Item 5 is the statement by the Cabinet Secretary for Health and Social Care on access to primary and community care services. I call on the Cabinet Secretary, Jeremy Miles.

Thank you, Dirprwy Lywydd. Primary care is the foundation of our NHS. This is the main point of contact with healthcare services for the majority of us. If we need more specialist care, it acts as the gateway to those services. Today, primary care professionals are seeing more people than ever. They are providing a wider range of services, which means that more care is available for people closer to their homes, more quickly. We are investing in the skills of healthcare professionals and broadening the scope of practice in primary care. We are funding qualifications to support the delivery of new clinical pathways in optometry. We are making legislative changes to enable pharmacy technicians to deliver clinical services. We have also resolved the regulatory issue that prevented dental therapists and hygienists from providing treatment independently. These changes not only make these professions more attractive, but they also enable the workforce to deliver more services.

Dirprwy Lywydd, we have made important changes to primary care in Wales, in optometry, in pharmacy, in NHS dentistry and in GP services. Our intention is to continue to make such changes. I want to use this opportunity to update Members about the progress in each of these areas.

Optometry has undergone significant reform. Changes to the contract have expanded the scope of services available in the community. Optometrists on the high street can now manage, monitor and treat an increased number of eye conditions, providing timely care closer to home. This has reduced the demands on GPs and hospitals. More than 2,000 consultations a month are being delivered by independent prescribing optometrists in the community.

Contractual reforms are also transforming community pharmacy. I started the day today at a high-street pharmacy in Barry, and I'd like to thank Gwawr Elis Jones and the team for their welcome. An extra £9.9 million has been made available as part of the community pharmacy contractual framework this year. This represents a 24 per cent increase in the funding since 2016-17. Now 99 per cent of pharmacies provide free treatment for 28 common ailments through the common ailments service: back pain, sore throat—look online for the list.

Dirprwy Lywydd, more than 400,000 people were seen and treated last year by the service. Eight out of 10 people said that they would have gone elsewhere for help if this service wasn't available. Wales is the first part of the UK to provide a nationally commissioned community pharmacy prescribing service.

Trained pharmacists can treat a broader range of conditions, such as ear, nose and throat infections, without the need for a GP visit. Since its launch in 2020, around one third of pharmacies have adopted this independent prescriber service. There have been more than 0.25 million consultations. Both of these pharmacy services provide fast and convenient access to care for a wide range of minor illnesses without the need for a GP appointment, supporting GP services to see people with more complex health needs.

Dirprwy Lywydd, I turn now to NHS dentistry. The variation we made to the current contract, which focuses on prevention and treating people on a risk and needs basis, means that, since April 2022, more than 420,000 new patients have received a full course of treatment. More than 142,000 more people have also received urgent care. These arrangements are not perfect, but they have made a difference for people who have struggled to access NHS dentistry since the start of the pandemic.

Our focus is on a new dental contract, which will make NHS dentistry attractive for the profession and fairer for patients. We expect to consult on the new dental contract in the spring. In the meantime, we are implementing a 6 per cent increase to the contract. We have been working with the British Dental Association to develop this, and I'm aiming to have the contract in place in early 2026.

The final part of the primary care picture, and perhaps the most familiar part, is general practice. GP practices provide a staggering 1.6 million appointments every month. That's equivalent to seeing half the population of Wales. We have negotiated extensive reforms to general practice to improve access over the last few years. We have just resumed negotiations with the General Practitioners Committee Wales in relation to the current financial year. Practices are required to implement appropriate call-handling systems to manage high call volumes and prevent multiple call-backs. They're required to offer a digital way for people to request non-urgent consultations and ensure there is physical access between 8.30 in the morning and 6 p.m. every working day.

Despite these changes and continued efforts of hard-working practice teams, I know people can get frustrated when they feel they can't get through to their practice or struggle to get an appointment, but there are other primary care services that can help, such as pharmacies, so that those seeking a GP appointment are only those who need a GP appointment. We all have a part to play in that. The GP practice doesn't have to be the only option, and isn't always the most appropriate option.

