Therefore, we move on to the statement by the Cabinet Secretary for Health and Social Services—Betsi Cadwaladr University Local Health Board, special measures update. I call on the Cabinet Secretary for Health and Social Services—Vaughan Gething.

Thank you, Deputy Presiding Officer. I made a statement on 5 June on the progress made in some key areas during the time that this health board has been in special measures, the significant challenges that remained, and plans to work with the health board during the next phase of improvement. My statement today will focus on the progress against those expectations that I set out for the health board in May in the special measures improvement framework.

The framework sets out milestones for 18 months in four key areas: leadership and governance; strategic and service planning; mental health; and primary care, including out of hours. The health board is required to report on progress every six months, and the first report was discussed and agreed at its board meeting held last week.

I met with the new chair and the chief executive for one of their regular accountability meetings with me and the chief exec of the national health service in Wales last Tuesday to discuss the progress made and plans to deliver on the challenges and difficulties that remain.

On leadership and governance, there has been a strong focus on improving board capability. From May to September this year, all the board vacancies were addressed. Mark Polin has been appointed as the new chair, and a new vice chair and independent members appointments have been made. In line with my expectations, an executive director of primary and community care has been appointed to drive the required improvement in this area. A new executive director of planning and performance has also been recruited and will start in post in November.

More robust appraisal and reporting and assurance systems are now being introduced by the new chair to further drive improved good governance. There has also been increased commitment to and impetus on partnership working from the board to support ‘A Healthier Wales’ and the transformation agenda. I was pleased to announce last week support from the transformation fund for a north Wales project across north Wales to help people with learning disabilities live more independent lives and to get the care that they need closer to home. That will involve sharing resources, skills and expertise across health, social care and the third sector.

In relation to finance, the health board remains in a challenging position. However, if the control total set for this year is met, it will represent a real improvement on the previous year. The board are in no doubt that achieving this will require focused action over the latter part of this financial year to deliver the turnaround needed to secure stability and to drive the shift to transformation in its future plan. I announced in July additional funding of £1.7 million under the special measures arrangements to strengthen the management capacity and analysis capability in the turnaround team.

A key expectation of the improvement framework was that the board responded promptly and appropriately to the Health and Social Care Advisory Service—HASCAS, investigation findings and the Ockenden governance review recommendations. I am content that the plans the health board has put in place to implement the recommendations, both with mental health and more widely, are comprehensive and robust, with operational leads identified and being held to account. My focus now is on ensuring that there is rapid progress on implementing these plans.

We are already verifying the progress so far reported by Betsi Cadwaladr in their regular reports, and that is recognised by front-line staff in mental health, and that is in addition to the Healthcare Inspectorate Wales inspection programme, which is also reporting progress. Improvements so far include the confirmation of a new and visible senior management team, appointment of a new mental health nursing director, creation of listening leads across front-line staff and the launch of the 'Today I can’ approach. Furthermore, a stakeholder group has now been created to further test the improvements being made, and I am pleased that some members of the remaining Tawel Fan families have agreed to be part of this group, together with the community health council and other stakeholders.

Recently, I met with a number of Tawel Fan families, when I met them last week. I understand very clearly that a small number of families are not content with the process or the outcome of the HASCAS investigation. However, there was consensus on the need to ensure that the health board reports and action plans are prepared and that they do result in sustainable and meaningful improvements in both mental health services and care of those with dementia across services. My officials have been very clear with the health board on the need to ensure it communicates plans and actions effectively to all staff.

The focus of developments in mental health to date has been around immediate improvements to in-patient services, including environmental works. The health board is also working to assess and improve community services by implementing its mental health strategy, working closely with local authorities, the third sector, service users and the police to deliver local implementation plans. A key focus for the next six months will be to improve and maintain performance against the Mental Health (Wales) Measure 2010 and child and adolescent mental health services targets  To support this work, the delivery unit is reviewing demand and capacity and my officials are discussing what further support might be needed in this area to rebalance capacity and demand.

Improvement to engage and involve staff is ongoing, and the results of the NHS staff survey 2018 show positive changes since 2013 and 2016, most notably in staff engagement. That includes an 18 per cent increase from 2013 of staff who say that they are now proud to work for Betsi Cadwaladr. 

The strategic and service planning area, including performance, requires acceleration and more focused effort. There has been progress in individual specialist strategies with the sub-regional neonatal intensive care centre—otherwise known as SuRNICC—and primary percutaneous intervention plans implemented, and the vascular surgery plan under way. These plans increase success in recruitment and in delivering specialist services within north Wales for the people of north Wales. Work on other areas, including orthopaedics, needs to be further progressed on a whole-system basis and described more clearly in its plans for service transformation and improvement.

