The following amendments have been selected: amendment 1 in the name of Rhun ap Iorwerth.

We're going to move on, now, to item 6, and we'll have a debate on the Chief Medical Officer for Wales's 2018-19 annual report, and I call on the Minister for Health and Social Services to move the motion—Vaughan Gething.

Motion NDM7048 Rebecca Evans

To propose that the National Assembly for Wales

1. Notes the Chief Medical Officer for Wales’s Annual Report for 2018-19 ‘Valuing our Health’ published on 7 May 2019 and in particular welcomes:

a) the CMO’s reflections on the achievements, opportunities and challenges which we face in improving the health of people in Wales;

b) his focus on the importance of achieving best value from the resources available in health care;

c) the importance of research to health improvement and the Welsh economy; and

d) his assessment of the major health threats we face.

Motion moved.

Thank you, acting Deputy Presiding Officer. I'm happy to move the motion before us. The chief medical officer took up his post here in August 2016. He was attracted to come to Wales by the prudent healthcare agenda that we had set out upon. I have asked him to ensure that the prudent agenda does not stall, but continues to make a bigger, wider and more consistent difference, and therefore I'm very pleased to see that prudent healthcare, delivered more consistently by value-based healthcare, is at the very heart of his report, and I welcome the unique perspective that he brings.

Previous CMO reports have provided the opportunity to reflect on where Wales stands with regard to the health and well-being of our population, the challenges we face in public health and the changing provision of healthcare. Two years ago, the CMO report looked at how social disadvantage can impact on a person's life chances, their health and well-being. Last year's report examined the harms that gambling can cause to individuals, families and wider society. Those reports have informed our plans and approach to service transformation and delivery. This year, the CMO's report looks at three specific issues: prudent and value-based care; health and social care research; and health threats ranging from antimicrobial resistance to the environment.

The report also touches on the importance of getting children vaccinated against measles, mumps and rubella. Clinicians and other healthcare professionals have a responsibility to ensure that parents are fully informed of the benefits of vaccination. Members will be aware that this aspect of the report has already attracted considerable media coverage. We have worked hard to eliminate preventable childhood diseases and it should concern all of us that some parents continue to be taken in by anti-vaccination campaigns. So, I want to reiterate again the effectiveness and safety of the measles, mumps and rubella vaccination and urge parents to get their children vaccinated.

The report also considers the challenge of childhood obesity and the development of a healthy weight plan. My officials are currently considering the responses to the consultation that has recently closed, and that will inform what we hope will be a holistic approach. Members have heard today how assets such as the Wales coastal path can be promoted to help tackle obesity by providing enjoyable outdoor exercise and, of course, the role that active travel has to play. Members will be aware that there continues to be a high level of support for the principles of prudent healthcare. There are many examples across Wales of co-production, shared decision making, tackling inequality and variation and reducing harm. We now need to embed these principles much more effectively and consistently, not as part of good practice, but as part of standard and consistent practice.

The CMO is clear that a value-based care approach provides a route to making prudent healthcare much more of a practical, consistent reality. And that is an exciting prospect for our health and care system. It should allow our NHS to focus on doing more of the things that achieve better outcomes and a better experience with and for our people. We must be clear that looking at value in this way is not motivated by cutting costs. Rather, it is about equipping and incentivising health boards to use data to identify and then to disinvest in lower value actions and to reinvest that resource in those interventions that provide the best outcomes. A lot of good work has already started under the clinical leadership of Dr Sally Lewis and I have agreed to invest a further £0.5 million pounds in further developing value-based care here in Wales.

The report also highlights the importance of research and innovation in supporting not just better health, but also the way that our services are organised. It describes the rich history of research we have in Wales. Our modern-day research infrastructure is an essential part of the Welsh economy and educational landscape. The benefits of health and care research are profound, and its importance cannot be underestimated, whether that be in preventing ill health, enhancing well-being, reducing inequality or developing better treatment and shaping efficient and effective service organisation and delivery.

That is why we've invested in Health and Care Research Wales to enable us to put in place resources and infrastructure to support that research community, industry and people here in Wales. What is happening in Wales today across various fields of health and social care research is something that we should be genuinely proud of. NHS Wales is on the cusp of realising the significant benefits that can be delivered by advances in precision medicine for patients by offering the right test or treatment at the right time. Our work on new genetic and genomic technology is allowing us to develop a much more detailed understanding of the link between our genes and our health, helping us to develop new, advanced therapies and person-centred treatment. The pace of change in this area is rapid. We continue to be a member of the UK Clinical Research Collaboration and the experimental and precision medicine funders group and to co-fund a number of precision medicine fellowships.

