The following amendments have been selected: amendment 1 in the name of Julie James and amendment 2 in the name of Rhun ap Iorwerth.

We now move to item 7 on our agenda this afternoon, which is the Welsh Conservative debate on Betsi Cadwaladr University Local Health Board, and I call on Angela Burns to move the motion. 

Motion NDM6594 Paul Davies

To propose that the National Assembly for Wales:

1. Welcomes the crucial role Betsi Cadwaladr University Health Board frontline staff play in delivering services and supporting patients across north Wales.

2. Notes the Welsh Government’s decision to place Betsi Cadwaladr University Health Board in special measures in June 2015.

3. Believes that the Welsh Government has failed to address increasing waiting times in north Wales and the health board’s deteriorating financial position.

4. Calls on the Welsh Government to:

a) clarify what steps it is taking to ensure that the financial uncertainty at Betsi Cadwaladr University Health Board does not undermine the delivery of services;

b) publish a clear action plan for returning the health board to its normal status; and

c) explain the measures the health board will undertake to improve patient outcomes.

Motion moved.

Thank you, Deputy Presiding Officer. I'm delighted to be able to open the Welsh Conservative debate tabled in the name of my colleague Paul Davies. You'll see from our motion on the order paper that it can be taken in four separate points. We pay tribute to the staff, we note the Welsh Government's decision to place the health board into special measures, but we believe that those special measures have failed and we're calling on the Welsh Government to take forward some action.

We've chosen to focus on Betsi Cadwaladr because it is our largest health board, and it has been in special measures for the longest of time and I would like to start, before I do anything else, my contribution by paying tribute to the hard work that the staff, the NHS staff in Betsi Cadwaladr undertake. They're operating in a very difficult environment with straitened resources and increasing pressure, and if it wasn't for these dedicated, overstretched and often under-appreciated staff, then the situation would be far worse than it currently is. I've visited a number of hospitals in the Betsi region, and I've always left impressed by and grateful for the work of the staff and the staff themselves. 

We should remind ourselves briefly of the scale of the challenge, because the Betsi Cadwaladr university health board is the largest in Wales and provides services for close to 700,000 people and employs some 16,500. The size of the board's estate is massive—

Will you take an intervention?

You'll have to be quick.

Could I just ask, through you, that the Cabinet Secretary stops what he's doing and actually listens to the debate?

The size of the board's estate is massive. It covers three district hospitals, 22 other community and acute hospitals, 19 medical centres and 121 GP practices. And, as I've known when I've driven up there, it's in a geographically pretty diverse area and it can take literally hours to get from one side to the other.

However, we should also remind ourselves that, while recognising the challenges that an organisation of this size faces, the health board has been in special measures for nearly two and a half years now—since June 2015. This was a decision taken by the Welsh Government, and today I'm calling on the Welsh Government to provide a comprehensive update on where this health board's status currently stands. For the sake of its staff and the patients as well as the public of north Wales, we must know how close we are to seeing the board move out of special measures and what tangible improvements there are since special measures were imposed 29 months ago.

This is important because, despite being in the highest form of Welsh Government control, Betsi Cadwaladr still trails behind Wales's other six health boards on a number of major performance indicators. As well as having the highest projected budget deficit, waiting times for routine treatments have spiralled, with the number of patients waiting longer than 52 weeks for routine surgery rising by a staggering 2,550 per cent to stand at 2,491 individuals in September 2017. Given that more than an extra £10 million has been spent on keeping the health board in special measures and that its budget overspend is set to reach £50 million, I am concerned that we still haven't seen that coherent plan for improvement from the Government, from the Cabinet Secretary and from his team.

Other contributors will look more closely at some of the key issues that affect Betsi. They are local AMs who, with their families and friends, make use of the health service that the trust offers on a regular basis, and they see at their regular surgeries the problems that patients using the local health service face. However, I would like to highlight one key issue that I feel drives this message home: 100-day plans were put in place to deliver urgent improvements, but more than two years on since the improvement framework was instigated, there remain serious concerns about the health board's ability to manage its finances and to deliver safe, sustainable and timely services to the people of north Wales. This is coupled with the fact that, since being placed in special measures, Welsh Government Ministers have held more than 90 meetings or discussions with the health board, in addition to those held with Welsh Government officials, yet the boards de-escalation out of special measures seems to be lacking a coherent overarching strategic direction.

And it's not just Betsi Cadwaladr, obviously, that's under this cloud. I surely do not need to remind Members that three other boards are working under the targeted intervention level of Government support—those of Cardiff and Vale, Abertawe Bro Morgannwg and Hywel Dda health boards.

So, we talk about special measures and targeted interventions, but what do these terms actually mean for the people on the ground? Special measures should refer to a range of actions that can be taken to improve health boards in exceptional circumstances, i.e. as a last resort, and it happens when a health board or a trust is not making the improvements expected and there are concerns that the leadership and management require external support. Targeted intervention sits one level below special measures and means that the Welsh Government may take actions that include arranging mentoring for individual board or executive team members and appointing experienced individuals with the necessary clinical and/or governance skills onto the board for a finite period.

