettes, the tobacco company Philip Morris used an investor-to-state dispute settlement clause included in the 1993 Australia-Hong Kong investment treaty to attempt to sue the Australian Government. Ultimately, their attempt failed, but not without many years of political wrangling.

It was the Europe-wide public outcry, of course, over TTIP that led, ultimately, to the inclusion of other mechanisms. The EU’s trade deal with Canada, CETA, includes some provisions that limit the use of these powers and some exemptions for public services. Although it’s far from a perfect outcome in CETA, the public anxiety about the impact that international trade deals can have on a nation’s public services is now changing the way that trade deals are being negotiated, and that’s something we’ll have to bear in mind for if and when the UK leaves the European customs union in full.

But, as I said, any future trade deals, we can all agree, will have a major impact on Wales and on our public services in particular. Yesterday, I listened carefully to an answer given by the First Minister to a question from the Member for Neath on this matter and, frankly, I’ve got to say, it’s not good enough, I think, from our First Minister, to be saying that Wales should have a voice in future trade negotiations once we’re out of the European customs union. We can’t simply be consultees on matters that are clearly devolved and within this legislature’s jurisdiction. The logical solution, constitutionally, in my opinion, if we’re going to be outside the customs union in particular, is for the federalisation of trade so that’s a shared competence between the nations and the Governments of the UK, overseen by a UK council of Ministers and accountable to all the Parliaments of the UK. Of course, this is why several federal countries that have their own customs arrangements—that is why they have federalised international trade rather than exclusively reserved it to the centre, because there will be, invariably, an overlap. As I mentioned earlier, with the complicating factor of the UK Government acting as the English Government on devolved matters, it makes even more sense to have a UK council of Ministers to oversee our shared interests when it comes to future UK trade deals. So, anyone can have a voice, and I’d ask the Welsh Government to drop that as their demand, because, frankly, that is pathetic. I hope the Government will reconsider the ambiguity in this area, because it’ll be crucial in ensuring that our public services here are protected in a way that is democratically expressed by people and the ballot box, rather than in the interests of international profiteering.

I’d like to just briefly contribute to this Plaid Cymru debate today as a Member who serves a constituency where travelling across the border for specific specialist services is a standard occurrence, whether that be heading to Clatterbridge or Christie’s for specialist oncology treatment, Alder Hey children’s hospital in Liverpool, or even the well-established link between Betsi Cadwaladr UHB and Stoke-on-Trent hospital for major trauma treatment. As other Members have alluded to before, hospitals like Countess of Chester Hospital were set up to serve patients from both sides of the border. Without the intake from the Welsh side, hospital services in Chester would not be sustainable nor viable, and I’m proud that, under a Welsh Labour Government, our Welsh NHS has stayed true to the vision of its founder, Nye Bevan, free from marketisation and privatisation. But what’s clear is we do not exist or operate in isolation, and today’s motion rightly makes clear concern for the budgetary implications caused by the growing privatisation of the NHS in England, indeed, and the £3 billion top-down reorganisation. This greater privatisation and fragmentation doesn’t only have implications for our consequential ability to fund the NHS in Wales—health services in Wales—properly, but it also gives me cause for concern in regard to the implications for the provision and standards of services received by my constituents who travel over the border to the north-west of England.

I understand that there is a cross-border protocol that is in place between the NHS in Wales and the NHS in England, aimed at delivering high-quality care for patients who access cross-border health services, and that Welsh Government is continuing its work and co-operation with the NHS in England to address provision of healthcare in the border area. However, I have actually had highlighted with me instances from constituents where Wales-domiciled patients accessing services over the border have not been given, shall we say, for want of a better word, fair information with regard to waiting times and services by individuals and organisations in the NHS in England, and have been left sometimes feeling like the patients coming from Wales being treated in England are placed on a lower rung than those living in England accessing the same services.

So, with these agreements and funding arrangements in place, this should definitely not be the case, and just a few cases are a few cases too many. And I know that, when I’ve raised this previously in a meeting with the Cabinet Secretary, he shared my concerns on this, and, just in concluding, I would urge others and the Welsh Government that, in continuing the commitment to providing the best possible high-quality healthcare and fair funding to the people of Wales, my constituents and others accessing services in England are given the same first-class service expected as anybody else.

Thank you very much. I now call on the Cabinet Secretary for Health, Well-being and Sport, Vaughan Gething.

