The following amendments have been selected: amendments 1, 2, 3, 4 and 5 in the name of Darren Millar.

Item 5 on our agenda this afternoon is a debate on the primary care model for Wales, and I call on the Minister for Health and Social Services to move the motion. Vaughan Gething.

Motion NDM7042 Rebecca Evans

To propose that the National Assembly for Wales:

Notes the action being taken to transform services in line with the Primary Care Model for Wales.

Motion moved.

Thank you, Deputy Presiding Officer. I'm happy to move the motion before us. Our vision in 'A Healthier Wales' is that everyone has a longer, healthier and happier life, that we're able to remain active, independent in our own homes for as long as possible. And that, of course, requires a whole-system approach to transformation. The primary care model for Wales is a whole-system approach; a health and well-being system where people access a range of seamless care and support at, or close to, their home, based on their unique needs and what matters to them. Our approach aims to deliver an effective system to support people to look after their own health and well-being. So, we will make it easier for people to access the right help and support, help that focuses on prevention, earlier action and wider well-being as well as treatment for ill health.

The new model means changes in our primary care workforce, bringing together a wider range of professionals to provide a wider range of services directly with patients at, or close to, their home. Progressively and consistently, services will be delivered by multiprofessional teams with stable general practice at the core. I've briefed Assembly Members many times on the significant action that we are taking to develop a multiprofessional general practice and to train and recruit more GPs. This action led to a 98 per cent fill rate of GP training places last year, and was particularly successful in filling vacancies in areas that had previously struggled to recruit. In stark contrast, in England, GP numbers have fallen significantly over recent years, but in Wales, the position has remained relatively stable over the last 10 years. Given that, and the ongoing GP contract negotiations, it should come as no surprise that we will not be supporting any of the Conservative amendments.

Our approach promotes seamless working between partners at community level, through our primary care clusters, providing a health and well-being system focused on the needs of their local population. Our clusters bring together  the health board, the local authorities and community-based services to improve health and well-being together, not just a service focused on the NHS. And that is a significant change to previous ways of working. It requires practices to work together and with the wider community of service providers to make the best use of resources, and provide that joined-up care around the needs of people and communities.

We've seen that our ideas have gained interest from others. It may interest Members to know that the 10-year plan for NHS England published in January adopts something suspiciously similar to our cluster-based approach, but I see no credit given for the original ideas taken and advanced here in Wales. If you talk to people delivering primary care across the border in England, they recognise they have taken inspiration from what we are doing here in Wales, and that should be the positive part of devolution as we celebrate 20 years—to celebrate what we are doing and taking a lead on, to look at where other parts of the UK are taking it up, and, equally, to be open-minded about improvements that we could make here, learning from other parts of the UK.

So, cluster working continues to evolve here in Wales. When this Assembly debated clusters in January last year, I explained that our approach had been careful to avoid being overly prescriptive. So, our model in Wales is drawn on innovative practice, designed locally and agreed nationally by all stakeholders on our primary care board, bringing together people from pharmacy, from social care backgrounds and, of course, from general practice as well. And it's that range of stakeholders that have agreed on a new way forward. So, we're using our programme of reform of primary care contracts to support community pharmacists to be members of clusters, and for more general medical services to be planned and delivered at a cluster level. And I look forward to providing Assembly Members with a report on progress on wider contract reform across primary care this autumn.

Now, the Welsh Government continues to provide £10 million annually directly to clusters to make their own choices about what to invest in in their local healthcare needs. I expect in the future that more decisions will be made at cluster level. I have made clear many times that I expect scale and pace in all parts of Wales, in both adopting and adapting a transformative approach to primary care. To help continue to drive this, I will set national delivery milestones to transform and improve local healthcare, to hold to account the leaderships within our different health partners.

