Questions now from the party spokespeople. Welsh Conservative spokesperson, Angela Burns.

Diolch, Llywydd. Cabinet Secretary, the interim parliamentary review on health and social care has highlighted that there remain significant barriers for good ideas and policies to translate fully throughout the whole of the NHS due to cultural resistance and a fear of failure. There’s a recognition, evidence based, that a significant proportion of the public sector are often doing things without understanding what really works, and it stresses the need not to be afraid of failure, but to learn from it, because this approach will allow for a far more innovative and open approach to change that can only have positive outcomes.

Cabinet Secretary, I’m sure you’re aware that the Behavioural Insights Team, which works very closely with the Westminster Government, sets out to encourage the public sector to address change in a more similar way to the private sector. I was wondering, and what I would like to know is: have you engaged with or considered engaging with organisations such as the Behavioural Insights Team so that we can fully engineer effective and sustainable change throughout the Welsh NHS?

There is a serious point in the question that the Member asks about our ability to change and reform public services by choice, and understanding the choice we’ll be making in delivering a different service. There are arguments that we want the service to be broken before we fix it. And I accept that there are significant cultural challenges within every public service, including the health service. So, part of our challenge is, as you correctly identified, looking at where that experience exists. We have work ongoing, and I am certainly prepared to listen to and for the service and to engage with a range of different people, because, actually, delivering significant change in a large private sector employer isn’t easy, necessarily, and so there are insights to be gained in the private and the public sectors too. That does not mean we surrender the values and the ethos of the service, but we do need to understand how we deliver the change that is plainly required.

Business process re-engineering is never easy to deliver, but the tactics of nudge and leading and culture change are very well evidenced and have been used successfully in the private and public sectors. And I would urge the Cabinet Secretary to engage with organisations like that, because we can all learn, and there are good practices to learn from these kinds of organisations. Whilst the parliamentary review team are also going to be working, over the next few months, to develop more of a detailed map to aid the identified direction of travel for the NHS and social care sectors, do you think that these sectors should continue with current plans for structural reform? If you do, is there any Government-led work to ensure that any divergence is minimised between proposed structural reform now and what the parliamentary review may say in the longer term?

This goes back to the conundrum that we discussed in actually setting up and agreeing the terms of reference for the parliamentary review. Not just yourselves, but the spokesperson for Plaid Cymru also raised the point about, ‘Will the review mean that you will stop doing things you need to do now and kick things into the long grass?’ You have to look at the balance, in saying, ‘Do we want to put something off until the review comes up with their recommendations?’ There’s a balance to be struck, but I still think that where there is a clear case for services needing to change, and there is a clear case for different parts of the service needing to work more closely together, then that should happen. So, for example, on elective care, Hywel Dda health board and Abertawe Bro Morgannwg have had a joint planning meeting. I expect those to be a regular occurrence. The health boards in south-east Wales—Cwm Taf, Aneurin Bevan and Cardiff and Vale—are having joint planning meetings as well. So, there has to be an understanding of what needs to take place now under that, and not simply waiting and putting everything off for the parliamentary review to report. Because the challenge you raised in your first question about the cultural challenges—they exist among clinicians, they exist among the public and, indeed, politicians in our ability and our willingness to support and get behind change. So, I don’t think there is a need to put off the drivers to try and discuss and talk about change, but there is a need to properly understand what the parliamentary review will come forward with in a number of months—and I think they will go quite quickly—and then to understand how we do what they suggest and understand what we think works and then to do so rapidly and at scale across the national health service.

I think that the parliamentary review interim report is very clear on the direction of travel, and my understanding is it has buy-in from not just the health and social care sectors, but also political buy-in in terms of that direction of travel. The question I actually asked you was: is there some kind of oversight going on to ensure that any structural reforms that are currently being undertaken or currently being proposed by health boards have got some kind of backstop review to ensure that they are going in approximately the right direction of travel? Because, like you, I do not think we can just stop everything until we have a nice fat report in our hands that we can all study.

