The next statement comes from the Cabinet Secretary for Health and Social Services and an update on Betsi Cadwaladr University Local Health Board—Vaughan Gething. 

Diolch, Llywydd. In my statement on the 1 February this year, I confirmed that following the review by the Welsh Government, the Wales Audit Office and Healthcare Inspectorate Wales, under the escalation and intervention arrangements, that Betsi Cadwaladr university health board would remain in special measures.This week marks three years in special measures for Betsi Cadwaladr university health board. I want to update Members today on the progress made in some key areas during this period, the significant challenges that remain and the plans to work with the health board during the next phase of improvement.

Under the special measures arrangements, we have provided support to stabilise and recover the position in key areas of concern. This has included areas outlined for immediate action in 2015—on governance, leadership and oversight, mental health services, maternity services at Ysbyty Glan Clwyd, and reconnecting with the public and primary care, including out-of-hours services. More recently, steps have been required in finance and some performance areas.

This support has involved a higher level of scrutiny and oversight, appointing key advisers to work alongside the board on leadership and governance, mental health services, primary care and the NHS Wales delivery unit providing targeted support. During the first two years, an additional £10 million of funding was provided to support action in key areas, including mental health and maternity services. In the past 12 months, investment to reduce waiting times has included a £1.5 million commitment towards the unscheduled care programme, and over £10 million of additional support in planned care that has helped to result in a 45 per cent reduction in people waiting over 36 weeks, compared to the end of December 2017.  

Update reports from the health board and the Wales Audit Office and Healthcare Inspectorate Wales reviews did, during the first two years, evidence progress against the milestones and some evidence of recovery. The recent report from the Health and Social Care Advisory Service into the care and treatment provided on the Tawel Fan ward also reported on some recent progress, including key areas of work detailed in the dementia strategy and patient and carer support.

One of the substantive reasons that Betsi Cadwaladr was placed in special measures in 2015 related to major concerns in maternity services at Ysbyty Glan Clwyd. Due to the hard work of the staff and the support provided, this is a service area we have seen significant improvements in over the past three years. Following advice from the review, under the escalation and intervention arrangements, I announced earlier this year that it was de-escalated as a special measures issue.

Progress has also been made in other areas, including the management of complaints and concerns, with improved clinical oversight under the leadership of the executive director of nursing; in developing and delivering the mental health strategy in partnership with users and partners; improved performance in delivering Mental Health (Wales) Measure 2010 targets; restructuring the mental health team; and board governance processes.

The Deputy Presiding Officer (Ann Jones) took the Chair.

Since 2015 there has also been a continued investment in the estate and the services to ensure improved access and healthcare for the people of north Wales, with a number of these having been or due to be completed.

The major ongoing significant refurbishment work, involving over £160 million of capital investment on the Ysbyty Glan Clwyd site, is due to be fully completed in December this year, and the sub-regional neonatal intensive care centre, otherwise known as the SuRNICC, on the site is due to fully open this summer. Capital funding of almost £14 million has been provided to redesign, extend and improve the emergency and urgent care department in Ysbyty Gwynedd. Investments have also been made in two modular theatres at Wrexham Maelor Hospital and for environmental improvements to mental health wards as part of the drive to improve standards of care.

I recently announced £2.2 million of funding to convert a theatre at Ysbyty Glan Clwyd to a hybrid theatre capable of performing complex vascular surgery. That will bring benefits for patients, and is already increasing the attractiveness of the health board in terms of recruitment of consultants, with five vascular consultants successfully appointed and improvements in surgical training.  

It's not only in hospital settings that capital funding is making a difference, of course. Investments in primary care are supporting priorities to improve population health across north Wales, reduce health inequalities and provide care for people closer to home. Over £14 million has been provided to develop integrated health and social care centres in Flint, Blaenau Ffestiniog and Tywyn that provide a range of integrated, co-located, health, social care and third sector facilities.

However, despite the investment and progress in some key areas, significant challenges remain, as reported in the Deloitte review findings and, indeed, the HASCAS report. They both highlighted continued concerns on governance, clinical leadership and service redesign. In the last 12 months, the Welsh Government has escalated the level of intervention in finance and some areas of performance due to substantial concerns on referral to treatment waiting times, unscheduled care and financial planning and management. I am intensely concerned with the decline in performance in these areas, and generally exasperated with the pace of progress by the health board on the milestones set for the first part of this calendar year and the continued lack of clarity on its plans for the future.

