[R] signifies the Member has declared an interest. [W] signifies that the question was tabled in Welsh.

I now call on Simon Thomas to ask the second urgent question.

Will the Minister make a statement on Abertawe Bro Morgannwg, Cardiff and Vale, and Hywel Dda University Health Boards, in light of their escalation to targeted intervention status? EAQ(5)0036(HWS) [W]

Thank you for the question. Following the latest routine tripartite meeting between the Welsh Government, Health Inspectorate Wales, and the Wales Audit Office, it was agreed that the three organisations that you’ve mentioned should be escalated to the targeted intervention status in our escalation and intervention framework. I issued a written statement on this to all Assembly Members on 7 September.

Thank you, Minister. Of course, I did receive the written statement, but I was very eager to ask questions on the floor of the Chamber on the decision and the rationale behind the decision. This now leaves four of the seven main health boards dealing with primary care and secondary care in some sort of intervention from Government. Can you explain how this situation has arisen, after your Government decided to pass the National Health Service Finance (Wales) Act 2014, which was supposed to provide these health boards with far more certainty on the future, and as you’ve preached to the health boards on the need to plan the workforce, one of the main weaknesses within Hywel Dda health board as I understand it? Having explained why and how this has happened, can you explain who was responsible for these deficiencies? Was it administration and managers at a local level in a health board? Was it you—although you’re relatively new to this post—in your previous post and the predecessor Minister? In that context, can you also tell the Assembly what has happened to Trevor Purt, who was chief executive of Hywel Dda university health board, then Betsi Cadwaladr—two health boards that have suffered terribly after his tenure as chief executive? Is Trevor Purt still paid by the health service in Wales?

Thank you for the series of follow-up questions. In terms of your broad point about NHS finance across Wales, of course, eight of our 10 organisations achieved financial balance last year. One of those that did not is Hywel Dda. That’s a direct contrast with the position in England, where eight out of 10 acute hospitals trusts are not achieving financial balance.

The point about planning the workforce and the models of care is partially related to finance, but not exactly, because what we have to be able to do is to plan a system to deliver that whole-population healthcare, to actually work in proper partnership with local authority colleagues and housing in particular. The challenge that Hywel Dda faces is partly an historical one about its ability to manage its finances, and it’s partly about its ability to plan and manage its workforce. That does also mean it needs to look at its models of care, and that’s part of the broader shift in the NHS about the way that not just hospital services are run and managed, but actually the services we have in the community. So, this targeted intervention is about us looking to support Hywel Dda with a relatively new leadership team, and to try and understand with them not just the challenges they have, but what we can do alongside to support them to improve, because that is our aim and our expectation.

I want Hywel Dda to be in a position where it does have an approved three-year integrated medium term plan. That’s why they’ve been moved to targeted intervention status in the specific areas that I set out in my statement, and they’ll be the areas that we focus on with them. I think this does show that the intervention and escalation framework is real. It would have been much more convenient to find a way not to escalate their status. We chose not to do that because the advice we were given by the chief exec of NHS Wales and the Wales Audit Office and Healthcare Inspectorate Wales was that this was the right thing to do: to provide that support in a constructive manner. I hope and I do expect to return to the Chamber in the future to answer questions on this, and I have committees as well this week. It will be part of a regular discussion at the next tripartite meeting in the spring.

Cabinet Secretary, I did speak with the chair of Hywel Dda by telephone immediately after you issued your statement. What I took from that conversation was that the health board very much welcomes the support that the Welsh Government will now be able to provide it. I think we need to put on record that this isn’t the Welsh Government bailing out, and it isn’t the Welsh Government allowing the health boards to go to the wall, but it is the Welsh Government trying to move in, trying to support and trying to enhance the provision for the people who matter. That is, ultimately, the patient.

The framework of the four escalation levels will now allow us to chart trends. Simply, we will now be able to see whether things are improving or whether things will need some further action. In the case of Hywel Dda and waiting times, for example, we’ve seen a decline in the performance over a few years, including the period for which it’s been under enhanced monitoring status. But there is a contrast, and we have also seen some improvement on ambulance response times, for example. So, I’m really pleased, Minister, that we have intervened and we have recognised that there are weaknesses. What I ask of you is that you will feed back to us, Cabinet Secretary—I can’t get out of the habit of ‘Minister’—that the Government, through the targeted intervention, is able now to advise and to empower Hywel Dda to implement the strategy that will see the changes that we are all hoping for.