And, of course, one of the areas that has been highly identified by all of us here, by the health boards, by the parliamentary review, is that mental health services in Wales need, to be frank, to be totally overhauled for both adults and children. I do appreciate that there is work ongoing, and, indeed, I was pleased to sponsor and chair a session arranged by the NHS Confederation in which initiatives were outlined as to what we’re going to be doing to—or what they intend to do to improve and deliver transformative change within adult and child mental health services. And it is obvious that some areas in Wales have made outstanding progress. So, again, I ask you: whilst we’re not going to wait for this report to deliver all, what will you be doing to drive and to identify those initiatives that have delivered some outstanding changes, transformative changes, to child and adult mental health care? What will you be doing to identify those and to try to ensure that they are consistently and quickly applied throughout the rest of Wales? Because this is one area where we as a nation are not doing so very well.

I thank the Member for the question. In the general sense, about the backstop and the ability to think about whether we’re delivering change and making sure it’s going in broadly the right direction, that’s why there’s an NHS collaborative, bringing chief execs together to discuss and review evidence for changes that are proposed. That’s why we have integrated medium-term plans to try and set up the direction of travel for each health board—to have a plan, moving forward, about the changes that are being contemplated and delivered. It’s why health boards themselves [Inaudible.] they have processes that return a capital investment as well. There has to be a business case, and then there’s an investment board that looks at all-Wales capital bids, so, where capital is being used to try and re-engineer a service.

There are different layers of oversight about some of the plans and challenges over service reformation. In the particular area you raise about children and young people, I would not be quite so pessimistic about the need for a total overhaul. There are challenges in different parts of the country, of differing scale, but that’s part of the reason why, in recognising, if you like, the short-term, significant build-up of pressure that came in, we made the choices to start the Together for Children and Young People exercise with the NHS, working with the third sector, working with statutory partners, and, indeed, with young people themselves having an engagement in it, and it’s then about delivering a service model they recommend. That’s also why we invested the additional sums of money. We are seeing waiting times come down in this particular service area, and we are seeing faster access to therapies, backed up, of course, by tougher standards on waiting times in this area. But this is not a position where any of us should say we now have the perfect solution and the answer.

The progress we’ve made is real. The reality is that it’s also real that there are still too many children and young people and their families who wait too long, and it’s a constant process of reviewing where we are and what we need to do next, and that is already delivering transformative change within our service. But it isn’t just the specialist end; it is about the wider, broader services that wrap around families, and you’re right that it is about the consistency of the ability to do that. That’s why being reflective, having a national mechanism as well as a local mechanism to do so, really matters, and it’s also why we take the third sector and the voices of children and young people themselves seriously in designing and delivering our services.

Plaid Cymru spokesperson, Rhun ap Iorwerth.

Diolch yn fawr. On Monday, the auditor general released a critical report about the behaviour of Cardiff and Vale regarding procurement and recruitment. Now, I understand that. In response, NHS Wales’s chief executive has written to LHBs to seek assurances about their processes. What’s your hunch? Do you think that this was a one-off?

I think it is likely to have been a one-off, but part of the point about the chief executive writing to all health boards is to ensure that it has been a one-off. If there are other issues, then we want those to be uncovered and dealt with, because the Wales Audit Office investigation revealed a picture that is simply not acceptable and not in line with the established processes and recommendations, and, again, the chief executive’s letter to every chief executive in NHS Wales makes very clear that we expect those standards to be strictly adhered to.

The report itself highlighted what I think we’re justified in calling ‘nepotism’ when it came to procurement and recruitment. The auditor general also noted it proved extremely difficult to obtain a clear position of the facts relating to the matters subject to audit. UHB officers and former officers provided conflicting and inconsistent accounts. There was a tendency for them to blame each other for the failings identified in the report. I could go on.