In primary care, the new executive director will provide increased focus to deliver further improvements, working in partnership with clusters. Work is continuing to improve GP out-of-hours services and the health board performance is now more in line with the rest of Wales. The ambition of the health board is now to transform the service model so that it becomes fit for purpose and sustainable.

In this statement, I have noted areas of progress but also outlined the significant difficulties that do remain. I am determined that special measures is not a sticking plaster, but that it delivers sustainable improvement and puts in place the capacity and capability required for the medium and long term. During the next six months, the health board will need to focus on finance, strategic and service planning, especially in unscheduled care and referral to treatment, and delivering on the recommendations from both the HASCAS and Ockenden governance reports.

The chair and the board are clear on the work needed and are committed to making progress. Welsh Government will work alongside to provide the necessary support and I hope that regional partners and key stakeholders will also play a key role in ensuring improved and sustainable health and care services for the people of north Wales.

Thank you, Cabinet Secretary, for your statement. I think it's important that you keep this Chamber up to date with the situation in terms of the special measures in north Wales. You know that I've been extremely critical of the lack of progress that there has been over the past almost three and a half years since this organisation went into special measures. We've seen performance on a range indicators, including A&E waiting times, referral-to-treatment waiting times and mental health challenges, not going in the right direction so far, and I think that many people are very concerned also about the sustainability of their GP services in north Wales, given that 24,000 patients have had to find alternative arrangements as a result of their practices handing back their contracts across the north Wales area in recent years. 

We know also, of course, that the financial situation, rather than getting better under special measures, which was always the intention, has actually gotten worse. The deficit was £26.6 million at the year-end—[Inaudible.]—2015, and we note that that deficit—[Inaudible.]—was £38.8 million in the last financial year. Also, of course, there is concern about the control of escalating costs, with even things like capital projects. We saw in the news—

I'm sorry to interject. We have a technical problem, in which none of the microphones are working. So, I have been advised—. I'll let you have another extra two minutes. I've been advised to adjourn for 10 minutes. So, the sitting will now adjourn for 10 minutes, or until such time as the technical problem can be resolved. 

Plenary was suspended at 15:33.

The Assembly reconvened at 15:45 with the Deputy Presiding Officer in the Chair.

[Inaudible.]—why that was happening. We'll move back now to the spokespeople, so I'll come back to Darren Millar. So, you can start again, Darren. 

Thank you, Deputy Presiding Officer. Can I thank the Cabinet Secretary for his statement? I think it is important that this Chamber is updated on a regular basis about the situation in terms of any progress that is taking place in north Wales under special measures. My party has expressed significant frustration over the past three and a half years about the lack of progress. We know that some of the key indicators in terms of emergency department waiting times, referral to treatment times, outcomes for patients with mental health problems in accessing GP appointments, and, of course, the closure of a number of surgeries in north Wales have all been features of the public debate. In fact, 24,000 people are clients of surgeries in the north Wales region who, unfortunately, have had to make alternative arrangements, usually the health board taking over those surgeries in order to provide some continuity of care.

We also know, of course, that on the financial side, the situation has also deteriorated. The deficit in the financial year before the health board went into special measures was £26.6 million, but that has inflated itself to £38.8 million in the last financial year. And if I heard the Cabinet Secretary right earlier on, he's set a control total, whatever that actually means, to allow for some flexibility in expenditure this year. I would be interested, Cabinet Secretary, to know what that control total actually is in order that we can hold you to account for the delivery against it.

Now, I do welcome some of the changes that have been made at board level. I welcome the appointment of Mark Polin and wish him all the very best in the significant work that he and his fellow new independent board members have to get to get to grips with, because it is a significant challenge. But I am still concerned—and I will keep flagging this up—that there are people around the board table who are part of the executive team that was responsible for the significant failings of this board when it was put into special measures. There are two people at least who are still around that table—one of whom, rather astonishingly, has now appointed as the turnaround director at that particular health board, which I think is absolutely scandalous, frankly, given the history at this board.

Now, can I ask you: you made mention of the fact in your statement that you've announced additional funding of £1.7 million under the special measures arrangements to strengthen the management capacity and the analysis capability in the turnaround team? Is that going to be recurrent because, of course, this capacity is going to need to be there going forward, not just in the short term? Can you tell us whether that cash is going to be recurrent?

Can you also tell us as well what the outcome of your meeting with the Tawel Fan families was? You suggested that just a small number of families were dissatisfied with the outcome of the independent investigations that have taken place so far, but that is not my experience in terms of the communications with me and my post bag. Indeed, I had it reported back to me that from your meeting with those families, there was a request for an Assembly inquiry to be commissioned. Now, I would hope that you would support such an inquiry if there were calls for such an inquiry being made by Members of this National Assembly. Perhaps you can tell us whether that will be the case, because I do think that many people have a complete lack of confidence in the two very significantly different overall conclusions that arose from those independent reports by the Health and Social Care Advisory Service and Donna Ockenden. 