The Welsh Government's NHS Wales escalation and intervention arrangements document, produced in 2014, outlines the ways that interventions can be de-escalated. So, will the Cabinet Secretary please inform the Assembly about the de-escalation criteria for Betsi Cadwaladr, whether it has been met and, if not, when it is due to be met? I ask this question in light of a response that I received to a written question on 23 November, asking about the Cabinet Secretary's confidence that Welsh health boards are demonstrating improved financial performance. The Cabinet Secretary responded with:

'I am disappointed that Betsi Cadwaladr University Health Board is not yet demonstrating the necessary action to deliver their control total. My officials have commissioned an independent financial governance review of the Health Board which is currently being undertaken.'

Cabinet Secretary, can you clarify for me exactly what is meant by 'control total'? What worries me is that you have here a health board that is under special measures yet needs to have further intervention to tackle financial problems. Surely, after all the time and money that this health board has had pumped into it during its time in special measures, it is a dereliction of duty to only now realise that an independent financial governance review is necessary. It strikes me that a financial audit should have been done at the start of this process, Cabinet Secretary, not 30 months into it. How much worse do things need to be before this situation gets the focused attention it so desperately needs? Surely this will only delay the health board emerging from special measures. And this is critical, because, whilst that health board is in special measures, its reputation is tarnished, its staff are demoralised, it's finding it difficult to recruit people, and there are a whole range of ripple effects that being under that special measures process has.

I have absolutely no problem at all with you as the Cabinet Secretary, with you as the Welsh Government, looking at something and saying, 'This is not performing well enough—we have to improve it; we will put it into special measures.' I completely get it. But what I don't think anybody else gets is what those special measures mean, because, after almost 30 months, we should have seen some level of improvement, and that level of improvement is not there. I would lay against the Welsh Government that, actually, you have this problem throughout the whole of your public service delivery, because we have seen education, we have seen councils, being put into special measures, under ministerial advisory review boards, under targeted interventions, and I do not think there's a coherence as to what special measures mean.

I have highlighted that there should be clear routes in and out of special measures, clear ways to de-escalate, and such a lack of clarity leads to real confusion for people in Wales, and, in this instance, for the people of north Wales. I think that you are paying lip service to intervention; I think there needs to be a common approach across departments, a clear and definable understanding as to what constitutes the top intervention in a health board. I think special measures should be the final option; it should mean boots on the ground, a thorough review of all aspects of a health board—not, you know, reviewing aspects when you're half way in, or, in this case, 30 months in—and we should have a clear way of how those health boards, and this particular health board, can move themselves back out. And I ask you to listen to our debate today, listen to the comments my colleagues are going to make, as they are there, on the front line, and actually come up with a clear and coherent plan that all of us can understand.

Special measures are no good if it merely means 90 chats with you and your officials. It's got to be tangible, and if that health board is struggling to such an extent that you're now having to commission a financial governance review, you really have to put experienced soldiers onto that front line, because we ain't gonna win the battle for good health and good levels of healthcare in north Wales otherwise.

Thank you. I have selected the two amendments to the motion and I call on the Cabinet Secretary for Health and Social Services to formally move amendment 1, tabled in the name of Julie James.

Amendment 1. Julie James

Delete points 3 and 4 and replace with:

Notes the Welsh Government’s continued challenge to Betsi Cadwaladr University Health Board to address its unacceptable waiting times and financial situation.

Notes the significant support provided by the Welsh Government to Betsi Cadwaladr University Health Board to work to stabilise and recover its position.

Notes that following a review of progress with HIW and the WAO in early December the Welsh Government will consider further measures Betsi Cadwaladr University Health Board must undertake to improve.

Amendment 1 moved.

Formally.

Thank you. I call on Rhun ap Iorwerth to move amendment 2, tabled in his name. Rhun.

Amendment 2. Rhun ap Iorwerth

Add as new point at end of motion:

Believes that resolving the issues faced by Betsi Cadwaldr University Health Board will require a substantial expansion in the workforce, which will require an expansion of medical and nursing training.

Amendment 2 moved.

Thank you, Deputy Presiding Officer, and I speak as Plaid Cymru shadow Secretary for health, but I speak also as a representative of a constituency in the Betsi Cadwaladr region, as do other Members here, and I’m sure I’m speaking on behalf of many of those when I say that communication from constituents, my contact with constituents, show beyond any doubt the strain on that particular health board and the difficulties that health board is having in delivering the services that we expect.

It’s over two years now since Betsi Cadwladr was placed in special measures. We know what we expect when a health board is placed in special measures: we expect improvements. We expect performance to improve. But whilst not for one second doubting the Government’s aspiration to improve performance and managers’ desire to turn the corner, whilst paying the sincerest possible tribute to the staff who work so hard on the front line, there is far too much evidence, I’m afraid, that this is a health board that continues to face terrible problems. That’s not to ignore those things that have been done well within Betsi Cadwaladr, and I’m very grateful to the chief executive for contacting me and other Members yesterday, emphasising those areas where the board is performing well, but mental health workers tell me how difficult it is for them to respond to the needs of the people of north Wales, and that includes child and adolescent mental health. Yesterday, I mentioned a patient who couldn’t get an acute mental health bed and had to be transported overnight to the south-east of England.

Ophthalmic care is clearly under strain according to my inbox. The shortage of GPs is critical. When they’re not extracting teeth, dentists are pulling their hair out because of the strain that they are facing. Orthopaedics continues to be a very grave problem. A consistent flow of patients on waiting lists are coming to see me. They may be waiting for a hip or a knee in order to ensure that they can live vibrant, healthy lives, and it is quite unacceptable that they are told that waiting times for emergency surgery in some cases is 106 weeks. We know from the experiences of last winter when the capacity for orthopaedic surgery was cut—because of winter pressures, so they told us—then the situation has got worse in terms of waiting lists. Waiting over two years for emergency treatment for a new hip is scandalous. There is no other word to describe it.

