The next item is a statement by the Cabinet Secretary for Health and Social Services: 'The Chief Medical Officer's Annual Report 2016-17'. I call on the Cabinet Secretary to make the statement—Vaughan Gething.

Thank you, Deputy Presiding Officer. I welcome the publication of the second annual report by Dr Frank Atherton, the Chief Medical Officer for Wales, covering the period 2016-17. I'd like to thank Dr Atherton for his assessment of our progress in improving and protecting the health of the nation, his insights into emerging threats to public health, and his considered thoughts on actions needed to deal with them effectively. 

It is reassuring to read of the consolidation of a number of public health gains and ongoing improvements in a number of areas. At a time when outside commentators too easily make sweeping and ill-informed statements about the quality of our NHS, it's helpful to remind ourselves in an authoritative CMO report of some of some of the concrete facts about the state of health and healthcare here in Wales. 

The report outlines that overall life expectancy in Wales continues to rise, up to 78.4 for males and 82.3 years for women. Most adults report good general health, with over 72 per cent of over-16s reportedly in 'good' or 'very good' health. And our infant mortality rate, at 3.7 per 1,000, remains low in historical terms.

As we have rehearsed many times on the floor of this Chamber, there are many factors impacting on the health of the nation. High-quality healthcare is of course one of them, but there are a broad range of social determinants, such as housing, education, quality employment and the environment, that play an even bigger part. There are also a significant number of public health threats each year, and Dr Atherton's report highlights significant achievements in dealing with these. One of the examples it cites includes the impact of the introduction of the all-Wales hepatitis C treatment roll-out programme. The success of this programme has meant that, in Wales, we have now treated, or are giving treatment to, all of the patients that are known to, and have accepted referral to, hepatology services and are still accessing care, or, to put it more simply, we are ahead of every other UK nation in the treatment and the hopeful elimination of hepatitis C. That is a cause for recognition and thanks to that group of clinicians leading that work. 

It also refers to individuals infected with HIV benefitting from anti-retroviral therapies so that they lead the most healthy of lives. It notes the number of new diagnoses of HIV in any one year now being on a downward trend, and the number of individuals testing annually increasing. The importance of testing is crucial now that pre-exposure prophylaxis or PREP is available to all those for whom it is clinically indicated. I do look forward to the results of that PREP trial in due course as we roll through a genuinely nationwide trial.

The report also sets out priority actions for our seasonal flu and childhood immunisation programmes, which will be necessary to deliver to ensure that those programmes remain the envy of the world.

While communicable disease may be regarded a traditional public health threat, Dr Atherton also uses his report to shine a spotlight on the emerging public health risk of problem gambling. He focuses on the harm that can be caused by gambling, not just to individual gamblers but also family, friends and to society as a whole; harm that can include financial hardship, psychological distress, and the breakdown of personal relationships.   

The report sets out the prevalence of gambling. The UK has the tenth highest gambling spend per capita in the world. In Wales, 61 per cent of adults have gambled in the past 12 months: 63 per cent of men and 59 per cent of women. It is estimated that, each week across England and Wales, 450,000 children aged between 11 and 15 are involved in some form of gambling. That equates to 16 per cent of that age group; 1.1 per cent of our population self-report as having a problem with gambling and a further 3.8 per cent of people in Wales are estimated to be at risk of problem gambling. The report also highlights that the harm caused by gambling is unequal in its distribution. People who are economically inactive and live in deprived areas are more likely to suffer most harm.

Dr Atherton comments on the evolving nature of the gambling industry, its marketing and its products. Gambling is no longer solely taking place within traditional physical premises like arcades, bingo halls or racing tracks. The fastest growing method of gambling is of course online betting, with 24-hour availability, accessed through computers, mobiles or tablets. In the UK, nearly 9 million adults have gambled online in the last four weeks. In Wales, 9.2 per cent of online gamblers surveyed were identified as being problem gamblers. 

Dr Atherton sets out the case for a public health approach to deal with gambling—an approach that seeks to address the inequity of harm. He calls for a range of actions to reduce harm that do not just focus on individuals but also a wide range of measures, including advocacy, information, regulation and appropriate prohibition in a co-ordinated way. In doing so, Dr Atherton recognises that gambling is primarily regulated at a UK Government level, with a number of UK bodies having responsibility for different aspects of gambling. An effective response to the harms caused by gambling will require a co-ordinated response.