I want to use the rest of the statement, Dirprwy Lywydd, to talk about the changes we've made to improve access to community services, which play an important role in helping people live independently at home.

From April 2023 we provided health boards with an extra £5 million of recurrent funding to expand community allied health professional services. This has created more than 100 new positions, including physiotherapists, dietitians, occupational therapists, psychologists, speech and language therapists, podiatrists and a range of support staff. And the number of district nurses has increased by 49 full-time equivalent positions since November 2023. This, in turn, has increased weekend working. These new staff are making a real difference. In Cwm Taf Morgannwg University Health Board, urgent diabetic foot waiting times have reduced from four weeks to 48 hours using podiatrist services. In one month alone, Swansea bay’s expanded allied health professional workforce helped 240 older adults through early intervention, complex comorbidity management and end-of-life support, preventing 110 hospital admissions. And Cardiff and Vale's orthopaedic prehabilitation programme, which supports people waiting for hip and knee surgery through exercise and peer support, has reported significant post-surgery outcomes and a social return on investment of £2.86 for every £1 spent.

Dirprwy Lywydd, I’m clear that continuing to invest in and reform primary and community care services is the right thing to do for the public and for the wider NHS. One of my top priorities in the 2025-2028 NHS planning framework, which I published before Christmas, is building capacity in the community. I expect local plans to demonstrate action to continue to improve access to the right care, from the right health professional, in all communities right across Wales. But as we continue to make changes to improve services, we must ensure access is easy and consistent across Wales so that people understand where they can go to get the right care for their needs.

Finally, Dirprwy Lywydd, and importantly, I want to thank everyone working in primary and community care services. Their continued commitment and resilience has been absolutely instrumental in the ongoing reform of services to improve access and outcomes for people right across Wales.

I would like to thank the Cabinet Secretary for his statement today, and I'd also like to add my thanks to all those people working in community and primary care, right the way across Wales.

Just to pick up, Cabinet Secretary, on the £5 million of recurring funding for community allied health professional services, it would be interesting to know from you how that money is allocated across health boards across Wales, and how the Welsh Government tracks that to measure on deliverability across the service. The statement indicated that primary care professionals are managing increased patient load and offering a broader range of services closer to home. Yet the data from the British Medical Association's Save our Surgeries campaign reveals concerning trends. As of 31 March last year, the number of GP practices in Wales decreased from 474 down to 374—a reduction of 100 surgeries—and the full-time-equivalent number of GPs has declined by 25 per cent since 2012, with a further 3.8 per cent decrease since the campaign's inception in 2023. So, given these statistics, Cabinet Secretary, how does the Welsh Government plan to address the diminishing number of GP practices to the escalating patient/GP ratio, to make sure that people can have that efficient care right the way across Wales? Because we've heard examples, haven't we, from Members? I'm thinking of Alun Davies, up in Blaenau Gwent, about the eHarleyStreet practice, about the number of people there seeing the number of GPs available.

The Government's commitment to upskilling healthcare professionals is very commendable. However, the Royal College of General Practitioners has highlighted some significant challenges and that, in 2024, nearly 20 per cent of GPs reported feeling stressed and unable to cope with most days, and over 40 per cent experiencing such feelings at least once or twice a week, and more than 40 per cent of GPs are considering leaving the profession within five years, citing work-life balances and the stresses as primary factors. Given these statistics, Cabinet Secretary, what measures is the Welsh Government implementing to improve the retention of GPs and their well-being, to ensure that we invest in training, and that it does translate into sustained patient care across Wales?

You mentioned optometry and pharmacy services, and the expansion of those services is a positive development. It's something that we on these benches welcomed. However, the effectiveness of these services depends on public awareness and accessibility, doesn't it? Public Health Wales introduced the new primary care clusters dashboard in September last year to aid in the planning and address inequality. So, how is the Welsh Government utilising this dashboard to promote and monitor the effectiveness of expanded optometry and pharmacy services to make sure there's equitable access for all communities? And as I said, we need to ensure that people know that these services are out there. A lot of people who I speak to don't know about the common ailments service, and that actually they can go to their pharmacies to actually get these conditions seen—as I say, sore throats and different things, chest infections, for example—so it's good to know what the Welsh Government is doing to promote that across the system.