So, we welcome the motion. We will reject the Labour Party amendment because I’m afraid I am not willing to note the

'significant support provided by the Welsh Government' to the board

'to work to stabilise and recover its position', because that suggests that they are providing sufficient support. That clearly isn’t the case. Support takes a number of forms, of course—not just financial support. I want the board also to have support in terms of a Government that is far more innovative in its attitude to delivery of healthcare in Wales, which is truly pushing the integration agenda in order to enable care and health services to work together for example.

Turning to our own amendments, you’ll not be surprised to see me introducing an amendment that focuses on the workforce and the need to train more professionals for the health workforce. I hope I can rely on the support of all parties. There’s nothing contentious in saying that we will—

Will you take an intervention?

Yes, of course.

Thank you very much for taking the intervention. I'd like to assure the Member for Ynys Môn that we, the Welsh Conservatives, will be supporting your amendment, because you make a very valid point in it.

Thank you. I appreciate that support. 

There is nothing contentious, of course, in calling for an increase in the level of training. Where there is disagreement between ourselves and the Government is on how we provide that new capacity. There is an ambition for us to develop Bangor University as a centre—or there is a general ambition, if truth be told, to develop Bangor University as a centre of excellence in the area of research and healthcare training. We have an ambition to develop the medical education centre too, and there are very real opportunities to train nurses as well as other health professionals and doctors. In saying that, I’m talking about training undergraduates from the first year, not simply securing placements for students from other colleges to spend more time in north Wales, although there is nothing wrong with that, of course. There is a lot to be said for ambition. There is a grave risk in allowing others to show ambition and not trying to catch up. Chester University is in the process of establishing a medical school. There is very real concern about the impact that that could have on Bangor University, unless a real effort is made to bring medical education there too.

I will conclude. The risk register of Betsi Cadwaladr states this:

'There is a risk that the Health Board is unable to meet its statutory responsibilities to provide a primary care service to the population of North Wales.... There is a risk that the Health Board will have difficulty recruiting and retaining high quality staff in certain areas'.

I'm concerned about that. We really need to see this Government, which is in charge of Betsi Cadwaladr, start planning for the workforce that Betsi Cadwaladr and all our other health boards need for the future, with innovation. Otherwise, the current workforce will continue to be asked to do the impossible, and both they and their patients deserve better.

The performance, be it good or otherwise, of Betsi Cadwaladr university health board affects very directly my own constituents in Aberconwy and is currently making up a great deal of casework. It is worthy of note that, within this board, the MRSA and MSSA case rates are the lowest in Wales, and red ambulance call-out times and cancer treatment within 31 days are the second best in Wales. And, where we see good practice, we want to celebrate that and we applaud it.

However, the matters raised certainly in my contribution today will highlight the continued failings and much criticism of the Welsh Government health Secretary. Deputy Llywydd, in January of this year, I raised the issue of GP shortages in this Chamber. We've seen surgery after surgery close in Aberconwy, and yet this was an area of improvement as a means of the special measures process. In February, I raised the issue of trauma and orthopaedic waiting times. Since Government intervention, the number of patients waiting over a year for surgery has risen by 2,127 per cent to 1,782. I have constituents waiting 130 weeks—that's two and a half years—for what is considered to be urgent and vital treatment, all the while facing every day with sickening pain and real debilitation.

In March, I raised concerns over support for mental health patients. I had to do it again yesterday to the First Minister. I was distressed to learn recently that a patient requiring serious psychiatric intervention could face an unacceptable waiting time of up to 18 months. I have another case where access to mental health treatment is so bad that one of my constituents has previously attempted suicide.

Healthcare issues in north Wales that I've had to raise constantly, month after month, week after week—and yet, here we are, at the end of November 2017, and, as my colleague Angela Burns has said, 30 months after interventions by your Government and by you, as the Cabinet Secretary who's responsible for delivering good-quality healthcare across Wales. 

We see no noticeable improvement, with the board now facing the highest projected budget deficit and seriously trailing behind the rest of Wales on a number of high-level performance indicators. Next year, it will be refreshing to actually see better performance and not having to keep raising issues on behalf of my constituents—for each and every one of the 3,368 patients facing a wait of 100 weeks for elective orthopaedic surgery, for my elderly constituent who has not only faced a wait of almost three years for a colonoscopy, but whose frustration was further compounded by being forced to wait five months even for just a modest reply from the health board.

Now, I do want to highlight and commend the staff working within the health board. I actually feel very sorry for them, because they take a lot of the brunt of your failing in your performance. They're working under extreme pressures and they're performing a fantastic, often thankless, task. But I am concerned at instances of clinical staff working 24-hour shifts. Studies have shown the detrimental effects of a lack of sleep on performance and concentration, and such situations seriously harm, putting patients and our staff in danger. We saw last month the number of deaths this year caused by unintended or unexpected incidents—41. More than half of those recorded occurred within Betsi Cadwaladr university health board. Deputy Llywydd, that is 41 patients, 41 families, loved ones torn apart by loss, grief and unbearable devastation.

