Questions now from party spokespeople. The Conservative spokesperson, Angela Burns.

Diolch, Llywydd. Cabinet Secretary, following the July publication of the Welsh Government response to the parliamentary review, I note you indicated that the regional partnership boards are to be responsible for directing change and that you intend to issue guidance. Could you please tell us when will this guidance be forthcoming on the transformational change, and, considering that the progress of the regional boards has been highly inconsistent to date, how can you be confident that progress and transformation will be equitable across all the health boards?

I welcome Angela Burns back following the reshuffle. I look forward to many continuing jousts of varying natures and temperatures.

The guidance you refer to has already been issued. We've already issued guidance about the use of the criteria for the transformation fund. And, more than that, in terms of the second part of your question—the confidence that we'll see real progress—I've made the time, together with the Minister, to make sure that we have met every single one of the regional partnership boards, we've met the health and local government leadership together, to be clear about what we expected in the development of 'A Healthier Wales', and then afterwards to be clear that we expect it now to be delivered. And, in meeting those people, what's been very interesting is that they all have ideas about the joint use of resources, where health and local government are genuine partners rather than one party being the decision maker and somebody else being a mere consultee—but, more than that, the range of projects and bids that we have already. I am hopeful that, within the coming weeks, not months, I'll be able to announce the first areas that will receive additional support from the transformation fund. And I think it will make real some of the discussions we're having now. I'm also confident that those parts of Wales that are not in the first group to have their transformation projects approved will see that as a helpful kick start to make sure they are not left in the slow lane. There is real ambition, I am pleased to say, to make sure that every part of Wales takes part in genuinely transforming services.

So, given what you've just said about the role that you see the regional boards performing, can you explain then how that ties in to the national transformation board? Will they be the ones who are responsible, ultimately, for the transformation of the national health service? And, as I'm sure you are aware, business process re-engineering is a highly defined skill and it takes a lot of experience to do it successfully, especially in an organisation as large as the NHS—and please accept that, when I refer to the NHS, I refer to NHS and social care, because the two are integral to each other. So, I'd like to understand what additional resources you might be putting in place to support both the national board and the regional partnership boards in terms of people with absolute transformational business process re-engineering skills. And when will you be measuring—or how will you put in place a series of key performance indicators so that we know how well they are doing and what timescales they are doing it to?

Thank you for that. I can confirm that the national board has already met, and its role is to have oversight for the progress in delivering 'A Healthier Wales', rather than, effectively, providing a second decision-making course for individual regional partnership boards agreeing on bids they want to make for transformation. That will still be my officials looking at those bids and then giving me advice about whether I should or should not agree to fund the bids that are made. The reason for that is that we've issued guidance already, with the clarity about the criteria for regional partnership boards to meet in actually providing those transformative projects. And the ones that we've highlighted are that they have to be genuinely transformative—so not simply rebadging a current, existing service—and also have the potential to deliver at scale, because I'm looking for a genuine transformation across the system and not for a series of micro projects that are about more local circumstances and ultra-local leadership. I'm looking for genuine scale and scalability in what we have.

I'm looking to measure our success by the process of accountability. We have a fund that is looking at whether we have genuinely transformed where we are, whether we're meeting the headlines and meeting the targets, the 40 different targets, we have in 'A Healthier Wales' over the initial three-year period. And I know that we will be judged on that. There will be scrutiny here, there will be regular opportunities to ask me questions. But part of the challenge is that, for each of those bids to transform the service, I have to be prepared that, even on the best advice and the best service design, with people available within the health and social care field working together, it's possible that they won't all succeed or they won't all succeed in meeting all of the goals and objectives that are set against each bid to come in. It's important that I accept that at the outset, because otherwise we won't see real innovation and we won't see a real transformative approach to re-engineering our services to meet the challenges of the future.

So, for each bid, you'll see what it encompasses, you'll see the basis on which I've made my decision and you'll see something about a timescale to understand whether it's been successful or not. 

Actually, I'm really glad to hear you say that you're not going to expect every single bid to be successful, because the key to being able to achieve this recalibration of the NHS is that we've got to be prepared to accept failure, and there will be some failures along the way in all of these projects. But you are talking about the projects—you're talking about the transformation fund and the moneys coming out of it, but, of course, the parliamentary review was about so much more than that, because it actually talked about a cultural transformation within the NHS, about this shift towards a much more staff-focused empowering, enabling person-centred care to really work in its ultimate sense. So, whilst all those projects are going on and you're using the transformation money to fund the 40 or so specific projects, how else is this message being transported throughout the NHS? How else are you getting the buy-in from the rank-and-file staff who've got to be able to cleave to that national vision of: this is where we want our NHS to be in 10 years' time; this is how we want it to focus? The old specialist centres, the silo mentality—it's all got to go. We've got to look at it in a different way, and that affects everyone from the porter all the way through to the most specialised consultant that we currently employ and, of course, through all the management strata.

