Questions now from party spokespeople. Plaid Cymru spokesperson, Helen Mary Jones.

Diolch yn fawr, Llywydd. Thank you. Last year, the General Medical Council struck off 76 doctors and the Nursing and Midwifery Council struck off 257 individuals regarded as no longer fit to practice in the health service across the UK. I'm sure the Minister will agree with me that it's right for professionals in the health service to be held accountable for serious malpractice and misconduct. Does the Minister believe that managers in the health service should also be held accountable and, if so, can he tell this Chamber how many senior managers or board members in the Welsh NHS have lost their jobs as a result of service failures or mismanagement since 2016?

Well, of course, the Member's aware that I don't have at my fingertips the number of staff who have left the health service from managerial positions going back to 2016. It is worth reflecting, as I said yesterday when a similar point was made, that a number of managers and leaders in services within the health service are, of course, registered clinicians as well and have professional duties too. So, you'd need to look at those people who are caught by their professional responsibilities as well as their responsibilities as managers. This goes into the broader point about leadership, governance and accountability within each one of those NHS organisations.

I'm sure that the Minister will understand, after yesterday's statement, that issues with regard to leadership and accountability are of great concern to Members in this Chamber. Can the Minister explain to us why he has had Betsi Cadwaladr health board in special measures for about four years and we don't seem to have seen any change after this lengthy intervention? Can he account for why, if we come back to the Cwm Taf situation, there were eight reports over six years and none of those reports triggered the change that was clearly needed, and mothers and babies continued to be let down and some grievously harmed? Can the Minister explain to this Chamber why families in the Cwm Taf area should trust him, his officials and the measures that they've put in place to sort out the system in Cwm Taf, given that he failed to pick up on any of these eight reports over those six years after the first concerns were raised and that the problems in Betsi Cadwaladr are nowhere near being solved after four years?

I think there are three particular questions there, Llywydd, the first about—[Interruption.] The first about special measures in north Wales, and, of course, it's factually incorrect to say no progress has been made. For example, one of the main issues that saw Betsi Cadwaladr go into special measures were challenges in their maternity services, and they have come out of special measures, because real and sustained improvement has been made, because the steps that we took, including new leadership within the midwifery service and a change in culture across the whole service, actually have made a difference. It's also true, for example, that the out-of-hours service in north Wales has come out of special measures as a concern. There are remaining concerns, and that's why that health board remains in special measures, because I'm determined to make sure there is a real measure of progress and it's not simply an artificial device for a politician to use.

When it comes to Cwm Taf, as explained at length yesterday in the statement and in answer to questions to it, the seriousness and the depths of the concerns were not apparent from those previous reports, which is why action was not taken until I commissioned the joint royal colleges review in October last year. Part of the concern is about why other factors, why other flags of concern and complaints, in particular, did not lead to a change in culture and practice within the health board at the time. That's why I've taken the action that I outlined in detail yesterday in writing and in the oral statement.

And in terms of the confidence that public and staff should have, a key part of that is the work that not just our independent regulators will be doing, but the independent oversight group that I have appointed, with independent clinicians, to oversee the 43 serious incidents and to look back to 2010. I will meet directly with families over the next two weeks, as well as staff, to hear directly from them, together with Mick Giannasi, their concerns and to understand how we help to rebuild confidence in the service that must improve, and that certainly requires significant change.

Well, I'm sure, Llywydd, that this Chamber will be rather concerned that after eight reports over six years, the Minister and his officials had not picked up on the seriousness of this situation. We heard individual testimonies in this Chamber suggesting that those concerns actually go back a lot further than the first report that I'm referring to in 2012. I'm just really concerned, Llywydd, that this is suggesting that we have a Minister who doesn't have a grip on the system. Eight reports over six years, and nothing was done until you called for the report years ago.

I try to avoid being sensationalist in the Chamber, but during those years children died, mothers were traumatised and families were traumatised. I have to ask the Minister why he thinks that we should now be reassured that he and his officials will be able to pick up on these issues effectively when they didn't for that period of years.

I wonder if the Minister agrees with Owen Smith MP when he says in the Western Mail today that the Welsh Government cannot be absolved of blame for the failings in Cwm Taf. I wonder if the Minister understands that many people are concerned about what appears to be a complacent response from him. I was astonished, for example, to hear him yesterday dismiss the implications of the inverse care law—the fact that these communities that were so badly served were so poor. I was shocked to hear him dismiss that. It suggests to me that he doesn't understand those communities very well. I was also shocked—and I am not easily shocked—to hear the Minister say, when asked by ITV yesterday whether the buck stops with him, the Minister's response was that the buck stops with everyone. Well, I'm afraid I must put it to this Chamber, Llywydd, that the buck does not stop with everyone—the buck stops with the Minister. And I am going to ask him again to consider his position, and if he is unable to consider his position, to explain what further, what more serious situation would occur in the health service in Wales, what more has to go wrong before he is prepared to take personal responsibility?