In March I launched the Welsh Government's new national standards for access to general medical services, and this, of course, is a key concern from the national survey for Wales when it comes to primary care. I visited Taff's Well Medical Centre when I launched those standards, and I was pleased to see, first-hand, the excellent access to their services for their patients. It has been running large parts of the primary care model for several years, and the wait time for a routine appointment in that practice is one to two days. That is our aspiration to be delivered right across the country. 

In March I also announced the creation of an all-Wales locum register. This provides a much-needed way to manage and understand arrangements for locum GPs—a key concern of partners in general practice. And I'm happy to confirm that, already, since the launch, we now have 508 locums taking part in this register, and more expressing their interest in taking part. We have just launched the pharmacy phase of the 'Train. Work. Live.' campaign and we will extend the 'Train. Work. Live.' campaign to allied health professions to help deliver on our ongoing commitment to support multiprofessional teamworking within and for our communities. Core to our approach in Wales is the principle of services planned and delivered across the 24/7 period. Now, that naturally includes a transformation of out-of-hours services and the roll-out of the 111 service, and I know that public accounts have taken an interest in that part of our services—again, a significant step forward and a difference to the way that those services were delivered in the past.

Other examples of our priorities in the strategic programme for primary care include a national system to identify people at increased risk of unscheduled care; a system for monitoring escalating pressures on our services; peer review for the urgent care from a community-based health and social care service perspective; a new template for cluster plans to move forward; national support for conversations with our public about how local services are changing and, crucially, why. We will evaluate and report publicly on the impact of the new primary care model in all parts of Wales. The aim is to have a better job for our staff to do and, crucially, a better service with and for the public. The national primary care board is expected to ratify detailed action plans underpinning our approach later this week.

That does mean that, together with that national leadership, local leadership and innovation are vital for transformation. More and more general practices are developing multiprofessional teams, introducing systems to signpost people to local services and triage people with clinical needs, so they see the right person at the right time, the first time. More and more GP practices are embracing the role of non-clinical well-being services. For example, a general practice in Wrexham is collaborating with community services for people who are homeless, and I've been to a GP practice in Cardiff that has developed a community garden—the dual benefit there of improving community unity and helping people to address problems such as loneliness, isolation, anxiety and stress. And as we heard earlier on in questions, there is lots of activity taking place in community pharmacy. Community pharmacies now offer a treatment for a range of common ailments without the need for a prescription—again, innovation taking place here first in Wales. Pharmacists continue to train to prescribed medication as well as to dispense and advise.

The 'A Healthier Wales' transformation fund that I created is, of course, trialling new, larger scale models of care and support. For example, the Cwm Tawe cluster is improving population health and well-being by strengthening self-care and building community resilience. Across the Aneurin Bevan health board area, integrated community-based health and social care teams are transforming into a 24/7 hospital discharge scheme. People are able to get home faster with the right package of care and in the right place for them. North Wales is implementing plans for co-ordinated community services designed around the principle that we discussed earlier of what matters with and for and to the citizen, who should be at the centre of our service redesign.

Now, time is short, so I can't set out every single action that we're taking to transform primary care services in Wales. However, the approach I have set out is fundamental to delivering our vision in 'A Healthier Wales' and the long-term future for health, care and well-being outcomes for the people that we all represent. I look forward to hearing Members' contributions towards today's debate.

Thank you. I have selected the five amendments to the motion, and I call on Darren Millar to move amendments 1 to 5 tabled in his name. Darren.

Amendment 1—Darren Millar

Add as new point at end of motion:

Regrets that some of the aims within the Primary Care Model for General Medical Services will be undermined by the current GP recruitment crisis.

Amendment 2—Darren Millar

Add as new point at end of motion:

Notes that GP recruitment challenges have led to the closure of GP practices, practices being managed by local health boards, an increasing reliance on locums and gaps in GP out-of-hours service rotas.

Amendment 3—Darren Millar

Add as new point at end of motion:

Regrets that Wales is training insufficient numbers of new GPs to meet the needs of the people of Wales.