I know that a number of Members in this place have taken a very active interest in the issue of problem gambling and the need to both support problem gamblers, as well as to deal with the prevalence and the ease of gambling. You will no doubt join with me in welcoming this thoughtful report drawing attention to the risks and making recommendations for action. I'll certainly be joining Dr Atherton and relevant stakeholders to consider how we best take forward those recommendations, not only through our calls for effective action at a UK level; in addition, we will look to use any new powers in Wales in a sensible and proportionate way to reduce the harms caused by problem gambling. I look forward to answering Members' questions. Thank you. 

Cabinet Secretary, thank you very much for bringing forward this statement about the chief medical officer's report. I do welcome this report today. I believe it clearly lays bare the challenges of ensuring that we all age well. It's great news to see the increases in longevity—I, for one, am very grateful to see that—but we must also recognise that over a quarter of the Welsh population will be over 65 in 20 years' time; that's a quarter of our population. And I would like to ensure that today's plans recognise that, so, Cabinet Secretary, I wonder how will you ensure that health and social care services will be delivered fit for a quarter of our population going further forward, especially when we hear things such as the Welsh Local Government Association and the Association of Directors of Social Services saying that the key determinants of health are largely outside the control of health services, and so the quality of and spending on social care has to have one of the greatest demands on healthcare.

It's also very good news to see the improvements in cardiovascular diseases and neonatal disorders, and I also recognise the very good work that's been done on hepatitis C. But Welsh Government does need to get to grips, according to the CMO's report, with the stasis that we see in cancer outcomes. And so, Cabinet Secretary, I ask what you might have up your sleeve to help us improve that, because those figures—the dailies on cancer outcomes—have not changed significantly for over a decade. 

The points made by the chief medical officer on gambling are pertinent and, I believe, well made, and I for one cannot understand why we are allowing this canker to develop. In fact, I'd like to pay tribute to Darren Millar because he raised a short debate on this issue back in July 2017, which called for greater restrictions on gambling advertising and fixed-term betting terminals, and I know that this has cross-party support. The then Minister for public health, Rebecca Evans, stated that Public Health Wales were commissioning research to map out all the gambling venues in Wales. An update on progress in this regard would be most welcome, and I wonder if perhaps you might be able to address your intention in that area. 

Although there are other issues and comments, I'd like to finish with the CMO's commentary on protecting the public from health threats and, indeed, staff from health threats. Seasonal influenza is one of the biggest winter pressure threats. It lays siege to GP surgeries and A&Es, and I've tried to get guidance from the British Medical Association as to what can be done to increase the numbers not just of doctors, nurses and healthcare workers, but other healthcare professionals, to take up flu vaccines. The public need galvanising but so, Cabinet Secretary, do the public sector workers. Is there any ability for Welsh Government to look at guidance, statutory or otherwise, for health and care workers to receive the flu vaccine? Because you yourself refer to our seasonal flu vaccination as being an envy of the world, and yet that is in direct contradiction to evidence we hear in the Health and Social Care Committee, and we do know that seasonal flu is one of those great winter pressures. If everybody in this Chamber, all our staff, the public and those who work in the public sector were to have the flu vaccine, it would help with that enormous pressure on our NHS, and I'd be very grateful for your thoughts on how we might increase the uptake. Thank you.        

I'll happily deal with that last point first. I welcome the fact that there's a recognition of the importance of the seasonal flu campaign, and part of the strength of that is that it is genuinely seen as cross-party. There are plenty of things that we argue about in this place between parties; this isn't one of them. We want to have more members of the public in at-risk groups taking up the opportunity to have the flu jab on the NHS, but also to think about those workers working with people who are by definition vulnerable, and in health and social care in particular. It's one of the things that I've concentrated on. Rebecca Evans, in her then role as Minister for public health, had a particular focus at the start of this flu season on trying to make sure that more public service workers who should have the flu jab actually take it up.

We have some challenges here, though, that we should honestly recognise. Part of that is that, actually, even though we think there should be some professional responsibility on people to do this and there is an interest for people in the social care sector from a business continuity point of view to ensure that their staff can come in to work as well as make sure that they don't impact on the people they're caring for, within social care and within the health service, it's quite difficult to say, 'You must' and in particular to say, 'You must have the flu jab.' 

There's still a conversation about how we have even more uptake. This year, I've been encouraged, comparing this year to last year—and I won't take credit for this year's campaign because, as I say, Rebecca Evans was the Minister at the start of this—we've had an increase in uptake amongst our staff. We still need to do more and more and more to try and make sure that staff realise that it's a good thing for them and the people they care for to continue not just to have the flu jab but to have it in greater numbers as well so that it becomes something that is accepted culturally rather than us having to fight to persuade people to actually have the flu jab. Some of the myths about this year's vaccine not being effective—that gets said almost every year, and yet we know it is the best front-line protection against the flu, which has serious consequences for a whole range of vulnerable people, from neonates to the very old and everyone in between.