Cabinet Secretary, I have raised this issue so many times with you, and, on occasion, when I've raised it with the First Minister, you sit there, quite often shaking your head. At the beginning of this debate—you're not even listening now. At the beginning of this debate, you hadn't the courtesy to listen to my colleague, our opposition spokesperson. Frankly, I'm not sure how seriously you take your role. It has been unclear from the start just how the Welsh Government is managing the board under special measures, so we're calling today for you to outline with some clarity what steps you are taking to ensure the financial uncertainty at Betsi board does not undermine the delivery of services, and to publish a clear action plan for returning the health board to its normal status.

The situation as it stands is unsustainable, and is actually quite unacceptable. We look across the border and we see so much better performance. Why should there be a postcode lottery? Why should my constituents, and any other constituent living in north Wales, have to suffer poor practice and a very, very poor Cabinet health Secretary who, frankly, in my opinion, isn't on top of his job?

The self-proclaimed party of the NHS really, really doesn't seem up to the job. Even using the excuse that it takes a while to turn around a health system once it's in special measures doesn't cut it, since Labour have been governing Wales for two decades now, and Betsi Cadwaladr got into its current state on their watch. Blaming Westminster is also tenuous at best, as Labour make a great play of wanting matters devolved to this place so that the Welsh Government can run them—all the recent argument over a potential Brexit power grab, and here we have an example of how this Government fails when it is given control of one of the most important public services. 

Labour keep saying that more should be devolved, but then, when they're shown up as not competent to run a service, as in the case of Betsi Cadwaladr, they try to find a way to blame Westminster. Well, this is the Welsh Government's fault, fair and square. The Government has been banging on about all the things that it is going to do to try and improve the Betsi Cadwaladr university health board, and unsurprisingly silent on the things it isn't doing.

Nowhere has Labour suggested making the members of the health boards more accountable. UKIP campaigned for elected health boards so that they would be accountable to the people of Wales. Accountability—this is on a single issue and can't be fudged, which is probably why Labour argued against this progressive idea. Whilst it is obvious that the Labour Government doesn't have the will to get rid of incompetence, I'm absolutely confident that the Welsh public do have the will, and elected health boards will enable that to happen. 

Nothing the Government has done is working, so why should we continue to let them try? The waiting lists aren't just statistics. They represent the pain and suffering of the people on those waiting lists and the stress imposed on patients, their family and front-line staff. The waiting lists are getting worse, staff morale is going down, health outcomes are taking a hit, but none of the health board have been given their marching orders and none of the mega-salaried NHS managers have been sacked. 

And there is the impact that is far wider-reaching than the health concerns of the patient. Front-line staff must be feeling incredible pressure, having to work even harder than our dedicated NHS staff already do to make up for the incompetence of senior managers in Welsh Government. Labour are also the self-proclaimed party of the workers. Are they happy with the pressure they're putting these public sector workers under? This is about a lot more than a public sector pay freeze. This is about valuing staff and their welfare. Labour also try to say that they're the party of equality, but where is the equality for those whose accident of postcode means they have to wait far longer for treatment than another Welsh or UK citizen?

Betsi Cadwaladr's problems are themselves symptoms—symptoms of a Government that doesn't seem to have the will to do what any other responsible manager would do and sack those big-salaried executives at Betsi Cadwaladr who are responsible for the mismanagement of the health service in north Wales. The Government-led failings at Betsi Cadwaladr show that Labour are not the party for the NHS, not defenders of front-line staff, and do nothing to reduce inequality in health outcomes except to impose the same mismanaged system on everyone reliant on the NHS in north Wales. I believe previous calls for a full public inquiry have been made, and I think they have a lot of merit. If that was to be proposed, I would be prepared to support it. The Welsh NHS is ill, and, unfortunately for the people of Wales, the waiting list for treatment, for when this Government in Cardiff can be replaced, is three years. Thank you.

Our north Wales Betsi Cadwaladr university health board is in special measures and overspent because Labour Welsh Government dismissed our warnings over many years. On each occasion, Labour Ministers dodged responsibility by instead accusing us of talking down our NHS when we were speaking up because staff, patients and families had asked us to do so. The board was only put into special measures in 2015 after an external investigation revealed that patients had suffered institutional abuse in Glan Clwyd Hospital's Ablett acute mental health unit. The then health Minister finally admitted that this decision reflected, quote:

'serious and outstanding concerns about the leadership, governance and progress in the health board over some time.'

The health board stated that it was alerted to serious concerns regarding patient care on the Tawel Fan ward in the Ablett unit in December 2013, but concerns about this ward went back a lot further. For example, in 2009, I represented a constituent who said that the treatment received by her husband there nearly killed him, that three other patients admitted around the same time as her husband had similar experiences, and she was now worried about the treatment others may receive in this unit.

Of course, there have been some positives since special measures. Further to my intervention on behalf of the neurotherapy centre in Flintshire, where health board funding had fallen to just £65 per person compared to £500 from commissioners in West Cheshire, the health board chief executive confirmed a framework on going forward.

When I visited fantastic staff at Wrexham Maelor Hospital this summer with the Hepatitis C Trust, they told me that there were now comprehensive treatment options. They added however that to do what the Welsh Government required would need between six and nine extra hepatology specialist nurses across the health board. We have seen patients waiting months for pain management treatment.