A flagship initiative here in Wales, HealthWise Wales, launched by the then Minister for public health to my left in her new role, is the largest study of its kind in Europe, with more than 30,000 people registered. The power of such a study to contribute towards our understanding of health, well-being and lifestyle choices is significant and it will no doubt be used in coming years to develop policy, services and treatments.

In addition, the secure anonymised information linkage databank, otherwise known as SAIL, based in Swansea University, brings together and links anonymised person-level data about the people of Wales. It provides this in a safe and secure way as a resource for conducting research. The data security and information governance that underpin the SAIL databank are internationally recognised as exemplars. The data resource is used to support a range of high-quality research projects in Wales and across the UK, including Dementias Platform UK, the multiple sclerosis register and the UK Biobank.

Now, there are too many research examples to mention in my brief contribution today, but, to give an example, the research done by the Wales National Centre for Population Health & Wellbeing Research, again based in Swansea, is at the forefront of research to inform obesity prevention initiatives, which, as we have discussed on more than one occasion, is a significant policy priority for us. Bangor University's research on family attitudes and experiences following the implementation of our groundbreaking Human Transplantation (Wales) Act 2013 is another good example of Welsh research informing and improving made-in-Wales policies.

We remain acutely aware, across the Government, of the challenges posed by Brexit, as we work to ensure safe passage for the future of health and care research in Wales, and to do so with a climate that continues to support our increasing success in research and wider prosperity. Finally, the CMO report looks at some of the health protection threats we face, including antimicrobial resistance, threats from diseases that are preventable, those that are communicable, and the changing environmental hazards that affect us all. These are serious issues that we must be prepared to tackle head on if we are to make progress and reduce the significant impact upon people's health and well-being.

We will continue to invest, therefore, in our national health protection service and infrastructure to ensure we remain resilient to the threats that we face. Members will know that antimicrobial resistance is a worldwide problem. In Wales, we must play our part in preventing infections as well as reducing the inappropriate use of antibiotics. The figures are heading the right direction here in Wales, but we must continue to both support and challenge our NHS and social care to meet the challenging targets that we have set. We are also working to eradicate hepatitis B and C as a significant threat to public health. The Welsh Government is committed to eradicate hepatitis by 2030, and our NHS is working hard to identify and treat people. The rise of sexually transmitted infections remains a matter of concern. The Welsh Government has accepted the recommendations of an independent review of sexual health services, which we've debated previously here. The aim is to reduce infections, with improved services, education and better patient experience. We must also do what we can to counteract health threats in the environment, and Ministers share the CMO's assessment that an integrated approach is required to tackle air quality and other hazards.

In conclusion, I'd like to thank the chief medical officer, Dr Frank Atherton, for a thought-provoking report and recommendations. We will carefully consider it, and it will continue to challenge and inform our choices for the future health and well-being of our services and people here in Wales.

I have selected the amendment to the motion and I call on Dai Lloyd to move amendment 1, tabled in the name of Rhun ap Iorwerth.

Amendment 1—Rhun ap Iorwerth

Add new point at end of motion:

regrets the continued failure to bring forward legislation to tackle air pollution as a way of improving health.

Amendment 1 moved.

Thank you very much, acting Chair, and I'm very pleased to contribute to this debate on an excellent report by the chief medical officer, and I move the amendment on air pollution. More on that in a moment.

In terms of time, the other point I was going to focus on was immunisation against MMR—a fundamentally important point that the Minister has already referred to. Our chapel in Swansea has an enormous cemetery, over four acres, and it's heartbreaking to see the graves of young children there. The cemetery has been there for two centuries. The names of very young children and babies are listed on the gravestones. They died in their hundreds over the years because of diphtheria, tetanus and a number of other diseases.

Back in 2012-13, when I was a full-time GP, a case of the measles arose—it started in Swansea—in my practice, in Cockett, where I was a partner at the time. The numbers that had received the immunisation against MMR weren't sufficient to prevent this disease from spreading. It does depend on herd immunity. It depends on the fact that 95 per cent of children can't catch measles because they have been immunised against it. The virus is still alive in our communities. It depends on the fact that 95 per cent, however, can't catch the virus because they have been immunised. There are a number of children who have particular conditions who can't receive the injection, so it is incumbent on all other people who are fit to receive this injection to have it.