Amendment 4—Darren Millar

Add as new point at end of motion:

Notes the ongoing dispute between GP representatives and the Welsh Government over GP indemnity and the potential adverse impact that this may have on GP recruitment.

Amendment 5—Darren Millar

Add new point at end of motion:

Calls on the Welsh Government to:

a) Increase the number of GP training places in Wales;

b) Increase the proportion of the NHS budget allocated to Primary Care; and

c) Address GP representative body concerns over GP indemnity

Amendments 1, 2, 3, 4 and 5 moved.

Thank you, Deputy Presiding Officer, and I do move the amendments that I have tabled. Now, to listen to the Minister for Health and Social Services, you would imagine that everything's hunky-dory in our primary care services across Wales, but, of course, nothing could be further from the truth. The primary care model for Wales is underpinned, really, by the GP services that many people, of course, enjoy as the front-line health service that they access, but, of course, we know that there is a significant crisis in GP recruitment at the moment that will undermine the delivery of the primary care model that the Welsh Government aspire to. Now, we've been warning about this GP crisis, along with the British Medical Association and the Royal College of General Practitioners, for many, many years. We were telling you to ramp up the number of training places almost a decade ago, and yet you have failed to do so up until recently. And even now, even with the ongoing shortages, we are still in a position where there are more individuals applying for those courses and eligible for those courses, in terms of being able to train in the GP specialism, yet you are knocking them back. This is in spite of the fact that we have got, according to the BMA, 24 GP practices that have closed across Wales, 29 that are managed by the health board and 85 that are at risk. Now, this situation cannot go on. You need to train more GPs and ramp up the opportunities for training as soon as possible.

On top of that, the Royal College of GPs, in their most recent survey, found that 23 per cent of GPs have said that they're unlikely to be working in general practice in five years' time. That's almost a quarter of the GP workforce. Seventy-two per cent tell us that they expect working in general practice to get worse over the next five years, and 42 per cent say that it's financially unsustainable to run their practices. So, I think that things are far less rosy than the Minister has tried to present today. We know also that managed practices, which are one of the things that the Government has highlighted as something that they want to see more of within the mix, are actually a lot more expensive—a third more expensive than the GP contractor role, which most people see as the traditional GPs in their local communities. Now, if you made the resources available that you're currently giving to those managed practices to the GP practices that are at risk, I think you'd find that many GP practices would no longer be at risk and would actually be managing quite well, thank you very much.

In terms of the applications—just in north Wales, by the way, we've seen closures of practices in Wrexham and elsewhere in north Wales, including in my own constituency, and yet there were 50 per cent more applicants than the number of individuals who were actually given training places on the GP specialism over the last year. So, 2017 figures suggested that there were 22 applicants, and yet just seven were offered places in Wrexham; 24 applicants in Bangor, yet just 12 were offered places—and this is in spite of the fact that we've got a dreadful GP shortage. So, I think that you need to look very carefully at those GP numbers, or else, frankly, your primary care plan is not going to work.

Now, on top of that, you're also making it less attractive to come and work in Wales and be a GP practitioner, because of the indemnity situation, which you barely touched on in your opening remarks. It's not surprising that you barely touched on it, of course, because what you're actually doing is top-slicing the income of GP practices, taking £11 million out of the cash available to support those practices in order to introduce a GP indemnity scheme, quite different than the current situation in England where they've had a significant uplift—[Interruption.]—where they've had a significant uplift—[Interruption.] You're not listening to me—where they've had a significant uplift in the income that is available to them in the same year that they had their indemnity insurance scheme. Bear in mind, it's not me saying this; this is the GPs themselves who contact me and contact you, and no doubt contact everybody else in this Chamber. Dr Philip Banfield, a representative of the BMA council in my own constituency, said it's

'having an immediate and catastrophic collapse of morale from GP colleagues in North Wales'.

Dr Conor Close, also a GP in my own constituency, says that the cut is a step too far for his surgery and that, I quote,

'Reducing the global sum is potentially the final straw in the long-term viability of the practice'.