Can you also tell us—? You made reference to developments in mental health. One of the developments in mental health that has taken place in recent months is a withdrawal of funding for capacity-building organisations in the third sector, which I think is of significant concern across the region. So, the organisation Un Llais, which has developed advocacy services in recent years, has had its funding pulled, with effect from December of this year. That funding has been responsible for training advocates, for establishing advocacy services, and we know that the capacity of advocacy services is not managing the demand that is being placed upon them at the moment. So, I would be interested to hear what assurances you have that those advocacy services, given the quality of mental health services in north Wales, are going to be able to meet demand in the future.

You made reference as well to the results of the most recent NHS staff surveys, which show some positive change, and I acknowledge that there's been some positive change and that there is increasing confidence in most parts of the new leadership team. However, you haven't mentioned patient confidence levels, and we know that those have been on the slide of late. We also know that the complaints system is broken. In north Wales, we have people waiting sometimes for over two years for outcomes to their complaints, even in respect of mental health services, at a time when the board is in special measures. Now, that's clearly unacceptable, and I'd like to know what you are doing to make sure that this is an organisation that learns from its mistakes, particularly those that are brought to its attention through the complaints process. Even Assembly Members have problems getting substantive responses when we are asked to intervene in securing them. So, I think, frankly, we deserve an explanation as to what you're doing to build the capacity in this organisation to be able to learn from its mistakes and respond to Assembly Members and other elected representatives who are helping to raise questions.

You also made reference, of course, to the neonatal intensive care centre, which I absolutely welcome, on the Glan Clwyd Hospital site. You didn't mention the fact that 10,000 people had to march on the streets in north Wales in order to secure that. I appreciate the intervention of the First Minister, but if it hadn't have been for those people marching on the streets, we wouldn't have that neonatal intensive care centre. We'd be sending poorly babies and small babies over the border into England in order to be born where there were predictions of problems for mothers. So, I do think it's a bit rich, really, to claim all of the credit for that, when the reality is that you bowed to public pressure in terms of your Government's position. 

On capital investment, I welcome capital investment that's going into the board. I do think that there are problems in terms of the sign-off process, while the board is in special measures, for securing capital investment. I've raised in this Chamber before concerns about the orthopaedic capacity, for which the board has a plan in place to improve, but it can't do that unless it gets the capital investment from the Government in order to implement its plan, and it's taking sometimes years to get a response once a plan has been submitted. Now, how do you expect a board to make the sorts of improvements that we all want to see on a cross-party basis in this Chamber if you're not putting the investment in in order that it can actually help to deliver that? And we know of the rising costs, of course, in terms of some of these capital projects. Pre-election promises of a new hospital in Rhyl, for example, which have never been realised, as yet, in spite of the fact that they were promised back in 2013, when some facilities closed in that locality and in neighbouring Prestatyn, that a new hospital would be built. Now the forecast is that it won't be built until 2022 and that the cost will almost double. So, I think what needs to happen here is we need more rapid progress, we need to see greater levels of capital investment in order to get the systems right and the capacity right, and we certainly need to see more investment in those mental health advocacy services and the complaints process in order to make sure that this health board learns from its lessons. 

Thank you for that range of comments and questions. I will, of course, keep the Chamber up to date on progress with special measures. As we have the reports and the updates on the special measures, I fully expect that statements will be made in this Chamber for Members to ask questions.

I just want to correct a point at the outset: 24,000 people have not had to make new arrangements themselves for GP services. The health board has always managed those arrangements, either in partnership with surrounding general practice or, indeed, by running a managed service until that service is able to go back into the usual manner of delivering general practice services. So, it isn't that people have to go out and make their own arrangements, it is about the health board still managing and delivering that service. There is, though, within north Wales, for the significant challenge that there is in GP clusters—and I recognise that, I've met a range of GPs and others in north Wales, just as around the country—. The appointment of the new exec director for primary and community care is a real step forward—somebody who is a primary care clinician who has trust and credibility within the service and is now in a place to try and bring people together to have a more positive plan for the future and for what could be done, who understands the real challenges of colleagues, not just in general practice as doctors, but the nurses and the therapists and others as well.