Cabinet Secretary, we have some excellent—many excellent—managers and officers in the NHS in Wales, but I’m sure you’d agree that, in this case, behaviour has been unacceptable. We have a GMC for doctors, an NMC for nurses and midwives, so where is the body for regulation of NHS managers? Of course, managers can do just as much damage to patients from poor decision making. Is this something that you would consider?

I’m always open to considering whether our accountability framework is in place as it should be, but this should work by the proper challenge of the board itself—those independent members, the non-exec members. And that’s part of the challenge here in understanding what information was provided, how information was not provided to the board, and I think the honest truth is that the people responsible for the choices in this particular report, as has been revealed by the Wales Audit Office’s report, which is an unusual step—. It is unusual for a report to be provide all of that and I do not think the auditor general has provided a report like this before about NHS Wales. It’s a bit more common in England, where procurement is a different beast. The challenge here is to make sure that we are clear about our expectations, clear about the accountability that must flow where people do get this wrong, and that that is proper accountability. I think, actually, the health board now—and I was encouraged by the response from the new chief executive, who, again, made clear that what had happened was not acceptable and won’t be defended, and it’s important that there is confidence amongst the staff and the public about the processes in place today, and the expectation of behaviour today as well.

You mentioned their accountability within the NHS and how the NHS itself seeks to better itself through its own governance. You have recently published a White Paper on reforming NHS governance, and real concerns, actually, have been brought to my attention about some of the suggestions that have been made, certainly in relation to the replacement of community health councils with new arrangements and, in particular, the potential erosion of local knowledge, and also a lack of assurance that there will be a continued, real, strong patient voice in any new proposals. But, would you accept that a better way forward perhaps, rather than reforming NHS governance now, would be initially to have an independent review of management across NHS Wales, highlighting and seeking to promote the undoubted good practice that we have, whilst at the same time trying to root out the bad and using that as a basis for new legislation?

Well, the White Paper is a genuine consultation. So, it really is only for people to express their views and, if they don’t support the proposals, to think about alternatives to improve the quality and governance and direction of the national health service. So, this is not the Government saying, ‘We’re asking you, but we’ve already made our minds up’. It is a genuine consultation.

On the point about whether there is now a case for an independent review of managers and management within the health service, I would need to be persuaded that that’s the right thing to do, but if you think there is a compelling case to make, I’d be happy to consider representations that you provide on how that can add value over and above what we already have in place, and over and above the professional expectations we could and should properly have of NHS senior managers and the operation of boards within the national health service.

The UKIP spokesperson, Caroline Jones.

Diolch, Llywydd. Cabinet Secretary, the second Wales cancer patient experience survey has, once again, highlighted the fact that many cancer patients still do not have a key worker. While we have made progress, 14 per cent of patients still don’t have a key worker, and more than a quarter of patients said it was often difficult to contact the key worker. The survey also highlighted the benefits patients found in having a clinical nurse specialist, with the majority of the 81 per cent of patients who had one stating that their treatment was greatly improved due to this. As a result, Macmillan Wales is calling for every person with cancer in Wales to have access to a clinical nurse specialist. Cabinet Secretary, do you support this view and do you agree that the clinical nurse specialist should act as a key worker for Welsh cancer patients?

We certainly want every patient, where a clinical nurse specialist is appropriate to provide care, to have one. The challenge about whether the clinical nurse specialist is the key worker, I think, is different, because, for some people, it need not be the clinical nurse specialist who acts as the key worker, although, in practice, in the great majority of cases, it is the clinical nurse specialist who undertakes that role. There’s been a significant improvement on people knowing who their key worker is. In the previous cancer patient survey, in 2013, 66 per cent of people knew who their allocated key worker was. In this survey, that’s gone up to 86 per cent. Again, this is a significant undertaking. Over 6,700 staff have given up their time to provide their view on a wide range of their own experience of cancer care, and it’s as a result of this wide-ranging survey that we’re able to understand the state of our current services, the areas where we’ve improved, and, equally, those areas where we still need to improve further in the future.

