The following amendment has been selected: amendment 1 in the name of Lesley Griffiths.

Item 7 today is the Plaid Cymru debate on health inequalities. I call on Rhun ap Iorwerth to move the motion.

Motion NDM7877 Siân Gwenllian

To propose that the Senedd:

1. Notes the prevailing deep health inequalities that exist in Wales.

2. Further notes that due to these inequalities the COVID-19 pandemic has had a disproportionate impact on many individuals, families, and communities across Wales.

3. Calls for a strategy and action plan to tackle health inequalities in Wales. 

Motion moved.

Thank you very much, Deputy Llywydd. We are facing a health crisis: a crisis that is putting lives at risk, which kills; a crisis that means that the vulnerable face the greatest threat; and a crisis that we should all be desperate, some day soon, hopefully, to put behind us. And, no, I am not talking about the pandemic. I am talking about the health inequalities that exist within Wales. The pandemic is relevant because those inequalities have meant that the pandemic has hit some harder than others. And we could have anticipated that because time and time again some communities, some groups and some individuals suffer more than others. But that is not inevitable. And I'm pleased to formally move this motion that calls for a strategy and a clear action plan to tackle those inequalities.

I will explain immediately why we will reject the Government amendment: the Government deletes the call for a strategy in its amendment and the call for an action plan. It calls for us rather to acknowledge what the Government is already doing, as if that were enough. But the whole purpose of this debate, which is the result of co-operation between Plaid Cymru and a number of medical, health and care bodies and organisations, is to try and wake up the Senedd and the Government to the reality that any measures currently in place—and, of course, there are measures in places—are totally inadequate.

Health inequalities include many different factors. We're talking about differences in life expectancy—healthy life expectancy—and difference in access to healthcare. We're talking about the differing levels of prevalence of long-term health conditions, physical and mental, and differences between who—well, it could be along socioeconomic lines where poverty drives so many health problems; it could be geographic even and geographic differences in access to care, including between rural and urban areas. Experiences can differ along the lines of ethnic backgrounds as they often, often do, and according to physical ability. This isn't a uniform phenomenon. And it's about the inverse care law, isn't it, described for the first time by Dr Julian Tudor Hart just over 50 years ago, meaning those who most need care are least likely to be able to access it.

The scale of the challenge, the complexity of how we deal with all these inequalities is huge—frighteningly so—but that can't allow us to shy away from addressing those challenges. Indeed, there can be nothing other than to look at those challenges that could do more to spur us on to try to get to grips with the situation. Our health and care services, we know, right now, face enormous challenges. Levels of ill health made worse, of course, by the current pandemic mean that our fragile services are bursting at the seams. And we can't just say, 'Well, this is the hand we've been dealt; this is just how it is. People become unwell and our services then deal with that.' We potentially have an enormous amount of control over the cards that we ourselves hold. As the World Health Organization said in a report 30 years ago now, these inequalities are socially produced, and therefore modifiable. This is taking the preventative to its ultimate degree, if you like—not just working with individuals or families to try to promote good health and to help steer people away from as many risks as possible, but rather, taking a systemic preventative agenda, looking at all those issues that mean we are not a healthy nation, and importantly, crucially, that the burden of that ill health is not evenly shared between us. 

The Llywydd took the Chair.

Over the next hour, we will hear a number of examples of inequalities from my fellow Members as we try and paint a picture of the challenge that we are facing. The fact that so many different organisations have come together to push for a strategy tells us so much. And I'm grateful to many of them for their direct collaboration in preparing for today's debate. The Royal College of Psychiatrists argue that mental health is closely linked to many forms of inequality, including a lower standard of life, poorer health outcomes and early death. Platfform, the mental health charity, emphasised further that mental health is related to all sorts of inequalities. Depression is twice as prevalent among low-income groups. People who go hungry, who are in debt, or who live in low-quality housing are far more likely to suffer poor mental health. The British Heart Foundation Cymru underlines that systemic inequalities that previously existed have been exacerbated by the pandemic, and reflect a recent campaign by them—a campaign that I support—saying that women still face great disadvantage at every stage of their journey with heart disease. 

I am also grateful for the input of the Royal College of Physicians. They also emphasise how the pandemic has exacerbated inequalities and has demonstrated clearly the link between poverty and poor health outcomes. We know, incidentally, that the death rate in the most disadvantaged areas of Wales in this pandemic has been almost twice as high as that of more affluent areas. One in three people who needed intensive care treatment came from a BAME background. But what the Royal College of Physicians tells us, in looking at inequalities more broadly, is that we, for too long, have looked to the NHS to respond to the challenges that we face with public health. But of course, the NHS alone doesn't have the levers, as they describe it, to make the kind of changes that are required to create the necessary conditions to promote good health. To quote them:

'Meaningful progress will require coherent efforts across all sectors to close the gap.'