Only this afternoon, the health board announced yet another GP surgery closure. Although special measures saw some move from risk-averse complaints handling to problem solving via direct engagement with complainants, progress has stalled. Typical of this was a recent response to a complaint regarding a patient who died whilst receiving treatment from the health board. Although it apologised and stated that the complaint had been investigated in accordance with regulations, it coldly concluded that there was, quote,

'no qualifying liability on this occasion'.

The bereaved family were deeply distressed and told me that the response included several factual errors.

Betsi Cadwaladr is the only health board in Wales that does not commission services from the Bobath children’s therapy centre, which provides specialist physiotherapy, occupational therapy, and speech and language therapy to children all over Wales who have cerebral palsy. The cost to the remainder is negligible and the savings massive. Together with the centre, and a north Wales parent whose daughter had received its support, I met the health board twice to seek a way forward. They produced a draft report and copied it to us for comment. We each responded on the clear understanding that wider family engagement would only follow after our comments had been incorporated into the draft report. Instead, the unamended draft report was issued to parents with a questionnaire, unfairly biased towards internal provision of services, rather than the provision available from Bobath at a standard beyond which the health board can deliver.

Denied autism assessment, the parents of several daughters have told me that statutory bodies don’t understand that thinking has changed, and that autism presents differently in girls. Although forced to pay for private autism assessment, a 2017 letter from the health board said that Flintshire CAMHS had raised concerns about the rigour and conclusions in a number of private assessments, and in some cases didn’t accept the diagnosis, and that there was a requirement for these to be in line with NICE guidance. However, when I referred this to the clinical psychologist who had carried out these assessments, she confirmed that not only were she and her team NICE compliant, but also that she was a contributor to NICE guidelines.  

This approach helps explain why this health board has registered the highest number of serious patient safety breaches in Welsh hospitals, why it has the worst record for patients waiting longer than four hours in accident and emergency, and, with Wales having double England's level of patients waiting for treatment, why the number of Betsi Cadwaladr patients waiting over a year for routine surgery rose, as we heard earlier, 2,550 per cent, from 94 at the time when special measures were implemented to 2,491 in September 2017. This can't go on.

We've listened to a number of very powerful speeches illustrating the catastrophe that is the Betsi Cadwaladr health board, over which the current Cabinet Secretary, and the previous one who's temporarily left the Chamber, presided. Now, for many, many years, the Labour Party has been accustomed to saying that the national health service is the envy of the world. Well, as far as Betsi Cadwaladr is concerned, I don't know which world they're thinking of—it must be the planet Pluto, because it certainly isn't the envy of anybody in this world of planet Earth. 

Michelle Brown raised a very important point in her speech earlier on, and that is the unresponsiveness of the Betsi Cadwaladr health board towards its patients with the complaints that they've made. We've had a massive number of individual examples that have been trotted out here this afternoon, and I make no apology for returning to a theme that I have raised in the Chamber on several occasions since I was elected: the denuding of the Welsh uplands based around Blaenau Ffestiniog of any substantial health service provision. It's well over a year now since I asked the First Minister what the Welsh Government was going to do about this, given that Betsi Cadwaladr is in special measures. I said, in Gwynedd in particular, in the area around Blaenau Ffestiniog, the record is exactly the opposite to that which the Government claimed in its 'Taking Wales Forward' document's section on health, where they said, 

'We are committed to helping improve health and well-being for all.'

What's happened in the Welsh uplands is entirely the opposite. In the seven well-being areas defined by Gwynedd Council, there is a community hub hospital in every one apart from Blaenau Ffestiniog, because their 24-hour service was closed several years ago and downgraded to a 10-hour health centre, and downgraded again since then. Since 2013, therefore, we’ve seen the closure of a hospital, a loss of hospital beds, the closure of the x-ray service, the closure of the minor injuries unit, the closure of teledermatology clinics and therapy services, two rural branch surgeries have closed, and the GP practice in Blaenau Ffestiniog was supposed to have four full-time doctors, but it’s only got one salaried doctor and a variety of locums. As far as Blaenau Ffestiniog is concerned, they haven’t got a national health service; they've got a notional health service. And in the 14 months since I made that indictment to the First Minister, absolutely nothing has changed despite the special measures, and something has got to be done about it.

Now, we all know, of course, that areas like Blaenau Ffestiniog and its surrounding district pose problems. There's always going to be a tension with the provision of health services in sparsely populated rural areas, but the models that have been chosen are more related to what is appropriate for urban areas rather than rural areas. In urban settings, of course, the tendency is, for very obvious reasons, to pull services together into community healthcare hubs, but in rural north Wales it has been in the other direction. What we should be doing is pushing services into rural areas to gain the patient outcomes without too great a loss of financial efficiency. What we have seen is a very substantial expenditure of money in Blaenau recently—well over £1 million, I believe—but not a single bed is created; we've created dozens and dozens of desks for national health service pen-pushers instead. So, they closed the memorial hospital and replaced it with an office block. That is not what we expect from a health service, and the poor residents of Blaenau and district deserve a great deal better than that. 

Other countries seem to be able to manage to do this. Why can't we? In the United States, rural areas have long enjoyed support and protection from the Rural Health Clinic Services Act of 1977, and the Federal Office of Rural Health Policy and the National Rural Health Association provide a mechanism for rural health campaigners to receive significant support in their interface with Congress.  