It did touch, the statement did, on dentistry. While the statement notes that over 420,000 new patients received full dental treatment since April 2022, access to NHS dentistry remains a concern. The Royal College of General Practitioners 2024 general election manifesto emphasised the need for sustainable career options in NHS dentistry. So, what strategies are being implemented to make sure that NHS dentistry is an attractive and sustainable career choice? Because many of the dentists that I speak to say that they cannot afford to continue doing what they do now. And you said about the contract reforms coming into place, which you hope will be in place by the end of 2026. This has been ongoing since 2021. The now First Minister Eluned Morgan made a statement on this in 2021, saying it was going to be done and dusted very shortly, so I'd like to know what assurance you can give to the dentists across the country that this is going to be addressed. And also on dentistry as well, there's a growing concern about dental decay in young children across the country; 32.4 per cent of children in Wales are presenting with dental decay, compared to 23.7 per cent in England, so I'd like to know what more you're doing to improve access for children to dentist services as well.

So, I want to talk just a bit more about community care services. The addition of over 100 allied health professional positions and the 49 full-time district nurses is encouraging, and I just want to pay tribute to the role of our district nurses. They do an absolutely fantastic job across our communities. However, the Health Education and Improvement Wales strategic workforce plan for primary care highlights the need for ongoing workforce stability, so how is the Welsh Government ensuring the long-term sustainability of the community care workforce to meet future health demands across Wales. And the statement emphasises the need for consistent access across Wales. The introduction of the primary care cluster dashboard aimed to address that, as I mentioned earlier. So, I just want to emphasise to you, Cabinet Secretary—. What are you doing to make sure that all areas of Wales—whether that's north, south, east or west—have equal access to services, especially those pharmacy services, when we haven't actually seen everybody being independent prescribers? And it would be interesting to know what work you're doing around that as well. Diolch, Llywydd—Deputy Llywydd.

The Member asked a range of questions; I'll do my best to answer at least the key ones. In relation to the £5 million, those were allocated to expand the workforce right across Wales in terms of allied health professionals. I think what we are seeing is actually the highest level of funding ever allocated to support a record number of training opportunities for the AHP workforce, and that's right across Wales. I touched on the developments in the Cwm Taf Morgannwg and in the Swansea bay health boards, but I could have pointed to the frailty practitioners in Powys Teaching Health Board, which I'm sure he will have an interest in, or the work that Cardiff and Vale are doing in relation to the orthopaedic programme; I mentioned that in my statement. But also Hywel Dda have launched an integrated community stroke service, which reduces hospital waiting times. So, there is a range of ways, right across Wales, in each of the health boards, in which that funding is being put to very good and productive use, and having demonstrable outcomes, demonstrable impacts on patient outcomes, which is obviously the measure of success in relation to that investment.

He makes an important point in relation to the pressure on GP practices. I think the thrust of my statement was really about highlighting the range of other ways in which people can access primary care services, which have two impacts: one is to reduce the demand on GP services, and also to make sure that patients get access to the treatment they need in the most convenient way possible. So, it has those two benefits, and I think, actually, it's important that people do continue to make those choices. We see increasing demand on GP services. Where that demand is capable of being better met elsewhere, frankly we should be seeking those alternatives. So, it should be more convenient for us, but we should also be doing that proactively. He makes an important point about how one can ensure that the public understand the range of those services, and, in a sense, what we're trying to do is to bring about generational change in people's access to healthcare. This will take, I think, many years to embed, as a way of understanding how the health service can provide the support that we need. 