Finance remains a major concern with a £35 million deficit control total set. That in itself would not be a significant marker of success, because success is living within the budget, and I've been very clear about that since my appointment. But we want to set realistic improvement targets to meet that control total and then to move on to be able to live within their means in future years. That is why the turnaround needs to be accelerated. That is often about the short to medium-term improvement before longer term and medium-term transformation, but that is also why the finance delivery unit will continue to work alongside the finance team within the health board to try to make sure there is real purchase on delivering on those savings. That's why we've put in short-term support around the health board. Recurrent funding commitments will be made to health boards, as we need to do, but we're adding significant additional investment to help this health board through special measures.

On advocacy, I have undertaken to write to you, and I will chase it up to make sure that I do, because I recognise you've raised the point in the Chamber before, so I don't want to avoid dealing with that.

On Tawel Fan families, the remaining families are a small number but have significant challenges and significant unhappiness about the process as they have seen it and the outcomes of the report. They don't share and don't accept all of the outcomes into the care that their loved ones received. The great majority of families who are part of the HASCAS investigation have not contacted us and they're still unhappy and not content with either the process or the outcome. That does not mean that we won't take seriously the remaining families' concerns. That's why, in half term, I was in north Wales for an evening meeting that lasted much longer than originally planned for because it was important to have a full opportunity for them to express their concerns rather than simply me hitting the bell after a certain period of time and saying, 'I'm leaving'. That would have been entirely the wrong thing to do.

Within that meeting, the call for an Assembly inquiry was far from unanimous. A person made a call, there was some support within the room for that call, but other people made clear they did not want yet another inquiry. It is, though, for the Assembly to decide if it wants to take another inquiry; it is not for the Government to say there should be an Assembly inquiry. I've made clear that the Government's responsibility is to make sure that we do what we could and should do, and that the health board is held to account for what it could and should to to take forward the HASCAS recommendations. The plan they have to do so is a credible one; the challenge is that they need to deliver it. The plan looks like the right one, but they need to deliver it and they need to do so in a way that commands confidence, which is why the stakeholder group exists. It's why it's important there are some of the Tawel Fan family representatives on that group as well. So, it is not a group of cheerleaders for the health board—there'll be real scrutiny.

On your broader point about patient confidence, well, if the health board is regularly written about in terms that do not command patient confidence, it's hardly surprising people are concerned. And with a health board in special measures, I would hardly be surprised if patient confidence in that part of the country is different, say, to other parts of the country. However, I don't accept your statement that the complaints system is broken. The complaints system has a significant backlog, but, actually, the leadership of the nurse director has made a real difference to the complaints system. It is both important to learn from mistakes, but also to deliver the improvement that is required. And, actually, you don't need to take my word for it that the system has got better—the ombudsman has actually commented that he recognises that real improvement has been made, but he's also pointed out that that needs to continue and things are not perfect as they are now.

On the choice about the sub-regional neonatal intensive care centre, it was a decision the First Minister made with significant capital investment, and it came on the back of an evidence-led review by the royal college. There are people in this room who campaigned for a further review of the initial decision, and we took an evidence-led approach to do so. That has been the right thing to do, and, actually, it was only when the unit was delivered, and ready and open, as I said previously in the Chamber, that staff believed that it would definitely happen. It's a real positive. I think that the Government listened, listened to the evidence and we now have a new facility in north Wales for the people of north Wales. On the orthopaedic plan that you referred to, it is simply not true to say that the health board have been waiting for years for a response from the Government. Part of our challenge has been to get, within the clinical community within north Wales, an agreement on what to do between themselves as well as the health board that employs them, but, equally, to have a plan that can not just deliver more activity, but actually meet the demand and the capacity that exists now, let alone in the future. This Government or any other cannot be expected to spend significant sums of money not to meet the demand within the system. So, they have to have a plan that is approveable in the first place, and then the Government will have a choice to make about whether revenue or capital funding is made available. And I think that is entirely appropriate and what any Minister from any Government should expect from the service. But we are not afraid to invest capital within north Wales to deliver a better service. 

And that brings me to the Royal Alexandra proposals that finally went to board last week and have been approved by the board. They will now come to the Welsh Government investment board and I will then have a choice to make and I am determined to make an early decision. I can tell you that the most effective advocate, lobbyist and sharpest voice that you'd do well to listen to on this issue is, of course, the local Member, who happens to be sat in the Chair at this point in time. I will make the right choice for the service and I know that I will be tested on a regular basis by the local Member.

Thank you, Cabinet Secretary for your statement. There are some elements, definitely, to welcome. I'm particularly pleased to see the appointment of an executive director of primary and community care—I think that's clearly absolutely crucial, although I would share some of Darren Millar's concerns about some of the other people who are still there from the previous regime. I trust that you and your officials have satisfied yourselves that those people will be able to operate in such a way that they will fully comply with your expectations of a fresh start for Betsi Cadwaladr. I would not expect you, here in this Chamber or publicly, to say anything about those reassurances, but I would like to be reassured that you have received them.