Thank you for the question and the points made. I think it is worth reminding ourselves that there is a range of areas where Hywel Dda does particularly well—on diagnostics, for example, it’s done particularly well, and it’s in a position where, at the end of the last year, no-one was waiting more than eight weeks. So, there is a range of positives for Hywel Dda as well as their challenges, and that’s why they’re in this particular area of targeted intervention. Because this isn’t about an arm’s-length finger-pointing exercise; it is about saying, ‘Here are challenges we recognise have not been resolved in the last couple of years’. There is support that’s going to go in to be supportive, to help to deliver the improvement that we expect to see and they should expect to see from themselves, and I’m pleased there’s been a constructive response from the organisation, because we have to be able to identify challenges and then do something about them, rather than simply saying, ‘It’s your fault, now get on with it’. But it is worth while noting that, in the escalation discussion, it wasn’t that just three organisations went up. You mentioned ambulance response times—the Welsh Ambulance Services NHS Trust went down in its escalation status because of the significant and sustained progress it has made, and that is a success story that we should all be prepared to celebrate. It’s about the leadership of an organisation working with trade unions and the workforce to deliver serious and significant improvements right across the country.

Minister, I’m very grateful for your statement, and I’m very pleased, actually, to see you’ve taken this action, because I think it is time that we supported our health boards more thoroughly. Although, Minister, I do have to say that I lay it entirely at the feet of your Government, your predecessors, that they allowed the health boards to get into this state.

I’d like to just talk across the whole piece. I notice from your brief statement that you’re still looking to have IMTPs signed off. Will they still be a three-year IMTP after the one year of support? I’d like to ask about all three, if I may, in terms of: is it all about the money for all three health boards? Is some of it about standards? Is some of it about waiting times? Because I think there’s a slight difficulty in reading through the reasons for each of those health boards for going into targeted intervention. Could you just very quickly outline for us what ‘targeted intervention’ actually means? Is this more like a ministerial advisory board that somebody will go to, there’ll be a group of people, and they will help the senior management team to get to IMTP status? Or is it far more hands off than that?

I do have to just make the point that the ambulance trust has, I’m glad to say, gone out into more routine arrangements, but, let us be clear, there was a significant change of targets, so I’m not surprised that they managed to meet some of them.

Finally, Minister, to have four out of our eight major health boards in some kind of intervention or special measures is a blow for the public and a blow for the morale of the staff that work in these organisations. So, what guidance have you given these health boards as to how they can handle their staff and their staff expectation? Nobody likes to think that they might be working for a failing organisation. I think there has to be real clarity about what this is all about and that this is more of a support than saying that these organisations—or I hope you’re going to be telling me that this is more about support rather than saying that these organisations are actually heading substantially downhill, because the morale out there for patients and staff will be hit by this. I think that it is incumbent upon you to try to pick it up. I’d like to understand how you’re going to be able to do that so that we can reassure the public that accessing those four health boards is still safe, timely and that they will get the services that they require when they require them.

I thank the Member for her comments. There’s something of a contrast from the start to the end, welcoming on the one hand the action taken and then regretting the action taken towards the end. I think the honest truth is that the targeted intervention is not just an important recognition and reflection of where we are, but it is about supporting those organisations to improve. There are different aspects of improvement that have led to the targeted intervention in each of the three organisations, and I set those out in the statement. It is not just simply a matter of managing a financial challenge, although it’s clear that, for example, Abertawe Bro Morgannwg need to see some sustained improvement in their unscheduled care performance. They also need to improve some of their cancer performance. So, that was made explicit in the statement I made. So, their targeted intervention support will be focusing on those particular areas. In Hywel Dda, there are different challenges, and in Cardiff and Vale as well. So it really is about that supportive part.

I’m very proud of what these organisations are doing in global terms because we are not saying that these are failing organisations. This is part of our challenge in having a grown-up and honest conversation about the health service, about all the truly life-changing things the service does on a regular basis, each day, in each part of Wales, and at the same time being able to confront and direct ourselves to those areas of challenge where we need to see further improvement. That is what we have done with the targeted intervention decisions that have been made and with the support they will now get from the Welsh Government.