On your point about an ageing population, again, the report highlights figures given in other reports, including the parliamentary review and the previous Nuffield and Health Foundation work about the rise in the age of our population, and in particular the proportion of our population who will be over 65 and over 75 and the increasing demand in health and in social care in particular. Part of our challenge is that, as we make budget choices—again, that we will debate, discuss and, no doubt disagree with—whatever the sum we have and whether or not it's through times of austerity when our overall budget is decreasing, we have to make a choice about what we put into each area. At the moment that means that we have a real challenge in matching the demand in health and in social care.

We've actually met the health challenge in the way that Nuffield and the Health Foundation suggested we needed to. So, we've met that particular part of it, but social care is part of our real concern, highlighted again by the parliamentary review. That's why I think it's particularly important that we're prepared to engage in—. The debate on austerity is difficult because we take entirely different views about it, but on the debate around what we do in the medium term, there should, I hope, be an opportunity within this place and outside it to try and engage in the conversation about the social care levy proposed by Gerry Holtham. I think it's well worth pursuing because, if we're going to have a long-term funding answer, 'as we are now' isn't going to get us there, and it will be every single constituency, every single community that will be affected. If we can't resolve the longer term funding challenge for social care, we will have lots and lots of our older citizens, who we all want to see cared for with dignity—we'll find ourselves in a completely compromised position. So, it's in all of our interests to reach there.

There's something here for each party to do on that and for us to demonstrate some leadership on, but also it's a conversation with the UK Government as well. It doesn't matter what shade the UK Government is. I hope it's a different colour in the near future, but in any event the UK Government have to be part of the conversation because what we cannot get into is that if we introduce a social care levy and people then receive money to pay for their social care out of, if it works, if all those things happen, if the Treasury then say, 'Actually, that's effectively income', that will then affect people's ability to have income from other benefits as well. That's a really serious point, so the work that Dilnot and others have done—we have to get back to that and we have to make sure that our colleagues in the UK Parliament are prepared to have, again, a sensible and grown-up conversation about this too, because this is an issue for Wales, but it's absolutely an issue across the United Kingdom too.

On cancer outcomes, actually, on survivorship, we have a good story to tell. We've had statistically significant and material increases in survivorship. One-year survival is now at 73 per cent; five-year survival is at 57 per cent. But our challenge is that when we look at ourselves and England, for example, we actually have statistically similar survivorship rates between Wales and England, and you would actually not expect that to be the case, because the English population is healthier and wealthier. You'd expect the cancer survivorship rates to be materially different, but they're not. And there's something there to celebrate, actually, from Wales's point of view—that we're not seeing a statistical difference in Wales's and England's survivorship rates. But actually the bigger challenge isn't to say, 'We're not any worse than England' or 'We're as good as England'; it's actually to say that, on an international basis, when you look at other countries across Europe, every single nation in the UK doesn't do well enough at all. So, we actually still have a significant step forward to make in any event, and that's our challenge. Otherwise, we'll just persuade ourselves to narrow down our ambition and where we should be.

So, that's why I'm interested in the single pathway. It'll change the way that cancer is measured. We've got further work being done on that. It's also about the point about early diagnosis. It's also why we have this conversation about drugs and effective medication being available. It's why some of the debate has been about a cancer drugs fund and why we have a new treatment fund that is evidence based. But, in particular, for curative options, you're talking about surgery and radiotherapy, and we hardly ever talk about those when we talk or have a debate about improving cancer outcomes; we almost always talk about diagnostics and medication. So, actually, we need to spend more time and focus on that.

And on the work about gambling, the CMO is leading work on gambling with a group of stakeholders, and I'll be more than happy—some Members have asked for a meeting with the CMO, and I'll be more than happy to provide an update in this place or in writing. And, of course, when the CMO comes to the health committee—I think he normally does; I'm just looking at the Chair—I'm sure that he'll be happy to set out more detail on the work that is already in train and proposals to use the powers that will come to Wales in April of this year.

Thank you to the Cabinet Secretary for his statement. I will also note my thanks to the chief medical officer, Dr Frank Atherton, for his second report. It’s important, despite that, that I draw attention to the fact that we’re having a statement here today on this report, while in the past, including last year, we had debates on the report of the chief medical officer. I would encourage the Government to return to that practice and not let the political balance here and the fragility of that balance to decide in what way important matters with regard to health in our nation are discussed here at the Assembly.

We could go into several different areas, almost any area with regard to health in Wales here, as a result of this report. I will keep to what has been mentioned in the statement itself by the Cabinet Secretary today.