I was always very clear that the transformation at Betsi Cadwaladr would require a significant culture change to working in partnership, both externally and internally. This will require ongoing focus on board-to-ward engagement and a move from an underlying resistance to consistency in clinical practice in a variety of service settings, with strong professional oversight and clinical leadership. To deliver improved outcomes for its population, the health board needs to work in a systematic way, in partnership as one organisation at a local and regional level, and to play a full part on a national level.   

During my regular visits and contact with the health board, I continue to be impressed by the commitment and hard work of staff to deliver quality patient care in a challenging environment and in the context of high-level negative reporting and attention. I take seriously the well-being of our NHS staff. Whilst sickness levels in Betsi Cadwaladr have been lower than the all-NHS Wales position for a number of years, and it is delivering a range of initiatives to support staff, we will continue to engage with the health board and trade unions on how we can better support our staff.

To ensure the health board delivers on its short and medium-term expectations swiftly, whilst also planning and undertaking transformational change, I published on 8 May this year the special measures improvement framework. This sets out milestones for the next 18 months in four key areas: leadership and governance; strategic and service planning; mental health; and primary care, including out-of-hours. I expect visible progress before the summer on the framework expectations, including a reduction in waiting times, responses to the recommendations set out in the HASCAS and Ockenden reports agreed and being actioned, recruitment to key positions completed, the additional capacity and capability required in place, and turnaround actions having a positive impact.  

To support the improvements and drive forward the work in the short and medium term, the Welsh Government will provide more intensive support, with a team to work alongside the health board, and additional resources to further improve waiting times. This will include additional system leadership, turnaround and operational capacity support. We will also be increasing the NHS delivery and finance delivery units interventions to include individual unit members providing focused support on plans, intelligence and best practice. Advisory support will also continue under the special measures arrangements. 

The intensive support will initially be directed towards supporting improved governance and accountability, focused joint working with clinicians and partners to deliver substantial improvements, especially in planned and unscheduled care, delivery on financial turnaround and working towards developing an integrated medium-term plan for 2019-2022. Adviser support will include continued guidance on leadership and governance from David Jenkins and Emrys Elias on assuring the development and delivery of the thematic quality improvement and governance plan for mental health services.

The next phase of the improvement journey will be led by a new chair from 1 September, following the appointment of Mark Polin, who will bring clear direction and leadership. He will lead a renewed board, with the recruitment of a new vice-chair and three independent members, and changes at the executive level, including a recently appointed new executive director of workforce and organisational development, and the imminent recruitment of a director of primary care and a director of strategy.

I will continue to hold regular accountability meetings with the chair and chief executive and I will attend the board meeting this Thursday to discuss progress. I will set out my clear expectations of the board to lead and deliver sustained positive change.

Can I thank you, Minister, for your statement? But I have to say that it will bring precious little comfort to people in north Wales, because in spite of your claims of improvement, even in some areas, I do regret that that improvement is not being discerned by many of the patients in north Wales, and I think the statistics speak for themselves.

This is a health board that was put into special measures three years ago, and yet, over that period of three years, it has deteriorated in terms of its performance in its emergency department against the four-hour target, it has deteriorated in terms of the 12-hour target, the referral-to-treatment times have gotten worse for the 26-week target, and they've got more patients waiting in excess of a year for treatment than there were three years ago when this health board was put into special measures. In fact, they're not only worse than they were three years ago, they are the worst in Wales against all of those measures.

One of the other indications of the difficulties that the health board faces is in terms of its financial management, and you made reference to its financial management just now. Its deficit has ballooned from £26.6 million, in the year immediately prior going into special measures, to £38.8 million, in the financial year that we have just closed. And you may say that we're making more money available to deal with some of these aspects of performance, but the reality is that you clawed back £3.13 million just a few months ago. So, you can't give on the one hand, take it back with the other and expect improvement the other end, because it's not working. Your intervention simply isn't working.

You've claimed some progress on mental health, and yet, just a few weeks ago, we saw a HASCAS report that said that they couldn't guarantee that any situation would be different for a patient going into the system now than it was when the Tawel Fan ward scandal broke all those years ago. In addition to that, you made reference to complaints management processes improving. Well, I can tell you from my postbag, and no doubt other north Wales Assembly Members will too, that they are not hitting the 28-day target at all in terms of the Putting Things Right measure that's in place. In fact, many patients are waiting for years for their complaints to be addressed.

You made reference to primary care being improved. This, of course, was one of the key areas for which this health board was put into special measures, and yet we have seen general practitioners handing back the keys to their practices and bailing out of the system because of the pressures in it. And it's worse in north Wales than it is anywhere else. Now, I welcome the extra investment that's gone into some of the capital infrastructure, but when are we going to see some doctors so that people can get appointments with those doctors in their GP surgeries? They're not able to get them at the moment. You made reference to investment in some of the hospital estate. Again, I welcome the investment in the hospital estate, but where's the promised brand-new hospital in Rhyl, for example, in the Royal Alexandra, that was promised back in 2011? We're here eight years later, nearly, and there's no sign of any progress on that site—there's not a single bit of work that has been undertaken in terms of improving that particular site. Can you give us an update on that, Minister, perhaps, today?

