Questions now from the party spokespeople. The Conservative spokesperson, Darren Millar.

Thank you, Presiding Officer. Minister, can I ask you what plans the Welsh Government has to prevent a stall in the fall in smoking rates in Wales?

We're reviewing our tobacco control action plan to see that we do actually want to make further progress. We're looking again at the organisational structure, for example, of our stop-smoking services. Encouragingly, we saw more people come to the NHS Help Me Quit service this January compared to last January—a 20 per cent rise in people seeking help—but, of course, I'm always interested in understanding what tools are available and how we get to the point of persuading more people to take up the help that is available to persuade people to stop smoking. 

You may or may not be aware, health Minister, that today is No Smoking Day across the UK, which encourages people of course to take up the opportunity to explore quitting smoking. But, Public Health Wales have shown in their projections that they're expecting you as a Government to miss your target of reducing the prevalence of smoking across Wales to 16 per cent by 2020 and that you're currently around five years behind achieving that particular target. That of course is very worrying. It's worrying from a public health point of view in the future. I think that what we need to see is a radical sea change in the Government's approach, particularly in terms of the use of e-cigarettes to promote the cessation of smoking. So, as you will know, Cancer Research UK have been very clear that e-cigarettes are much safer than smoking tobacco. Everyone acknowledges, apart from the Welsh Government, it would appear, that they can be a very useful tool to assist people in quitting smoking in line with the advice of NHS Scotland and NHS England. So, can you clarify what the Welsh Government's position is on e-cigarettes as a smoking cessation tool? Thank you. 

I recognise the points about the targets and wanting to reach the targets and our ability to do so. Actually, before we achieved the 19 per cent interim target, there was widespread concern that we would not do that. So, it is possible for us still to match and meet that target, and that actually was an evidence-based target where we had a basis to set it and to want to achieve it. 

In terms of the evidence around e-cigarettes, information about e-cigarettes is already provided when people engage with stop-smoking services. The point about the future for e-cigarettes is one that we do need to determine here in Wales, but I would just correct the suggestion that e-cigarettes are much safer. I think it is much more preferable to recognise that e-cigarettes are much less harmful than tobacco smoke, but the big prize to be gained is to have more people not smoking tobacco, and I think the terms in which you talk about that really do matter. I'm interested in the latest evidence, but not only that—we are seeking to draw people together in Wales to draw up a consensus statement within Wales on the place or otherwise for e-cigarettes within stop-smoking services. 

You seem to be playing with words unnecessarily, Minister, with respect. The only reason you hit your previous target was because of the take-up of e-cigarettes by many tens of thousands of people across Wales who use them to quit smoking. But, of course, they took them up off their own bat because they were not available—as is not the case in England where they are available—through smoking cessation services here. So, can I ask you again: will you consider allowing NHS Wales's smoking cessation services to use e-cigarettes and to promote the use of e-cigarettes to patients and individuals across Wales who are wanting to reduce the harm that they incur as a result of smoking? You say that these are much less harmful, I say that they are much safer. I think both of those things are not incompatible to actually say.

Now, can I ask about smoking rates particularly amongst pregnant women here in Wales? At the moment, around 20 per cent of pregnant women in Wales are smoking, and we know that that of course can lead to significant problems and complications in pregnancy and birth, including the stunting of the growth of children later in life and increasing their chances of developing diseases like asthma. Now, we know that the percentage of pregnant women smoking is higher in Wales than in other parts of the UK, including England and Scotland, so can I ask you specifically what work you are doing as the Welsh Government to focus attention on smoking amongst pregnant mothers in order that we can reduce these levels and lead the way in the UK, not sit at the bottom of the league table?

Actually, there's significant work already under way on trying to help women to quit before and during pregnancy. That work is being undertaken together with midwives and health visitors. You may have missed that, last year, I actually launched part of our campaign on this in Ysbyty Glan Clwyd. And that's together working with the midwives who are actually undertaking that care in the community as well as on hospital sites, and actually trying to change some attitudes around smoking as well, because if you go outside almost every maternity unit in the country, you'll find a bunch of fag butts outside. Now, there's a challenge there for us about changing people's perception of what they're doing, not just for themselves, not just when they happen to be pregnant, but actually for other people going in and out of those particular units. So, we already have a range of actions that we're undertaking. It's being led by evidence developed by midwives themselves working together with families, because actually it's about the support that a woman has from her partner that often makes a big difference as to whether they will take up the opportunity to stop smoking. 