I want to first of all look at something that you don't say very much about in your statement, and that is about staffing. You do refer to the fact that you now have 65 per cent of the staff saying that they're proud to work for Betsi Cadwaladr. Well, that is a good thing, but, of course, that means that you have 35 per cent of the staff who are not. Now, if that was a private sector business and it had 35 per cent of its staff not being happy, they would still be very concerned, and I'd just like to seek your reassurance that there's no complacency from your or your officials about that percentage, because it isn't a good place to be. That 35 per cent is an awful lot of people on the front line who are dealing with patients every day.

I'd also be grateful if you can tell us a little bit more about the issues with recruitment and retention. Are you seeing an improvement—are you and your officials seeing an improvement—in the board's ability to recruit crucial staff and to retain them? Because, obviously, it's those front-line staff who are dealing with the patients and their families every day who are the crucial building blocks for the board, and, of course, for the trust of the public in the area, because those are the people who interface with patients.

I'd like to refer back to the Tawel Fan families. I was somewhat relieved to hear your response to the points raised by Darren Millar, because if one read or listened to your statement, one could be left with the impression that you were dismissing the concerns of those families who are not satisfied. Now, you have reassured us that that is not the case and I'm very glad to hear that. In your statement you refer—that section of the statement that refers to Tawel Fan—to your officials being clear about the need for the board to communicate effectively with staff. I hope that you will be able to extend that comment to say that you're being very clear too on the need for the board to communicate very effectively with those families, because it's very often the case, is it not, that if people don't feel informed—. Even if they're not entirely happy, if they feel informed and they know what's happening, that provides us with some reassurance.

I won't repeat some of the questions that Darren has already raised with you, but I finally want to come back to the point about timescale. Now, nobody would expect you to set some sort of artificial exit point for this, because you've got to be reassured that the board is in a fit state to run itself and manage itself and manage its staff before you can withdraw special measures. But it would seem to me that the special measures have been in place for so long now that they're beginning to feel like the status quo. So, are you able to give us some assessment—? You mention your expectation around further and more rapid progress, and I'm sure we'd all agree with that, but are you able to give us some sort of assessment about how much longer you expect this to go on, bearing in mind, as I've said, that nobody would expect you to say, 'Right, we'll be out of here by 30 June', or whatever it is? Because it is getting to the point, I think, when people are beginning to feel that this is going—you know, 'When is the end point?' Now, of course, it could be argued that there is merit in the Welsh Government actually managing the health service in Wales directly and taking direct responsibility for it. But that's not the situation here. So, if we could have some sort of sense about how much longer you think this is going to take, I think the Chamber—and, more importantly, the people of the north—would be very grateful.   

Thank you for the comments and questions. On scrutiny and accountability, as you said, I'm not going to comment on individual employees. The challenge for me is whether people can demonstrably do their job individually and collectively, and that's what the board scrutiny and oversight is for. That is my expectation, and, of course, the new chair is in a position where—as I've said in my statement—there is additional scrutiny on the process, both for the chief exec and the executive team, but more broadly about expectations across the organisation.

I recognise what you say about the improvement in the staff survey, in terms of people who say they are proud to work for the health board. The 35 per cent who aren't in that category doesn't mean that they are all unhappy, but it does highlight not just the improvement that has been made—the 18 percentage point improvement, which should be welcomed by everyone across the Chamber—but also, plainly, that further improvement is required. I certainly wouldn't want to soft-soap or try and avoid the fact that there is further work still to do.

On your points about whether we're seeing an improvement in training and recruitment, I've had a number of conversations with your colleague Llyr Gruffydd about the opportunity to have different training arranged, for example, for nurses in north Wales. I've also had conversations about recruiting two nurses in north Wales from across the border. There's a range of people interested in working in the Welsh system from across the border. That's particularly promoted by very proud nurses within the RCN and Unison in particular. But also, as a good example, in vascular services, we have been able to recruit new consultants—new surgeons—on the back of the change in the vascular service network and the way it's being organised, the additional investment in theatres that I have approved, but also, following special measures, the improvement made in midwifery services, we have managed to recruit successfully into hospital-based and community-based posts. I hope that those are good examples of where we are now seeing more staff successfully brought into the organisation.

On your broader point about public involvement and engagement on mental health, of course that's part of what the stakeholder group will allow us to do, to listen to the views of the public in that setting, as well as the regular point that we should always listen to the public, and for them to have a proper role. Whether we call them service users or patients, the reality is that citizens should be at the centre of the service, and, of course, we want to listen to them to improve every part of the service.