You made reference to the fact that we need to turn this situation around. They've only just appointed a turnaround director. We're three years into the situation. Their mental health strategy was only signed off last November. This is not the sort of progress that the people of north Wales deserve. We need to see more rapid improvement in the Betsi Cadwaladr health board.

I want to pay tribute to the staff that are working hard, grafting on the front line, trying desperately to deliver the services that they want to deliver, but I'm afraid that there has been an absolute failure by the Welsh Government to sort the problems in this health board out over a three-year period, now. You've set out an 18-month period ahead in which to turn things around. This is probably going to be the longest example of any NHS organisation ever in the UK being in special measures for such a long period of time. I think that's a shameful thing for you and for the Welsh Government that you haven't managed to turn these situations around.

So, when are we going to see the improvements? When can we expect your targets, which you set as a Government, to be hit in terms of referral-to-treatment times, in terms of emergency department times? When can we see Betsi moving from being the worst in Wales to at least being one of the average ones in Wales in terms of performance against those things? And when are we going to see the fundamental improvements in mental health care that people expected a rapid result on in the wake of the Tawel Fan scandal? 

One final question: you made reference in here to the need for them to accept the recommendations in the Ockenden report—I assume that that's the new Ockenden report, which is yet, of course, to be published. I assume, therefore, you've had sight of that report and the recommendations that it makes. When can we have sight of that report? When are we going to be able to see that? When are the public going to be able to see that, so that they can have some confidence in this system that is yet to deliver the improvements that they need to see?

I thank the Member for his comments with some questions provided, as well. I'll start with your final point about Ockenden 2, and no, I have not had sight of it; I'm making clear that I expect the health board to take seriously the report on reviewing and improving its governance and to deliver a real-time plan for improvement. I think it's entirely appropriate, because we expect that report to be provided this summer, for the health board to receive it and promptly deal with it, and for there to be a public board meeting at which they will set out their action plan in response to that.

The starting point, though, is that there is no cause for celebration that we approach the third anniversary of Betsi Cadwaladr university health board being in special measures. There is no hiding from the fact that it is not a cause for celebration that we are having this conversation at this point in time. I don't try to hide from the disappointment and from the way that staff will feel. It's not the situation that any staff want to be in, to continue going to work in an organisation that is labelled as being in special measures. That does not mean that every area of healthcare fails—far from it. There is real excellence—not just commitment from staff, but real excellence in the delivery of a wide range of healthcare services. The balance, though, is that we recognise there are still services within Betsi Cadwaladr that do need to improve significantly.

On primary care, one of the reasons why it went into special measures was in particular about out of hours, and I'm hopeful that we will see an improvement in primary care out-of-hours services during this next period of the improvement framework, and for that to be lifted out of special measures. The broader points you mentioned about those GP practices that have returned their contracts are part of a broader move across, not just Wales, but across the rest of the UK, and I don't think it's fair to label that change and the difficulty in managing that move as being part of the special measures arrangements. North Wales, just like other parts of Wales, have that challenge to manage, and that goes into other work that we have discussed in the Chamber, and I'm sure we will again—not just a new way to deliver local healthcare with the right numbers of doctors and other clinical members of staff, but how to organise those services to make it more attractive. For example, just before recess, we spoke about the challenges of indemnity and being able to move forward on that would make a really big difference right across the country, but, in particular, in north Wales too. About having the workforce being retained in different roles, whether they're staying in the profession or entering the profession, that would certainly help in out-of-hours arrangements too.

On the challenges you raise about financial management, and the challenges that the health board have with financial management, are not a special measures issue, but they're part of an increase in escalation and intervention. It is a point of real disappointment that they have not been able to deliver improvements in financial management, but I simply don't accept the point you attempt to make about the clawback on money for planned care improvements. We have done exactly as we have done with every other health board, in providing additional money from the £50 million improvement fund we have provided to NHS Wales; on having agreements about improvement to be delivered; and needing to reach those targets or not all of the money would be retained within that organisation. And it's exactly as we have done in other organisations this year and last year. They retained £10 million because they did reach a 45 per cent improvement in the 36-week waiters from the high point of December 2017. But we can't simply say, 'Have this money to improve and it matters not whether you reach that improvement or not, and we will treat you in an entirely different way in that regard to other health boards across Wales.'