That helpfully leads me back to your point about IMTPs, and, of course, these will remain as three-year plans. So, our expectation is that, with the targeted intervention and with the support will receive, they will manage through this year, and we want them to be in a position to have a three-year IMTP approved next year. That is our ambition for each of these organisations across Wales.

Finally, on ambulances, which you mentioned, we took a decision to change the ambulance targets that you referred to on the basis of the very best clinical evidence and advice. We better serve the people of Wales as a result of doing so, because we focus the high-quality and expensive resource that emergency ambulances provide to those people who need that intervention to help save life and limb. What we are doing with the ambulance service is completely transparent. There is going to be a proper review, and I announced, in the summer again, that there will be a proper evaluation of the pilot itself. I’m proud of the decision we’ve taken, I’m confident about where we are, and I’m looking to make sure we have a system, moving forward, that continues to say we’ll do the right thing by patients in the greatest need. Across England, Scotland, Northern Ireland and the rest of world, they’re looking positively on what we have decided to do, based on clinical evidence and advice.

I’d like to start by declaring that my wife is an employee of Abertawe Bro Morgannwg University Local Health Board. Cabinet Secretary, you’ve highlighted some of the good aspects that occur, as well as highlighting the targeted intervention for ABMU in unscheduled care and cancer services. What monitoring will you be undertaking to ensure that, as we see, hopefully, progress in those targeted areas, we do not see a slip in other areas to compensate for it? When will you actually be looking at producing reports and progress reports for us so that we can see how it is actually working? We do have the end-of-year figures, but we want to see progress throughout the year, so will we be having updates in the Assembly? Can you also tell us what action you’ve taken, because some of the concerns clearly are related to resource issues? Will you be offering support that includes and introduces more resources to some of those boards to allow them to tackle those issues that you’ve identified?

Thank you for the series of questions. There are a range of different challenges in each of the boards, as I have mentioned before, and I’ve discussed the financial challenge of Hywel Dda and the fact that, for Cardiff and Vale, one of the areas for their move to targeted intervention was our confidence in their ability to balance their books this year and through the next iteration of their intermediate plan. ABM does not appear to us to be a challenge about their finance in particular, but I do take on board seriously the point about the fact that there should be no slippage in the areas of performance that are working well whilst they actually address the areas of targeted intervention. That will be taken forward in our normal accountability frameworks and mechanism. I will speak to the chair on a regular basis whilst they’re in targeted intervention. There will be another routine meeting of the tripartite advisory group—the chief executive of NHS Wales, the Wales Audit Office and Healthcare Inspectorate Wales—in the spring to provide an update and advice for me on the progress of each organisation in the areas of targeted intervention. So, there will be clarity and, again, I expect to make a statement to Members in the usual course, once that meeting has taken place. But, there are many significant progress measures in ABM—for example, diagnostics, where again significant progress has been made and broadly sustained over this year as well. They’ve also made real significant progress in their waiting times as well. The challenge is doing more of that and, at the same time, dealing with the areas of targeted intervention. I think this action should be seen as both supportive and helpful in allowing that organisation to do what it should do for the population that it serves.

Minister, thank you for your answers this afternoon. I would be a little less generous than Angela was by saying that 50 per cent of the LHBs are now in special measures or under some form of Government supervision; it’s actually six of the health boards that have district general hospitals within their remit to run, and two thirds of them now—four of them—are under some form of Government intervention. Hopefully, that will be seen as a helpful measure for those health boards so that they can progress in the areas in which they do need to progress. But I do think it is not unreasonable to ask the question: how long do you foresee this level of intervention continuing, in particular for the three most recent entries into this programme of Government assistance, if you want to call it that, or Government intervention? When can staff and when can patients take some form of comfort that these LHBs will be emerging as more autonomous organisations running the services within their area of control?

Well, the point to make about targeted intervention, in response to the comments that have just been made, is that these are targeted on particular areas of the service, and it’s where the Welsh Government will be working with and alongside those organisations, helping to direct them along a path of improvement. In the other areas of their operation, they retain the responsibility that they had before this position was announced. So, in all of those areas, they will retain their measured autonomy and their earned autonomy, and there’s an expectation that they will continue to deliver improvements and confront the challenges that each health board faces across Wales and, indeed, across the United Kingdom. I think, when looking at what will then happen and when we’ll see the report—and I indicated earlier to David Rees and in earlier comments as well that the tripartite meeting will take place in the spring—I’ll receive advice then on the progress that has been made in each organisation against those areas of targeted intervention, and our desire is to see each of these organisations having a successful and approvable integrated medium-term plan when that comes up at the start of the next financial year. That’s what we wish to see. That’s why targeted intervention is in place, and I will, of course, report back to Assembly Members on progress that is made or not.