You mentioned the situation with locum lists. As I understand it, this is going to add a new differential between Wales and England, and, in addition to that, you're saying that you're going to pay for the insurance for the locums. You're not going to top-slice their income, which is going to drag more and more people into locum work and away from the less expensive way of running things in their GP practices. So, we need a radically different approach. 

One final point, if I may, Madam Deputy Presiding Officer, and that is in respect of the share of investment as a total of the whole budget in the NHS. Wales has the lowest percentage of NHS budget invested in its primary care services versus any other part of the UK: 7.64 per cent, according to the statistics that I have, compared to 9.51 per cent in England being spent on primary care, 7.75 per cent in Scotland, and 9.51 per cent in Northern Ireland. Clearly, what you're doing is you're starving our primary care services at a time when they need significant investment, and I would urge you to take a different strategy forward, and I urge people to support the amendments that we have tabled.

It's a pleasure to take part in this debate on the primary care model for Wales. I mean, I don't know if I've mentioned it before that I happen to be a GP myself, but—[Laughter.] Obviously, primary care is not just about GPs. Let me just put that out there for a moment. It's about practice nurses, it's about pharmacists, about district nurses, health visitors, dentists. Now, I count it a privilege to have been a GP for quite a long time now, and, obviously, 90 per cent of patient contacts are still at primary and community level, on only 7.6 per cent of the budget. Clusters, to be fair, are getting money. That money, though, to encourage even more the tremendous innovation that's going on, needs to be long term and in a proper strategy, rather than short-term pots that have to be bid for recurrently. So, to get a step change in the performance of clusters, they do need that long-term funding.

And individual GP practices need money in addition too. They are not getting any additional money now. It's all going to clusters. It is a system under pressure. It's overstretched, but despite that, some fantastic work is going on, and innovation. GPs see, on average, 60 patients per day, and that's not counting all the work that our practice nurses and district nurses and health visitors do as well. One recent Monday morning in the surgery in Gowerton, in my practice, we had 700 telephone calls from patients. Now, you have to have a way of dealing with 700 telephone calls, and that is triage. You are sifted to the best health professional to deal with your particular issue, which is not necessarily the GP. Certainly, in my case, for an awful lot of problems, it is not necessarily the GP. But that is an issue and it is a challenge for some people to get used to.

As hospital consultants have become more specialised over the years—they look at just bits of the body now—the concept of the consultant general physician has gone, and you wonder: who is the consultant general physician nowadays? Well, it's the GP. It's come from hospital. It's come to the community. So, you are asking now: who is doing the job of the traditional GP, then? Well, that's our practice nurse now. So, that shift has happened inexorably, but we would like to see some of that funding follow. All of those diabetic clinics and asthma clinics and so on that used to be in hospital are now carried by our nurse practitioners and practice nurse colleagues in primary care.    

The pharmacist is also vital to treat the kind of minor ailments that we used to see as GPs, but now that we see the complex cases in older people—. All I see now, and that’s fair enough, is those very ill people who need to see a GP only. Of course, there’s more demand on others to step in as full members of the primary care teams, as I've mentioned: the pharmacist, the optician, the dentist, and, of course, the community physiotherapist—we want to see more of them—the speech and language therapists in the community—we want to see more of them—and occupational therapists in the community—we want to see many more of them. It is a significant challenge to train more of these very valuable staff that we need to keep the team going in the community.

So, there are several major challenges, in addition to the need for increased recruitment and retention of health professionals across the board. The primary care estate—the physical state of the buildings—requires massive investment. It is starting to happen now after nothing much happening for many years, but the challenges of sub-optimal buildings remain.

And, social care requires radical transformation. It is no longer satisfactory just to merely tinker around the edges. Social care, I would contend, needs to be organised like healthcare—as a national service paid for by general taxation with salaried, qualified and registered care support workers delivering high-quality nursing care, with health and social care co-located, co-working in primary care hubs. It's starting, but there's so much more to do.