Before immunisation against measles, thousands of children and young people caught measles every year here in the UK, and hundreds died from the condition or suffered continuing after-effects, such as deafness, throughout their lives. Now, with the advent of MMR in 1988, for several years nobody died from measles, and there were no cases at all of measles for many years, until recent years when levels of immunisation have fallen below 95 per cent, and sometimes significantly below 95 per cent. Back in Swansea, around seven years ago, the level was around 82 per cent, so there is little wonder that we had a number of cases of measles, with one death, unfortunately.

The other point that the chief medical officer makes in the report—there are a number of points, of course, but, because our amendment refers to air pollution, I will talk about that particular issue, which kills or contributes to the deaths of 2,000 people in Wales every year. We've heard from Lee Waters this afternoon that there is an air quality crisis here in Wales, and of course there is a climate emergency as well. And, of course, air pollution is a public health crisis, as the chief medical officer has outlined in the excellent report this afternoon.

So, we do need to take action urgently, particularly to decrease emissions from cars and lorries on our streets and roads. We need to legislate in this field, because it is a climate emergency and it is an emergency with regard to public health. I am the chair of the cross-party group on a clean air Act, created here at the Senedd, so that we can create clean air zones in our towns and cities. Our children deserve no less than that. We need the infrastructure for our counties to gather information on pollution in their areas. Air pollution is damaging to our lungs, and to our hearts now because nanoplastics—those tiny particles are so small now that they can reach our hearts through our veins and our blood vessels. Those nanoplastics are so small that they reach our hearts and they do cause heart disease. So, do support this amendment. Thank you.

I call on Janet Finch-Saunders.

Diolch, Dirprwy Lywydd. Dr Frank Atherton has quite rightly outlined well the multiple issues that require all of our attention and, indeed, some Government action. He reminds us all of the importance of research, awareness and effective collaboration in order to tackle the major health threats facing us in Wales, and also to be prepared for expected health and social changes. Infections, environmental threats, rising obesity levels—particularly childhood obesity, with 27 per cent of children aged four to five now classed as overweight or obese—smoking-related deaths, and the ever-evolving needs of our ageing society are major causes of concern.

The recent levelling of life expectancy rates requires monitoring. Most concerning, however, is the variation between the most and least deprived areas of Wales, generally being an eight-year gap between economically secure households and less economically viable ones. In terms of healthy life expectancy, this variation increases to a momentous 18-year difference.

Crucially, as explored in chapter 1, care of the elderly population in Wales needs to be based on a whole-system approach that acknowledges the right for elderly people to age well, both physically and mentally. And it also takes into consideration the forecasted population increase by 58 per cent for those aged 75 and over. This is pivotal. As we are all aware, elderly people are most at risk of developing dementia—and that has been discussed earlier today—along with other illnesses such as cancer, which has become one of the most fatal and painful illnesses of our generation. This, however, should be considered alongside the fact that older people are more likely to experience complications from multiple health conditions, which can make diagnosis and treatment difficult.

Further, the medical officer outlines four recommendations so that our healthcare system and approach is both prudent and value driven. This includes a development of infrastructure, data, good practice and excellent communication. Now, I recognise that creating a data-driven system is integral to ascertaining where investment should be channelled to tackle the biggest health threats. Research is integral to the successful delivery of our health strategy and therefore I do urge the Welsh Government to continue funding such meaningful research, co-ordinating activity among key stakeholders and, where possible, to further engage the public in those various stages of research.

The Government should also look to promote the work of Health Wise Wales, which is now asking the public to share their thoughts on the most pressing health, well-being and social care questions as part of their national project. Indeed, Cancer Research UK’s report, ‘Bench to Bedside’, calls on the Welsh Government to drastically improve its funding for medical research, particularly quality-related research. More precisely, I wish to bring attention to Cancer Research UK’s calls that the Welsh Government innovates its strategic thinking and planning mechanisms to attract and support researchers with new funding opportunities. This is urgent in light of Brexit, as funding streams from the EU to UK medical research could be lost.

Deputy Presiding Officer, I encourage the Welsh Government to be proactive with other devolved nations, such as Scotland, in order to improve our knowledge, understanding and response to the health challenges affecting us today. Obesity is one of these, so I therefore welcome the introduction of the healthy weight plan. I hope that this will improve the current worrying statistics on fruit and vegetable consumption.

