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.