Thank you, Deputy Presiding Officer. I’d like to thank Members for tabling a debate on this topic, as it allows me to reiterate the continuing commitment of this Welsh Labour-led Welsh Government to the principle of a national health service that is publicly funded and free at the point of delivery. We agree with the movers of the motion. In fact, the 2009 reforms in Wales reaffirmed Nye Bevan’s founding principles by removing the market-based purchaser-provider arrangements and implementing a planned, integrated health service. And that planned and integrated service has now been identified by Simon Stevens as a way forward for the NHS in England. They are moving away from the purchaser-provider split; they’re recognising that it’s inefficient and unhelpful. The contrast, though, with the current system between Wales and England could not be clearer.

As has been mentioned already, the Health and Social Care Act 2012 for England, it sees health as a commodity, subject to procurement and competition provisions, including setting up Monitor as an economic regulator. In doing so, the UK Government of the day made an active choice to open the market on the provision of healthcare to any willing provider, including private healthcare providers. The figures quoted by Angela Burns on public spend, or rather private spend, here in Wales, equate to less than 1 per cent of the NHS budget, and both the contract services—. But we do not parcel those services off. But you see that in wholesale transfers within the English system: from non-emergency ambulance services to sexual health services in England, these are being parcelled out wholesale to private providers. That has not, and that will not, happen here in Wales.

It is undeniable that the 2012 Act has led to increasing privatisation in England. The Department of Health accounts for 2015-16 showed the private sector delivered over £8.7 billion of NHS services, or over 7.5 per cent of the NHS budget in England. And that creeping privatisation does have significant consequences, including increased legal and transaction costs within the English system with private companies, but also NHS providers taking court action if they lose out on a procurement exercise for contracting services, and also the points that Rhun ap Iorwerth, Julie Morgan—or rather Jenny Rathbone—and others have made about the impact on the budget here in Wales as well.

And we should be concerned about a more insurance-based system too. It does involve upfront payments for basic care. For example, in Ireland, if you want to see a general practitioner, you can expect to pay upwards of €50 just to have the consultation, and then there’s a real fee to pay for the medication as well. It changes the way people behave and their access to high-quality medication. It changes the trust in those people as well. I think that, if we are going to see political will maintained—to actually reiterate the truth that a publicly-funded national health service is good value for money and sustainable, if there is a political will to invest in our public services. That does require a significant change in approach from the United Kingdom Government.

But, despite the undeniable privatisation in England, the Welsh Government continues to take a pragmatic approach to cross-border flows, as outlined by a number of speakers in this debate, including Hannah Blythyn just before me. We will continue to focus on providing the best care for all of those who need it. Of course, our approach to collaboration between the Welsh and English health services focuses on the needs of our respective populations. A slight disagreement with the good Dr Lloyd, but I understand there are more than 20,800 English residents registered with a Welsh GP, but well over 14,000 Welsh residents registered with an English GP—the reality of cross-border flows. And, of course, we see those in specialist healthcare between Wales and England and from England to Wales. Hannah Blythyn outlined those flows from her constituents into north-west England, but, of course, as Dai Lloyd mentioned, Morriston hospital—the burns unit—is a specialist centre not just for Wales but also the south-west of England. Velindre cancer centre in Cardiff provides specialist cancer services to most of Wales, as well as treating patients referred in from England as well. The flows go in both directions. We do want to see that being maintained. Our aim, as a Government, is to ensure that all patients receive high-quality healthcare at the right time and in the right place. Sometimes, those will be services provided across the border in England. Other times, it will be here, the service in Wales. There are long-established patient flows into England for some hospital-based care for people living in the east of our country. Local health boards do have the flexibility to refer patients out of their area for treatment where a patient’s clinical need and circumstances justify it, or where services are not provided here in Wales.

Now, turning to the point made in the motion about the European Union, we recognise that a majority of the people of Wales voted to leave. We’ve been clear that that democratic decision will be respected. However, we do not believe that the people of Wales voted to be worse off, to see harm done to our economy or to our public services. So, we’re determined to secure a positive future for Wales in a post-Brexit world, and we’ve been clear that our priority for the future relationship of the European Union is full and unfettered access to the single market. We set out our broader position in detail in the joint White Paper with Plaid Cymru. The Welsh Government will continue to—.