On the challenge about whether we describe e-cigarettes as safer or less harmful, actually the language really does matter. If you describe in advice something as being 'safe', then you're giving an impression about it. And I do think it matters. That's why, if we're going to have e-cigarettes used, we need to be clear about the language and the terms on which healthcare professionals in whatever part of healthcare engage with the public on them. You may have missed my answer to the last point about smoking cessation. We are drawing together people in Wales to have a consensus statement on the use or otherwise of e-cigarettes in smoking cessation services. That will be specific and targeted. There won't be a blanket position that e-cigarettes are safe. It will be about whether they're a useful tool or not and, of course, we'll look at the evidence provided by both England and Scotland when we're making a decision here in Wales. 

Plaid Cymru spokesperson, Helen Mary Jones. 

Diolch, Llywydd. In February 2016, the then First Minister used an Organisation for Economic Co-operation and Development report to defend the then Welsh Government's record with regard to health service delivery. Of course, when you look at what that report actually said, it said, among other things, this: 

'at present, Health Boards do not have sufficient institutional technical capabilities and capacities to drive meaningful change, and a stronger central guiding hand may be needed.' 

Then, two years later, the parliamentary review told us last January that a risk-averse culture hampers change in the health and care system and limits efficient and effective decision making. Does the Minister accept the OECD view that a stronger central guiding hand is needed, and what is he doing to change that risk-averse culture? He will no doubt tell us that the vehicle for delivering lasting change is his transformation fund, but I'm sure that he would acknowledge that that is a very small amount of money compared with the overall budget. How confident is the Minister that local health boards are delivering now on key Government priorities? 

Actually, when talking about the way in which the health service was being discussed in 2016, you'll remember a blanket, lazy and wildly inaccurate suggestion by a number of political players that the health service in Wales was the worst part of the United Kingdom. Actually, what the OECD report said very clearly was that simply is not true. It did, however, have criticisms to make about each part of the health service within the four nations of the UK, and that included the criticism that you've read out about where we are in Wales—having a more logical structure to the way we organise health services, but needing to see that made real in terms of the delivery. 

And, actually, in terms of that point about there needs to be a more central guiding hand, I am regularly urged to take more interventions in the way that health services are run. Actually, I have taken a more interventionist approach, but the challenge is how we have a system that is set up, not just the attitude of an individual Minister. And you'll recall that in 'A Healthier Wales', we do talk about more central funds, we talk about having a national clinical plan, we talk about having a central NHS executive for Wales as well, and that work is well under way and is being drawn together. And I will consider options for the creation of that body to provide that clearer central guidance and leadership within the service to work together with our health boards and trusts here in Wales. 

I am, Llywydd, encouraged to a certain extent by what the Minister says there, but he does use the phrase 'talk about', and I think we need to refer to what is actually happening  now. From April, our local health boards will be responsible for an unprecedented amount of public funds in Wales, and I think there's nobody in this Chamber that would disagree with the need to invest. Now, other public sector bodies will be looking on with envy at those resources that are available, despite the fact that other public sector bodies, as the Minister has said himself in response to other questions this afternoon, have key roles in supporting the health of the people of Wales. Those public bodies will be entitled to ask us, I think, whether such money is really being used to push the stated national strategic objectives. Now, one of these objectives is to shift services from secondary care to primary care and, again, I think that has broad support across this Chamber.

But we need to look at what the actual spending has been over the last five years, and we've seen local health boards continue to do the opposite. Spending on primary care has increased in cash terms by £74 million, but that, of course, over the five years is a real-terms cut. Spending on secondary care has swallowed up the vast majority of the increases, getting around £845 million extra. Now, this is a clear illustration to me of local health boards failing to move resources and services from hospitals into communities, despite that being a clear Welsh Government priority. We see that also in increases in staff numbers, a very small rise in hospital doctors, but offset by the fall in the number of GPs. Can you explain to us, Minister, why you are allowing local health boards to disregard your stated policies in this regard? 