We know that there is something called distance decay—that is, the further away you live from a hospital the worse the health outcomes tend to be, because people find it much more difficult to get to hospital so they don't go for treatment in time and regularly enough. There are problems with poverty in rural areas. People have to pay to travel to hospitals that are a distance from their homes, so they don't have a free health service because it actually costs them a great deal of money often in order to get the treatment that they deserve. 

In Scotland, there are some more imaginative models than we've got here in Wales. For example, in the Isle of Skye, they have a model of rural practitioners where the Broadford Hospital is staffed by GPs with additional skills and training in anaesthetics and trauma. The model was developed after a consultation with the local community, and the realisation that the size of their community, which was about 13,000, had a need for some emergency service but couldn't sustain a general hospital. Instead, the Broadford is now an enhanced community hospital. Why can't we do that in Blaenau? The previous health Secretary refused to intervene in the closure of the hospital services in Blaenau because it was supported by the local community health council, but, of course, the local community health council is not elected by anybody in the area that is covered by the hospital closures. That's why we need to introduce the kind of democracy to the health service that Michelle referred to. 

An Assembly Member rose—

I'm afraid I think I'm at the end of my speech and the Deputy Presiding Officer would not allow me to accept an intervention, although I would have been otherwise delighted to do so.

So, I'm afraid that this catalogue of disaster continues, and I believe that, until we change the Government of this country, it is likely to continue further.

I welcome the opportunity to speak in the debate this afternoon. Although obviously not from the north, through my role as leader of the Welsh Conservatives here, I obviously spend quite a considerable time going up to north Wales and seeking first-hand experience of the plight, as I'd put it, that many people feel they're in about the service that they're getting from the health board, which has now been in special measures for some 30 months. It's worth noting that, obviously, in England, for example, the average special measures stay for a similar health body would be about 21 months.

I don't detract from the fact that there are tensions and issues across the whole of the United Kingdom when it comes to health services. In particular, there is something to be celebrated in that more people are being treated in our health service across the United Kingdom. That's because, obviously, there are far more people on these islands and we're living longer as well, and so health services across the United Kingdom have a real dilemma on their hands of rising demand and an inability to attract the staff that they require to man the wards and man the primary practices.

And there's no more significant case to highlight than that in north Wales, which, for many years—virtually I think for the entire time that I've been an Assembly Member—has struggled with recruitment and retention in particular. We do focus a lot on the recruitment of new staff into the health service, but, actually, retention is a critical part of what we need to be doing in the health service, and no more so than in north Wales. It is regrettable that, if you look at the stats on staff sickness within the health board, they are some of the highest within the health service in Wales, and stress in particular is identified as being one of the most common causes, or the biggest single cause, for staff taking time out, because, obviously, of the pressure that they're under.

It has been now, as I said, some 30 months since the health board has been in special measures. The current Cabinet Secretary has been in position for now 16 or 17 months—maybe even a little longer than that—and I hope he will use the opportunity in responding to this debate today to actually give an honest and frank assessment of where he sees the health board going. It cannot be right that, after 30 months and with the health Secretary in position now for that length of time, we cannot get an honest assessment of how the Welsh Government, with all the resource that the Welsh Government has at its disposal, is not getting to grips with the waiting times, with the staff retention and recruitment and, above all, the budget issues that this health board faces; until recently, it was projected to have, for this financial year, a budget deficit of £50 million. As I understand it, the latest figure indicates that the deficit situation now has been brought down to £36 million, but, in itself, that's the biggest budget deficit as I understand it that this health board will have incurred in a single financial year.

When you do look at the waiting times and the graphic examples that have been given by Members from north Wales, and in particular from my benches here by the regional Member Mark Isherwood and the Aberconwy Member Janet Finch Saunders, of people waiting 12, 18 months, in excess of 100 weeks for treatment, that is something that, in the twenty-first century, we just should not be tolerating. When you actually look at the numbers, if you take the 52-week wait for routine surgery, it has risen from 94 patients in 2015 to, now, a figure of 2,491 in September 2017. That's a rise of 2,500 per cent. Those sorts of figures, for most people, are just incomprehensible. Most people, all they want—they don't expect instant treatment, but they expect a reasonable time for that treatment to be provided.

I do hope that the Cabinet Secretary will give us something hard and tangible that we'll be able to hang on this debate to say that the waiting time situation in the Betsi health board area is being grasped by the Cabinet Secretary and his officers in Cathays Park along with the health board to address these spiralling waits. Accident and emergency, for example, is another area of huge concern that my colleague Darren Millar has highlighted in First Minister's questions and, I believe, in questions to your good self, Cabinet Secretary, with regard to the appalling waiting times that people are having to face in Glan Clwyd, in his own hospital, which serves his constituents, where under 70 per cent of people are being seen within the four-hour target—your own target. Surely, you do not agree with that situation being allowed in a major hospital here in Wales. And so, I would ask, in your address to the debate this afternoon, that you do give us a clear route-map out of special measures that we can hang the hat of this debate on, so that Members can go back to their constituents and say what progress has been made since the health board went into special measures. I do hope that you will clarify the budget situation that the health board finds itself in, because this is your opportunity do that.

Above all, I do hope that you will give us something meaningful on staff recruitment and retention, because without the staff on the front line within our health board, whether that be in a primary or secondary environment, there is no health service. As Angela Burns touched on, they are the backbone, they are the blood that makes our health service work, and it is incumbent on you, with the levers at your disposal, to be able to offer a significant and substantial package of measures that address the chronic understaffing that the Betsi health board faces, both in primary and secondary care.