They suggest what a strategy—the kind that we're calling for today—could look like, what a cross-Government response could look like. It should define 'health equality' and what exactly success would look like. It should provide clear, measurable targets and outcomes with a defined timescale. It should bring together existing work on inequalities from across Government departments, because, as I say, there is work going on, of course. It should define the kind of collaboration needed across Wales with many, many partners involved to bring about the change that we need. And, of course, it must be underpinned by the necessary funding. And perhaps at that stage, I see any Minister wincing at the sheer scale of the challenge. But as we ponder how on earth we find the money to do it, consider the 2011 report from the Welsh Government itself, saying that the annual economic cost of dealing with the consequences of inequalities in health in Wales was estimated then to be between £3.2 billion and £4 billion. 

In the recent strategy, 'A Healthier Wales', inequality, I think, if we're counting correctly, is only mentioned three times. Plaid Cymru wants to make a difference and the updated programme for government resulting from the co-operation agreement includes, I think, 11 mentions of the words 'equal', 'inequality' or 'inequalities', including a key promise to move to eliminate inequality in all its forms. And the most basic form of inequality—or to turn it on its head, the equality that we seek—has to be health, surely. And that's why, again, we say that the Government's amendment today, removing the call for a clear plan of action, is contrary to their own stated ambition. I'm afraid, Minister, words aren't enough in themselves.

Our own health as individuals is clearly the main ingredient in giving us the best possible quality of life, by a country mile. And translating that to a vision for the nation as a whole, while improving our levels of health overall across the board and making a particular effort to eradicate the inequalities, surely has to be at the heart of creating the better Wales that we all should strive for. I look forward to today's debate.

I have selected the amendment to the motion and I call on the Minister for health to formally move the amendment—Eluned Morgan.

Amendment 1—Lesley Griffiths

Delete all after point 2 and replace with:

Acknowledges the causes of health inequality are multifaceted and require an integrated and cross-government approach.

Further acknowledges the significant commitments set out within the Programme for Government across all areas of government activity designed to tackle health inequalities in Wales.

Amendment 1 moved.

Formally.

Can I thank Plaid for bringing forward this debate this afternoon? I think it's a very worthy use of time this afternoon to be debating this topic. We haven't put forward any amendments to this motion tabled by Siân Gwenllian, because we agree with the motion as it's been tabled. We're not minded to support the Government's amendment, because it deletes important points of the Plaid motion, as Rhun ap Iorwerth has pointed out.

I wanted to use my time in this contribution to talk about some of the work of the Health and Social Care Committee's inquiry, which we launched just this week, actually. Our piece of work is focusing on mental health inequalities across different groups in society. We made a point, really, of not revisiting, perhaps, some of the other good work that's been done by previous committees; we don't want to repeat work that's been done. So, we're focusing particularly on the inequality aspects of mental health. The inquiry will focus very much on those who are disproportionately affected and look at what the barriers are that exist to accessing mental health services. The inquiry will also look at the extent to which Welsh Government policy recognises and addresses the mental health needs of particular groups.

I was very interested in the work of the Centre for Mental Health, which works in conjunction with a number of other bodies as well. They refer to the triple barrier. Particularly, when they're referring to the triple barrier, they're talking about the disproportionate risk that people have due to the inequalities generally in society. But secondly, and perhaps most importantly, groups with particularly high levels of poor mental health can have the most difficulty accessing services, and when they do get support, their experiences and outcomes are often poorer. So, as a committee, the work that we've launched this week—we'll ask for some written evidence first and listen to oral evidence later in the year, but we do want to get to the bottom of mental health inequalities across Wales. I don't think it is right, of course—and I'm sure we can all agree—that people in society are disproportionately at risk and struggle, just because they're in a particular category.

We know, for example, that children from the poorest 20 per cent of households are four times more likely to have serious mental health difficulties by the age of 11 as those from the wealthiest 20 per cent. Other groups affected as well are older people—85 per cent of older people with depression receive no help from the NHS, according to the study that the mental health centre has undertaken. On autism, 70 per cent of children or 80 per cent of adults with autism have at least one co-occurring mental health condition, and one particularly disturbing statistic is that children with autism are 28 times more likely to think about or attempt suicide.

Deaf people are twice as likely to experience mental health difficulties, and those with learning difficulties are three times more likely than average to have a mental health problem occurring as well. So, we do want to hear the experiences through this piece of work from real situations. We want to try and get the voice of those who are often unrepresented in society and use those experiences. I hope as a committee that we can make recommendations that help set a direction for the Welsh Government in terms of policy on mental health. So, diolch, Llywydd. I'm pleased to take part in this debate this afternoon.

Health inequality has been known for over 50 years, when Dr Julian Tudor Hart wrote an article in The Lancet on the inverse care law. The inverse care law is the principle that the availability of good medical or social care tends to vary inversely with the need of the population served. He said:

'In areas with most sickness and death, general practitioners have more work, larger lists, less hospital support, and inherit more clinically ineffective traditions of consultation, than in the healthiest areas; and hospital doctors shoulder heavier case-loads with less staff and equipment, more obsolete buildings, and suffer recurrent crises in the availability of beds and replacement staff.'

Has it changed? As Frank Dobson put it when he was Secretary of State for Health,

'Inequality in health is the worst inequality of all. There is no more serious inequality than knowing that you’ll die sooner because you’re badly off.'