On your broader point about special measures, I've been really clear that special measures cannot and will not be normalised. It is not a normal way of delivering the service. What I hope to see is that we will see organisations at different points of escalation go through both being raised as there are challenges, but also to come back down through escalation, as indeed Powys health board has done, as indeed the Welsh ambulance service has done. I want to see large health boards in a heightened state of escalation move backwards as well. To do that, though, we work together with Healthcare Inspectorate Wales and the Wales Audit Office, so it is not simply the Government marking its own work, or a Minister making a political choice. On special measures, the publicly announced and published specialised improvement framework goes up to September 2019. I would be delighted if the health board has made sufficient progress to come out of special measures before that, but that must always be on an objective basis to judge that, rather than doing it for my simple convenience; that would be the wrong thing to do.    

I thank you for the update, Cabinet Minister. As you say, much has been done, and there's still work left to do. I'm sure that patients and NHS staff would be reassured to know that special measures is not a sticking plaster, as you say, but is an approach and an intervention that is there for as long as it is needed. And that can be a positive, because it means that the Government, Welsh Government, are there to support those people, both the staff and the patients, for as long as that might be the case, and, within that, they can sort out the structural problems and make sure that this service, to those people and the staff who work within it, becomes sustainable in the long term. This cannot be, and it isn’t, a short-term fix. You do say that there will be a key focus for the next six months on improving mental health provision, and I’m sure, again, that that will be very much welcomed, especially in light of all the discussions that have happened here this afternoon regarding Tawel Fan.

I think what people would want to know is how that process will go along, what those improvements might look like, and what any of those target areas are. You do mention additional funding of £1.7 million to strengthen the management in the turnaround team. In August, you also announced £6.8 million to support improvements directly for patients at Betsi Cadwaladr university health board. Are you able to provide any update on the outcome of that spend, or where that spend has happened?

On the new spend, we recognised that the health board didn’t have the required level of capacity in some of the senior and middle management roles that actually make the service work to allow clinicians to do their job. So, we have a range of new directors in post to make sure that hospital management, but also management in community services, is improved. And I expect that we'll see, over the next quarter, not just that the money's being spent, but actually that those staff are then making a difference.

On the broader point about mental health, it is an area where the visible leadership really matters. On the areas of mental health provision that I've visited, in the community and within secure and semi-secure settings, the leadership at both direct level—so, staff and their peer leadership, as well as their managers—but also the mental health director has been very important, and, since returning to work after a period of unavoidable long-term sickness absence, the director has made a real difference, not just in having a strategy, but a plan for the future that's involved staff and people using the service. And, actually, there is much greater optimism about the future of the service. 

This highlights two things, I think. One is the importance of visible, high-quality leadership, because that person is making a real difference. The second challenge, though, is that Betsi Cadwaladr as an organisation—it doesn’t yet have the significance both in the structure and the fragility of leadership that exists, because, if you took that director out of the position now, I would be less confident about improvements being made in the future. So, there's a job of work to do to build a team around that person who can continue to drive improvement even if that person is not there.

That will also need to be borne out, as I said earlier, in making sure that, in the action plan following the HASCAS report, led by the nurse director, who I think is a good person with a real grip on her part of the organisation to make sure that improvement is real—. So, that should give us confidence: a high-performing member of the executive team and a director who know what they are doing, and engagement and involvement of our staff and the people that they’re serving.

Thank you for your update, Cabinet Secretary, but I have to say that it’s such a shame for the people who need Betsi Cadwaladr that the Cabinet Secretary’s statement doesn’t contain more good news than the broad assertions that there have been unquantified improvements in some areas.

Now, I’m not going to rehearse the disgraceful statistics that have come out of Betsi Cadwaladr; we're all aware of them, and they’ve been rehearsed many times in this place. At the same time, I acknowledge that Betsi’s problems are complex and have built up over a long period of time. Similarly, I acknowledge that the Cabinet Secretary doesn’t possess a magic wand that he can wave and instantly solve the problems at Betsi.

But to solve the problem, or a myriad of them, which is what we’ve got at Betsi, you have to understand the nuts and bolts. Expert reports of course show a big part of the picture, and they're very useful documents; they're detailed investigations and they go a long way to helping you solve the problem. But staff who are delivering these health services on the ground, and those other staff and workers who enable them to do it, also have a wealth of knowledge about Betsi and form a pool of solutions that appears to be untapped. I understand the Cabinet Secretary has conducted a staff survey, and it's one of the positives that the Cabinet Secretary reports that staff satisfaction has risen markedly, although, sadly, how good a piece of news that is very much depends on the content of the survey itself. But on the face of it, it's very good news.