I was at a pharmacy, as I mentioned in my statement this morning, and discussing very much with the pharmacist there the strategies that they had used to work with local GP practices to highlight the range of alternatives. So, if someone calls up and asks for a GP, there’s a conversation that says, ‘Well, have you tried your local pharmacist? It's a prescribing pharmacy, so you’ll be able to get the support that you need there.’ So, it’s ensuring that that’s part of the discussion through GP practices, but also in terms of public information campaigns and also the work that pharmacies themselves do to promote the increasing range of services that they can provide. It’s also information that is available through NHS 111, both on the phone and online, so I encourage Members to point their constituents to those services, and we can all play a part, I think, to encourage people to take up those services.

He asked a series of questions in relation to the access to dentistry. Negotiating a contract is an exercise for two parties; it isn’t entirely in the gift of the Government. So, these things sometimes take longer than, frankly, any of us would wish. But I think it is important to say that there have been a number of reforms to the existing contract, and we’ve been in a period of annual variation, and, whilst each of those has sought to reflect the consequence and emerging understanding of changes in demand, and, obviously, there is a gap in provision in terms of NHS services, which we obviously know and have discussed in this Chamber many, many times, I also accept that having an annual set of variations doesn’t provide that stable platform that is important for the resilience of practices and for our ability to describe with confidence and in an attractive way what dental practice looks like. So, I’m sure we all look forward to the point at which we have that new contract in place, which will be a new platform to make dentistry, as I said in my statement, both fairer for patients and more attractive for the profession. I can say, as I did in my statement, that we expect to consult on that in the spring, and we will see what the responses to the consultation say. It’s obviously a negotiated contract with the BDA, and my expectation is that that will be in place for the early part of next year, so the spring of next year, at the latest. And what I’ve also heard, in talking to dentists, is that they appreciate a bit more lead-in time when there are changes to contracts, so they can make the necessary adjustments to their practice.

Finally, the Member made a point about children’s dental health, and, in particular, the changes that we’ve made have released additional appointment capacity for children and young people, and I know that you'll be pleased to hear that we continue to invest, for example, in our Designed to Smile programme, which the First Minister spoke about in First Minister’s questions earlier; 60,000 children have benefited from that scheme in the last year; 5,000 teachers and teaching assistants trained to provide those services. So, that is a successful programme, and we know that it makes a real difference.

Primary care is responsible for over 90 per cent of patient contacts with the health system, yet it continues to be underfunded, and the percentage of funding that goes to primary care has shrunk significantly over the past 20 years. As I’ve mentioned several times, this is highlighted in the fact that we are over 600 GPs short of the Organisation for Economic Co-operation and Development average here in Wales, without any indication that this is about to be rectified. Indeed, NHS Wales lost 51 GPs between September 2023 and March 2024 alone.

Now, remedying these issues is not going to be easy, and it will not happen overnight, but here are some short-term measures, informed by our discussions with health professionals, that could ease some of the most immediate pressures. First, it was noted that the persistent inability to book an appointment online in practices in Wales is a particular barrier to having a more efficient appointments system. Could the Cabinet Secretary therefore confirm whether the Welsh Government is considered setting aside specific funding to support the cost of introducing online appointment systems on a wider scale? Video consultation systems, such as the Babylon system, have significant potential to foster greater flexibility in staff and patient contact, but it's clearly underused here, particularly compared with GP practices in England. Why? What measures is the Government taking to promote the use of such technologies?

Consultant nurses have a role to play, but since the Government withdrew funding for this role back in 2008 their numbers have fallen. Is there any intention to reintroduce a budget in order to employ more, or at least to create a career path for nurses to develop into consultant nurses and to develop these skills in Wales?

Finally, the Royal College of General Practitioners has called for the roles of care navigators to be upgraded to improve patients' understanding of the triage process, to ensure that time is not wasted in redirecting patients to the appropriate level of care. Is this something that is being considered in the Government's plan for primary care?