I thank the Cabinet Secretary for giving way. I know he’s repeating the line on the single market, but specifically in my contribution I asked about customs arrangements and the UK Government’s signal intention at least to partially withdraw from the European Union Customs Union. Therefore, with that in mind, what, as a Cabinet Secretary in the Welsh Government, is your view of future arrangements for trade deals? Do you want your Government to have a full voice that is meaningful at a UK level in future trade deals in order to protect public services, or do you simply want to be a consultee in that process?

Well, you’ve heard the First Minister set out our position on a number of occasions about the relationship with the customs union in relation to having a joint ministerial committee to take those matters forward. We do need a proper voice for Wales in the future, and we will continue to set our priority for the exit and future trade deals through a joint ministerial committee. We’ve also been clear that, under the devolution settlement, any powers in devolved fields currently held at European Union level must be exercised at devolved level. And, unless there’s clear and unequivocally an agreed reason for them to be exercised by the UK Government, those powers must come to this place first without flowing through the UK Government. Any other position simply will not be acceptable.

Turning to some of the comments made, just, I think, clarifying some of the misunderstanding about what happens within the health service here in Wales, and the comments made by the UKIP spokesperson, because I think that the reference to a private involvement in the national health service gets us a significant distance away from privatisation that we do understand—. It’s not difficult to understand the distinction and the difference. Neither I nor the movers of this motion say that we should try and remove those people in the private sector who developed medical goods, medical equipment, medical devices, or all the other forms of treatment and improvement that we see our national health service taking advantage of. That is a significant distance from the reality of privatisation, of course. The current UK leader of what is left of UKIP has, on many occasions in the past, stated his belief that the national health service is a barrier and impediment to competition, and he would see it downgraded and removed.

We do not support the Conservative amendment, which is a fairly obvious attempt to remove reference to Tory privatisation in England. This Welsh Government is committed to a high-quality national health service in public hands, and I am proud to say that we will continue to stand up for Wales and we will continue to stand up for the national health service.

Thank you very much. I call on Rhun ap Iorwerth to reply to the debate.

Thank you very much, Deputy Presiding Officer, and thank you to everyone who has contributed today. The purpose of this debate and the purpose of the motion is clear and very simple, I believe. I think that the Conservatives are eager to transfer more powers and funding for the health service to the private sector. The evidence shows that. The figures—. The 8 per cent of the budget going to the private sector excludes the third sector, by the way. But even if the Conservatives can’t influence directly the policy on the NHS in Wales, their decisions, in terms of expenditure by their party in London, do have a direct impact on us. I hope that we have been able to explain that today.

On top of that, of course—and while I welcome the support of Labour to this motion—the failings of the Labour Welsh Government to maintain services of the standard that the staff of the NHS in Wales and patients deserve do push more people towards the private sector. We had a speech from Angela Burns saying that Plaid Cymru shouldn’t be narrow minded and oppose cross-border services. Now, I’m not entirely sure where she got that from. I certainly didn’t mention that. The motion before me here doesn’t mention that, and, indeed, Dr Dai Lloyd, in his speech, emphasised how good cross-border services are working in both directions. I’ll give you an opportunity if you want to explain exactly why you went along that path, but otherwise, I will continue. She talked about excellent services in Southampton. Now, I would send my child to the moon for the best service, and I would take it as a personal insult if you were to suggest that I would prefer no service rather than a service outwith Wales. You’re the one who is talking nonsense by suggesting such a thing for the patients of Wales.

But—and I very much hope that the Conservatives would agree with me on this—the underperformance of the NHS here or any privatisation agenda should not undermine the services that we should be able to expect to receive and to be provided in Wales. And, in looking at your list, in your amendment, of services that you believe that we should recognise as being in England, do you genuinely believe that we should sit back and accept that children with mental health issues can’t be treated close to home? In Mental Health Awareness Week—[Interruption.] The Member says that she didn’t say that. Well, I will read from your motion: that the Assembly should acknowledge the dependency Welsh patients have on specialist services in England’, including ‘child mental health services’. If you believe that we should sit back and accept that during mental health awareness week, then shame on you. I’m afraid that the threat posed by the Conservatives is clear. Support the motion today.

Thank you very much. The proposal is to agree the motion without amendment. Does any Member object? [Objection.] Therefore, we will defer voting under this item until voting time.

Voting deferred until voting time.