In terms of the improvement I expect to see happen, as well as setting out an 18-month framework, I have been very clear that I expect to see continued improvement in unscheduled care, with the additional— . Not just resource in financial terms, but the support being provided by PricewaterhouseCoopers. And indeed, in my most recent visit to north Wales, I met with staff in Ysbyty Glan Clwyd who were talking about the way in which that was helping them to look again at what they were doing, and actually there were improvements in the way they felt they were working as a team. Meeting front-line nurses, alongside their consultant colleagues, was a very constructive and positive conversation, alongside the recognition they themselves want to deliver better care, and that would improve the working environment for them. So, they themselves recognise some improvement is taking place. They also recognise there is more to go, and part of our challenge is how challenging we are in holding them to account, as well as being supportive of the job that front-line staff do. But I certainly expect to see improvements in quarter 1 and quarter 2 of this financial year. I do not expect the health board to recede backwards, having reached an improvement at the end of the last financial and performance year to March 2018, to fall significantly backwards at the end of the first quarter. That would not be an acceptable position for the health board to be in. Part of the challenge is that they do have real problems in the significant rise in long waiters that took place over the last financial year. That was part of the reason why not only escalation arrangements changed, but there is now a heightened level of direct accountability with the chair and chief exec. That will continue until there is real and sustained improvement, and I make no apology for that.

I also want to reiterate and deal with your point on complaints management. I expect Assembly Members do get a postbag that talks about where complaints have not been well handled. That will always be the case. As an individual constituency Member, I get those complaints too, in my area. But actually, objectively, we definitely have seen an improvement in complaint management. That does not mean that everything is perfect, but it is absolutely in a better position than it was previously, and the executive director of nursing deserves real credit for her leadership in delivering some of that improvement, together with the team.

So, I expect improvements to take place over the 18-month framework that we've announced. I expect there to be more to say once the new chair is in place and we've recruited additional people, but also that the turnaround function, which I am—. I recognise the Member's frustration. I can assure you that I am frustrated myself that it's taken so long, having agreed to have a turnaround director, for that person to be in place with a team. That is also why, in my statement, I have outlined the additional steps that we will take to ensure that that turnaround function is actually in place, with greater operational grip within the organisation. 

So, there are no places to hide and no attempt to hide from the position that the health board is currently in. I recognise the progress and real progress that has been made, and also I recognise the further progress that is absolutely required because the staff of the health board and the people of north Wales deserve nothing less.

Surely the time comes, after three years of special measures, when special ceases to be special and you move into a state of permanent underperformance. So, I think the key questions at this point in time are: what are the signs that patients should look for? What are the signs that staff should look for to show that Betsi Cadwaladr health board is getting back on track? Because, the evidence seems very thin currently.

Deputy Presiding Officer, I was told off earlier for speaking for too long, so I’ll keep my comments very brief. There have been three years now since special measures were put in place and your statement is quite honest, truth be told, that very little progress has been made over those past three years. You use the words yourself: 'some evidence of recovery', 'some recent progress'. I think that we should be able to expect a little bit more than that after three years.

You describe that support from the Government has included greater scrutiny and oversight, of appointing specialist consultants, but the first question is: is this tantamount to you taking responsibility for what is happening at Betsi Cadwaladr health board after three years of special measures being put in place? What I see are patients waiting longer. The figures confirm that—patients waiting much more than a year for treatments that they genuinely need in order to improve their quality of life; people who are waiting far too long for mental health care; young people waiting far too long for mental health care. The evidence is all there, which proves how much further we have to go.

I'll ask three questions. Do you, as Cabinet Secretary, believe that the current structure to deliver health and social care across the north, with one health board, seven local authorities and external providers as well, is fit for purpose, if you like? If it's not now, is that kind of structure likely to develop to be fit for purpose in the near future? Do you believe, as a second question, that significant improvements to the referral-to-treatment times and waiting times for emergency departments are possible without improvements in social care services, including beds one step down in the community? Third, your statement refers to new health and social care centres, but can these centres and services genuinely deliver what they could, in principle, whilst there is that temptation for the board to continue to throw money at hospitals, at the secondary level of healthcare, in order to tackle waiting times? That is, that funds are sucked somehow into some kind of bottomless pit. If we can't deal with that, how can we strengthen primary care? Because I think that it's only through strengthening primary healthcare that a health board that serves a predominantly rural area can improve its performance significantly.

Thank you for the questions and the comments. I'm happy to state at the outset that I certainly don't see special measures as a permanent status or indeed something that could or should be normalised. It is absolutely different, not just to the rest of the healthcare system, but there is also the fact that there have been real improvements in some areas of activities that I've highlighted in my statement.