Then there's a social gradient in lifespan. People living in the most deprived areas in England and Wales have an average life expectancy of about nine fewer years than those in more affluent ones for men, and seven for women. Men and women living in the most deprived areas can expect nearly 20 fewer years in good health. So, people not only die younger but are ill for a larger period of their life. If I were living now in the area I went to school, the likelihood is, as a man of over 60 years of age, it would be over 50 per cent that I would be suffering from serious ill health. Almost half the gap in life expectancy between the two areas is due to excess deaths from heart disease, stroke and cancer.

As well as lower life expectancy, there's a higher prevalence of many behavioural risk factors among the most deprived areas compared with the less deprived areas. These health inequalities are underpinned by inequalities of both social and economic circumstances that influence health. Health cannot be looked at on its own. The unequal distribution of the social determinants of health, such as education, housing and employment, drives inequality in physical and mental health, reducing individuals' ability to prevent sickness or to take action and access treatment when ill health occurs. People cannot afford to stay home from work when they are ill because the effect it has on their income. That has a serious effect on their life expectancy in the long run, but it certainly affects them very badly in the short term.

These inequalities are complex; they are embedded in society. But they're also preventable. The dimensions of inequality are complex and overlapping, as is representing the overlapping dimensions of health inequality. Health inequalities such as deprivation, low income and poor housing have always meant poorer health, reduced quality of life and early death for many people. The COVID-19 pandemic has starkly exposed how these existing inequalities and the interconnection between them, such as race, gender and geography, are associated with an increased risk of becoming ill with a disease such as COVID-19. But it would be true of any pandemic.

The link between poor housing and poor health is well established. Clement Attlee created a ministry of health and housing under Nye Bevan. Unfortunately for me, no Labour leader since has managed to join the two together. The Labour Party has a strong and proud record of providing good-quality social housing, and this leads to improved health for the residents of these properties. But we also have people living in cold, damp and unsuitable privately rented accommodation. Is it any surprise that they have poor health and many children have poor educational outcomes?

Homelessness has a huge impact on a person's physical health. Sleeping rough makes it difficult to get good-quality sleep, maintain an adequate and healthy diet, stay clean and take medical treatment. It's not surprising that research by University College London discovered at least one third of homeless people have died from readily treatable conditions, and almost all of them died young.

Many studies have found a direct link between good health and interaction with the natural environment, with stress lowered, obesity rates lessened and concentration improved. Health inequality is just another manifestation of poverty: poor diet, poor-quality housing, inadequately heated housing, lack of interaction with the natural environment, lack of exercise, and continually worrying about money inevitably producing less good health outcomes and early death.

Can I just finish by talking about worrying about money? I think it comes as a shock to most of the people in the Senedd, but there are large numbers of my constituents who daily worry about the amount of money they've got and how they're going to pay their bills. They live throughout my constituency, and I think that, really, it's about taking that stress away. I remember once saying that if I was in that situation of not knowing how I was going to feed my children, if I didn't know how I was going to pay my rent, I would be depressed as well, and it seems mental health is driven by the fact that people are poor. So, let's deal with the real cause of it, which is poverty and poor housing, and if we can deal with those, then we can improve health and health outcomes.

Health inequality is not new in Wales, though the pandemic has highlighted this inequality and exacerbated the situation for many constituents living in my region, reflected in the high level of deaths from COVID in Rhondda Cynon Taf. It has not created this inequality, and it is clear that more should have been done long before the pandemic to tackle this.

Obviously, austerity has not helped either. Research shows that austerity measures, which include reducing social spending and increasing taxation, hurt deprived groups the most. They increase the risk of unemployment, poverty, homelessness and other socioeconomic risk factors, while cutting effective social protection programmes that mitigate risks to health.

Austerity also has consequences for health and health services. It impacts most on those already vulnerable, such as those with precarious employment or housing, or with existing health problems. It is associated with worsening mental health and, as a consequence, an increase in suicides. Yet, this is not an inevitable consequence at a time of economic crisis, as evidenced from the research into those fortunate to live in countries with strong social protection systems, such as Iceland and Germany.

In 2015 the UK experienced the largest annual rise in the mortality rate for 50 years, and the number of deaths in the UK has been rising since 2011, apart from a recovery in 2014, after a steady decline from the late 1970s onwards, and this rise has been particularly large amongst the elderly. Austerity measures, rather than economic hardship per se, appear to have played a role in this rising death rate. Analysis that examines changing patterns across local areas finds that cuts to social care and financial support to elderly pensioners are associated with the rise in mortality among those aged 85 years and over.

As I know from my personal experience in supporting communities still impacted by the devastating floods of 2020 as a result of storm Dennis, extreme weather and flooding are also likely to disproportionately affect those on low incomes, those with fewer resources to prepare, respond and recover from floods or other extreme weather events, and those less likely to be fully insured against damages to property from such extreme weather events. Damp mould in properties as a result of flooding poses a significant risk to health. However, many of those on low incomes simply cannot afford to fix the problem, meaning many continue to face significant risks to their health, due to the ongoing and worsening effects of climate change.