So, whilst the transformation fund is welcome—and the projects—it can't work in isolation, because you're only going to be fixing little bits of the problem as we go along. You've got to be able to take that entire structure all the way through and that's what I don't see and I don't quite get a feel of: where the people are coming from to enable that, because that's not always a cost element. It's all about cultural change and about re-working how people are doing specific jobs today, and it's not something that necessarily has to go into a project to go and get some money from the Welsh Government to make happen. 

I shall remind you of your recognition that we have to accept some projects won't succeed, if that happens. But, look, the cultural change point you make is one that I accept completely. But the transformation fund particularly will help to kick-start new models of care. That will be part of generating cultural change, but it won't do it in itself. If I said the transformation fund was the thing that would generate the cultural change we want to see then I'd be setting that fund up to fail from the outset, because actually it's about much more. If you go back to not just the review but to 'A Healthier Wales' itself, and then accepting the four main pillars of it, a large part of that is about the engagement of the staff in helping to re-engineer and redesign the service. That isn't just a discrete group of managers, leaders and planners. It is about a wider group of staff buying into how they are the most effective agents for change for the service. It's a message that I've regularly given in going out and meeting with staff and listening to them, saying that, actually, they're in a really privileged position, because they're trusted by the public in a way that no politician in this place will be, and they have the opportunity to change the system from their own experience and their own view on where there is waste and inefficiency and opportunity for improvement. Getting right the cultural change is something that they'll understand when we have it, but it's rather more difficult to measure. If we can't, though, generate that cultural change, we won't deliver the sort of shift that I think everyone, regardless of their party in this place, wants to see across our health and social care system.

Plaid Cymru spokesperson, Rhun ap Iorwerth.

Thank you. Your Government has run the Betsi Cadwaladr health board for over three years now and we haven’t seen sufficient improvements as of yet, I’m afraid. So, what are the main reasons why you have failed in that regard?

Since the introduction of special measures, we have announced a range of improvement frameworks, a range of actions and support that we have taken. Of course, I'll be dealing with more of this in question 3, but you will have noticed over the summer, for example, the additional £6.8 million of investment we've made within the health board.

The reasons why the health board performance has not improved to a level that we would say is acceptable on all counts are varied. There are challenges about central leadership within the health board and there are challenges about shifting some local culture within the health board as well. We have seen some improvements, for example, in maternity services, which have been removed from special measures. We've seen improvement in some out-of-hours services. But I think I've covered the reasons for and my frustration with the inability to make as rapid a progress on a number of occasions—I'm sure I'll have an opportunity to do so again—including in the last statement I made in this place before summer recess.

Of course, you do report back to the Assembly often that you feel that improvements are being made in several areas, but it’s clear to me that there is a block in the system. I don’t know if it’s a funding block, or a block in terms of management, or if there is a more major problem that needs to be addressed. We are talking about the need to deliver services more and more in the community through GP surgeries and pharmacies and so on, but I fear that we are moving in the other direction in terms of the use of resources, with hospitals, which are under huge pressures, of course, taking more and more of a share of the cake.

I know that changing structures is not child’s play, but I do think that the time has now come to scrap the Betsi Cadwaladr health board. I would propose that what is needed is to split it, not geographically, but in terms of strata—as hospitals and primary care. The budgets for primary care would be safeguarded and the primary care board could create a new model of real integration with social care, whilst the hospitals could focus on their own challenges. Does the Government, like me, have the desire to seek new solutions?

I of course want Betsi Cadwaladr to succeed. I want it to deliver the sort of quality of healthcare that each of us, in every single community, would expect. Your proposal to break up the health board is not one that is supported by the overwhelming majority of staff within the health board—we've been through this in responses from them. And I don't believe that the structural re-engineering that you suggest would deliver a better service. Splitting hospitals and primary care is something that we've tried before in Wales, and it didn't deliver the sort of improvement that we wanted. Splitting hospital trusts away from primary care has not delivered the sort of improvement that everyone would want in England across the whole system either. So, I would caution the Member before he suggests that that sort of re-engineering in north Wales will provide the eventual outcomes that, I think, all of us do wish to see.

The result of your caution, you see, is that Betsi Cadwaladr has been in special measures now for over three years. I'm clear in my mind that patients in the north of Wales deserve better. And here we have a model that I believe could work for the whole of Wales after being rolled out in the health board with the biggest population and serving the biggest area. People living in the north of Wales can see the problem. And staff, who tell me that they like this idea of doing something different to try to get to grips with the problem in the way that this Government have failed to do so far, are frustrated and they're under pressure. By putting a model in place that protects primary care budgets and keeps people out of secondary care, which allows secondary care to concentrate on its many challenges and provides a new focus on integration—. Well, I think by doing that we might just start heading in the right direction. Isn't it time to say that, with special measures not working, it's time for radical measures instead?