Finally, I believe that Dr Atherton has brought attention to less overt health threats, such as antimicrobial resistance, anti-vaccination trends, healthcare acquired infections, chemical contamination, and the effect of changes in our climate and natural environment, such as the release of radiation, flooding, and extreme weather variations.

The chief medical officer states that more work with GP practices is needed to ensure appropriate antibacterial use. Similarly, schools should continue to be encouraged to provide both MMR vaccinations to children so that the current percentage rates of those being vaccinated rise. I am keen to ask the Welsh Government what plans are in place to improve the uptake of vaccinations in harder-to-reach demographics. I uphold Dr Atherton's recommendations and urge the Government to act on this most interesting and robust report so that we can continue to protect the health of Welsh people and deliver our healthcare aims. Thank you.

Minister, I'd like to refer specifically to the part of the report in the annex that is dealing with the progress that's been made in respect of the public health issue that's been raised with regard to gambling. I raise it because last year's report was a groundbreaking report and has been recognised throughout the UK in identifying and starting the process of looking at how we tackle what is, I think, a latent, growing, hidden and emerging but incredibly serious epidemic.

I have to say that, although there are aspects of the annex in terms of work that has been done that I welcome, I think it is not enough by any stretch of the imagination. I certainly welcome the survey questions to young people with regard to prevalence, the consideration of looking at the planning system, raising concerns about advertising with the standards authority, seminars and so on. But I don't think this, by any stretch of the imagination, recognises the actual scale of the public health issues with regard to gambling.

Certainly, much of the responsibility in respect of gambling is at UK level, but certainly there is much that we can do in respect of the public health aspects. If I can just refer the Minister and the Members to a leading market research company's comments on gambling:

'Global sports betting market expected to reach approximately $155 billion by 2024...growing at a healthy 8.83 per cent...with digital revolution transforming the world every second, the sports betting market is likely to grow dynamically in the future.'

If we actually look at the state of gambling and its impact within Wales, the Gambling Commission estimates that 1.1 per cent of the Welsh population are problem gamblers. That is approximately 40,000 people. It estimates that there are a further 4 per cent at risk—that is, a further 160,000 people—and for every one problem gambler, research estimates that a further seven are adversely affected. That is a further 280,000 people, and I think those are extremely conservative estimates based on old information and do not reflect the scale of what is happening.

I chair the cross-party group on gambling and we've had some very interesting academics who've been doing research in various countries, particularly Australia, identifying some of the impacts on young people, and it is the young people that I think we must particularly look at in terms of our public health policy, and I don't think the report actually really does start getting to grips. Eighty per cent of 11 to 16-year-olds have seen gambling adverts on tv, 70 per cent have seen gambling adverts on social media, and 66 per cent on websites. Seventy-eight per cent of young people we spoke to think betting has become a normal part of sport, and this normalisation of the association with gambling and sport I think is incredibly significant. It has become part of the culture of sport and it should worry us considerably.

I was looking at the programme of the new Tottenham Hotspur White Hart Lane stadium recently—the £1 billion stadium, which is fantastic—and the first thing that jumped out was the statement that there would be no gambling facilities within the stadium. I thought, 'That's impressive', alongside its recycling policy, until of course you read that there is internet throughout the stadium. Betting outlets are no longer necessary. It is the internet gambling. And when you look at the actual amount of money that's ploughed in, let's be honest about it, gambling is the new nicotine, the new tobacco industry of sport. That is why we need to seriously tackle the issue of public education.

Three in five students have gambled in some way over the past 12 months. One in 10 have used all or some of their student loan to gamble. Minister, the scale is phenomenal and it is growing. In the UK alone, it is a £15 billion industry, and growing year by year. We all know that you cannot turn on satellite, you cannot turn on the internet, on your phones, on YouTube—anything that you utilise—the extent to which there is gambling advertising. And of course, that is within the UK responsibility, and, of course, we have to engage because there is a desperate need for new gambling legislation that seriously tackles and restricts that.

But in the meantime, in terms of what we have within our competence, I think we actually need a very, very clear and dynamic strategy that is up to the scale of the gambling epidemic that is approaching and is already hitting and indoctrinating our young people. It needs to be one of public education. There has to be far greater focus on how we can use planning laws in terms of outlets, how we can look at outlets in respect of advertising themselves, and also, ultimately, the pressure that we have to put onto the gambling industry and the gambling commission for the proper funding of what is needed to tackle gambling addiction and gambling education.