As one of the Senedd's clean air clean champions, I also want to highlight the issue of air quality and how this also disproportionately affects those on low incomes. It's worth bearing in mind that it's children in low-income households that are worst affected by air-quality issues. Air pollutant concentrations are currently higher in areas of socioeconomic disadvantage, meaning that those on low incomes tend to be worst affected by health problems related to poor air quality. We've heard from other contributions already the gap and difference in life expectancy with the least and most deprived areas in Wales, with 8.9 years for males and 7.4 years for females. And further, the proportion of total deaths in 2019 that were avoidable in Wales continued to be substantially larger in the most deprived areas, compared with the least deprived areas. Cwm Taf has the lowest healthy life expectancy at 61.2 for men and 62.6 for women, compared with 67.6 for men and 69.2 for women in the Betsi Cadwaladr area. That is a stark difference of between six and seven years of healthy life for constituents living in the region that I represent. 

We can do more, we need to do more to end health inequality in Wales, and what we are proposing today is bringing together a plan to tackle health inequality. I hope Members from across the Chamber will support our motion.

Samuel Kurtz. Samuel Kurtz. Can I have Samuel Kurtz's microphone unmuted? 'Computer says no', Samuel.

You've got the wrong Sam, sorry.

Oh, it's the wrong Sam. Okay. We've got the right Sam. Samuel Kurtz.

Thank you, Llywydd. I'll start by thanking Plaid Cymru for bringing this debate forward this afternoon.

I'd like to use my contribution to draw Members' attention to the ongoing health inequalities in rural Wales, by highlighting examples within my own constituency of Carmarthen West and South Pembrokeshire, in particular those inequalities that have arisen as a consequence of the COVID-19 pandemic and the reorganisation of vital health services.

Just last week it was announced that Hywel Dda University Local Health Board had reallocated services across west Wales to the Prince Philip Hospital in Llanelli, an effort to sustain vital NHS cancer services throughout the current stage of the pandemic. Whilst this temporary prioritisation is largely welcomed, it does raise important questions about the future of services in west Wales. A resident from the village of Angle, the furthest point west in my constituency, has roughly a 46-mile round trip to attend Withybush hospital in Haverfordwest, or an 86-mile round trip to attend an appointment in Glangwili hospital. Under the temporary service, a resident of Angle will now have to travel a total of 122 miles to and from Prince Philip Hospital. This is difficult at the best of times, but is made even more frustrating by a fundamental lack of public transport infrastructure. With this example alone, you can see how counter-productive it would be to channel resources away from Glangwili or, indeed, Withybush hospital, in my colleague Paul Davies's constituency of Preseli Pembrokeshire, to Prince Philip Hospital in Llanelli.

Over the last 20 years, we have consistently seen hospital services based in Withybush and Glangwili hived off to the east. For the last four years, Welsh Government have dangled the carrot of a new hospital being built on the Pembrokeshire-Carmarthenshire border, but the site and the funding for this project still remains a mystery. Minister, we will be lucky to see a new hospital built before the end of this Senedd term in 2026. My constituents are becoming understandably concerned that the erosion of health services out of Pembrokeshire and west Carmarthenshire are only moving in one direction: eastwards. Time and time again, Minister, we've been told, and colleagues of mine, that services would not be reduced until a new hospital was in place, yet services are systematically being run down and exasperating health inequalities for those who use them. If you combine this with west Wales's poor ambulance waiting times and the distance it actually takes to reach a hospital in an emergency, you then have the perfect storm for a front-line services crisis. And it is residents in Carmarthen West and South Pembrokeshire that will be forced to suffer. That is why it's imperative that these services return to their usual points of delivery as soon as possible. Diolch.

Well, as we've already heard, health inequalities are as a rule symptomatic of other inequalities, with income usually the main factor. According to Public Health Wales, as Mike Hedges and others have referred to, people in the poorest areas of Wales live healthy lives for 18 years less than people in more prosperous areas, and people in those poorest areas are 23 per cent more likely to experience cancer, and 48 per cent more likely to die as a result of illness. And with mental health too, Rhun ap Iorwerth has referred to the fact that the charity Platfform has demonstrated that depression is twice as prevalent among low-income groups, and that those who are short of money and food are more likely to suffer mental health problems. The same pattern can be seen in relation to serious mental health problems, with those on the lowest wrung of the socioeconomic ladder eight times more likely to be diagnosed with schizophrenia.

So, material inequalities lead to a vicious circle of other inequalities. It's also true of race inequalities in Wales. We know that people from ethnic minorities receive 7.5 per cent less income on average than white people, and that income inequality leaves them more exposed to illness, including COVID. The same is true of housing in Wales, as we've already heard. The Welsh Government, when they commence the work of rebuilding society post COVID, must prioritise breaking this vicious circle, so that opportunities are shared more equally. The best way of improving the general standard of living is to start from the bottom up, because that's where the need is greatest.

So, I urge Members to support the Plaid Cymru motion today, which calls for a specific strategy to tackle health inequalities, and to reject the Government amendment that supports retaining the status quo. It's crucial that this happens as soon as possible as we face an energy-price crisis that will have an appalling impact on people already struggling to make ends meet. According to the Marmot report, around 10 per cent of excess winter deaths are the result of fuel poverty, and therefore it's crucial that there is real action on the problem between now and next winter, if not sooner.