Turning now to the issue of community care, the regional partnership boards are clearly an important element of delivery in the context of the regional integration fund and the Further, Faster programme. But professionals say that the remits of the regional partnership boards are too unclear and that they don't succeed in fostering collaboration across health boards and local authorities. Now, in response to a question from me last week, the Cabinet Secretary mentioned that there is no need for legislation to place the boards on a statutory basis, because a ministerial directive can compel more systematic regional collaboration anyway. So, could the Cabinet Secretary explain why the ministerial directive is not working, at least not so far? 

The Further, Faster programme also identifies the need to engage with the third sector to increase the number of community co-ordinators and referral options. But this ambition will inevitably be entirely undermined by the UK Government's decision to increase employers' national insurance contributions, with no guarantee from the Treasury of refunds for third sector organisations and GP practices. The Welsh branch of Marie Curie, for example, which is a key partner in the provision of palliative care, is looking at an increase of over £0.25 million in the next year, and the Tenovus charity is in a very similar position. The BMA has also warned of the possibility that GP surgeries will close as a result of these measures, which is not at all surprising when we consider that surgeries such as the Treflan Surgery in my constituency face an additional £19,000 in costs.

So, in order to provide some much-needed clarity to these organisations for them to survive during this challenging time, could the Cabinet Secretary confirm the total additional costs that third sector organisations and relevant GPs are expecting to pay? Thank you.

I thank the Member for those questions. In terms of the impact of payments, that work is ongoing. Of course, I can't talk about specific financial support for GPs at the moment. We're in the middle of further negotiations with them on the contract, as I mentioned in my statement. But these things are regularly discussed by us and the GPs, as the Member would expect.

He made an important point on online services and enabling people to have equal access to appointments through the appropriate standards. I think that when we do see the launch of the NHS app, this will strengthen the offer, if you like, and the opportunity for people to operate online in terms of getting appointments. We have provided a budget in order to expand equal access, and that's around £12 million, if memory serves me correctly, and that is being delivered by health boards, working along with GPs.

As I mentioned in my statement, we have prioritised investment in community nursing, and that has been successful in terms of an increase in the numbers available. Of course, we need more of that, but the objective we have is to ensure that nursing provision can, on the weekend, provide some 80 per cent of what's available during the week. We haven't reached that target as of yet, but that is the work currently ongoing, and numbers have been increased.

The Member made the same point, I think, that he raised last week on Further, Faster, and I think the Member's challenge is that we need to put the RPBs on a statutory basis so that they can collaborate, but that's not the function of the RPBs; they are not boards for delivery, they are boards to co-ordinate the work of two bodies that are already on a statutory basis and already have primary responsibilities in statute and elsewhere. So, I myself don't believe that creating another statutory structure, once again, in terms of our overly complex nation, is the solution to this; I think better collaboration and co-operation is the solution.

The Member posed another challenge to me, where there is an example of activity in terms of a ministerial directive and whether that's worked. Well, the First Minister, when she was health Minister, gave a directive to Hywel Dda and Swansea bay health boards to create a joint board to work together on providing services jointly, and that has worked; we have seen that bear fruit already in terms of orthopaedics, but in other areas too. So, our system is structured in order to devolve executive powers, as the Member knows, to the health boards, and that, generally speaking, is the right way of doing things. It's a specific challenge, I think, to generate regional co-operation; we haven't done as much of that as we should have done, so that is the message I've given to the sector more generally: if we don't see more of that happening, then I will be willing to continue to use those ministerial directive powers to ensure that that happens on the ground. I myself don't believe that creating a statutory body will be more effective than the ability to direct bodies that already exist to take particular actions.

Thank you for the update, Cabinet Secretary.

I welcome the statement's emphasis on primary care as a main point of contact that most people have with healthcare services, and that's why, obviously, supporting it and investing in it and building on it is so important. I've raised here previously with you the findings of my recent health survey in my constituency, and many of the points raised there were around access to GP services or getting through or not being able to get an appointment. I recognise what you say and I'm pleased that, whilst you rightly referred to the changes to help people access GPs, you recognise that there are still frustrations out there, and there's probably still some work to do to build on what has already come before.