The statement has noted there are many factors that influence public health. That has been discussed several time here. But possibly these reports and what we’ve heard from the Government in general could give greater clarity for us about the true effect that austerity and expenditure decisions in areas separate to health can have on health outcomes. Cuts to social care, housing and so on are cuts to the health service in general as well and I would ask for ways of having an evaluation to measure exactly what the effects of those cuts are on the health service in future.

I will move to the main body of the statement today, which is on gambling. The report does shed light on the problems that are caused by people becoming addicted to gambling and it notes the progress with regard to betting advertisements on television. We are aware of the hypocrisy of the football association in England banning players from gambling on games whilst drawing a great deal of sponsorship from gambling companies.

Your statement, Cabinet Secretary, says that you regret that gambling is being regulated at a British level. I would agree that, when something is regulated at a UK level, that should be the cause of regret because very often it means that regulation happens for the benefit of industry rather than the benefit of the public. I would hope that that’s something that we could look at in Wales in future. But, there are some things that the Government could do. The chief medical officer’s report notes that the Wales Act does give powers for Welsh Ministers with regard to fixed-odds betting terminals to decrease the highest stake from £100 to £10 in B2 categories. I would ask whether you will do that. Is that something that you would wish to do?

Also, there are powers available to local government with regard to giving planning consent for the change of use of shops to betting shops. Research here with regard to discussions on a potential Bill has found that several local authorities are very careful and are concerned about using the powers that they have to increase the number of betting shops, in case of legal steps that might be taken against them. Will you ask the Cabinet Secretary for local government to give greater clarity and certainty for local authorities who want to take steps to prevent the increase that there has been in the number of betting shops?

I will finish, if I may, by referring to what you said about hepatitis C. As one of the champions of the issues related to hepatitis C in the Chamber—I and many other Members—it’s good to see that Wales is in the vanguard in this area. Very often, the situation that we face is finding those people who have hepatitis C—finding enough patients to go through our system. It’s a good problem to have, but it is an issue that we need to solve. May I take this opportunity—and I often find, as do other Members, an opportunity to do this—to press you to make a statement today, perhaps, to be even more ambitious with regard to the need to move forward with getting rid of hepatitis C in Wales?

Thank you for the comments and the questions. I note everyone's preference to have a debate not a statement, although, actually, to be fair, statements provide more questions from Ministers to answer and more scrutiny in that sense, but these are choices that are made.

I broadly share your concern about the impact of austerity on health and health outcomes. I think both Dai Lloyd and Simon Thomas from your party have also indicated their concern and interest in reports and studies that have been done trying to look at the impact of different changes driven by austerity to welfare benefits, for example, and in physical and mental health outcomes as well. They're things that we should continue to be cognisant of—the evidence over and our ability and our choices in what we choose to do in running the health and care system here in Wales and recognising the different drivers of healthcare need in the country.

On your three substantive points about fixed-odds betting terminals and also, then, planning, public health, betting shops and hepatitis C—. On fixed-odds betting terminals, the UK Government are out to consultation on this issue, and one of the proposals is that they could actually reduce the maximum stake down to £2. Now, actually, we think that would be a good thing to do, and the chief medical officer has submitted evidence to that effect as part of that consultation. The odd thing is, we're about to get powers in April that will allow this place to reduce the maximum amount—you might want to give local authorities the power to reduce it to £10. So, if we got to the point where we reduce it to £10, there's a potential opportunity to reduce it to £2. Actually, if we're clear that the UK Government are going to act in that way, I think that would be preferable. It would be a consistent system across the UK, and we could indicate that in itself. If that isn't going to happen, then we will of course look to use our powers here in any event. We ought to be really clear about—. There's very clear advice from the chief medical officer about wanting to take a deliberately proactive approach in this area, and I'm sure that I—whether it's me or another Member of this Chamber who's in this particular role—will want to take this seriously and take appropriate action.

On betting shops and priority health impact, there's a broader context—not just about betting shops but a range of public health considerations in planning. I'm quite open-minded about how we could do that, but we need to have a conversation across the Government about the planning policy and governance that we currently have—from a national perspective as well as that in place in local authorities. But we should certainly be prepared to again be led by evidence on what we could and should do to deliver a greater public health benefit.

On hepatitis C, I know that you, Angela Burns, and Julie Morgan and others have raised the progress that is being made, and, again, I welcome the fact it's been highlighted in the CMO's report about what they're actually doing on hepatitis C. We have a genuine national approach that—. It was really interesting and I've actually—. I don't always read journals and medical publications, but there was real praise for the approach that's been taken here, in professions in England and in Scotland too. They like what we're doing and, in fact, people in England would rather like to have a generally nationally joined-up approach, where they're looking at the most effective medication and not always the most expensive, but it's delivering the real benefit. It's the next stage in eradication in terms of getting to those people who're the hardest to reach, and that, I think, is the point you're making: how do we get to those people who either don't present to healthcare services, present infrequently, or are living chaotic lives, and, actually, even if they may want to, how do you maintain a link with them to actually deal with the challenges that they have?