I'd like to conclude by talking about another factor that drives inequality, namely geographical inequality. The Marmot report on health inequalities in England looked at this too, noting that geography plays a huge part in health outcomes. The truth is that the south Wales Valleys communities are still suffering the impact of mine closures in the 1980s. It's staggering to think that people in Valleys communities continue to face low incomes, and the poor health outcomes that come as a result of that, 33 years after the last pits, Cwm and Oakdale, were closed. It's almost as many years as I've been on this earth. What a political failure we see there. The people living in these post-industrial areas still suffer industrial illnesses, and the rates of other health problems remain high because of their economic conditions, and unemployment remains a serious problem.

The Sheffield Hallam report on the economic and social situation of the impact of pit closures in England and Wales reported in 2019 that health problems were a curse in these areas, with almost 10 per cent receiving health-related welfare payments and the number of jobs available so low. It's about time to have a Welsh Government that's serious about bringing back economic rejuvenation in the Valleys. Unless there are no signs of this by the end of this term, the question this Labour Government will need to ask itself is whether it's their failings that's responsible for the lack of progress, because if that's not the case, then the only other explanation is that all of this stems from being part of a United Kingdom that has inequality at its very core, and that that is what is preventing these communities from delivering their potential.

I'm very grateful to be able to speak in today's debate, and I thank Rhun ap Iorwerth for bringing this forward, and I put my comments in line with the Chair of the Health and Social Care Committee as well.

If I may, I'd like to focus my comments, following a recent discussion with the Royal College of Occupational Therapists. The Royal College of Occupational Therapists have recently launched a report, 'Bridge to Recovery', and they are calling for fair access to occupational therapy expertise. This access, Llywydd, should be open, it should be appropriate, and fair to the population groups who have been known to experience reduced access to healthcare and services. I won't go through and repeat those groups we've already heard by many this afternoon.

But Llywydd, sadly, the COVID-19 pandemic has exacerbated the impact of already existing health inequalities in my constituency and constituencies across Wales. The necessary lockdowns and measures we had to put in place to protect public health have also led to an increase in loneliness, an increase in isolation, an increase in substance misuse and domestic violence, and, if we look at those issues, it was particularly for those who were shielding. 

Now, as has been mentioned before today, this has resulted in an increase and an urgent need for urgent mental health support in primary care. Very early in the first lockdown, Llywydd, the occupational therapy service in north Wales proactively stepped forward and proactively acted to support primary care, reaching out to those who were shielding. This quickly grew into supporting individuals presenting at primary care with common mental health concerns. From this, a co-production project developed, linking occupational therapy services with the iCAN programme, an established programme led by mental health services in north Wales. 

The iCAN programme offered easier, earlier access to prevent and mitigate health inequalities, and I commend the iCAN programme and the co-production of that programme to this Senedd, and I also urge members of the health committee, and those off the health committee, to look at the report and its positive evaluation.

However, Llywydd, from these positive steps there is still an issue. Occupational therapy is still predominantly accessed through secondary and tertiary services, and it tends to focus on individuals rather than on populations. Access to occupational therapy services needs to be early, it needs to be easy, it needs to be across the lifespan, preventing the development of long-term difficulties and addressing some of the wider social detriments of health we already heard this evening. Services should be both universal, across all aspects of life, and targeted, shaped and placed according to the needs of the local population groups. 

Llywydd, I wish to see good practices like projects such as the iCAN project in north Wales replicated across the whole of Wales, and I urge Members to take part, and organisations to take part, in the Health and Social Care Committee's upcoming committee inquiry, an important step forward for health inequality in Wales. Diolch yn fawr. 

It's a pleasure to take part in this debate this afternoon, and I've got no problem supporting the motion as it stands this afternoon. 

According to the World Health Organization, there is ample evidence that social factors such as education, employment status, income level and gender and ethnicity have a marked influence on how healthy a person is. In all countries, whether low, middle or high income, there are wide disparities in the health status of different social groups. The lower a person's socioeconomic position, the higher their risk of poor health.

Sadly, there is ample evidence of this in my own constituency. The Vale of Clwyd is home to some of the poorest wards in Wales, if not the entire United Kingdom. It has one of the lowest life expectancy rates for men, one of the highest rates of premature death from non-communicable disease, and there are incredibly high rates of cardiovascular deaths as well as high prevalence of diabetes. One out of every 16 adults is on long-term sickness or disabled and economically inactive.

Economic inactivity amongst those not battling long-term illness isn't much better. Nearly a quarter of the adult population are economically inactive, so it's little wonder that health inequalities are so prevalent. Governments are supposed to ensure that their citizens are healthy, supposed to lift them from poverty, supposed to improve their life chances, and this Welsh Government has failed on all counts. It's been Welsh Labour, propped up by Plaid Cymru and/or the Liberal Democrats, that have run Wales for over two decades. And during that time, our economy has remained stagnant. 