So, I'd be interested to hear whether the Cabinet Secretary would consider the suggestion that staff at all levels, from the cleaner to the chair of Betsi's board, be asked to complete an anonymous and confidential survey into their opinions on the challenges they face in their own role, those they face when interacting with other roles in the organisation at all levels, and where the successes are as they see them, where the problems are, and seeking their opinions and suggestions as to the solutions in their particular department and around them. It's something that private sector businesses do periodically when they experience problems of a similar seriousness.

Now, I appreciate that there are whistleblowing mechanisms and a way of reporting concerns confidentially. I also appreciate that the kind of survey I'm suggesting would be a big task, but I think it's a valuable task, and it would be a worthwhile task, because surely the time now has come for a full, proactive 360-degree review of Betsi Cadwaladr at all levels via the staff, who actually live this organisation day in, day out; one that goes out of its way to seek the input of the clinical and other staff in a way that’s guaranteed to be anonymous and confidential and comprehensive.

Now, moving on to the board itself, I know that on the board there are journalists, an ex-police officer and a variety of other non-NHS-related backgrounds. None of the top three posts—chairman, vice-chair or chief exec—is held by anyone with a single day's clinical training or work experience under their belts. The chairman's an ex-police officer, the vice-chair's from the BBC, and the chief exec is a politics and economics graduate. Now, all of the members of the board have worthy curriculum vitae and they're impressive in their own fields, but I'd like the Cabinet Secretary to explain what the purpose is of appointing non-clinical people to run a health service, and what he believes they actually bring to the management of the NHS in north Wales. Doesn’t he think that perhaps the majority of the board should be clinicians if the service in north Wales is to be clinician-led, as the Cabinet Secretary has said in the past that he wants? And does the Cabinet Secretary think that it's acceptable, and does he feel that the public feel that they can trust the decisions of a health board that has comparatively few health professionals on it? Does the Cabinet Secretary not feel that the public would be more assured if his actions also included ensuring there were far more board members with clinical practice backgrounds, together with direct and current experience of the NHS as it exists in north Wales? The Cabinet Secretary's party likes to talk about quotas on management boards when it comes to gender and other things, but why not when it comes to knowledge and experience? Thank you.

Thank you for the comments and questions. There were two broad questions. On an anonymous staff survey, actually, I took part in a number of anonymised staff surveys when I worked in my previous job in the private sector, both as an individual member of staff, when I was not a leader or manager, and then again when I was a leader and a manager, including a 360-degree review of how my staff saw me in that role, and it was a useful point of learning and improvement. So, I recognised the value before coming into this job, and that's exactly what the NHS Wales staff survey does. It is anonymous and it is detailed, and we actually saw an encouraging increase in a range of areas of people actually taking part in the survey. The more people that take part, the greater the value of the survey, and that includes a range of comments—it isn’t just a tick-box exercise—a range of comments about how people feel about working in their part of the organisation, and comments for improvement. So, we do essentially, with the NHS Wales staff survey, do what the Member asked us to do, and I'm not persuaded there is value in undertaking a health board-specific exercise when we have just completed the NHS Wales staff survey.

It's also worth pointing out, from a staff point of view, there is real excellence that takes place within healthcare in north Wales as well, as highlighted in the recent NHS Wales staff awards, and I think people in this Chamber could and should be very proud of the real excellence that those staff deliver.

On your broader point about the make-up of the board, we have, of course, consulted on the shape and nature of boards, and if we are able to, and time permits, within this term, the First Minister's already announced we'll take forward a healthcare quality and governance Bill. We currently have a range of clinical roles. We have a medical director, we have a nurse director, and we have a director for, essentially, allied healthcare professionals, So, we have a range of clinicians around the board in executive director roles.

These are roles in running significant organisations. The chief executive of a health board requires the skills to be a chief executive. They require the skills to be a significant leader and manager within a service. Now that doesn't mean that they have to be a clinician or, indeed, have had time in clinical practice. This isn't about providing the best clinician with an opportunity to run a health board. If you look in general practice, a range of general practices employ people as either the practice manager or as a business manager to run the business part of that organisation, to make sure that they can do what they need to do. Because the skills that a general practitioner has in training and then in many years of practice are actually how to treat and care for people. The chief executive's job is to make sure they do their job properly as the chief executive officer. That is what I expect, and I certainly won't be introducing a requirement that somebody has to have had a level of clinical experience, because I don't think that is going to deliver a better service and, ultimately, that is what I am interested in.

Thank you. And finally, Janet Finch-Saunders. And can I remind you, you are the second speaker from your party?

Yes, and thank you for allowing me to speak. Cabinet Secretary, it's fair to say that over the past 12 months in particular, I've been extremely vocal. It's not wise for anybody to stand up in this Chamber and just pontificate or use anecdotal information here. When I speak, I speak clearly from what I receive coming into my office. And I can tell you, my casework file is—[Interruption.] There's no let-up in the number of complaints and the type of serious complaints that are coming in as regards this particular health board. Now, you'll be aware, no doubt, of my constituent, where it's just only been announced—. Can I carry on?