What is happening at the moment—

Can you bring your remarks to a close, please?

What is happening at the moment is mere peanuts and I don't think the strategy we have at the moment is a strategy or in any way adequate to deal with what we could, potentially, be doing.

I thank the chief medical officer for his latest annual report. Dr Atherton has highlighted several health challenges facing our nation. I want to focus my contribution on two of those challenges. Two challenges to our nation’s health that, if left unchecked, could do untold damage to the well-being of Wales. Those challenges are antimicrobial resistance and the spread of the 'anti-vax' movement.

I welcome that, as highlighted by the chief medical officer, there has been progress made in reducing inappropriate use of antibiotics in health settings. However, we can’t tackle antimicrobial resistance by just reducing the number of antibiotics handed out by our GPs. We have been overusing broad-spectrum antibiotics for decades. When we take an antibiotic, a percentage of it ends up going down the toilet, and a result, a large amount of antibiotics ends up in our waste streams, our rivers and oceans. This pharmaceutical pollution does not only have an adverse impact upon wildlife; it also adds to the pool of microorganisms that are drug resistant. We also must consider the impact that agricultural use of antibiotics is having. Concentrations of antibiotics in soil can approach the therapeutic doses given to livestock because of overuse.

We have seen several cases around the world during the last few years were bacterial infections were resistant to every antibiotic in the arsenal. Infections for which there is no cure is a clear and present danger to human life. We must act to reduce opportunities for these microbes to become resistant and to find alternatives, and that means that as well as reducing human use of antibiotics, we also must tackle overuse in agriculture and stamp out pharmaceutical pollution. We must also invest in research into alternatives to antibiotics such as bacteriophages.

As well as the threats we face from bacteria, we are seeing a growing threat from viruses that were once under control. Again, it is human behaviour that is the driving force behind the threat. This time it’s not the arsenal that is failing. Lies and misinformation have led many to abandon the arsenal altogether. The growth of the 'anti-vax' movement has skyrocketed thanks to social media. While the social media companies are finally acting, it’s too little, too late. Too many parents have listened to the lies spread by the likes of disgraced former doctor Andrew Wakefield and American actress Jenny McCarthy. The end result of those lies is the death of children from measles.

The number of measles outbreaks has increased in recent years and we are seeing more than 10 per cent of children failing to receive two doses of the MMR vaccine. We must actively combat the spread of 'anti-vax' propaganda online with our own stark messages. Unvaccinated children may die because some person online convinced a parent that vaccines cause autism. Vaccines prevent death from disease. We all have a role to play in highlighting this, and I thank Dr Atherton for including the threat from vaccine-preventable disease in his annual report. Diolch yn fawr.

Can I also thank the chief medical officer for the report? It's curious that we've had an afternoon where we've debated some elements that appear within this report—the issue of behavioural change and active lifestyles, whether it's through active travel or elsewhere. We're very cognisant of the fact as well that 'A Healthier Wales', the strategy that the Minister laid out last year and that he's driving forward, gives us that opportunity to transform healthcare in the way we look at it. A real transformational and generational change towards prevention and community and primary care, prudent healthcare, to people living longer and independently at or closer to home and so on. I'd urge the Minister, because I know his commitment on this, to continue to drive this change with partners right across Wales and make this transformation and make it irreversible. 

But I want to turn to something else entirely, a different way to view this, and for this I'm grateful to the Equality and Human Rights Commission for their submission to all Assembly Members, which I'm going to draw extensively on and I'm sure the Minister will have seen it too. They draw on their report earlier this year, 'Is Wales Fairer?', and they report the key findings from that report, the particular challenges, the entrenched issues that affect the Gypsy/Roma/Traveller communities, not least in terms of their access to health provision. But also the mistrust and the reluctant uptake of health services is still a major issue.

The fact that amongst non-disabled people when they report good health it's almost twice as frequent as disabled people, and disabled people report poor mental health nearly three times more frequently than non-disabled people. The fact that up to one in five women are affected by perinatal mental illness and still face the challenges within Wales of access to specialist perinatal mental health services.

And of course as we all know the challenges for looked-after children, who tend to be at greater risk of experiencing poor mental health than children in the wider population. We all know too well that men in Wales, from statistics in 2016, are four times more likely than women to die by suicide. The challenges that we have not just in Wales but across the UK and across many developed nations in terms of matching the provision for mental health with the rise in demand.