Mental health hasn't made quite the progress that we wanted it to. That actually highlighted some of the fragility in the structure of the service, in not just delivering a new strategy but, actually, a part of the hold-up in the improvement journey was due to the absence of a key member of staff. There was something then about the resilience of the whole service. We're now seeing further progress again being made in the wider mental health service. But, actually, maternity services, which were one of the big triggers for the board going into special measures, have come out of special measures. They've been de-escalated and that, in itself, is a positive, and not just for that service, but for other parts of the health board, to recognise that it absolutely is possible to de-escalate out of special measures—a very real and significant and sustained improvement to be made and recognised through the escalation and intervention measures and frameworks.

That should provide the assurance that members of the public and members of staff will want because this is not a process where politicians are making a decision for their own benefit, or for my benefit, to take the health board out of special measures. It's why we have a tripartite process involving Healthcare Inspectorate Wales and the Wales Audit Office. We'll continue to have that structure to make clear to the public and to the staff that there won't be the choices made simply to deal with the convenience of a politician within this Chamber.

When we talk about a description of consultants to assist and work around the board, actually, in the part of my statement where I talked about additional system leadership and support, we are talking about having extra pairs of hands around the board to help them do things that, currently, we don't think they're able to do, and not just to get them in through a short-term fix, but actually to have a more sustained position in recruiting not just figures to go to the health board, but the organisational culture in planning and delivery that we recognise is plainly required.

I'll deal with your three points in the questioning. I think the second two go into each other in some respects, but a straight answer to your first question about whether the structure is fit for purpose: I do not think that the challenges that the north Wales health board face are because it is a single health board across north Wales. Actually, when we had a previous consultation on this there was a very clear message from staff that they did not actually want to see the health board broken up into two or three constituent parts. So, I don't think that is a reason why the health board should not be able to perform to high standards. If you look at other health boards within the country, there is a significant geographic spread in Powys and in Hywel Dda, and the geographic spreads themselves are not the reasons why the health boards do or don't succeed, just as having a significant number of partners is not a reason why other health boards don't succeed, because in Gwent, where they have five local authority partners, they're actually one of the better performing health boards in the country. So, it isn't the size or the number of partners. But there is something about the culture and the operational ability and planning function within the health board to deliver improvement.

I'm pleased, in terms of your point about emergency department improvement, that you saw that as a system-wide challenge, because it absolutely is, both in primary care, about how people are supported to stay within their own homes—that's part of the reason we've invested in health and social care centres across the health board area, and that's a strategic choice we've made not just in north Wales but across the country—but also the link between what takes place in a hospital and with our colleagues in social care. Now, I'll have more to say on health and social care integration over the next week or so in taking forward a response to the parliamentary review. But we will need to see an improved way of working between social care partners and the health board, and that is absolutely true. That's something about how they plan and deliver services, as well as agreeing on what those services should be, and having a joint way to understand the health and care needs of their population, and then being able to meet them. I'm positive that we'll be able to support not just north Wales but other health boards and their local authority partners to do so, but I don't want to pre-announce matters that we'll go into at some length next week on more about the way in which we expect health and social care to work more closely together. But we already see a range of teams that exist across the country, including north Wales, where there is already recognition that they must work together to deliver improvements for services for citizens, regardless of whether that person has a need that is a social care need or a healthcare need, and it's not simply about getting people out of hospital quickly.

Your final point about health and social care centres, whether they might be able to deliver improvement without the further conversation with the health board about assigning priorities and sinking money into the hospital system—that's part of the challenge in running an integrated unplanned system. I do not expect health boards to simply be hospital provider trusts with a bit of something else tacked on to them. They are genuine, population health board—. They are genuine population health level organisations. That is a requirement that we have of them, and they must look more clearly at prioritising more and more of their primary healthcare—not just early intervention, but prevention work as well. We'll see more of that as we not just make budget choices, but in the conversation we'll have next week and through the rest of this term. There are clear examples of local authorities already being more engaged in and around those centres, not just in Tywyn and not just in Flint, where I did the formal opening of the health centre, and I was pleased to have the Member, the local Member for Delyn, there as well, and to actually meet members from the local authority who are already running services from that centre. And, indeed, when I visited Ysbyty Alltwen, again, seeing members of the local authority there from Gwynedd, they were talking about what they were already doing with healthcare staff there to take account of the health and social care needs. So, we are already seeing some of that partnership work on a local level, and our challenge now is to scale that up and to have a more considered and joined-up approach across the whole of the north Wales region, which every local authority recognises is good for them and their citizens, just as the health board do as well. But I recognise the challenge that the Member provides.