I’m of course concerned that Cardiff and Vale are facing targeted intervention and would not want to deny any issues there are, and I know that the health board is very keen to work with the Government to improve the situation. But I do think there are particular circumstances in Cardiff that are having an impact on Cardiff and Vale’s financial performance rather than its clinical performance. I know the Cabinet Secretary is aware that Cardiff is the fastest growing city in the UK, with, I think, 10,000 more in its population a year, and this obviously has a huge impact on the health service, and, of course, the LHB—Cardiff and the Vale—does take on the tertiary and the complex cases from a wide area in Wales and I don’t know how much that is reflected in the funding that it has. I wondered if the Cabinet Secretary could comment on that. I also think it’s important to recognise the big improvements that have been made in performance for the very reason of public reassurance. So, I want to make the point that waiting times in Cardiff and the Vale have improved for seven consecutive quarters; that urgent suspected cancer waiting times have improved by 25 per cent in less than a year; there’ve been big improvements in ambulance handover, and, in particular, in stroke care. I think it’s very important in this statement that we recognise those achievements because we do want the public to be reassured, and the health board is keen to work with the Government to tackle what is a financial issue.

I thank the Member for the question and the comments, and it is fair to say that there is a positive ambition and vision from Cardiff and Vale health board. You’re right to point out the significant progress that has been made and sustained on waiting times in A&E and, indeed, in cancer care as well. There’s more to do but we do recognise progress that the health board has made. On your broader points about financing the different challenges that people face in delivering healthcare in different parts of Wales, every health board has its own case to make as to why it’s in a unique position and why that needs to be reflected in the funding that it receives, whether it’s delivering healthcare in a rural setting, delivering healthcare to deprived Valleys populations or delivering healthcare to other fast growing cities in the country as well. We consider all those things in the round about the future of funding. In working alongside Cardiff and Vale health board, I expect to see progress made and I expect to see us in a position where they will have an approvable three-year plan at the end of this year. This is absolutely about having progress on that area and not about throwing aside or refusing to recognise the real progress they have made, which I’ve pointed out to staff when I’ve met them on a number of occasions as well as the leadership of the health board as well.

Finally, Caroline Jones.

Diolch, Lywydd. Cabinet Secretary, we now have over half of all local health boards requiring some form of Government intervention. My own health board is receiving targeted intervention due to poor performance in unscheduled care and cancer care. This poor performance is putting people’s lives at risk and is a damning indictment of our health policies. It is abundantly clear that there are serious failings in healthcare across Wales. The people of Wales deserve an NHS that provides the best possible care regardless of where we live and which health board we come under. Cabinet Secretary, what is the way forward? Do we need an independent inquiry? Can we relook at our policies and the way we deliver them? We have to instil confidence in the staff who work in the NHS but also in the patients. Thank you.

I thank the Member for her questions and comments. People regularly talk about the morale of staff within the service and the worry about the level of confidence the public has in the health service, and, frankly, that is affected by the way we talk about the service. When you talk about ‘serious failings’ across healthcare in Wales, it is no surprise that the debate is injected with a level of pessimism that does not reflect the reality of the high-quality healthcare that most people experience. Every single patient survey recognises that people have a good experience of healthcare the overwhelming majority of time, whether it’s 92 per cent or 93 per cent, or other figures.

The challenge is what we do about those areas where that is not the case, and how we honestly confront and resolve those areas. That’s what we are focused upon. And in terms of having an independent look and review about healthcare and health and care across Wales, of course we’ve committed to having a parliament that will look at the future of the service. We want to have a sensible and mature conversation about the future of the health service that does not set us back into a fairly hysterical series of accusations and arguments about what is really happening within the NHS, and that will allow us to be sensible and serious about the areas that do require improvement, which is what the targeted intervention measures are about, and does not, as Julie Morgan was making the point, put us into a position where we refuse to recognise those areas of significant and continuing excellence in the health service here in Wales.

I thank the Cabinet Secretary.