Questions now by the party spokespeople, and Plaid Cymru spokesperson, Rhun ap Iorwerth.

Diolch, Llywydd. I'm sure you'll be aware, Cabinet Secretary, of the decision of the highly respected Professor Siobhan McClelland—health economist, health manager; held senior positions on health boards—to leave Wales to seek better care for her husband, who has cancer. She's reported as saying:

'There is neither capacity nor capability in Welsh Government to be making really good health policy.'

Surely you have to agree that, coming from somebody as respected as Professor McClelland, that is about as damning an indictment as you could hear of your running of the Welsh NHS.

I am, of course, sorry that Professor McClelland has cause—and, from the statement made by the health board, good cause—to complain about the care that her husband has received. I'm also sorry that she feels the need to change where they live. But I don't accept the system-wide criticism that she makes of the national health service here in Wales. I accept that her view is—. Of course, as with every patient, you understand your own individual experience. When I look at what the system-wide reviews have shown here in Wales—. Look at the Organisation for Economic Co-operation and Development review; that did not suggest that there was a system-wide problem, as described by Professor McClelland. If you look, indeed, at the more recent independent review that every party in this Chamber agreed to in the form of the parliamentary review, they did not agree with the criticisms that are now made by Professor McClelland. That independent parliamentary review process has led to the creation of 'A Healthier Wales'. That is the joint plan for health and social care, it includes system reform and improvement, and I'm committed to delivering that.

Professor McClelland has looked at the NHS in Wales and how it's run probably more forensically than anybody else and one of her concerns is that your Government struggles to get health boards to do what you want them to do. 

Now, in the most recent budget, your Government has chosen to add over £500 million extra to health and social care—on the face of it, good news; we all want to see investment in health and social care. But, with plenty of other areas of need and other departments, other public bodies, facing cuts, who could blame them for asking, 'Is this really investment or is it just a bail-out?' So, in light of Siobhan McClelland's concerns, are you in control of what happens to that £500 million or is it just going to disappear into a black hole of financial mismanagement?

I think the Plaid Cymru spokesman should be careful in the manner in which he sets out his views. It almost sounds as if he's inviting the Government to cut the health budget. I think, actually, what we need to do is we need to deliver on our joint plan for improvement across health and social care. It has taken a significant—[Interruption.] It has taken a significant amount of work to get to having a joint plan with buy-in from health, local government, the third sector and housing. There will always be a need to look at financial efficiency and discipline within the service. If you look at that, then, actually, there has been real improvement over the last three years, and much more to do. The health service will never be completely perfect—there will always be room for error and improvement, as well as significant achievement. I am content with the fact that we understand there are real challenges, and we're not complacent about actually managing and meeting those.

A rather glib response, I must say, in terms of me inviting a cut in health and social care budgets. My question is: are you in control of what happens to that increase, which I welcome, if it is an actual increase, if it is investment? Now, the danger, of course, is that it's a fire-fighting fund. We've seen it time and time again—£100 million here, £200 million there, in order to plug gaps. Where you have a fire-fighting fund, you have £500 million that won't address, for example, chronic underinvestment in primary care. It won't form part of creating long-term sustainability. So, let me invite you to spread this investment and make sure that this investment works. Yes, you say it's for social care as well as health, but, in looking at where in health to put that money, will you commit, if you're in control, to instructing the health boards to give, say, half to primary care so we can start at last to build a sustainable service?

I'm committed to delivering 'A Healthier Wales', which is our joint plan that has a real focus on shifting our investment and activity into local healthcare. I've said before on a regular number of occasions that trying to have an artificial figure on the amount to go into one part of the system is not the right way to go about doing that. We've set out not just a transformation fund, but we've set out additional resource to go into that transformation fund as well. That is joint funding for health and social care to choose how to use together on joint priorities. We set up, for the first time, additional money directly from health to go into social care as well. That is a choice that I have made as a portfolio Minister because I recognise the need for the system to be properly funded across social care as well as health. So, I am keeping the promises I have made to health and local government on the way in which we will use resources to deliver the joint plan that they have all signed up to. That is exactly what I will not be blown away from doing because it is the right thing to do for our citizens because that will deliver better care, more integrated care and care that is generally closer to home.

The Conservative spokesperson, Angela Burns.

Diolch, Llywydd. Cabinet Secretary, what specific action is the Welsh Government taking to reduce the prevalence of suicide in Wales?

I've given evidence on suicide prevention to the committee that you're a member of and I'm looking forward to the report. You'll understand from the 'Talk to me 2' mid-point review that a range of measures have been looked at. For example, we took measures immediately following the evidence I gave to make sure that information that should be available on a wide basis—which we understood from, for example the Jacob Abraham Foundation was not—. So, we've taken immediate steps to try and make sure that help and support is available, both after the event and as well as things that we could and should do to try and prevent suicide in the first place. 