Thank you for your statement, Cabinet Secretary, and for the progress update that you've just given to us. There doesn't seem to have been a great deal of progress. I see that the waiting list for planned care has reduced by 45 per cent in a relatively short space of time, and that's a really good headline figure. But let's put it into context, shall we? The reduction that the Cabinet Secretary is referring to is from just under 10,500 people waiting to just over 5,500. Of course, that's a big improvement, and I do commend the hard-working staff who have delivered that achievement, but it still means that nearly 6,000 people are waiting for more than nine months for planned care, and that's a terrible statistic, particularly when you put it against the other statistics that are coming out of Betsi Cadwaladr, such as that the orthopaedic waiting list has increased by 16 per cent over the last year, against a backdrop of a 5,000 per cent historic increase in that waiting list. And we can't forget, and we shouldn't forget, the 1,000 plus children and young people who are currently waiting between 12 and 18 months for a neurodevelopmental assessment, which is going to impact on their educational attainment.

So, you know, while the—. The Cabinet Secretary says there have been improvements in various things, including the management of complaints, clinical oversight, and developing and delivering the mental health strategy, so I would ask the Cabinet Secretary to quantify those improvements for the Members here today and for people in north Wales. It's all very well saying in your statement that there have been improvements, but can we have some figures? And can we have actually some detail on that, please?

The Cabinet Secretary has detailed the large sums of money spent on Ysbyty Glan Clwyd in particular, on the buildings and facilities there, but I remember that when Ysbyty Glan Clwyd was originally built it was considered by locals to be too large for the area. We were all a little bit suspicious of how big it actually was. But it's now clear that Betsi Cadwaladr, who are the people who have been responsible for that hospital over the years, haven't extended the facilities there to cater for an increased population. So, does the Cabinet Secretary agree with me that the vast amounts of money that he's having to spend on Ysbyty Glan Clwyd now are the result of successive Governments sticking their heads in the sand and failing to ensure that the facilities there kept pace with the likely population? What analysis has the Cabinet Secretary done to ensure that the money spent so far on Betsi is bringing real benefits rather than just assuming that there's a causal link between improvements and spend?

The Cabinet Secretary points out that a significant cultural change is required. I take your point there, but can you actually tell us what sort of cultural change is required, and what's currently wrong with the culture at Betsi Cadwaladr at the moment? And what measures are you putting in place to achieve that cultural change?

I totally agree with the Cabinet Secretary that the commitment and dedication shown by front-line staff at Betsi Cadwaladr is truly, truly impressive. These front-line staff go into this work to make a difference and to deliver, as you say, quality and compassionate care. But it must be truly, truly soul destroying to have institutional challenges thwart their efforts to do that, and it goes some way to explaining the levels of stress-related absence reported at Betsi Cadwaladr. So, given the number of staff going off sick with stress, what support can you tell us about, Cabinet Secretary, that there is in place, provided by Betsi Cadwaladr, to support front-line staff who are suffering from workplace stress?

I'd also be interested to hear what expectations you're going to place on the Betsi Cadwaladr board members, and, in particular, how are you actually going to incentivise that board to deliver on those improvements? Are they going to be at risk of possibly being removed from the board if the board doesn't perform properly? Are heads ever going to roll at Betsi Cadwaladr?

And then, turning finally to the anniversary of Betsi Cadwaladr going into special measures, you've had control of that health board now for three years. What lessons have you actually learned? Thank you.

Thank you for the series of questions. And, just in terms of the challenges about planned care, I've never stated that the challenges of planned care have been resolved. Far from it. I've said exactly the opposite. The improvement that has taken place has only been part of the improvement required, which is why money was clawed back, which I'm absolutely clear is the right thing to have done, and to be clear that I expect to see further improvements through quarter 1 and quarter 2. So, there isn't any attempt to soft soap the remainder of the challenge that still exists, not just in the shorter term challenge of reducing waiting times, but also in the challenge of the medium term and actually having a more sustainable way of seeing and treating the healthcare need that exists within north Wales as well. So, this isn't a single shot about spending a lot of money to resolve the waiting list and everything will be fine; there is a larger challenge to deal with as well, which is why we are taking time to look at the revised, again, orthopaedic plan and the ophthalmology plan provided by the health board.

On your points made about supporting staff, just a few examples that you asked for on the services that are available: there is a range of counselling services, including the Lighten Up programme, mindfulness, stress control, resilience training and Schwartz Rounds. We also have a range of services being provided with Welsh ambulance services as well. So, there is a range of deliberate and specific programmes, and, again, that's why I say we work properly with trade union colleagues as well as the health board itself as the employer.