As I set out in a previous statement in this place, we think we're in a good place to carry on making further progress. The ambition remains, though, that we want to be a country that eradicates hepatitis C. We're now at the more difficult end, and it's the best problem to have, but I'm confident that we'll continue to make further progress, and, indeed, whatever progress we do make, we'll update this place and the committee as to the progress that is being made by staff within our national health service.

Cabinet Secretary, I do welcome the chief medical officer's annual report, and I welcome the focus on the adverse impact of gambling on public health.

Dr Atherton, our CMO for Wales points to the fact that gambling has great potential to cause harm to individuals, families and society and he calls for better research and monitoring of the impact of gambling on health and for greater regulatory control in Wales and the UK, and you've been answering questions on that point. But last year, I co-sponsored research undertaken by the University of South Wales for a report, 'An investigation of the social impact of problem gambling in Wales', with Jayne Bryant, Mick Antoniw, Ken Skates and Lesley Griffiths. Alongside this, do you welcome the research undertaken by Citizens Advice Cardiff and Vale on gambling disorders and gambling-related harm, and welcome the conference that they're holding on 23 March to consider the findings and the way forward? I would invite you, or, indeed, an official to attend that event, which I'm addressing.

I also welcome the case studies in the CMO's report taken from Citizens Advice. Do you agree that advice services are playing a vital role in supporting people who fall into debt and distress as a result of gambling? If you're minded to accept the recommendations in the CMO's report, will you draw on the expertise of third sector organisations like Citizens Advice in producing an action plan on this issue? And do you recognise that this needs to be tackled at all levels of Government, but also needs to involve those at the front line supporting people affected by what can be a drastically negative impact of gambling?

I thank you for those brief comments and points. I'm interested in the work being done by Citizens Advice here in Cardiff and Vale to understand the scale of the problem with gambling in this particular part of Wales. On the event on 23 March, I won't give a commitment without having checked my diary—I've been told off about that before, about giving commitments and then not understanding whether I can do them or not—but to look at the event on 23 March. I would be interested, if I'm not able to attend, in whether we can have someone there from Welsh Government to understand the nature of the report and the evidence that's been collected, and what that looks like.

So, that leads into your second point about advice services, not just Citizens Advice, but a range of other organisations, a number of which are mentioned in the report. They are really important in helping people to try and get through problem gambling and understanding where it gets picked up and how people are supported. That's not just about financial advice, but a whole range of other impacts that problem gambling can have. And that, absolutely, is part of the work that the CMO and stakeholders are considering in actually having a response to the problem of gambling and its public health impact. So, I think the points are well made, and in coming back to this place to have an update on that, I'm sure that'll be part of what we'll want to cover in doing so.

Thank you for your statement, Cabinet Secretary, and I would like to add my thanks to Dr Atherton for his second annual report as chief medical officer. I'm pleased that Dr Atherton has opted to use his annual reports to shine a spotlight on growing public health challenges. Last year, he singled out the health inequalities that exist between those living in our most and least deprived areas, and this year he has focused on gambling.

When you consider the major public health challenges facing our nation, such as obesity and drug, alcohol and tobacco addiction, these are well known and well understood. Problem gambling, or rather the public health implications of problem gambling, aren’t as well understood. Whilst there have always been problem gamblers, we are starting to see them in greater numbers. It is therefore welcome that Dr Atherton has drawn attention to this issue now.

In 2005, the Labour Government, under Tony Blair’s stewardship, undertook the biggest deregulation of gambling our nation has seen. This led to an explosion in online betting. With tv ads for gambling now permitted, you can’t escape prime-time adverts for online casinos and bingo.

It is now much easier than ever before for young people to gamble. A recent Gambling Commission survey found an increase in students who gamble, with two out of three gambling, many online. This finding led the Gambling Commission to produce advice to universities, encouraging them to provide information and support about potential gambling-related harm to their students—much as they do for drugs, alcohol, and safer sex.

As Dr Atherton highlights, 1.5 million of us gambled in the past 12 months. Whilst there is nothing wrong with the occasional flutter on the grand national, or buying a lottery ticket once in a while, the sheer ease of access makes it easier for gambling to become problem gambling.