It cannot be right that one in three people who die by suicide have been in contact with mental health services in the year before their death. It goes beyond a doubt that we're failing to support some of our most vulnerable members of society and to provide effective support. Patients in Wales are consistently exposed to lengthy waits for assessment. Imagine the experience of approaching your GP and sharing some of your most intimate feelings only to be told to wait and endure this for a further 56 days before you have an initial assessment to determine whether you're ill enough to receive support. According to your latest statistics, this has been the reality for 528 people in Wales. This mentality of 'deteriorate before you can access treatment' would not take place in any other care pathway. So, why is that the case in mental health? We know that you rejected much of the children and young people committee's frankly damning report to see preventative mental health services improved. As you've mentioned, the health committee is currently undertaking a consultation on this issue. However, can you tell the Chamber today what exactly is your Government doing to strengthen access to preventative mental health services for people in Wales?

I think you raise an interesting point about one in three people being in contact, but it also means that roughly two in three are not. So, there's a challenge about what we do if people are in contact with the health service as well as a broader societal challenge of actually persuading people to talk and to listen as well. On your point about what we are actually doing, there are two broad points I'd make. The first is that we're investing an additional £35 million into mental health and learning disability services in the next year, and a specific part of that will go into crisis care, because part of what you're talking about is what happens at a point of real crisis. We recognise that some parts of our system are better than others, so we will invest more in crisis care over the next year.

The second point is in respect of 'Mind over matter' and the more preventative end, of earlier intervention and prevention, not just the broad phrase of the missing middle, but in particular about children and young people. We're taking forward the commitments that we've made. Today was the first meeting of the joint task and finish group, chaired by myself and the Cabinet Secretary for Education, Kirsty Williams. You'll be aware that the Chair of the children and young people's committee is an observer on that, able to speak freely, as she certainly did during the committee today. That's to understand whether we're not just pointing in the right direction but whether we have the right people together to try and make a difference not just in a whole-school approach, but more broadly across our whole system as well. So, we are taking seriously the messages in the 'Mind over matter' report. We're committed to doing what we promised we would do, and I expect that we'll come back before the committee. As the Chair has indicated, she will give us the opportunity to appear before the committee in the spring to be able to say what we have done over the first six months and where we expect to be in the future as well. I recognise that Members do take this matter seriously, as they should.

What I'd also like to try to drill down to is this issue of funding, because that's exactly what I wanted to determine from you today. You've just mentioned, and I believe that I quote you correctly, that you're going to put an additional £35 million into the mental health budget. To be frank, the budget is so opaque that it's very difficult to discern all of the lines—it's difficult to understand whether the ring fence for mental health still exists. 

I believe that you said, in some written evidence to our committee, that you were going to be taking money for crisis and out-of-hours care into mental health out of the £100 million save-everything-in-the-NHS transformation fund—that's what was in the written evidence. Is this additional money of £35 million going to pay for that crisis and out-of-hours intervention uplift, or is that coming out of the transformation fund?

I believe that you're bringing a statement forward on the transformation fund, and I would like to see a list of where all of this money is going, because that £100 million has got so many people saying they're having money out of it that there's a real, real difficulty in discerning exactly where the funds are going. After all, it is our job to scrutinise the spend and to ensure the outcomes are achieved, so clarity on this matter would be most appreciated. 

I'm sure I'll have the opportunity during budget scrutiny to go into much more detail on those specific areas that we've got, but I'm happy to clarify the points you raise. Yes, you're correct: there'll be an extra £35 million—that is what I plan to invest in addition to what we already provide in mental health and learning disability services. The ring fence does still exist for mental health services.

There is some confusion about the term 'transformation fund', because there is a specific mental health transformation fund to do exactly what it says—to try to help to transform mental health services in different parts of the country.

The 'A Healthier Wales' transformation fund is separate; they're not the same amounts of money and not the same fund. I will be making a statement on the transformation fund to help deliver 'A Healthier Wales'—I think it's next week or the week after. I'll be able to confirm the process that organisations are going through and also how we're looking at the initial bids that have come in. So, I should be able to give you more detail then on what's already happened and what I expect to happen in future, but they are different funds. I hope that's helpful in clarifying, but I understand, given that there is a mental health transformation fund and the 'A Healthier Wales' transformation fund, why there may be some honest confusion about the issue.

The UKIP spokesperson, Neil Hamilton.

Thank you, Llywydd. I was rather staggered to hear the health Secretary's response to Rhun ap Iorwerth's questions in today's session. Effectively, what the health Secretary did was to dismiss Professor McClelland's views as along the lines of not being able to see the wood for the trees or, perhaps, magnifying her own personal experience and universalising it unfairly to the health service in Wales.