So, can I ask today what assurance you can give that strengthening access to GPs and primary care remains a key focus of the Welsh Government's work? And touching on the broader services that may be available in the community now through other means, whether that's through pharmacies or elsewhere, is there a way in which we can have a mapping exercise that educates people and makes people aware of where these services can be found, so that we can increase people's ability to access those services, not just through their GP, in the future?

I thank the Member for that. I think she makes an important point, and others have touched on this as well, about the challenge of demand in the system and providing access to GP services specifically. I think it's quite a complex landscape, because it is a changing landscape. So, clearly, the level of demand is increasing and the question is whether the profile of that demand is changing as well. So, people may want to see a GP immediately, but there are two questions in that, aren't there: whether the GP is the right person to provide the care and whether there is, if I can put it in these terms, a well-founded need for urgency, or whether that is a preference of the patient. And it will vary, clearly, from case to case. It isn't clear to me that there's an obvious pattern in there; GPs will report different things.

I think there's also a sense that, when so many other aspects of our modern life are available with a real sense of immediacy, then there is a level of impatience when people can't see a GP immediately, and that may well be fair enough, but there'll be other circumstances in which, maybe, that urgency isn't there. So, I think it's quite a complex picture. What is absolutely the case is that, where we know that there are other alternatives, as I've been talking about in the statement, we need to make sure that people understand where they can access those. I think people's understanding of how you access NHS services is generally, from a patient point of view, either at your GP practice or A&E, and there's a challenge for us there, because both those parts of the NHS are under very significant pressure. So, I think there is a case for looking at what we can do to help people navigate the NHS better. NHS 111 has been very effective at doing that, but as we bring about such a level of reform in the system, there's a constant challenge to us, I think, about how we can make sure that people are able to navigate the service in that way.

Cabinet Secretary, of course, the majority of my constituents receive their treatment from providers in England. When I speak to opticians, pharmacists, dentists and GPs, they often tell me about the complexities of dealing with providers in England when it comes to information technology systems in particular; there's a lot of inefficiency in the process as well. I wonder, in terms of what you've outlined today, what considerations you've given to this issue, and what work has gone on in sharing digital platforms.

The other issue, of course, you spoke about is improving access to primary care providers. One of the big issues we have across Wales, particularly in rural Wales, is attracting primary care professionals to come and work in Wales, particularly in rural Wales. Often, the issue raised—it's a historic issue for some time—is the issue with the all-Wales medical performers list, so, one list for Wales. I wonder, since you've been in post, whether you've considered this. Many staff shortages arise from the issue of having GPs, perhaps, being trained somewhere else in England, but not prepared to come to Wales because of the complexities of having to sign up to a different performers list. So, can I ask, also, whether you've considered this, and considered the possibility of working with the UK Government to have one performers list for England and Wales?

I thank the Member for that. He makes an important point for those parts of Wales that are on the border. It's a more challenging landscape even than the one he describes, I think, in practice, because there isn't one NHS England approach to IT, any more than there is in many parts of the Welsh NHS. So, what you are effectively looking at is the IT arrangements that exist on a trust or a board level, so it's actually a more complex picture than even the one he paints.

What we are very keen to do from a digital perspective in Wales is twofold. The critical element to this, and I touched on this in the committee the other day, is to have in place a national digital architecture for Wales, so that, then, initiatives, either at a health board level or at a national level in Wales, can all conform to the journey that we want the system to be moving on. We aren't in that place yet, but it is an absolute priority to get that architecture in place. That will then allow a once-for-Wales approach for a certain number of interventions, which will help with the challenge that he's describing. It won't solve it, because there isn't a 'once for England' approach over the border, but it will contribute to solving that, at least.

But then there will be some things that I think—. You know, we don't need to reinvent the wheel constantly, do we? There are things that are existing—commercial applications—that are available for health boards or practices to purchase themselves, and the critical thing is that they all form part of that larger picture together, so I think that's important on the digital front.