In terms of your points about complaints, I can tell you, for example, in terms of improvements, that 94 per cent of complaints have been acknowledged within two working days. That is a significant improvement on where we were some time ago as well. That is a real improvement that makes a difference to people making complaints. The challenge always is that, if you're the person who hasn't had your complaint acknowledged in good time, if you wait for longer than you should do, then actually that is the person most likely to come and see us as elected representatives. That's part of what we see. So, there is honesty about the improvement that has taken place in complaints handling.

In terms of an example of the cultural change required, you only need to look again at the Health and Social Care Advisory Service report itself, which noted some of the challenges in the cultural change between clinicians about their buy-in to a service. Now, there's a challenge there that doesn't just exist in one service, and you'll see this right across the national health service in every single part of the country. It's often difficult to persuade people who are used to working in one way to change and work in a different way, and yet we also know that some of the biggest and best advocates of change in delivering a service are actual front-line members of staff themselves, who recognise they could and should deliver a better quality of care.

In terms of your broader challenge about whether money has been wasted at Ysbyty Glan Clwyd, I'd say I don't think the money has been wasted. We will of course learn lessons from every large capital project that we undertake in looking at whether that amount of money and the way it was a capital project could have been better managed. I certainly expect there will be lessons to learn about the more effective management of the capital spend there, but I don't accept your broader point, your concern, that Ysbyty Glan Clwyd was too big when it was built. The challenge is how we continue to change the way our hospital estate works, the services run from it, and that that actually does keep pace with the changing way in which healthcare will need to change, and the twin moves that we've discussed many times before in this Chamber of some services coming into a specialist centre, and vascular surgery being an example of where some of the specialist services are coming into Ysbyty Glan Clwyd, for example, but regular vascular surgery is not being taken out of the other two centres within north Wales. But the money we've invested in the hybrid theatre has also helped with recruitment of people to go into that service as well. So, there is always more to learn about what has happened in the here and now, and always more for us to do. That is part of the joy and the challenge of doing this job and being involved in and around the national health service.

Thank you. We have two more speakers and five minutes, so can I appeal for the speakers to ask just their questions, and can I ask the Cabinet Secretary just to answer the questions that he may be posed with? Mark Isherwood.

Okay. Why do you believe that those waiting for more than four hours in A&E has shown a deterioration of 3 per cent over the last two years to what remains, sadly, the worst performing of all local health boards? You referred to management of complaints and concerns. How do you respond to concern not only evidentially from my casework, but from constituents, that we've seen a reversion to risk aversion and legalistic responses when, at the beginning of special measures, there was a positive move towards building bridges with constituents, with patients and ourselves, with round-table meetings to see if we could agree ways forward or resolutions to problems? You refer to the integrated health and social care centres at Flint, Blaenau Ffestiniog and Tywyn Memorial Hospital, and of course in most cases these replaced community hospitals with beds. When will your Government accept that the consequence of stripping out those community beds has put extra pressure on hospitals, our district general hospitals, on our GP practices, and has actually led not to enhanced care in the community, but to enhanced suffering in the community for too many when they can't get the support they previously called for?

You refer to the Tawel Fan HASCAS report, which Darren of course referred to earlier. In accepting that report, why have you apparently dismissed the concerns expressed by North Wales Community Health Council that most of the families they've spoken to over recent months and years have still not received clear answers to their questions and concerns? Why have you accepted the conclusion that care was good and that institutional abuse didn't happen when that's directly contradicted by Donna Ockenden's 2015 report, the Healthcare Inspectorate Wales report in July 2013, internal work on dementia care mapping in October 2013 and many other evidenced reports that previously had been accepted? We know, because—

Are you winding up, please? I did ask for a couple of questions and you're not being fair to the other speakers.

Okay, well I'll conclude by asking what action you propose to take to ensure that the health board works better with third sector providers, who are delivering a wide range of services, but despite engagement, some of which I facilitated with some of those bodies, years later we're still waiting for new arrangements to go into place to ensure that proper commissioned services, which don't replicate or duplicate but enhance the experience for patients, are finally put in place.

On the final point, it's difficult to answer that without some particular examples. So, if you want to come to me with particular examples of where the third sector have been engaged or not engaged, that would be helpful, rather than more general involvement and engagement with the third sector in a wide variety of services, which I can't properly respond to.

On the point about the four-hour deterioration, we have seen a deterioration, and it's due to a range of factors that affect the health service around the UK. It's partly about an increase in demand, it's partly about the ability to have a more joined-up approach with primary care and social care. It's also partly about changing some of the leadership and the challenges within those departments. That's part of the improvement work that we've been doing.

