Questions now from party spokesperson. Welsh Conservative spokesperson, Suzy Davies.

Diolch, Lywydd. Good afternoon, Minister. The draft budget shows a £3.6 million cut to direct social services funding. Where is that money going and, if it is still for social services purposes, how will I be able to find it in order to scrutinise how it’s spent?

The draft budget shows an extra £25 million for social services, and that was in respect and in understanding of the severe pressures that the social services sector are under at the moment. Pressures include, for example, the national living wage coming in next year, which will impact on local authorities and providers themselves. But it’s very important to respect the fact that it’s great news that low-paid workers will receive an increase in pay, but also to understand that it’s going to put some pressure on the sector, which is why we’ve allocated an extra £25 million for that. We also allocated more than £4 million extra in order to be able to take the first step in achieving our manifesto commitment of doubling the capital limit that people can keep before paying for care. So, we’ve allocated more than £4 million for that, and, also, money to enable us to put in place the full disregard of the war disablement pension from April of next year.

Thank you for that answer. Obviously, we would support the final point that you made regarding the pension. But, effectively, what I’ve heard there is that I’m then to look for this money in wages. Perhaps you can tell me then—. You issued a statement last week, indicating that the recurrent transfer of £27 million a year from the UK Government to meet the cost of providing support to the former independent living fund recipients, is now going straight to councils, as it is in England, rather than to the independent disability sector preferred third party, as in Scotland and Northern Ireland. The purposes of that money is not to sub councils’ cuts. Why have you turned your back on the more co-productive models encouraged by the future generations Act, and what guarantees have you secured that this money will be ring-fenced for its initial purpose?

I don’t recognise the picture that you’re paining in terms of the support that we are giving to sustainable social services, to our third sector grant scheme, which is where the funding to which you refer, which was formally in the family fund, has been brought into. We have that fund, which is worth £22 million, which brings together four previous grant schemes, and we had 84 applications for grants, seeking just over £69 million for that scheme. So, we did try to look at a fair allocation of funding right across that, and the most that any organisation could have in a grant was £1.5 million. So, the family fund received the full £1.5 million in that.

With regard to the future of the family fund, we’ve actually provided them with £400,000 in order to try and become more sustainable in the future. So, that is one of the ways in which we’re supporting disabled families, and Disability Wales and Carers Wales were also awarded funding within the social services third sector grant scheme as well. On the independent living fund, we’ve tried to take a pragmatic approach in terms of speaking with the sector, with social services and also people in receipt of independent living moneys, in order to try to take a step approach in terms of future delivery, by taking the changes over two years. This was the approach that was suggested to us by our advisory group.

Thank you for that answer. I don’t think I heard that the money was going to be ring-fenced for its original purpose and, from my point of view of as a scrutineer, I think it’s going to be difficult for me to follow the money.

Perhaps I can move us on now. You may have heard, Minister, that, after court action for breaching statutory time limits, Swansea council faces further potential legal action, as hundreds of deprivation of liberty safeguard assessments are yet to be signed off. A few weeks ago—and things may have changed by now—there were over 600 needing completion, signing off or allocation, and, of course, these orders affect very vulnerable people, all of them with limited mental capacity. Now, the council and unions don’t agree as to why, but it is clear that social services in Swansea are very stretched. I’m just wondering how Welsh Government can help Swansea social services meet the demands placed upon them, not only for the sake of the social workers that are involved in this, but also for the people who are the subjects of the orders.

This is an issue affecting local authorities right across Wales, and, in terms of the why, I think the reason there is that, in 2014, the Supreme Court reached a decision known as ‘Cheshire West’, which widened the definition of what’s meant by deprivation of liberty, and Care and Social Services Inspectorate Wales and Healthcare Inspectorate Wales have jointly described a 16-fold increase in the number of applications, so I recognise the picture that you’re painting in terms of the significant pressures on this right across Wales. I know that the Law Commission are currently looking into this issue at the moment, with a view to publishing a report in December. So, there might be changes as to what deprivation of liberty standards might be and what orders might involve in the future. So, obviously, changes will be decided at UK Government level, but we’ll be keen to have our input into that and to make strong representations.

We have provided local authorities and health boards with funding over the past three years in order to try and have them fulfil their legal obligations with regard to those timescales, but, obviously, I recognise that there is still significant pressure there.

Cabinet Secretary, there were 108 deaths involving C. difficile and 22 deaths involving MRSA in Wales last year. While great strides have been made to improve infection control and hand-washing campaigns have been successful, we still have a problem with cleanliness of hospital facilities. I fully accept that we cannot achieve 100 per cent cleanliness in a working hospital. However, there is no excuse for overflowing bins on a ward or dirty walls. So, what action are you taking to improve the cleanliness of our hospitals?