Thank you for that answer, Cabinet Secretary. Staying with the Wales cancer patient experience survey, nearly a quarter of patients said that the GP didn’t take their symptoms seriously before their diagnosis. In fact, 6 per cent of patients stated they had to see their GP at least five times before being referred to hospital. As stated in the cancer delivery plan, detecting cancer earlier makes it more likely that treatment can be curative, less intensive and less expensive. It is therefore vital that, when someone presents with symptoms that could be caused by cancer, they are taken seriously. Unfortunately, we seem to operate in a model where we rule conditions in rather than out. We work up to the most serious rather than working back. So, Cabinet Secretary, what more can be done to improve early cancer diagnosis in primary care?

I don’t think the way in which you’ve characterised the way that general practitioners approach their job is particularly fair. I do think there is a serious case, though, about improving the number and the quality of referrals. This is a really big challenge for the health service, because the overwhelming majority of people referred in with suspected cancer are actually given the all clear. So, we already have a significant undertaking where we’re looking for the minority of people who are referred in and who are then told that there is a form of cancer to be treated.

It is also the case that cancer referrals have gone up significantly in this last year. They’re up 12 per cent within this year alone, and it is about how we continue to improve the rate of referral, but also what the conversion rate is as well, because, within health boards, there are different referral rates, but also different conversion rates. So, for those who aren’t aware, the conversion rate is the number of people who are referred in and then go on to be told that they have a particular cancer. That may be about the communities themselves. It may also be about the numbers of people and how and why they are being referred in. It’s really important again that we have a properly reflective approach where general practitioners are able to talk to each other, and other actors within the service, to understand what is happening and the outcomes they’re delivering for their patients. I think there’s got to be a properly reflective and supportive approach as opposed to looking to say that there will be blame apportioned to GPs, who are being told that they are doing their job in their wrong way. I think that’s unlikely to see the sort of reflective and positive approach that people want to take. Let’s not forget that people make a choice to go into medicine to care for people and to help improve lives, and we need to help them to do their job as well as being properly reflective of where that improvement is required.

Thank you, Cabinet Secretary. Finally, less than half of cancer patients have the opportunity to discuss their needs, and only 18 per cent of patients were offered a written care plan. Care plans are not only focused on healthcare needs, but they also pick up on emotional, financial and practical support. Less than half of Welsh patients were given information on financial support and benefits or had the impact their cancer would have on their day-to-day life discussed with them. We need to improve the way we deal with the impact cancer has on the patient, not just on their physical health, but the broader aspects. So, what is your Government doing, Cabinet Secretary, to ensure that all patients are offered a written care plan that incorporates a holistic needs assessment?

We’ve set out clearly our expectations for improvement in the cancer delivery plan. There’s no dispute within the wide range of healthcare professionals in tertiary, secondary and primary care services of the need for improvement, or in the real value of having written care plans. It is indeed because people see the whole person, so not just the particular direct impact of cancer in treatment terms, but what that means for that person—their ability to work, their ability to live their life, to make different choices and, actually their prospects for the future. So, it is really important to have that wider discussion and to understand that it will be at different points in time for different people. Some people, at the point of diagnosis, may want to know everything. Other people may want to get out of the room as soon as possible. It’s understandable why that happens, and that’s why a service cannot have a one-size-fits-all approach; it’s about being more agile and for it to be wrapped around that person. It also reiterates the need to have not just primary care and hospital-based care in a proper and constructive relationship with each other, but actually the real value of people in the third sector being able to support people in a different way, in a non-medicalised setting.

But I do think that it’s important not to lose sight of the fact that more people are being referred for cancer, more people are being treated for cancer, more people are treated in time for cancer, and more people have better outcomes. More people survive now than ever before, and, actually, on the experience of care, 93 per cent of people have a good experience of cancer care here in Wales. So, more improvement required, I accept that completely, but let’s not try and say that everything is bad here. We have many things to be very proud of.