So, finally, I do feel enormously privileged to have had involvement in hundreds of people's lives over 35 years in Swansea as a GP. It is enormously rewarding, and you can truly make a difference. And primary care is pivotal to the whole NHS. Otherwise, everything and everybody ends up in secondary care, inappropriately managed and extremely expensive, like in the United States of America. But, pivotal also is social care. No longer can Government stand on the sidelines and say, 'This is just to big, social care. It's just too complex. It's in the "too difficult" tray.' Justice for our elderly residents must compel us to act. We don't sell our houses to fund health care, nor should we to fund social care.

Can I thank the Welsh Government for bringing forward this debate? It is vital that these changes are seen as part of the main stream of delivering our healthcare services, not just something that's happening on the periphery.

Last year, Llywydd, I spent some time taking a more detailed look at the health and social care provisions in my own constituency, and some of the innovation in neighbouring areas like the Cynon valley. I was impressed by much of the work that was happening, some of which the Minister and others have detailed. In Merthyr, GP clusters were employing GP support officers, and they were easing the pressures on surgeries often dealing with a range of non-medical issues that caused concerns to patients, and therefore freeing up GP time. And also the work developing neighbourhood planning zones across the upper Rhymney valley. I certainly heard very encouraging feedback about the work of the virtual ward in Aberdare, with active outreach work to help patients at risk. And I heard high praise for the community nursing teams in Hirwaun.

Some of these initiatives are very important, because they're easing pressures on GPs, as I’ve said, but also, just as importantly, they’re improving the quality of the working experience for the wider workforce. That was a very clear message from the community nursing team in Hirwaun, where they were using technology to allocate cases and were able to build in breaks, training time and team meetings so that, without a reduction in their caseload, they were able to manage their time more effectively.

So, all of these transformation initiatives, which Welsh Government is supporting and driving forward, are delivering improved patient care, but they are also easing pressures on GPs whilst improving the quality of the patient experience. And that’s really important. It’s part of the effective workforce management that we need moving forward. Because I know from my constituency work that access to primary care services does remain a high priority for many patients. Our task is to get them to the right type of support as early as possible—the point I think that Dai Lloyd was making—and, of course, it's now widely recognised that this is not necessarily always the GP; it also means, as you mentioned, Minister, the community pharmacist. It means the allied health professionals, the occupational therapists, the physios, and so on, as well as those that are accessing social prescribing, especially for low-level mental health conditions.

Yet even in these early days of transformation, I will think back to lessons that I can see from previous rounds of reforms in the Welsh NHS, and in drawing parallels from changes like the south Wales programme, the lesson that stands out for me is that the changes take too long to implement. For example, I’m currently dealing with an example around hospital-based dementia services in ward 35 at Prince Charles Hospital. In spite of decisions taken some five years ago—and I think that means two health Ministers ago—the alternative provision in the locality is not yet available. So, I have a developing stand-off with the health board over the remaining users of that service.

For my part, I’m clear that a move away from that hospital-based service is an improvement in support for those patients. But, unlike some other services, when dealing with dementia, an alternative is required in the locality, not only for patients, but also for the benefit of elderly husbands, wives and the wider family, who themselves must be considered in the process of that change. And, as we learned last week, in maternity services, there can be professional resistance to approved plans, and as a result, the changes that were aimed to deliver much-needed improvements in care were delayed.

So, I strongly feel that one lesson that the transformation programme could quickly learn is to adopt vital changes at a speedier pace. In short, we need transformation to succeed, we need alternatives to be in place as the changes take place, and we need that change to move at a greater pace.

Like others, with the exception, perhaps, of the Conservative spokesperson, I want to welcome the publication of this plan, and there’s much to be welcomed in it. I think one of the things that scares Darren Millar is the sheer scale of the ambition alongside the vision of a primary healthcare sector that is coherent and that treats a range of conditions and illnesses at the most local level. It’s what we need to be able to do.