I had the opportunity of talking to somebody recently at a dinner that I attended, and I'd had a day when I had been reminded throughout the day of the challenges in the NHS in Wales, and I was feeling, at the end of the day, a little bit low. I sat next to a woman at dinner and she explained to me that she was a nurse practitioner in a practice in Powys. She described how successful the model was, the morale and the things about that practice that had drawn her to work there, and I thought that that was a salutary reminder to us all, actually, that every day there are people choosing to work in the Welsh NHS who are committed, driven and have very, very high levels of motivation. So, for all of the challenges, and he's mentioned some of them today, I think it's really, really important that most people's experience is that they're going into work driven to help people and able to do that in a way that we're all grateful for.

The Cabinet Secretary will be aware of the difficulties that a lot of patients in the Rhymney valley and throughout the south-east are having in getting doctors' appointments in those surgeries that are being run by eHarley Street. This private company is running surgeries in Bargoed, Gelligaer, Brynmawr, Tredegar and many others, and patients are finding it almost impossible to get those appointments, but when they do get to the doctors' surgery, waiting rooms are almost empty. Now, we know, and it has been raised in the Chamber a number of times, that doctors haven't been paid by eHarley Street; they are owed thousands of pounds, and, as a result, many doctors are refusing to work more shifts in those surgeries, and that means that patients aren't getting the care that they deserve.

I've raised concerns in the Chamber for many weeks about this, and about clinical governance as well, doctors’ pay, and the pressure that's being put on nurses in those surgeries. Everyone seems to be agreeing that something is very badly wrong here, but nobody yet seems to be promising exactly what is needed in order to ensure that this improves in those surgeries and that it doesn't get repeated. Could you tell us, please, what conversations you've had with the health board about this, and could you assure the Chamber that you will do everything in your power to ensure that patients start getting the care again that they deserve to get?

I think I mentioned in the questions last week, when Alun Davies and the Member raised these very, very important points in the Chamber, that, clearly, staff should be paid, suppliers should be paid, not least because we know what the implications of the alternative are. It's obviously right in its own terms, but it clearly has ongoing consequences if people aren't paid. I made it clear—and I'll repeat that—that I'd spoken to the health board chair, and expressed my concerns, to make sure that practices should be complying with the general medical services contract, making sure that people were paid, and that the level of clinical governance and the availability of appointments was as they needed to be. 

In my most recent conversations with the board, their understanding of the availability of appointments was that it was broadly consistent with the arrangements that had been in place previously, in terms of the volume of appointments that had been in place, when the health board was directly managing those practices, but I have asked for a further account from the health board this week, after the further discussions they've been having. There clearly needs to be a plan to make sure that services are sustainable and providing the level of access that we want people to see. So, as I mentioned last week, I'll be happy to report back to the Senedd when I have that further account.

Primary care sees more people with health needs than any other part of the system. The share of the health budget being spent on primary and community care services has reduced. The health and care system must be radically refocused to put primary and community care at its core if it is to be effective and sustainable. The decision that has had the biggest adverse effect on primary and community care was the merging of primary and secondary care, which resulted in the proportion of spend on secondary care going up at the expense of primary care. The community health service and general practice face multiple challenges, with insufficient staff and capacity to meet the rising patient needs and complexity.

Most primary care providers provide an excellent service in difficult circumstances. When people cannot get primary care, they go to A&E, thus further clogging up an under-pressure system. In some practices, if someone says they need an urgent GP appointment, they then get sent to A&E, also clogging the system. It's easy to say how important primary care is and how dependent we are on it. I have two requests: that the share of the health budget spent by health boards on primary and community care is protected next year, and to increase the proportion of minor surgical interventions carried out in primary care.

I thank Mike Hedges for those questions. The way he put his question, I think, shows the complexity of it. He made the point about separating secondary and primary care, but then the example he gave was one that reminds us of the interdependency, if you like, between people's access to primary care and what that can mean for access for secondary care. So, the relationship, obviously, is very interdependent in that way.