I'm listening.

Seven hours ago today, one of my constituents, sadly, has passed away, through waiting for an ambulance for over four hours and bled to death. A 37-year-old constituent. That is just one of many people that I'm dealing with. Another lady, who had a very bad fall in Conwy, waited three hours for an ambulance then waited for 10 hours for treatment. She was taken to Llandudno hospital, and then, such was her bleeding on her leg, and it was a replacement knee joint, they had to cut her jeans off her, 10 hours later. So, she wrote to the chief executive. To date, she wrote to the chief executive in July. I followed it up, asking him where the response was, in August. We're now in November—no response. 

We have dozens and dozens of complaints. You know, because sometimes, I get very frustrated because my constituents come to me in all good faith and they say to me, 'Janet, we don't want to get anyone into trouble, we don't want to criticise, we just want the people at the top running things to know just how bad things are', and they don't receive any response.

And I just find, if a chief executive or anybody working within a senior management team cannot put pen to an e-mail, a standard response even saying, 'I'm very sorry to learn of your experiences, but your information coming back helps us to improve the service'—. There's nothing like that. I've asked Gary Doherty, I've asked Andy Scotson, and, you know, things are so bad for my constituents that now we have a weekly phone session with a member of my staff to go through all the cases where they are just massively delayed.

I had an e-mail when I was sat in Plenary about four weeks ago. An elderly gentleman has been waiting four and a half years for a hip operation. He's in agony. He said he finds it hard getting out of bed. These are people who are not being supported by care. He lives alone. He just needs—. He's been told by the doctor, his GP, he's been told by his consultant he needs a hip operation. Luckily, as a result of him contacting me, they are now prioritising him some treatment. So, please God that he gets his operation, and I think it's going to be fairly imminent.

But people are coming to me, and I want them to, but there's an awful lot of people out there who are not coming. There has not been any improvement, honestly, Cabinet Secretary, as regards their complaint processes.

Now, I know that the senior management team—

Can you make some progress, please? I haven't heard a question yet.

The senior management team—. Yes, it's quite noteworthy the number of new staff that have been taken on, but the old staff are still there. So, you've got this ballooning, ballooning, ballooning management team, and yet, Llandudno hospital have had to close wards—they can't get staff. There has been no improvement in the short or medium or long-term planning in terms of attracting nurses. Have you seen the number of vacancies now for nurses in the Betsi Cadwaladr health board? Things may be better on paper in some areas, but, frankly, as an Assembly Member, my workload is no less and the distress to my constituents, if anything, is growing. So, all I would say to you is you do need to look more at some of the other things.

But, the point that Michelle Brown made earlier, and also Helen made too, about—you can't guess when you might take this board out of special measures. It's been there the longest it's ever been in any of the four parts of the United Kingdom, three years and counting. You mentioned in June 18 months and you're still saying 18 months. So, it looks almost like it'll be the next election before we even consider it.

Can you just tell this Senedd and the Members here when you yourself, as a Cabinet Secretary, as a Minister in a Government of a nation, when do you see this health board coming out of special measures? But, more importantly, when do you envisage that being a situation where real improvements have been made? I will always have a casework load, I appreciate that, but when will we as AMs and my constituents and your patients actually say, 'Do you know what? Things have improved'? Just tell us a timescale, please.

On the individual cases that you mentioned, I can't comment, but I'm not going to try and say that extreme long waits for treatment are acceptable. I've made very clear that they're not and there's a need for improvement not just in north Wales, but in every other part of our healthcare system if people wait too long. I rehearse again that the ombudsman has said objectively the complaints system is improving. That may not be seen in your casework file, but that is what the ombudsman himself has said objectively.

On your question about a timescale, it's essentially the same question and the same answer I gave to Helen Mary earlier. The improvement framework that I published previously goes up to September 2019. I will not give a timescale for when special measures will end because it must be on the basis of the objective advice and assessment we get from Healthcare Inspectorate Wales and the Wales Audit Office that sufficient and sustained progress has been made and the health board should come out of special measures.

If I do as you urge me today, then it might be convenient for me or somebody else in the Government, but it may be entirely the wrong thing to do for people who work in our health service and people who rely upon it. I will do what is right for the health service, even if it means that you and I must agree to disagree. 

Thank you very much, Cabinet Secretary. We've overrun that statement by a considerable amount, and I will not be overrunning the next statements by the same amount. So, can I just remind everybody that if you're the second speaker from your party it is a 30-second introduction and one question, not a five-minute speech that you've already prepared?