I agree with the breadth of this approach, but also its focus—a focus on proactive well-being, a whole system rooted in that focus, and the empowerment of knowledge that the model seeks to describe. However, we need to deliver it, and the point that’s just been made by my colleague the Member for Merthyr and Rhymney speaks about the time it’s taking in order to deliver on this vision. And I believe that we do need to ensure that we are able to deliver this in a timely way.

I speak to constituents on a regular basis who are concerned and worried about the move away from the familiar, single-handed surgery to a cross-disciplinary centre for primary care. I share their concerns and I share their worries. What we need to be able to do is to make the case that Dai Lloyd made very well—that the GP is not the only answer, but accessing the sort of primary care that is appropriate for their needs. This demands—and the plan recognises this—an informed public and what it describes as empowered communities being the basis for delivering on that vision. In fact, an informed public is described as critical to the success of the overarching vision.

I agree with this, but I would go further. I would say that confidence in the system, and the confidence of people and communities in the services they receive, is also essential to the delivery of the vision, and essential to the delivery of a proactive well-being system and not simply a reactive illness system. All too often we see a public that does not feel sufficiently informed and empowered to access these services easily. A public that does not understand the changes being made and the reasons that lie behind those changes. This lack of understanding disempowers people and undermines confidence in the changes and the investments that are being made.

Now, this is a time in Blaenau Gwent when we are seeing fantastic investment in our national health service. We've had the focus on the Grange university health system down in Cwmbran, which I fully support, and, as the Minister knows, I think the changes will transform health in the south-east region. But we also need to see, and we have seen, investment in Brynmawr, and the plans for a new well-being centre on the site of the general hospital in Tredegar. I think it's absolutely fantastic to be discussing investing in twenty-first century care on the site of the old cottage hospital established by the Tredegar Medical Aid Society just over a century ago. In the same way as this became a model for the NHS, so this new model of care needs to come home to Tredegar. Bevan wanted to 'Tredegarise' Britain; now it's time for the people of Tredegar to have the same coherence and quality of care as we wanted to share with the people of Britain 70 years ago.

But we have to have the confidence, Minister, that that investment will make a real difference, and will lead to an increase in the quality of care. We know that in Brynmawr this has not been the case. We know that people, if they are unable to access the doctor, access an appointment with the primary care system, do not feel empowered—they feel disempowered, and they feel a lack of confidence in the system. We need to ensure—. It's many years—. Dawn Bowden spoke about the number of health Ministers that have perhaps passed in the time the south Wales system has been under review, but I'm old enough to remember Sir Jeremy Beecham and citizen-centred services. I think it's time that we did actually being to deliver these and not simply deliver the visions and the speeches. So I think we do need to ensure that we're able to do it.

The final point I'd like to make is this: it's about equality and access. We lost Julian Tudor Hart last year, and we lost his vision of the inverse care law, but I hope we haven't lost the focus on it. I'm concerned to ensure—. We understand that poverty is a determinant of health outcomes, and we also know it's a determinant of some of the health issues in any community. I also want to ensure that it drives spending, that it drives the investment that we see. I want to ensure and I want to understand that we do have the GPs, that we do have the health facilities in the communities that need them most. We need to have equality and access, and equality in terms of class and in terms of geography. All too often, I don't believe we appreciate that.

So, I look forward to the modernisation of primary care. I fully support the Government's vision and the vision that has been outlined by the Minister today. I hope what we'll see is the delivery of this vision and the building of confidence in the communities that we seek to serve.

I don't think we are surprised by Dr Dai Lloyd reminding us that he's a GP, because I think many of us have had informal consultations between debates in the tea room, asking his advice, and very good advice that's been.