Professor McClelland is one of our most distinguished health economics experts in the United Kingdom, but has also had a practical role in health service management as vice-chair of the Aneurin Bevan health board. She has been head of evidence for Macmillan Cancer Support and much else besides. I think she has drawn attention to a significant systemic problem in the health service in Wales, which she encapsulates in these few sentences. She says that:

'We've got a fundamental problem here with health boards, not in terms of geographical boundary, but in the autonomous way in which they act.... Health boards are neither strongly controlled by the Welsh Government nor are they accountable to the people. We have a void in Welsh Government where robust, rigorous, innovative health policy should be made.'

When somebody as distinguished as Professor McClelland makes points in that way, isn't it right that the health Secretary should listen?

I have enjoyed working with Professor McClelland on a number of matters, in particular when she was the chair of the emergency ambulance services committee. I do value her contribution to the health service here in Wales.

But, her view on the nature of a systemic problem is not borne out and not supported by a range of other people. I've referred to the OECD, and I've also referred to the independent parliamentary review that looked at the system that we have and whether the system itself is fit for purpose. Their challenge to us was not to say, 'You need wholescale, system-wide reform because the system is broken'. Their challenge was how we actually use the levers that we have available to us to set a proper policy direction and deliver against it. There's a difference between delivering and whether the system itself is not fit for purpose. And the robust policy, the review and improvement of that, well, we've seen that with the parliamentary review and with 'A Healthier Wales', and if you look, for example, at the NHS Wales awards, you will see innovation taking place within our system. You will see evidence being used to generate new policy initiatives to generate new and better practice. That is exactly what we should have. That is what I expect for our system as we deliver on the joint plan for health and social care in Wales, and I am determined to do so.   

Of course, there are improvements in some parts of the health service in Wales, but in other respects we seem to be going backwards. So, in spite of all the money that is spent and the fact that half the health boards are either in special measures or in targeted intervention—in some cases, like Betsi Cadwaladr have been, for many years—progress is, at best, painfully slow. So, this, surely, gives us pause for thought as to whether the system itself is working or, indeed, can ever be made to work.

But I'd like to focus my next question in this respect particularly on Betsi Cadwaladr, just to pick up on answers to Mandy Jones at the start of questions today. One of the features of Betsi Cadwaladr is that more and more GP practices are being taken in-house and managed directly, most recently in Porthmadog two weeks ago—yet another practice taken directly under the wing of Betsi Cadwaladr. We've now got nearly 100,000 patients in north Wales who are under the direct management, ultimately, of the health board. What I would like to know is what performance reviews have been conducted on directly managed GP practices in Wales and what impacts it's thought that this management change has had upon patient care? When I met with GP representatives many, many months ago, they expressed some concern about this because, in particular, one of the problems that's developed is that individual patients no longer feel that they've got a personally accountable GP, because a lot of these practices are populated by locums. That leads to a growing lack of confidence not just in the hospital system, but also in the provision of primary care at the local level.

Yes, there are a number of managed practices across our system. As an overall percentage, it is still very small. However, I recognise there is a change in the structure of general practice that is taking place. We will see fewer small practices of single or double-handed practitioners in the future, because our ambitions for the delivery of general practice, as set out in 'A Healthier Wales' and as we were encouraged to do from the parliamentary review, are to be able to deliver services together in a more integrated way and to be able to deliver a wider range of services. We are likely to see larger practices that are fewer in number. We're likely to see more general practitioners employed by other general practitioners as partners, much as you do see now currently in the law where most solicitors are employed by other solicitors.

The challenge is: do we still have good value for money? Do we still provide high-quality patient care? And in every managed practice and in all of the surveys that come back, the public are still happy with the service they get, and so there isn't an impact on patient care that you can see. We would, though, expect to see a higher cost because they're having to employ locums at a point in time to make sure the service continues, and that is the price that we will pay to make sure that general practice survives whilst we change it deliberately to make sure we have a better structure to deliver better care with more services in the future.     

Certainly, as far as north-west Wales is concerned, part of my region, Blaenau Ffestiniog and now in Porthmadog as well, we have a situation where things are actually getting worse, because patients do not feel that they have a personal relationship with an individual doctor, because they can't develop that sufficiently with a locum by definition, because they're not necessarily going to be there permanently. 

There is another problem that this brings about as well, because when Betsi Cadwaladr takes a practice in-house, it withdraws the My Health Online internet tool that allows patients to make online GP appointments, and that makes it more inconvenient for patients as well. So, why is it that one of the features of directly managed practices is the withdrawal of useful technology that is vital to improve healthcare? Surely, this is not absolutely necessary. As Betsi Cadwaladr is still in special measures, perhaps the heath Secretary could enquire of the health board whether they can reverse this retrogressive policy. 

I'll be happy to look into the matter and write to the Member and copy in other Assembly Members as soon as possible.