I do agree with him that what we should see, as far as we possibly can, is the provision of more and more services in the primary care setting, whether that's diagnostics, but in the way that he said also, minor surgical interventions and a range of others. Some of them I touched on today, but he makes a point, I think, about a larger volume of activity in primary care. I have no doubt whatsoever that that is the right way forward, and I hope that we will be able to see progressively an increase in that. Whether it's at a practice level, or at a cluster level, I absolutely think that that is part of the solution to being able to provide more funding to primary care settings and the sustainability of the model into the future.

We've done some great work on getting better use out of the community pharmacists, because they're highly skilled individuals, and them dealing with the common ailments scheme seems to me just a much better use of their skills than simply dishing out somebody else's prescriptions.

I'm a little bit confused about the way in which GP practices work, because I've yet to come across a GP practice with the skill mix that I would expect. For example, which GP practice employs a diabetes nurse, given the prevalence of diabetes in our community? You would expect that there was plenty of work for such a person. Instead, we seem to have four or five highly skilled GPs all acting as consultants in primary care, with maybe one practice nurse. That just doesn't feel like the right balance. And then we have a separate service called community nursing, or community allied health professionals, and I just wondered if we don't need to think a little bit more creatively in the way we're delivering primary care services.

I was very interested at lunchtime to hear from Nia Boughton, who's a consultant nurse for primary care at Betsi Cadwaladr. She's done some fantastic work on getting somebody with endometriosis back into work—

You need to ask a question now, please.

The key there is the fact that Nia is working in a practice that is being directly managed by the health board, rather than one that's being managed by a GP practice. Clearly, there are different ways in which we need to look at the GP contract to have a more holistic service for what people need in primary care.

I thank Jenny for that question, and for the discussions we've had over recent weeks in particular about funding for GP practices. I think it is clear in the way that she puts the question today that one of the threads through those discussions we've had recently has been what the mix of services is that can be provided by GPs, which is a way of strengthening the model, but also, more importantly, providing the kind of service that patients want and will be able to benefit from. There are a variety of different models. The example I gave to Russell George earlier was an example where the nurse practitioner in that practice was a very significant, visible part of the offer to local residents. I think there is a range of models, but I think we need to keep the level of ambition about moving services into primary care settings high, and also that relationship between primary care settings and community services, to keep that creative and keep that evolving so that we make sure that we have the level of flexibility in service delivery that best meets the needs of patients.

And finally, John Griffiths.

Diolch, Dirprwy Lywydd. Cabinet Secretary, the newly opened 19 Hills health centre in Ringland in Newport East will provide a range of primary and community services delivered by general practitioners and a range of healthcare professionals, physical and mental health services. It serves a number of relatively disadvantaged communities where the inverse care law strongly applies, with those most in need of healthcare least likely to receive it. I wonder how the Welsh Government will work with Aneurin Bevan University Health Board and the 19 Hills health centre to make sure that we see a real improvement in access to healthcare by those in the community badly needing those services but currently not receiving them, to make sure that the potential of pulling these services from the acute sector into primary care and into a community setting is fully realised.

The Llywydd took the Chair.

I agree with what the Member has said is the ambition and the direction of travel. I think I'm right in saying that I had a conversation with one of the practitioners in that practice over the course of the last few weeks, and he echoed the point that the Member has just made again today about the persistent and pernicious existence of Julian Tudor Hart’s inverse care law, even 50 years on from the point at which he first declared that as a concept, which motivates us, doesn’t it?

I think there are absolutely challenges. The question is how best to make sure that we are able to make sure that those practices serving patients in disadvantaged communities, which we know are likely to have a wider range of more complex needs and to need to deliver the services in different ways, with more outreach work in particular, with a community work element—those imaginative solutions—that we can do that in a way that is sustainable into the future.

There have been discussions in the Chamber and elsewhere about the formula for allocating that funding. That appears to be a complex area, but that doesn't mean that we shouldn't seek other ways of making sure, in particular at a cluster level, where you can have the resilience of a number of practices serving that larger footprint—. I think that is part of the answer to the challenge that the Member has set out today.

I thank the Cabinet Secretary.