I don't think that's a fair characterisation at all. When you look at what we're doing with NHS spending, I'm proud of the fact that we're putting more resources into the national health service, despite being 10 years deep into Tory austerity, and the choices we make are incredibly difficult and they have a real-world consequence in every single public service. And there is no easy choice to make. If we put more money into different public services, then we will obviously face challenges about whether we're adequately funding the health service to deliver the sort of care that each and every one of us expects for ourselves. So, we made an upfront choice within the last term to put money into the national health service and accepted that would reduce money for other public services. You can't pretend that you can add more money into everything, as some people in this Chamber, despite campaigning for austerity in three successive general elections, regularly do in these sets of questions.

In terms of how we're getting different organisations to work together, the transformation fund is focused on moving more activity and resources around it into our primary care system, and more than that, in the partnership between primary care and other public services. That requires the health service to be a better partner in that conversation and in, then, the delivery of those services together.

So, actually, when you look not just at the activity we're undertaking now, but if you look at the transformation fund itself, you'll see that each and every one of those has been supported by each regional partnership board. And that now includes not just health, social care and the third sector, but, from the start of April, every regional partnership will also include voices from housing and education to make sure we have a joined-up conversation with each of the regions of Wales about how to transform services, and how actually the resources should follow the event when there's an agreement about what we should do to change it, to make sure there is real, system-wide change and not small, individual projects that each one of us may talk about on a local level but won't transform our system. That is absolutely my objective.    

Llywydd, I'm very pleased to hear the Minister say that that is his objective, but I would put it to him that his party has been running the health service for 20 years in Wales and since the very first days of the National Assembly, we have been talking about—with, again, broad cross-party support—removing resources from secondary care and investing in primary care and indeed taking that a step further and ensuring, as the Minister has already said this afternoon, that there's much more effective co-operation between social services and health. I would put it to the Minister that this is nothing new and this is not rocket science and nobody's arguing with him about whether or not some of the projects under the transformation fund will be positive and deliver positive results. I mean, for example, I'm very glad to see—I know this has been put forward as a priority by Hywel Dda and their partners—that the local health board is actually paying for some elements of social care to enable it to get people out of hospitals more quickly. That seems to me to be entirely positive, but I don't know why we need to do that on an experimental basis and why the Minister can't simply encourage all—well, actually, instruct—all local health boards to do this.

I appreciate some of what the Minister's already said this afternoon about trying to give a stronger guiding hand, but let's be clear here, Llywydd: the Minister appoints the local health boards, he sets their priorities, he gives them their funding. I was here in this place and actually assisted the then Minister in writing the legislation that makes it completely clear that the local health boards are accountable to him. And the then Minister used these words, I think, in this Chamber: it is absolutely crucial that decisions about health are made by the people the people can sack—in other words, the politicians.

What assurances can the Minister give us this afternoon that once he has learnt those lessons from the transformation process—and I'm not sure that we need to learn them again—but once he's learnt those lessons, he will insist that local health boards and their partners deliver on the good practice that the transformation fund's projects identify? Because, as he has just said, what we do not need is more small, little, local projects, however successful they are, if those are not sustainable and then rolled out. 

Well, when we talk about how we transform and change the system, I'm not sure that there's a great track record in the conversation about who can sack who. Actually, that doesn't generate the sort of system transformation we want to see. If that were the case—you look at the system in England, where, actually, chief executives of acute NHS trusts have an average life span of less than two years—and that's no way to run a system. In fact, it was very interesting to hear—. Sir Bruce Keogh, in his leaving speech—not in his speech while he was looking forward to many more years in post at the NHS Confederation conference—when he was leaving NHS England, talked about that challenge, the way in which leadership, in the English system, has been brutalised and it doesn't allow people longer term choices to deliver the sort of paths to deliver the value that each of us wants to see. That's absolutely why having a joint health and social care plan is so important. It's why the transformation programme really matters—to get to the point where there are models to scale up.

I've been really clear about my expectations. The way in which we do it will not be a simple pulling of one lever or me going around and potentially threatening people with their employment if they don't do as I want. That is not the way to deliver change in the system. It will be a combination of different things depending on where each partnership is. In different parts of Wales, they're more aligned to come and do that somewhere together. So, in Gwent, we see a real commitment to transforming children's services across health and social care. I think they'll get somewhere. They won't need me to stand over them to encourage them to do it. They want to take the lead in those areas. That's the cultural change that we need to deliver because that will be much more effective in delivering outcomes that she and I and everyone else in this Chamber wish to see.