Finally, they point out that one of the greatest challenges is the lack of disaggregated data meaning that it's hard to actually identify the outcomes and do the analysis of the potential barriers in access to healthcare for those with specific protected characteristics. So, they do make some specific recommendations, and again I'll touch on them very briefly here. 

First, that in taking forward 'A Healthier Wales', the overarching strategy now of Welsh Government in terms of transforming health, equality and human rights are absolutely embedded within its implementation. So, those points that I refer to in a moment, that those are recognised but that equality and human rights are deeply embedded within that strategy.

That healthcare in Wales is accessible to all without discrimination, and that's with particular reference to Gypsies and Roma and Travellers, to the accessibility and quality of translation services that are available to migrants and refugees and asylum seekers, and that there is a fully integrated gender identity service in Wales where you can monitor the impact on health outcomes for transgender people within Wales. And also that we fully evaluate progress made under the Mental Health (Wales) Measure 2010 and the 'Together for Mental Health' strategy. 

Now, we are doing some incredible things in Wales, despite the challenges in funding and the wider challenges within healthcare, but it is right that we constantly challenge ourselves to do more, and I hope the Minister will welcome the analysis and the challenges laid down by the Equality and Human Rights Commission as actually a useful contribution to doing things better as we go forward. 

The Llywydd took the Chair.

I call on the Minister for Health and Social Services to reply to the debate—Vaughan Gething.

Thank you, Presiding Officer, and I want to thank Members for their largely thoughtful contributions to today's debate. I want to thank Dai Lloyd for his speech and, in particular, reiterating the point that was taken up by some other Members about the importance of vaccination—his own direct experience as a GP, but also parents like myself who have gone and made sure that our children are vaccinated—and the points made about the fact that the conspiracy theories about vaccination continue to be promoted. The current occupant of the White House has taken his turn in trying to do exactly the same thing, and then taken a step back, but it's important that we all have a consistent message about the importance of doing so. 

I want to turn to Mick Antoniw's contribution. I, too, share your concern about the normalisation of the link between gambling and sport. Sport is such a wide-scale activity, with so many people involved and engaged, we can't protect our children and young people from seeing the pervasive messages there around professional sport, and, indeed, adults, and it does have an influence. People don't advertise the opportunities to gamble freely just for the sake of their own conscience, that they think it's a good thing to do, they advertise it because it has an impact and it draws people in. That's why the chief medical officer has directly engaged with the Advertising Standards Agency and why we continue to do so. And I recognise that there are challenges in this area. The work we're currently doing with directors of public health, the work that we're doing bringing together a range of stakeholders, we set out some of the detail in the report, but we do agree that an integrated approach with other policy areas, like substance misuse, is required to provide an initial framework for action. So, we will continue to look at how we maximise our opportunity to make a difference, bearing in mind not all of the powers we would like to have rest within this place. 

There was much of what Janet Finch-Saunders said that I wouldn't disagree with, but I would say that, any time people call for an increase in a budget, they can't expect to be taken seriously unless they say where that money will come from. We are in an environment where there is less money available. The health service gains the largest share of that. So, if we're going to call for extra money, let's be clear about where that will come from and what that means—either to call for an increase in the budget provided to this place in the first place, or to set out which areas people prefer to see cut to do so. 

And, on Huw Irranca-Davies's points, I'm more than happy to agree with him on the point about mental health, but also more generally the point about equity in the delivery of health care, recognising the challenges that particular groups of people have in having a genuinely fair service from our health service. And I do agree that the report from the Equality and Human Rights Commission is a helpful reminder for us across the whole service. I'm also, of course, happy to reiterate my commitment to deliver the vision set out in 'A Healthier Wales', to do better, to improve the experience and the outcomes across a range of measures, because that is what the people of Wales deserve. 

I won't repeat many of the points that I've already made on a number of occasions about the challenges that lie ahead of us, however it is helpful to consider the CMO's report and his recommendations as part of the solution. So, we're looking generally to deliver on the promise of prudent healthcare through value-based healthcare. That is something that would be of great benefit to all of us, to unlock significant resource within our system and to direct that towards better outcomes. 

I would, therefore, in ending, Presiding Officer, like to thank, again, the chief medical officer for his analysis and recommendations, and I look forward to his continued advice, challenge and support as we move forward with improving health and social care services and shaping a healthier and happier Wales. 

The proposal is to agree amendment 1. Does any Member object? [Objection.] I will defer voting until voting time.