I thank the Member for her question. She’s right to point out the significant progress that has been made on reducing these levels of infection rates, but there is much more that needs to be done. Every health board has an improvement target each year. Not every health board has managed to achieve that. It’s a regular feature of accountability meetings with both chief executives and me in terms of contact with chairs, and there are often very simple hygiene standards to be addressed that will help with infection rates. There is also a challenge in some parts of the population where there is, if you like, a reservoir of some of these particular infections. But the real challenge is for the health service to do what it could and should do, and we recognise the need for further improvement and that does start with basic hygiene.

Thank you for your answer, Cabinet Secretary, and staying on the topic of hospital cleanliness, it was disappointing to learn that Bronllys Hospital received a food hygiene rating of 2, while the majority of hospitals score a hygiene rating of 3 or more. I hope that you will agree with me that every hospital should have a five-star hygiene rating. Food served to frail patients should not only be of the highest nutritional standards, but also prepared, stored and served hygienically. Cabinet Secretary, what is the Welsh Government doing to improve food hygiene in our hospitals and in the wider care sector?

Thank you for the question. Again, you make the point that the great majority of settings in both the care sector and the hospital sector do comply with high hygiene standards. I am particularly disappointed and frustrated by the recent outcome at Bronllys. They have been made very aware that both I and the Minister expect there to be significant and rapid improvement and a reassessment to provide the assurance that not only patients, but their families, will quite rightly expect.

Finally, Cabinet Secretary, we can’t totally eradicate hospital-acquired infection, but we must ensure that we’re properly equipped to treat infection. With antimicrobial resistance on the increase and very few new antimicrobials being discovered, we are reaching a crisis point. What lessons has the Welsh Government learnt from the O’Neill review and what role can the Welsh Government play in encouraging greater research into developing new antimicrobials?

Thank you for the third question. There are a range of challenges here. It’s actually an area where the four UK components of the national health service family actually have a joint approach—a recognition of common challenges in antimicrobial resistance, but also in prescribing behaviour as well as a need for further research. So, you will see Wales play its part within the research community. There are significant areas, not only of health gain, but also within the life science sector, for potential further activity. But I think we need to start with, and probably our biggest contribution can be in, making sure that prescribing guidelines are adhered to. There’s got to be a change in both attitude and behaviour from clinicians in both primary and secondary care, but also, importantly, in terms of public expectation about what will happen during healthcare interactions and whether people will be prescribed antibiotics that are appropriate and, equally, will accept and understand when a clinician says an antibiotic is not appropriate as well. We’re actually harming ourselves by overprescribing and overuse, and we’re now going to deal with the reality of some of that challenge. So, there are real challenges, both in behaviour as well as in research and the future in this particular area.

Plaid Cymru’s spokesperson, Rhun ap Iorwerth.

Thank you, Llywydd. Another critical report has been published by the ombudsman today into the quality of care in Glan Clwyd hospital. This time it was a cancer patient who had to wait far too long for treatment. This is the third critical report from the ombudsman in just two months. It happens, of course, in a wider context where Betsi Cadwaladr is in special measures. Why does the health service in north Wales reach the point where we’re hardly surprised in hearing news such as this?

Thank you for the question. Obviously, I’ll be providing more detail in response to the urgent question after this that the Presiding Officer has accepted. The particular issue that you raised is incredibly disappointing, not simply from the point of view of someone who has received care that was not adequate, but also because, actually, Betsi Cadwaladr is a high-performing health board when it comes to providing cancer treatment. So, this case really does stand out, and not in a way that does credit to the health service. But I’m pleased that the chief executive has indicated he would apologise directly to the family, and I’m pleased he recognised issues in 2014, and I also expect not just the points about the care provider but the complaint handler to be dealt with as well. And obviously, I’m deeply disappointed that a citizen who came to the health service with real need has not been treated in a way in which any of us would expect or want to be. So, there are real points of improvement, but in the areas of cancer care, I think there can be some confidence that Betsi Cadwaladr has been a high-performing health board in the past, and we can expect it to be in the future. I expect the new medical director would obviously input into that as well.

But we know, of course, of the wider problems across the board, and when the health board reaches such a point then one would expect radical steps—truly radical steps—to be taken to change things. All we’ve seen in reality is a change in senior management, and, at the moment, I tell you that people have no confidence that that in and of itself is going to introduce the change required.

One thing that is constantly pushed is more centralisation, and rather than dealing with services that are failing, one proposal on the table now is to move vascular services, which are of a world-class standard, from Ysbyty Gwynedd. We are pressing for a consultation on that. Can the Cabinet Secretary explain the rationale for tackling poor performance by destroying those things that work well? And in terms of the future of Ysbyty Gwynedd, does the Cabinet Secretary believe that there should be more or fewer specialist services provided there in the future?