I welcome Dr Atherton’s recommendations for the need to conduct further research. We need to fully understand the risks and the harms, and develop evidence-based policy that balances the social benefits of gambling against the harms related to problem gambling. Cabinet Secretary, could you outline what action you are taking to implement Dr Atherton’s recommendation for further research into the impact of problem gambling? How do you intend to balance the need to take action to target problem gambling without impacting on an adult’s ability to gamble responsibly? Finally, Cabinet Secretary, how will you involve the Assembly in the development of an evidence-based policy approach on tackling problem gambling?

Thank you once again for your statement and to Dr Atherton for his latest report. I look forward to working with you to develop a balanced approach to this and other emerging public health issues. Diolch yn fawr. Thank you.

Thank you for the comments and questions. On the overall point—the liberalisation of gambling—that's something that we have all recognised: that, actually, the growth in online gambling, in particular, is causing real challenges for us. For all the exhortation encouraging people to be responsible gamblers and encouraging the industry to be more responsible, actually, it hasn't led to the sort of shifts in behaviour that we'd want to see, and that's why I think, even within the UK Government, which instinctively wants to encourage people to act in industry, as opposed to having, if you like, a regulatory approach, they are shifting their own views. Certainly, the fixed-odds betting terminal issue is a good example of where they are now consulting and, actually, regulating a very different approach, because they recognise the harm that's being done. This is a completely liberalised area, with very significant harms that can be done in a very quick period of time. So, there is some awareness, but we will need to think about how we can actively use our powers here in Wales.

That's why, as I've indicated earlier, the chief medical officer is leading work with stakeholders to look at what we can do, what we should do, both in the here and now, and also looking ahead to the powers that we'll acquire in April of this year. Indeed, you've heard in the statement and the questions already today about the research Jane Hutt referred to that Citizens Advice are doing in Cardiff and Vale. There's a range of other people who are undertaking their own research, anecdotally and more generally, about the problems they're seeing coming through their doors—some of those are mentioned in the report as well—in addition to the research that was undertaken by five Members in this place. Jane Hutt was one of them, and Mick Antoniw and Jayne Bryant—the three that are in the Chamber now. That research matters, highlighting the challenge that we have, the scale of it, and the need for not just a policy response, but a practical one too. So, as I've said on a number of occasions, I actually expect to come back to this place to update Members on the work of that group and the concrete action that we expect to be able to take here in Wales.

Cabinet Secretary, I won't go over many of the points that have been covered on the gambling issue. Can I just say, first of all, you'll remember the individual Members' debate we had here in 2013—I think this Assembly is one of the first of the Parliaments to actually have a detailed, thorough debate on the issue of the emerging problem of growing gambling? In fact, it was that debate—when people say, 'Well, what do these debates mean?'—that actually led, in the Wales Act, to at least some devolution of powers in respect of fixed-odd betting machines. Unfortunately, it didn't attract the sort of attention that occurred later on, but I think it's fair to say that this Assembly has led the way, actually, in identifying and looking at ways in which gambling could be dealt with as a public health issue. 

What's important about this report as well is that almost half of it—17 pages of it —deals with what is identified as an emerging public health challenge, and this is the thing that we've had in the various debates in this particular Assembly. And it's a very good report, because it also, in terms of establishing a task and finish group in terms of the need for more research—. You'll recall that all that research was stopped in 2010, so that the actual data we have has been limited until the work that was done in terms of the report that Jane Hutt and myself and others funded. But this gives us an opportunity now to do proper analysis, proper investigation, into the actual scale of the problem. Very importantly, what is identified is that whatever work is done has to be free of the influence of the tobacco industry—I beg your pardon, the gambling industry; that's another issue—an industry that has ploughed money into research, but has a stranglehold over that research, the direction it has, and research that seems to go around in circles for decades. So, it's very important that we are independent of that.

Can I also say one other thing? Of course, many of us have been watching some of the recent sporting successes of Welsh soccer teams, and of course Spurs are playing Newport tomorrow night. There may even be Assembly Members who will be at that very game. But I raise the point not to diminish anyone's enthusiasm for their local team, but because of the stranglehold that gambling now has over sport: the identification in people's minds of sport, of soccer, of whole varieties of sports, with gambling. Those of us who will watch that game that night will see, around all the ground now, all the gambling adverts. We will see the texts that come on the phones, the stuff that comes onto online and so on. And whatever capacity we have—we can do some things on fixed-odd betting machines, we can do stuff in terms of our planning powers—I think we also have to look at our association with sport within Wales in terms of how we actually tackle and ensure that there isn't that growth of gambling advertising taking place, and that we also engage with Westminster over the fact that, having identified a public health issue, we actually need the powers to be able to deal with it. One of the problems, of course, with the Wales Act is it limits the capacity we might have had in certain areas of gambling as a public health issue—

Are you coming to a question?