As a constituency Assembly Member—and of course there is doctor-patient confidentiality here as well—I took a call from the Aneurin Bevan health board about two years ago to tell me that the doctor at one of the major surgeries serving Bargoed, Bargoed Hall, was closing because the doctor there was retiring, and they were going to rationalise and make the business case for rationalising into one surgery in Bryntirion. I think it's a call that none of us wants to hear as Assembly Members, that a local surgery is closing, because you know that there are people loyal to that surgery and you know that the transfer to another surgery is going to be difficult.

Indeed, it was, because Bryntirion surgery is the other surgery in Bargoed on West Street, and that surgery wasn't running as effectively as it could have been. Indeed, the closure of Bargoed Hall led to an enforced evaluation of the service at Bryntirion, which wasn't delivering effectively for patients. Indeed, the doctor there was reducing his hours over time too. So, we were looking at a running down of the other major surgery in Bargoed.

I was really grateful to the health Minister then, the Cabinet Secretary for health, who came to Bryntirion to talk about some of those problems and how patients were going to be transferred to that surgery. I subsequently had a series of meetings with the Aneurin Bevan health board, which led exactly to this discussion about a new model of care that is described in the primary care model, and that was what was prepared for Bryntirion surgery to build in improvements. That's an ongoing piece of work, but we have seen those improvements.

I don't talk to patients, though, about improved model primary care, because I don't think that describes very well what we're doing. What we are aiming to do is to make sure patients get the care they need quickly and from the appropriate expert. That is what we are talking about when it comes to GP practices and I think it's a lot of what Dr Dai Lloyd outlined.

I completely understand the point made that we do need to invest 11 per cent of the budget in GP services, as the Royal College of General Practitioners has said, but you've got to say, 'Where is that going?' And where it went in Bryntirion, where an increased budget went in Bryntirion, was to recruit a lead GP, Dr Mark Wells, who would then take responsibility for the design of the practice, design the practice himself, and then take responsibility for the running of it. And they did. They were successful in recruiting Dr Wells and he is now running that practice in Bryntirion. I would like to invite the health Minister to come along to see that practice again and see some of the improvements that have happened.

If you go on my Twitter feed, and I wouldn't normally recommend you do, but if you go on my Twitter feed today, you'll see a video that I made, a recording, an interview, with Dr Mark Wells, in which he described three key things that he thought that had been big changes at Bryntirion surgery. The first thing was improved on-the-day access. What they've done is they've put a call centre in the building away from the front reception desk, where patients ring in in privacy and can be dedicated and moved to the correct services. They have open access to other services. That means extended services, exactly those kinds of mental health services, physiotherapy services, practice nurses, and those specific experts that are not necessarily the GP, although you can still see the GP if it's necessary. That was the second: open access to other services. Finally, he said they see better continuity of care. So, from the time you first see your health professional, because of this streamlined service, there is a stronger record and an easier record kept of the plan that each patient has.

He also would like one day, and one day soon, for the practice to be a teaching practice. Why not have Valleys GP practices as teaching practices? A great way to go and learn your trade in a wonderful Valleys community, and Bargoed really is picturesque. If there's any GPs out there, it's a wonderful place to practice.

So, I want to see these changes take place. If I'm going to be critical—. Well, I'm not going to be as critical as Darren Millar, because I think he painted a bleak house and a way over-exaggerated picture of some of the problems. In fact, we are seeing positive change. But, what I would say is, in future, services should be redesigned and remodeled through a plan the Government has and not by necessity, as happened in Bryntirion in Bargoed.

Thank you. Can I now call the Minister for Health and Social Services to reply to the debate? Vaughan Gething. 

Thank you, Deputy Presiding Officer. It was interesting to hear a range of views today about how we do want to see improvement in health and care services here in Wales. And of course much of that is about the stability of general practice at the heart, as I set out in my opening.