UKIP spokesperson, Gareth Bennett.

Diolch, Llywydd. Minister, recently, WalesOnline published a news story highlighting the difficulty many patients are having in finding an NHS dentist to register with. The news reporter had herself moved to Carmarthen from Kent and, suffering a dental problem suddenly, she found that the closest dentist willing to offer an appointment was in Llanelli, which meant a 50-mile round trip. Of course, this problem isn't confined to west Wales. I checked the NHS Wales website this morning and found only three dentists in Cardiff offering NHS appointments. To be fair, that's a little better than the last time I looked in January, when there were none. There are no dentists in Newport currently accepting NHS patients, and if you live in Brecon and Radnor you can expect a long drive, as there are only two practices in the whole area with appointments available. What steps can be taken to address this problem?

I've actually been very encouraged by the response of the dentistry world to 'A Healthier Wales' and wanting to see that as a kick-start to the reform that they wish and need to take to make sure they're delivering the sort of service that they want to provide and that each of our communities expects as well. There are challenges around the country about our capacity to take on extra NHS patients, but, actually, that really is tied up with contractual reform. So, since she came into post, the chief dental officer has undertaken a much faster rate of reform within the contract here than prior to her arrival. I've encouraged her and empowered her to do so, and, actually, when you see the next statement on where we are with dentistry, I think Members will have a degree of optimism about the future, and I'm expecting to announce more in the autumn, depending on the evidence we've had. We now have an increased number of dental practices taking part in the contract reform programme. Far from being reluctant to do so, as a number of practices were, we're now having real enthusiasm from different people in order to change the way that they work, because, actually, they'd rather have greater capacity to do the right things, and this really is about providing the right care at the right time, rather than providing treatments that aren't evidence-based in a contract that rewards the wrong sort of behaviour.

So, if the Member will bear with me for a short period of time longer, I'll be able to make a statement to him and other Members about where we are and our expectation for the future.

Well, thank you for that anticipatory report of the contractual overhaul. And it's encouraging that you are looking at this, and I look forward to the statement in the autumn. Now, of course, I can't really pre-empt what that statement is going to say, but if I could flag up a few issues relating to the contract—the British Dental Association say that the recruitment and retention of dentists in Wales has been a problem for some time, and, of course, the contracts currently in place are part of the problem. They have called on the Welsh Government in the past to devise a system that makes Wales a more attractive place for dentists to work. Some of the problems are relating to the tough UDA targets, which are currently called for—that's, as you know, units of dental activity. We do have the system of clawback as well, whereby if they underperform by more than 5 per cent, there is this clawback of money. So, these are all issues that feed into this rather unwieldy contractual system that you've identified. So, I know you say there is an overhaul and we are going to have a statement in the autumn. I don't know if you can make any comment at the moment on some of the issues that I've raised.

Yes. The British Dental Association are key stakeholders. I meet them during each year. They have access to meet the chief dental officer and her officers within her department. And you're right that the UDA, along with the contract, is an essential part of reform. Where we're actually seeing practices undertake the contract reform opportunities—it's changing the way they deliver their work, and that in itself is making Wales a more attractive place for dentists to work, but also the skill mix of people, so the numbers of dentists, assistants and others who will work within each of those practices. So, that is absolutely part of delivering better care, a better place for people to work, and, actually, better value for the public money we invest in the system.

Yes, that's encouraging. Now, if I can go back to the UDA issue, obviously, this is all going to hopefully come out in the autumn statement, but one issue with the clawback is that the money that is taken back from the dental practices is not ring-fenced and so is not necessarily going to be reinvested in the Welsh dental service. As we know from matters that are continuously debated in this Chamber, the national health service in Wales are short of money in many areas, so the problem is that much of this money that's clawed back is used to plug funding gaps in other areas of the Welsh NHS system. So, we do have this rather perverse situation at the moment, which the BDA have identified, where there are large waiting lists and patients having to travel many miles for check-ups, but, at the same time, money is being taken out of the dentistry system and put into other areas of the NHS. So, hopefully, that will form part of your thinking with this overhaul of the contracts.

Yes. I'm very clear about the way in which money that is allocated and earmarked for dental services should be used, and it should not be used to fill gaps in other budget lines when, actually, we recognise there is more for us to do to provide the quality of care and services that, as I say, each community in Wales deserves and expects.