—but we have to ensure that we do have the ability to deal with those issues.

Thank you, and I want to start by recognising the consistent concern that Mick Antoniw has expressed in this particular area, as well as generally across parties. The evidence on the scale of the problem and what our most effective response is is really important. I recognise we have some evidence and a building picture, but to move beyond anecdote to understand not just the survey evidence, but then to that point about the challenge and what is the most effective response if you would like a treatment response if someone presents as being a problem gambler, and the report recognises that we don't yet, in this area, have an effective consensus on what the right response is, because, actually, it's unlikely to be a pharmaceutical intervention.

This is more about the field of talking and supporting people, and that in itself is challenging, about understanding what is the right sort of intervention. The report looks at brief interventions, it looks at work that we're doing. We want to get involved with the National Institute for Health and Care Excellence, for example, on work that they recognise they need to develop in this area to support health and care services for people who do have problems with gambling. But in particular, I do recognise your particular point at the end, not just about—. Almost all of us in this place, I'm sure, will wish Newport well against Spurs. I recognise the Member's longstanding loyalty is in a different direction.

But this point about advertising, and the ubiquitous nature of advertising—so many different events. It is hard to ignore. If you think back about where we are now with sport, it wasn't that long ago that alcohol was advertised in sport in a way that was—. It was odd, wasn't it? Almost as if you were being encouraged to drink lots, whilst you were at a sporting game, and to look at the physical activity and prowess of people on the pitch. And before that, tobacco was regularly associated with advertising all sorts of sporting events. Fast food still is. Even fast food, they are looking to change it. There is still a challenge about all these different areas of activity and their willingness to be associated with sport, because they recognise the power of sport and advertising and what it can do for their products. So, as the report recognises at point 6.4 in the chief medical officer's report, there is a need to look at controls on advertising of gambling. That is something we do need to continue to have conversations with the UK Government about.

I also welcome this report, particularly the section dealing with gambling. Without rehearsing what's already been said, I do note that the report states that the cost of addictive gambling to public services in Wales is around the £40 million to £70 million mark per annum, because of the impact on the health service and care services particularly. I share the concerns clearly expressed by many Members on the way that gambling and gambling advertising have permeated into the normality of everyday life, so that it's appeared recently on children's sports shirts, emulating some well-known football teams.

One thing I particularly wanted to ask the Government on is the comment made that research into this area is done, to all intents and purposes, by the industry itself, by GambleAware. But, GambleAware has been under the influence of the industry. They have tried, I think, to re-establish themselves to be more independent, but it strikes me that what we need is something similar to a levy on the industry, where you could have complete independence and funding could be provided, not only for research into gambling, but also to mitigate some of the unfortunate and detrimental impacts of gambling. That's not a power in the hands of the Cabinet Secretary, but I wanted to ask, is that the view of the Welsh Government: that they would want to see a levy of that kind, and that they would work and put pressure on the Westminster Government to introduce such a levy.

And the second element of the report, which I believe is important, is the fact that, once again, the chief medical officer has outlined the impact of air pollution on society and the impacts of that—2,700 premature deaths because of air pollution. I would like to know exactly where air pollution sits now within the range of causes of premature deaths in Wales. It's around third, or even second, in terms of the reasons now. I know that the Government is doing some things to tackle the issue, but the problem is that this is disseminated between Government and local authorities. The local authorities are specifically responsible for monitoring and tracking and then putting particular zones in place, and this Government is facing a court case because some of those steps have failed recently. So, specifically, and in looking at the costs and health impacts of air pollution, will the Welsh Government be taking a further step on a national level now to ensure that all schools have an air pollution monitoring unit outside the school, so that we have a better understanding of the true impact of air pollution, and that we have a national strategy to tackle the health problems emerging from air pollution?

Thank you for those comments and points. I'll deal with your points about air pollution first, if I may. As you know, air pollution, the lead for this across Government is Hannah Blythyn, the environment Minister, but the points that you raise recognise that it's an issue that has an impact right across a range of departments. There is clearly a public health impact. If you're talking about monitoring in and around schools, then I'm sure that the education Secretary will want to be involved and engaged in that as well. So, I won't give you an off-the-cuff answer about a national strategy and about the work that's being done, and I will certainly talk to colleagues across Government, not just to answer your question but more broadly the continuing conversations that we are having across the Government about a Welsh Government strategy on improving air quality and recognising the significant benefits to all of us in doing so across a wide range of policy areas.