I tried to be polite to the Member in my second answer, to give him an opportunity to reconsider the track he was going down. I have to say that the orders are not just to re-engineer health in north Wales, but your plan—I assume on behalf of your party—to take a wrecking ball to the way we organise and run the national health service in Wales in every single part of the country is not something that I would support at all. The last thing that our health service needs is a major structural reorganisation such as the one that you have just proposed. It would be an additional distraction to delivering healthcare in the most challenging of circumstances, with additional financial pressure, the challenges of Brexit on the horizon, the additional public health challenges that we all know that we face, and an ageing population, and it would an additional barrier to integration within the health service, let alone to delivering the plan 'A Healthier Wales', which has been designed and agreed by health and local government, for the first time together working to deliver a joint health and social care plan with buy-in from the third sector and housing. I think the proposal that you make is foolish. It runs in exactly the opposite direction of every respected commentator and expert across health and social care. Even in England, Simon Stevens recognises they have got it wrong on dividing trusts from primary care. He is now looking at integrated models of care in England. He won't say, 'Look at Scotland or Wales' when he looks at them; he looks further afield. He can hardly say to the Tories in England that he likes the look of integrated healthcare models. Nobody who is serious about the organisation and running of a modern health service is agreeing with the plan that you propose, and I strongly suggest you go back and reconsider your position.      

The UKIP spokesperson, Gareth Bennett. 

Diolch, Llywydd, and good afternoon, Cabinet Secretary. I wanted to ask you some questions today about social prescribing. As you know, social prescribing—sometimes referred to as community referral—is a means of enabling GPs, nurses and other primary care professionals to refer people to a range of local and non-clinical services. So, it does promote a more holistic approach to health matters and, as such, I think it is a welcome development. 

Now, it's widely acknowledged that Wales does have a major problem with obesity, with 59 per cent of adults in Wales classified as being obese and, more worryingly still, the figures for children also show that almost a quarter of children are obese. What steps is the Welsh Government taking to encourage the use of social prescribing to tackle the obesity problem? 

This Government has already taken an approach to promoting social prescribing and to developing the evidence base for its impact on physical and mental health. I've made a series of announcements about a range of projects that we are supporting with additional resource. You may have missed them; I'll happily direct you to them again. In addition to that, you may also want to take a look at some excellent examples of large-scale social prescribing, some of which are taking place in north Wales with a broader health board approach, and, of course, the excellent Valleys Steps initiative that has its headquarters in Cynon Valley. So, we recognise the case for more social prescribing. We'll look at more evidence about what we could do with it. It's not just in the field of having a healthier weight but of a range of potential benefits we wish to understand and then properly exploit. 

Yes, I think you're right that there is a range of approaches that are needed to tackle the problem, and I'm glad to hear that you are taking social prescribing seriously. Now, I do think that it's a good idea, as I said, to use this method. However, part of the problem with social prescribing providers is that many activities are led by volunteers and the charitable sector, so they may be vulnerable over the longer term to funding changes. Has the Government given any consideration to ring-fencing funding for some of these vital projects in the future?   

As I said in my first answer, I have announced additional funding to support particular social prescribing projects organised by a range of people in the voluntary sector in particular. Part of the challenge about social prescribing is often—these are low-cost or no-cost activities in any event—about encouraging people to make use of them. You may also wish to look at the national exercise referral scheme, which is a scheme that has run for a number of years. A number of Members will be familiar with it in this Chamber, and it has excellent results in terms of helping to improve people's physical and mental health. But, of course, we'll always review the amount of funding available to try and deliver on the objectives that we wish to deliver for the people of Wales. We will continue to do so, of course, in the face of continuing austerity.  

Yes, thanks for that answer. I will endeavour to familiarise myself in more detail with the reports that you mentioned. Now, there is one report that I will refer to. There was a recent primary care hub report on social prescribing that indicated that there is a lack of awareness amongst the public about social prescribing. Obviously, for social prescribing to work, we need the public to be well aware of it and also, of course, GPs. What is the Welsh Government currently doing to increase the knowledge of social prescribing among the general public and also among GPs? 

I'm familiar with the primary care hub that sits within Public Health Wales and their report on social prescribing. There's a challenge, I think, for all of us in the way we talk about healthcare issues in this Chamber and with the wider public. I don't expect the public to become more familiar with the term 'social prescribing' in general terms or understand what it is, because there are a variety of things that we would call social prescribing. It's actually about how we renormalise a conversation about different ways to help people to achieve their health and well-being goals across physical and mental health. You don't need to know, I think, if it's suggested, for example, that you join your local ramblers group that that's a course of social prescribing. It's more about how you're helped to achieve different goals to improve your health and well-being, and I think we've regularly used language that excludes the public from a well-informed conversation. Because, actually, if you say, 'If you did this particular activity or if you joined a particular group, that might have a benefit', that's the sort of conversation we need to re-engineer and that is, in many ways, about access to information about what is already available as well as developing an evidence base for the impact on physical and mental well-being.