In my constituency, gross value added has increased. It has gone from 59.8 per cent of UK GVA to 60.2 per cent—not even half of 1 per cent in over 20 years. So, it's little more than a statistical rounding error. While our economy remained flat, my constituents got poorer and, as a result, sicker. Many of my constituents can't afford to eat healthily. One in five adults are likely to have not eaten their recommended five a day, and it's not surprising therefore that the number of people waiting for hospital treatment has doubled in the last decade. Health spending has also doubled during that time. We now spend over half the Welsh budget on health and care, so what happened to treating the disease and not the symptoms? If the Welsh Government focused on removing health inequalities, we would not need to spend ever-increasing amounts on the NHS. We have to ensure our population has access to well-paying jobs and good-quality housing if we are to have any hope of tackling long-term sickness. 

There have been so many wasted opportunities to tackle this issue. The Welsh Government promised to raise the GVA of Wales to within 10 per cent of the UK average, and then dropped their pledge before it was broken. They wasted structural funds on vanity projects. And I can only hope, for the sake of my constituents, that they will take a leaf from the UK Government's book and the levelling-up agenda, as my constituents are already benefitting from multiple schemes. But this is not a competition between nations. The Welsh Government has to put aside party politics and petty nationalism and work with the Governments across the UK to raise our citizens out of poverty and tackle health inequalities head-on and for good. Diolch. 

Thank you for the opportunity to participate in this debate. 

There exist huge inequalities in wealth and health in our society. I don't believe that anyone taking part in this debate could claim otherwise, but I would be delighted to show them around some of the communities in my region of South Wales East if they need further convincing. The pandemic over the last two years has amplified these differences that already existed, exacerbated by more than a decade of Westminster austerity. As we have seen this week, with news of yet another lockdown-busting party in 10 Downing Street, the privileged few seem to be living by a different set of rules. There is also a gulf between the wealthy and those in poverty when it comes to health outcomes. Dr Ciarán Humphreys, a consultant in public health on the wider determinants of health at Public Health Wales has said, and I quote:

'Many conditions contribute to the gap in life expectancy between the least and most disadvantaged communities. This shows that we must look beyond simple medical explanations to the root causes and to the wider conditions in which people live.'

We could improve these inequalities through a greater focus on community-based early intervention that is universal but especially targeted at those most in need. We are all familiar with the health backlog created by the pandemic, but, if timely access to primary health services improve, the need for hospital care can be reduced. This would also drive down healthcare costs by reducing the pressure on A&E. People on low incomes and those living in deprived areas often consume a less healthy diet and are therefore more likely to experience the adverse health outcomes associated with poor diet. Unfortunately, affordable healthy food options are often not easy to come by in many of our communities. The Welsh food poverty network noted in 2020 that not having enough money to reach affordable food shops or access a nutritionally balanced diet is now a common reality for many people in Wales. This is why I'm proud that Plaid Cymru has secured free school meals for all primary school children as part of the co-operation agreement. The security of a decent nutritious meal made with local produce for all young children in Wales will go some way to reducing the health inequalities associated with food and dietary practices. 

I also want to talk about some sections of our society that are digitally excluded. Digital exclusion is often linked with poverty. It is also linked with age, with many older people unable to access the internet, for whatever reason. This is something I wrote about last October on the United Nations International Day of Older Persons. With so many essential services now being offered and run online, we cannot afford to leave such large sections of society disenfranchised by technology. As GP services move more and more online, I hope the Government redoubles its efforts to ensure that people are not left out on account of their age or their income levels. 

Finally, I wish to mention dementia. As the Plaid Cymru spokesperson for older people, this is an issue that is close to my heart. The rights of people with dementia have also been in the news in recent days, thanks to my Plaid Cymru colleague, Liz Saville Roberts. She spoke passionately in the House of Commons about the need to end the isolation and separation of people with dementia in care homes and hospitals. As Liz herself said:

'The Welsh Government has a respectable policy text in place with our dementia action plan for Wales 2018-2022. But there is a yawning chasm of a gap between what it describes and the reality of what is happening in our hospitals and care homes, in both Wales and England.'

End of quote. There should be more awareness that an individual's risk of developing dementia can be significantly determined by a number of factors. Health inequalities have become a vital component as we learn more about the potential for reducing the possibility of developing dementia. Consideration of health inequalities should feed into dementia care plans, as well as dementia risk reduction, and I would like to hear from the Government today how that is happening in the here and now. Diolch yn fawr iawn. 

This debate presents a timely opportunity to discuss the anxiety caused by the recent announcement of changes to cervical screening by Public Health Wales and explore it within its wider context. I appreciate that Public Health Wales has acknowledged that the announcement should have been dealt with better, and that Cancer Research UK has said that, whilst the announcement made the headlines, the story had a lot more to it than meets the eye. The new programme, in fact, provides more opportunities to spot symptoms in people who are at a greater risk of developing cervical cancer.