Can I now call the Cabinet Secretary for Health and Social Services, Vaughan Gething?

Thank you, Deputy Presiding Officer. I'd like to thank Members for a spirited and difficult debate, with lots of criticism, and that is to be expected. I'll recognise at the outset that the Government will support amendment 2, as we do recognise the workforce challenges faced. We might have worded it differently, but I think it's wrong to try and dance on a pin about individual wording in the amendment. We recognise the central challenge that is made and recognised in the amendment.

Following special measures in June 2015, areas outlined for immediate action at the time were: governance, leadership and oversight, mental health services—the most significant area of concern—maternity services at Ysbyty Glan Clwyd, reconnecting with the public, and GP and primary care out-of-hours services. Now, special measures themselves do not amount to the Welsh Government taking direct control and running the health board. They are the highest level of intervention, but the health board are still in place and running services. There's no-one directing in Cathays Park and making choices about how to run the organisation. The intervention in place has worked alongside the board and staff to try and make progress and improve services and has significantly increased our oversight and the accountability arrangements.

I, of course, value the hard work of our staff in delivering services and supporting patients right across north Wales. When I visit north Wales, as I do regularly, I meet staff and I'm impressed by the recognition and commitment they have to delivering the improvements needed. I am pleased that people, in this debate, recognise the commitment of our staff, but I would gently say to all Members in all parties—I do not want to point at any particular person—when recognising the commitment of staff and their hard work, to then refer to the health board as being a catastrophe or in crisis does undermine that. It undermines and it affects the staff on the front line. The challenges that the health board faces are not in every single area of operation. Having that broad brush does have an impact on the staff as well as the politics in this place.

In the Government's statement of October 2015, I stated that the health board would remain in special measures for a minimum of two years and that longer plans were needed to build on this initial phase of stabilisation in order to tackle more fundamental challenges that do exist, particularly to improve mental health services in north Wales.

In January 2016, the Welsh Government published an improvement framework, setting out the progress milestones to be met under three phases: the plan, if you like, for improvement. The health board reported on the first phase in March 2016, the second phase in December 2016, and is due to report on the third phase next month, December. Healthcare Inspectorate Wales and the Wales Audit Office have undertaken a third review on progress on governance arrangements, and this was published in June this year. That review recognised the health board was broadly moving in the right direction. It noted that leadership has been strengthened, the board is working more effectively and special measures are helping to focus on areas where action is required.

Progress has been made in meeting a number of the milestones set, including a full executive being in place, including six new appointments since special measures. Time and effort have been applied to improving the performance of the board with an ongoing board development programme, and the Wales Audit Office and HIW joint review noted they had seen visible improvements to the effectiveness of the board. Complaints and concerns, as mentioned here,  are now led by the nurse director, and there's been a material improvement in responsiveness. A mental health strategy was developed in partnership with service users and staff, and agreed in April of this year. There's been a successful approach to turn around primary care services in Prestatyn, now modelled with not just interest across Wales, but further afield as well.

On maternity services, one of the most significant challenges at the time of special measures, we have seen significant progress in key areas, including, for example, reduced reliance on agency, from 50 per cent to 10 per cent. The service is now compliant with Birthrate Plus, and pre-registration midwifery students who were removed in 2015 from Ysbyty Glan Clwyd have now all returned, so that all sites across the health board are being fully utilised for training purposes. And, of course, the work on the sub-regional neonatal intensive care centre is progressing well, and I expect the unit to open in spring next year.

The HIW and Wales Audit Office review also noted continuing pressing challenges, including the need for a clear plan for clinical services, and that will require brave and visible leadership to build on and ensure progress. I am, of course, disappointed that some issues have escalated during the last six months in other areas that now require significant improvement, notably in terms of finance and performance. I have never tried to shy away from the reality of significant challenges in finance and performance, in both scheduled and unscheduled care. Due to the concerns that I have, I increased the accountability from summer this year, with increased direct contact between myself and senior officials. I meet directly with the chair and the chief executives. In fact, I have already arranged to meet them tomorrow in north Wales as part of that more frequent contact.

The Welsh Government amendment recognises the continual challenge to the health board to address its current financial situation and its unacceptable waiting times. My focus is on ensuring action and providing the support needed to stabilise and recover the position. I've already taken action and a number of steps to help do so. That's why we're trying to note the support already provided under special measures, and the additional taken action that I've taken, including the additional external advice and support for the mental health team, who have placed more staff in and around the board, and the allocation of over £13 million to improve referral-to-treatment waiting times. We expect that to improve by around 50 per cent by the end of March 2018. There's £1.5 million of investment committed to the unscheduled care programme team to transform the delivery of services and improve unscheduled care performance, with targeted support from the NHS Wales delivery unit. Direct support has been provided by the national programme for unscheduled care team.

The independent external financial governance review that has been commissioned has been provided to discuss with the board. We deliberately chose to do that at an earlier stage rather than wait for further deterioration in the health board's position. It was a proactive measure to understand the challenges they have, and then to understand what further support would be required. We've extended the time of the independent oversight panel for Tawel Fan to April 2018, to make sure their work is done properly and to ensure there are conclusions that people can rely upon. I have, this week, agreed further support for the health board with David Jenkins, an external experienced former chair of Aneurin Bevan health board, one of our more successful health boards in Wales, and he will now undertake an advisory role to support both the chair and the chief executive on the work to stabilise and recover that is required. And he will not just work with the chair and the chief executive, he will obviously report back to myself with his findings.