Thank you for the follow-up questions. In terms of the radical steps that are taken, putting a health board into special measures was a radical step. It’s the only health board since the history of devolution to be put into special measures, and it’s not just about changes to only senior managers; there is a need to change the culture within the organisation. That’s why we expect the health board to be in special measures for a significant period of time, because the changes that we need to see, for example, in mental health services, will take a significant period of time. So, I don’t really accept this characterisation that radical steps have not been taken and are not being taken. We also have the reassurance of the tripartite advisory body, so we have external advisers, not just the chief executive of NHS Wales, reviewing the progress that is, or is not, being made with regard to special measures.

On your particular point about vascular surgery, we’ve been through this before, and I simply don’t accept or agree with this characterisation of the issue. The proposals are for about 20 per cent of activity, the highly complex vascular surgery, to be moved to a central unit, and that central specialist unit is based upon evidence it provides better outcomes—better outcomes for the people, regardless of where they live across north Wales, who go into that specialist centre. Eighty per cent of activity will remain where it is. So, for example, the diabetic debridement service that takes place within Ysbyty Gwynedd would stay where it is.

I don’t have a set objective for how many specialist services will remain in their current settings, either in north Wales or anywhere else. I simply set out that the health board, with its local population, wherever it is, must confront those obvious challenges it knows exist, and must address the best clinical evidence and advice on what to do to improve that service. Sometimes, that will be about delivering a service within a community and making care more local, and sometimes, where the evidence tells us the best and the biggest health gains to be made, which will also improve our ability to recruit the right staff in the right place, is actually to have a specialist centre. And I just don’t think it’s tenable for serious players within the debate about the future of the health service to only ever say, ‘We disagree with any proposal to centralise a specialist service’. There is significant evidence that the move for vascular surgery will improve outcomes across north Wales, and I hope that Members will look at the evidence here objectively.

We do have a specialist vascular centre in north Wales and that is in Bangor. According to all the statistics that we have now, in terms of the question on specialist services in Ysbyty Gwynedd, I realise that you don’t have a figure in terms of the number of services, but, as Bruce Forsyth says, ‘Higher or lower?’ That’s all I was asking for. In terms of special measures, it’s not placing the board in special measures that was the radical step, but the declaration that those radical steps were needed.

But we will move on. Plaid Cymru, as the Cabinet Secretary knows, is keen to see the development of medical training in Bangor. Funding for medical education formed part of our recent agreement on the budget. Does the Cabinet Secretary agree that, if he is serious about developing medical education in north Wales, removing specialist services from Bangor makes no sense at all? We see these threats and we have seen threats in the past—maternity services, for example. We are still awaiting investment in the emergency department. Shouldn’t the Government be developing healthcare in Bangor now, as the health centre for north-west Wales, and centralising, if you like, in preparation for introducing that medical training?

I thank the Member for his final series of questions. I think it’s really important that we separate out the right model for the right form of specialist care, wherever that is across the country, when we focus on north Wales, and in particular on Bangor, so that we don’t just have an argument about one site and one geographic centre. The danger there is that we play the three centres against each other and that’s really not helpful. We have to understand what the very best clinical evidence and advice tells us about what should be a specialist service, what that conversation should or should not be, and then what we can expect in terms of outcomes for the patient as a result. What we do know is that, where those specialist services are created, they’re more likely to recruit staff into them in a sustainable pattern.

So, part of the challenge is not simply about saying, ‘This isn’t broken, so we’re not going to fix it’, because that just means that you wait for a service to fall over before you actually make change and you ignore all the evidence and advice around it, and that can’t be the right way to plan and deliver healthcare in any part of our country. So, that is not what we are prepared to do. And it is not what I expect health boards to do. I expect health boards, in meeting the needs of their local population, to be properly aware of all the evidence and advice of the different services that they have that develop their own place and understanding that their duty is to provide the very best healthcare for their local population. That will mean that the way that some services are delivered will need to change. Not to do that would be to fail the responsibilities that they have to the local population.

We will see a different pattern of services in primary care, in secondary care and tertiary care across this next five years. It’s important that we do, because, otherwise, we simply pretend that running the current model of care, in five years’ time, is going to meet the needs of our population, it’s going to make sure we recruit the right staff in the right place and deliver the right care. Then, we’d be fooling ourselves and we’d be poorly serving our public. I’m not prepared to do that and nor should health boards be. That is not the lead that I’m giving as the Cabinet Secretary for health and I expect other people who really want the health service to succeed, to join that debate in a much more open-minded way and to think again about the quality of care that we’re providing. Service quality and service outcomes drive what I want to see and they should drive what all of us want to see within the health service here in Wales.