When we talk about gambling and the significant financial cost on health and care services that's recognised, the report does also recognise that, for lots of people, it's a mild and modest activity. Most people in this room have gambled and probably gamble regularly, if you think about it. The amount of times that we are invited to either take place in local lotteries or raffles at the different events that we attend, then actually, if you're the serving politician in the room, it's very hard for you not to buy raffle tickets when the jar goes around. So, we're really talking about problem gambling where people are betting more than they can afford. 

Interestingly, in the report, it sets out the particular points that others have made about the difference in problem gambling between different income quartiles. It does show that the lowest income quartiles are most likely to have the largest problem with gambling itself. That's the concern that the chief medical officer, in particular, is highlighting for us. Interestingly, your point about the levy is mentioned in the report. It's the example in New Zealand, on page 21 in the report, which looks at the levy they've had there and the way they designed that. I'm open and interested in what we could do, both with our current powers and in that continuing conversation with the United Kingdom Government about a real clear and present challenge that will only get bigger, if we don't act now, in the future.

The Llywydd took the Chair.

I just need to declare that I am a director and trustee of The Living Room, which has pioneered the focus on gambling as just as harmful an addiction as alcohol or tobacco or any other addiction. So, of course, I welcome this focus on it, because I have many constituents who have lost their home, lost their business as a result of their gambling addiction. We need to ensure that we are getting large organisations, like the football industry, to use their excessive wealth and dominance of the television schedules not to promote gambling, which is what they're doing at the moment, and that is a very worrying concern.

I think we should also worry that video games are being used to target children and promote a form of gambling in order to prepare them for the future. I know that the Advertising Standards Authority is on to this and endeavours to be vigilant, but I think that it's something that we all ought to worry about. I completely agree that we need to reduce our stake to £2, so I do hope that you're successful in persuading the UK Government to take the plunge on that one.

Probably the only thing I agreed with Mrs Thatcher on was that she was worried about the lottery being located in our post offices. The poorest people in our communities collect their benefits from the post office still today, despite the electronic transfers of money, and then they are invited to spend some of it immediately on gambling. That is quite an uncomfortable situation, and we all see it every time we go into a post office. So, I think it's a major concern, and I very much welcome the emphasis in this report.

I just wanted to focus on something that's not in the report, which is the issue of breastfeeding, which wasn't in last year's report either. It is confined to two lines in Dr Atherton's report. We are told that children in the most deprived areas are half as likely to be breast-fed, and that, obviously, is combined with the fact that they are twice as likely to have decayed, missing or filled teeth. There is a link in all this. When I asked you about this subject back in November, you did say that this remains a priority for Public Health Wales, and that you have asked your officials and the Royal College of Midwives to explore ways to further improve uptake and support and provide better support to families. So, I'd be keen to understand, if this information isn't available in our public health report, where we are going to find out what our strategy is on this really important subject. Because it does actually follow babies right through their lives; if they are not breast-fed, there are serious consequences to all this. It is particularly concerning that it is in the lowest income households where people are least likely to breastfeed and therefore need more support to do so. So, I'd be keen to hear what you can offer on that.

Thank you. I'd like to recognise Jenny's role in being a director of The Living Room, which is actually mentioned on page 24 of the report as part of section 7, about how people are helped to access support for people who suffer gambling-related harm—one of a number of positive initiatives. Again, I recognise what you have to say about the power of sport and gaming, either to impart positive messages or, indeed, to be used to advertise things where you think potential harm is caused as well.

On your point about breastfeeding—to finish, Llywydd—in last week's debate on the committee report into perinatal mental health, there was a section in that report and in my response that dealt with breastfeeding, not just in one specific area but more generally about our breastfeeding strategy in Wales, because we do recognise that, across all groups, we would like to see more people take up breastfeeding—well-recognised health benefits for the mother and the child. There's something there about having supportive partners as part of that as well, and a supportive society that recognises that it is an entirely natural thing that we want to encourage more of. And, within that, we recognise that, sadly, there is definitely a relation between income and likelihood of breastfeeding. So, that is part of the work that is being done now to understand where we have been successful and not, and, in both committees, in both the health committee and, indeed, in the Children, Young People and Education Committee, I expect to report back on when that strategy is ready. I expect I'll be scrutinised on that—every time I go before the children's committee, I know I can expect to have questions on breastfeeding. Until we see sustained improvement, I expect those questions will be there. So, I don’t shy away from it; it is an area of work that is being developed and led by Public Health Wales, and I will of course report back, not just to the committees, but to this place as well, as we do make progress—certainly as we reformulate where we wish to be on promoting breastfeeding right across Wales in every particular income group, but in particular those with the lowest take-up at present.

I thank the Cabinet Secretary.