I will, of course, be reviewing the phase 3 report from the health board on progress, and taking on board the views of the regulators in early December. I recognise the calls that are made in this debate for a route-map out of special measures, and I would gently remind people of what we said at the time when this health board went into special measures. It went in based on the advice we received—the serious, concerning advice we received from the chief exec of NHS Wales, from the Wales Audit Office, and also from Healthcare Inspectorate Wales. So, putting this organisation into special measures was not an act of political convenience for Ministers. Coming out of special measures should not be a politically designed route-map. There will be the obvious suspicion that that would simply be a matter of convenience for myself or this Government. I will, of course, receive and act upon the objective advice that I receive about what to do and when is the right time to do it. I will, of course, review the progress against the current improvement plan and see what further is required.

My objective is to strengthen the work we're already taking to support a turnaround approach to ensure the health board makes the required improvements. There is no disguising the seriousness of the situation, or indeed, the seriousness with which I approach the task. I know very well that questions will and should be asked until there is sustained improvement in the areas where this health board has fallen behind. I'll continue to report back I'll continue to report back honestly and transparently on the progress that has been made and the progress required. I will of course update Members before Christmas following the review processes on any additional action to be taken.

Thank you very much. I call on Darren Millar to reply to the debate. 

Thank you, Deputy Presiding Officer. Can I thank the Minister for his response to the debate, which I thought did acknowledge in a greater way than has been the case before that there's still a serious need to improve things in the Betsi Cadwaladr university health board? You've heard the comments from Assembly Members from all parties this afternoon, which have spelt out in very clear terms the areas where this particular health board is failing. I think what is very concerning from our perspective is that these things have further deteriorated, many of them, since the board went into special measures. That ought to be a concern. I'm sure it is a concern of yours. You suggested that the Welsh Government was not in direct control of the board, but of course, in the immediate aftermath of special measures, you did appoint the deputy chief executive of the department for which you are now responsible to run the health board. So, to suggest that the Welsh Government was not running the health board frankly seems a little bit bizarre.

Of course, we shouldn't forget either that the journey into special measures was a difficult one. We had been calling for a long time for that board to go into special measures but it wasn't until the publication of the Tawel Fan report that the balance was finally tipped on the scales and that the Welsh Government decided to put that board into special measures. Yet, the publication of that report was some six months after it had been shared with the Welsh Government, and actually shared with that health board. The Tawel Fan report that was done by Donna Ockenden, which spelt out the horrendous treatment—the completely unacceptable treatment and the shortcomings in care on the Tawel Fan ward—was given to the health board in September 2014, and yet it still took until June 2015, which I have to say was shortly after a general election, before that report was published in the public domain and this Government decided to take some action. So, I do think there are some serious questions to ask about why the special measures that this board has been placed in have not worked to date and why you're now having to, how can I say, take more of a personal interest in turning that ship around that is Betsi Cadwaladr.

We've already heard they're in financial turmoil. When they went into special measures their deficit for 2014 was £26 million; it's going to be £36 million now—worse performance, in spite of the fact that financial performance was one of the issues it was put into special measured for. We've already heard that more people are waiting longer for their operations than ever before in the Betsi Cadwaladr university health board—some people in excess of two years from referral to treatment, particularly for their orthopaedic operations. It's completely unacceptable. It is the worst performing health board when it comes to access to emergency departments. This is a health board that is supposed to be under much more careful scrutiny than any of the other health boards in Wales. So, if that's what very careful scrutiny does to a health board, perhaps you'd have been better off not getting involved at all, because it clearly hasn't been working.

GP services: the crisis seems to be getting worse and worse and worse. Five GP practices this year so far—six if I'm to believe what Mark Isherwood has shared with the Chamber today—have so far decided to hand back their contract to the health board because they're not able to sustain and deliver that contract. It's got the highest number of GP practices that are regarded as hotspots by the British Medical Association, which suggests that things are getting even worse in the future. So, the problems seem to be accelerating on the GP and primary care services front as well.

Janet Finch-Saunders made references to the patient safety issues in the health board, which no doubt you will tell us is because they're more honestly reporting these things these days. But, to have more than half of all of the recorded deaths as a result of mistakes in that one health board—which does not account for half of the population of Wales—is irregular. It's not right. It shows that there's something more problematic taking place there. Quite rightly, we heard about some of the staffing pressures that that particular health board has faced. I'll be the first to praise the staff of that health board. They do a fine and fantastic job in the face of significant pressure on the front line, but there aren't enough of them. I visited two mental health units just last week and they were telling me that they're having to rely on agency staff all of the time. That means that you have people who do not know the patients from one day to the next, they're not regular people and, as a result of that, that causes pressure within those working teams.

So, what's been happening to date isn't working; we've got to see some significant change in that health board. The Tawel Fan families deserve to have that situation in the mental health services in particular turned around. They're not going to see any outcomes in terms of the follow-up work that has been commissioned until at least March of next year. I think all those things suggest that the Welsh Government has failed completely to date to deal with the challenges in this health board and that we need a significant change of track if we going to get this right.

Thank you. The proposal is to agree the motion without amendment. Does any Member object? [Objection.] Therefore, we defer voting under this item until voting time. 

Voting deferred until voting time.