This led me to question why a decision made by Public Health Wales, backed by the evidence of scientists and researchers, had caused so much fear and anger in our communities. And I think the social media comments that I had from women were very honest and revealing. Sarah told me, 'It's such a shame that none of this was explained. Women's health is really struggling more than ever. I have had difficulty in even getting birth control. This is now another thing to make women feel anxious about their health.' It reinforced to me that we cannot shy away from the wider context of health inequalities that are deep-rooted within our systems.

And it is my belief that we cannot begin to discuss health inequalities without addressing the fact that medicine and research have predominantly been explored and developed through the vision of white men. We know this from both our history and everyday experiences, from sexual health and birth control to certain cancers and diseases. The politics of agency to address healthcare has historically been through the decision making and priorities of men. Women have told me that it is no wonder then that a decision such as that on cervical screening is met with concerns, when historically what we have known is that those without a cervix have made the decision for those whose lives were at stake. Although this is starting to change, I think extra effort must always be made to engage and listen to women. 

In my brief time as MS for Bridgend and Porthcawl, I have spoken to constituents about their experiences of the barriers faced by people seeking diagnosis and treatment for diseases such as endometriosis and polycystic ovary syndrome, or the fact that menopause remains an under-invested area of research for the ongoing experiences of people facing the effects and symptoms, or the horrifying statistics identifying that people from ethnic minority communities are more likely to die from childbirth than white people in the UK. We have so much to do to unpick the systemic inequalities, inequality that has seen women, ethnic minority communities and queer and trans folk in the background, rather than leading on the research that affects their own bodies and lives, which is why I support the amendment today that acknowledges the causes of health inequality are multifaceted and part of a wider context of structural inequality.

I know that our health Minister has already been doing a lot of work to address this, and I'd welcome hearing more about this work today. I also acknowledge that the First Minister did address the cervical cancer screening changes yesterday, and that we will be having a debate on it next week, but I do feel that we need to grab every opportunity to address this, because there are a lot of women out there who have been left very scared.   

The Minister for Health and Social Services to contribute. Eluned Morgan.

Diolch yn fawr, Llywydd. I'd like to begin my contribution by thanking Plaid Cymru for bringing forward this really important topic for debate today. Since my appointment, I have been absolutely clear that reducing health inequalities is one of my key priorities as a Minister. The links between where you live, your socioeconomic status, your life expectancy and how many years you can expect to live healthily are well-known and have been revealed by many Senedd Members today.

We know, as so many have stated, that people from the most deprived areas of Wales are more likely to live shorter lives than those in the least deprived, and that, sadly, they live fewer of those years in good health. I'm sure that all of us in the Senedd can agree that the fact that this continues to be a reality across Wales today is socially unjust, and it's something that this Welsh Government is absolutely determined to put right.

It's important to be clear that we are not starting this work from scratch. Over many years, we have worked to build a solid legislative and policy context to ensure that tackling health inequalities is hard-wired into the way that we plan and deliver public services in Wales. I think that one of the best examples of this work includes embedding the use of health impact assessments across Government and, through this Senedd, legislating to cast a healthier Wales and a more equal Wales as statutory goals in the Well-being of Future Generations (Wales) Act 2015.

We have been proud to share our approach to tackling health inequalities through the framework of the Act internationally, as a lead partner of the recent joint action on health equity in Europe. This joint action saw 25 countries work collaboratively to address health inequalities. Members may also be aware that my predecessor signed a memorandum of understanding on health equity with the World Health Organization Europe region in 2020. Through our work with the WHO, Wales has established a Welsh health equity status report initiative and has become a global influencer and a live innovation site for health equity.

Now, in addition to establishing the right policy and legislative context, the Welsh Government has developed a number of key programmes to tackle inequalities, such as our flagship Flying Start programme. Flying Start reaches around 36,000 children under four years of age who are living in some of the most deprived areas across Wales. It works to ensure that they have the best possible start in life, which we all know is critical in terms of the window of opportunity to influence development and those longer term outcomes.

But despite the strides that we have made, COVID-19 has brought the true impact of health inequalities into sharp focus.

Can I just say that I think that I have an intervention request from Jenny Rathbone? Yes, I do. If you are willing to take the intervention request, Minister—.

Of course.

Good. Jenny Rathbone.

Thank you very much indeed. I am delighted to hear you highlight the importance of Flying Start, but also the really important role of midwives and health visitors, who can really change the dial when people become pregnant and have these very, very young children. Everybody wants to do the right thing for their child when they are first born, and so I look forward to hearing how the enhanced Flying Start programme is really going to drive the agenda on this, so that we have all the next generation eating healthily, doing the right amount of exercise and looking after their mental health.

Minister.

Thanks very much, Jenny, and you are absolutely right: I think that midwives are very key, and health visitors are key, particularly in those early years. I think that we have got to take every opportunity to make every contact count, to make sure—. We know that we are managing to vaccinate children—about 90 to 95 per cent of children come for vaccination—but what an opportunity to talk to them about how to make sure that your child is developing properly, eating the right food, and making sure that they are getting the right exercise. I think that there is room to be more creative in that space, and that's certainly something that I've been talking to my officials about—how we can make sure that every contact counts.