I'm delighted to reconfirm that 96 per cent of GP training places in Wales were filled in the first round. That's in direct contrast to England, where 80 per cent of places were filled. So, much, much better in comparison, our fill rate here. With two rounds to go, I've also agreed to provide further flexibility to fill more places than planned to take advantage of the capacity that we do have in our system. And, as I've previously announced, Health Education and Improvement Wales are reviewing the future need and numbers for GP training places in Wales. So, we may have a permanent expansion of GP training places, informed by evidence.

I will turn to some of the comments that Darren Millar made, and I'm happy to reconfirm that, on indemnity, he was wholly wrong. His praise of England's indemnity deal does not stand up to scrutiny, and I look forward to us reaching a conclusion on the general medical services contract for GPs. Those negotiations continue in good faith between partners, and I believe there is a better offer on the table here in Wales than the one accepted in England. All partners in that negotiation—the NHS, the Welsh Government and GPC Wales—are keen to conclude negotiations in the near future, so that GPs themselves can see the details, but crucially, that will help us to unlock further investment in local healthcare.

And in terms of some of the more rounded comments made in the debate, you learn something new every day, and Dai Lloyd's revelation that he worked in general practice for over 30 years was new to me. [Laughter.] But on the broader point made in other contributions about the wider team in local healthcare, I remember as a child going to the general practice and the doctor did virtually everything, from taking blood to a whole range of minor things that, today, you should not expect to see GPs themselves do. And that's the point: to see that progress continue, but continue more consistently and at a greater pace. And I was really pleased to hear Dai Lloyd recognise that investments are being made in the local healthcare estate, and it's a real issue for the quality of care, but also to make sure that people want to carry on having a career in local healthcare as well.

Of course, on social care, Dai Lloyd knows that I'm chairing the inter-ministerial group on paying for care. But one of the points that Dai, Dawn, Hefin and Alun made was about having that broader team of people—in particular, Dawn Bowden's point about the fact that we do need to see more pace in change. And that is what I'm determined to continue injecting. Not just that we agree there's a better way of running the service, but to make sure it actually happens, so people see that the future isn't somewhere else in Wales, but it's a service that they're receiving that's changed and for the better, because I, too, share the very real frustration as to how quickly we're managing to change the health service.

Part of that is us, actually, because as local politicians, we're always under pressure to support the case to keep what we have, rather than see what we could and should have if we really had best practice within and for our local communities. And that often means improving what we have and changing it. And that's the point that Alun Davies made as well, because empowered and informed people tend to make different choices, and that would drive our services in a different direction.

Will you take an intervention?

No.

And I'm also happy to point out that, on inverse care, both Aneurin Bevan and the former Cwm Taf health boards are taking a lead on addressing that to make sure that we have equity and quality across our health and care system. 

Finally, to turn to the comments by Hefin David—not a medical doctor—I do recall visiting Bargoed Hall and Bryntirion with you a couple of years ago, where there was real fear and concern, not just that there would be change, but that there would be a loss of service that would not be replaced. And that's part of the challenge, because as people do see change taking place, the concern is always not that there'll be something better, but that what they have will just simply disappear. And that's part of why I'm really pleased where Members described local examples of where change has happened and it is delivering a better service. And that better service isn't just good for the public, it's actually good for our staff—a better job, where they're more likely to recruit more people in the future, and more likely to give the quality of care that each and every one of us deserves. To improve that access for the public, delivering the right care at the right time and in the right place. And I would be very happy to visit and see what has changed two years on and to see for myself what every community should see more rapidly and more consistently as we continue to deliver a new model for primary care here in Wales.

Thank you very much. The proposal is to agree amendment 1. Does any Member object? [Objection.] [Inaudible.] Okay, but I did hear 'object' from somebody else, so I am going to take that as a valid objection. Okay, so we defer voting on this until voting time. 

Voting deferred until voting time.

Unless three Members wish for the bell to be rung, I now will proceed directly to voting time. You want the bell rung. Can I see three Members to show for the bell? I've got more than three. Ring the bell please.

The bell was rung to call Members to the Chamber.