Again, going back to the visit that I had in Ysbyty Glan Clwyd, they recognised that the work that was being done there—they could recognise that it was improving the position for them as staff and the care that they were able to provide. But if we're not able to have something to keep more people in their own homes successfully and get them out of hospital appropriately as well, then we'll continue to see a deterioration that is most recognised at the front door of our hospitals. So, actually, being able to deliver more effectively on resolving delayed transfers of care and moving people out of the hospital sector is a big challenge in the front-door problems that we see in every part of our system where we recognise it, including, and in particular, in north Wales. And again, I've never tried to hide from the fact that the challenges in the four-hour figure are there and are real for staff and patients as well.

I simply reject your assertion that we've seen enhanced suffering from the way in which we're trying to support a shift in local healthcare arrangements. The investment we're making in joint health and social care centres is delivering better care closer to home, and actually, we need to carry on with that journey—it's been validated by the advice and the challenge that we've had in the parliamentary review. We're not going to take a step back to the older provision that we have had, but we do need to think about how we invest in different capacity within our system. Some of that will be in social care, some of that will be in the residential sector, or in step-up and step-down facilities. And that's also why health and local government need to work more effectively together to commission and agree on the funding and provision of those services.

In terms of your point about Tawel Fan families and the report and the difference in the conclusion of the Ockenden and HASCAS reports, we've run through this on a previous occasion when I actually made a statement and answered questions on the HASCAS report. And again I've been clear that there was further information available in much greater clarity, volume and certainty to the HASCAS organisation, and it is understandable to see why, with different information being provided to them that was not available to Donna Ockenden, to be fair to her, when she undertook her first report, different conclusions have been reached. Individual families are still being worked through to have their individual reports provided to them and an explanation from HASCAS about the individual-level challenges they've seen. That is a process that will need to continue and is being worked through with the help of HASCAS and the families in question. 

And finally, with a brief question, Janet Finch-Saunders.

Thank you. I'm just going to narrow it down now to orthopaedics, because I think it's fair to say that on record in this Chamber I've raised time and time again with you my concerns about how long people are having to wait purely for orthopaedic treatments. Only today, whilst I have been sat in this Chamber, I have received a letter from a constituent's daughter about her 85-year-old mother who has already been waiting 74 weeks for a knee replacement. Yes, get that now—an 85-year-old lady. She's been waiting 74 weeks for a knee replacement and has been told she can expect to wait some 106 weeks before she's even considered able to have that operation. This is a scandal. Now, I notice, Cabinet Secretary, that the future milestone requirement for April to September next year to provide evidence of continual, sustainable improvement on referral to treatment, with no patient waiting longer than 36 weeks for treatment, expressly excludes orthopaedics from this target. Why, when the majority of my health cases that come to me are where people can't walk, where they can't sleep, where they can't eat, where they're in terrible, terrible pain, where they're elderly, where they're young, where they're middle aged? Their quality of life is being abused, really, by your Government. So, will you tell me why, just why, have you excluded that from your targets? It's a shame.

I really do reject the assertion that this Government is abusing people who are waiting for orthopaedic surgery. I think there is an entirely proper scrutiny process to undertake with questions to be asked about the challenges that do exist for your constituents and others, but I do not think that that sort of offensive statement helps anyone, and I don't think it helps a reasonable case that should be made about the improvement that is still required. 

The reason why orthopaedics were not included within the 36-week target for improvement is that we know that they will simply not be able to achieve it within the timescale offered. We know that the extent of waits that are there to be resolved won't be achieved in that fashion, and I do not want to have an improvement target that is plainly unachievable. That does not mean that the health board should not improve. That does not mean that there is a lack of focus on the issue or a lack of awareness, and it is absolutely a matter that I've raised directly with the chair and the chief executive. It is absolutely something that I expect to see progress on, and it's part of my exasperation that I've expressed previously that, despite the clear and obvious challenges that have been raised, the health board do not have a signed-off orthopaedic plan, not just to deal with the shorter term challenges of getting on top of their waiting list, but also to have that more sustainable solution for the future. 

And for all the entirely reasonable explanations about why they didn't do more over the last few months, the challenge is that actually the waiting list went out when it should not have done over the last year. That's where I expect to see further progress made and I know that I will face questions from Members in this Chamber and in committee until the length of waits that people are able to accurately recount are resolved and there are fewer and fewer people, until we do reach again a position where we don't have people waiting over 36 weeks and we certainly don't have people waiting more than 52 weeks for their treatment.

Thank you very much, Cabinet Secretary.