But, as mentioned, I think COVID-19 has been cruel and it's been unequal in the way that it's affected our population, with all the more vulnerable people with pre-existing health conditions, such as obesity, being at far greater risk of severe disease. In this sense, COVID-19 has highlighted even further the crucial importance of public health prevention work in tackling health inequalities. So, we know, don't we, that obesity and smoking have an enormous impact on people's life expectancy and healthy life expectancy, and that people who are from those most deprived communities are more likely to be obese or to smoke than those in the least deprived communities. And that's why tackling health inequalities is at the core of our proposals to tackle obesity and to support people to stop smoking. So, alongside my colleague the Deputy Minister for Mental Health and Well-being, we're committing over £13 million of funding to our forthcoming 'Healthy Weight: Healthy Wales' programme to tackle obesity, with actions to reduce diet and health inequalities across the population at its core. And on smoking, Members may be aware that we recently published our draft tobacco control strategy for Wales for consultation, and in recognition of the health inequalities that arise as a result of smoking, tackling inequality is noted as one of the draft strategy's central themes.

Now, I'm determined to ensure that we make all possible efforts across my portfolio to tackle health inequalities. That's why I've been clear with officials that we must redouble our efforts across health and social services, and across health services in Wales, to ensure that tackling health inequalities is an integral part of the post-COVID-19 recovery.

Now, as we consider how broad the factors are that impact on people's health—and many of those have been listed today—our work on health inequalities has to be broader than simply working on health and care services alone in order to have the necessary impact. And we must take action on health inequalities as a golden thread across all policies and strategies of Government, because they all have the potential to impact people's health—from our childcare offer and measures to improve air quality, to the quality of housing and the ability of people to heat their homes. But I do think that it's important, given the breadth of the factors that have an impact on people's health, that we must recognise that there are some areas beyond the competence of the Senedd, such as welfare. So, we do have to work together in an integrated way in order to ensure that we all contribute as much as possible to tackling health inequalities.

From the Government's perspective, our programme for government includes significant commitments across all our work areas that are planned to tackle health inequalities here in Wales. And in addition to that, during this Senedd term, we will be bringing forward regulations under the Public Health (Wales) Act 2017 to make it a requirement for some public bodies to undertake health impact assessments in particular circumstances, in order to ensure that we take all opportunities to tackle these health inequalities.

Today's motion calls on the Welsh Government to develop a specific strategy on health inequalities. I'm afraid that I don't think that that is the right approach. I am determined to see action happening now, and we already have the legislative framework and regulations, such as the well-being of future generations Act and the socioeconomic duty, which has been implemented, to give us the tools to do those things that we know need to be done. With the tobacco control strategy, our LGBTQ+ action plan and our race equality action plan, which are all in the pipeline, the steps to address health inequalities are being incorporated across our ambitious plans for this Senedd term. And in order to ensure that we continue to focus on making a difference and on delivery, I do ask Members to support our amendment to today's motion. Thank you very much, Llywydd.

Rhun ap Iorwerth to reply to the debate.

Thank you very much, Llywydd, and thank you, Minister, and thank you to everyone who's participated in this afternoon's debate. I don't have much time. I appreciate the Minister's thanks to us for bringing this before the virtual Senedd today, but we're not doing so because we like talking about health inequalities; we are doing this because we believe action is required on those health inequalities, which are so deeply rooted within our society in Wales, unfortunately.

I really am grateful to Members from across the political parties for their contributions, and the sheer range of inequalities that have been put forward by everybody highlights, doesn't it, the scale of the problem that we face. I think the seriousness of the situation is reflected in the seriousness of the contributions that we have heard today from, I'd say, almost all Members, other than the Member for the Vale of Clwyd who decided to have a pop at those of us who have ambitions for Wales, whilst missing the irony that he was doing so by playing to a right-wing British nationalist audience, but there's always one. But we're calling today, aren't we, for clear action, a clear plan of action from Welsh Government? Nobody is denying—the Minister, certainly, is not denying that there are deeply ingrained inequalities in Wales.

What this motion today is doing is trying to get us to agree that dealing with those inequalities has to be a a joined-up affair. The Minister argued that dealing with inequalities is hard-wired into the Government's thinking, but I'm seeing a loose connection. Whilst the Government believes that it is already acting in a joined-up way, how is it that all these highly respected organisations, which are drawn together from all parts of the health and care spectrum, professionally and representing patients, how come they believe that we do not have a coherent strategy, and how come they believe that now is the time to put that strategy in place?

To Labour Members, in particular, who outlined eloquently the issues that you are seeing within your constituencies: use this opportunity to send a positive message to the Government that we need more; that, yes, there are positive things in what Government is already doing, but we need more and we need it to gel together. So, support our motion today, so that we don't have to look forward to generations again of talking about the inequalities that we have in Wales, because they do not need to be there, and we are in the privileged position of being able to take action to address them.

The proposal is to agree the motion without amendment. Does any Member object? [Objection.] Yes, I see an objection and, therefore, we will defer voting until voting time.

Voting deferred until voting time.

That brings us to voting time, so we'll take a very short break to make technical preparations for that vote.

Plenary was suspended at 17:29.

The Senedd reconvened at 17:32, with the Llywydd in the Chair.