I return to the range of points—I think there are five different points made at that time, Llywydd. In terms of the eight reports that the Member refers to, none of them refer to the depth of challenge that was revealed in the autumn of last year, which led to my commissioning of the joint royal colleges report. That was a decision I took because of the concern that had been properly revealed at that time. And it's a matter of a simple fact that, of course, I hadn't been in this role during the whole six years that you refer to. I've acted in the time that I have been in office on all the information that I have had available to me. And it is part of the challenge to understand how and why concern was not flagged up and acted on at an earlier point. That's why the independence in the oversight arrangements in the review process is absolutely crucial, to rebuild the trust and confidence that staff and the wider public will expect.

I certainly have not dismissed the inverse care law. I have made clear that I expect every person, every family, every community, in Wales to be treated appropriately by our national health service, with dignity and respect, to have their voices listened to. It is part of what I have found deeply upsetting in respect of Cwm Taf maternity services. That clearly did not happen to a range of families who have spoken about their experiences. So, the action that we have taken more broadly about the inverse care law, we have particular programmes undertaken in Aneurin Bevan, together with Cwm Taf. So, this is something that we are deliberately taking proactive action upon here within the health service in Wales.

Now, when I say, 'Who has a share of responsibility?', everyone in this health service does have a share of the responsibility for the way the whole health service works. But, ultimately, I'm the Minister for Health and Social Services, and I have overall responsibility for what happens. And I am far from complacent about my responsibilities, not only in the sense of the whole performance of the service, not just the challenges, but the good that the service does. But my responsibility is to see through the improvement that I recognise is plainly required and I am determined to see delivered.

The Conservative spokesperson, Janet Finch-Saunders.

It is widely known among stakeholders, users, politicians in Wales that social care funding across Wales is considered to be very serious. Alongside the 2019-20 local government settlement, providing councils with nothing but real-terms cuts once again, leaving them with little choice but to cut vital services, Wales is likely to have a 35 per cent increase in population over the age of 65 by 2039. The additional pressure on local authorities has been noted by the Welsh Local Government Association, who have estimated that there will be £344 million-worth of service pressures in social care by 2021-2. Clearly—[Interruption.] Allow the Minister, if he can, to respond to me. Clearly, a realistic vision is required, rather than the current rhetoric so often heard in this Chamber. The introduction of a transformative reform package is a necessity, and one that frees up local authorities from the continual, significant and ever-increasing financial burden. The provision of appropriate social care for our most vulnerable in Wales is not only an entitlement, it is a basic human right. Will you, as the portfolio holder and Minister, acknowledge the fact that local authorities across Wales are massively under-resourced by your department, by your Government, financially to provide social care? And will you look at transforming how this is funded?

Well, Llywydd, the questioner shows a staggering lack of self-awareness in asking the question. The unavoidable reality is that the Welsh Government has suffered a 7 per cent real-term reduction in our budget—well over £1 billion—and that has consequences that are unavoidable and directly flow from the policy of austerity implemented by the Government that you support, a policy that you have campaigned for in three successive general elections. 

I should also point out that if all of the spending demands made by Conservatives in this Chamber, and outside it, were acceded to, then we would have a much larger sum of money because we simply cannot meet all of the demands you make upon us. They are wholly unrealistic, as well as ignoring the impact of Conservative austerity. When you talk about the challenges of local government and paying for care, the biggest challenge they face is austerity. If you want to see a change in the position of local government and their funding, you should join with others in this Chamber and outside and call on the Conservative Government to end the policy on austerity to stop the damage being done in each and every one of our communities. I think many people will hear what you have had to say and wonder if at all you understand what is happening, or that if you do, whether you're potentially just a touch hypocritical. 

I thought we were in for a kinder politics, actually. I haven't insulted you personally.

Now, one recent idea as to how to fund social care is the proposal this week that has been outlined by the Rt Hon Damian Green MP in his paper on fixing the care crisis. It's fair to say that the UK Government realise that it's a ticking time bomb where social care pressures are and they are prepared to do something about it. Now, this would see a pension-style system introduced, guaranteeing a reasonable universal safety net. I'm not endorsing this at this point, but what I'm saying is that they are looking at it and coming up with meaningful and potential ways to address the issue. The way you smile, you look as if you don't even believe that there's a social care funding crisis in Wales. Now, this would help increase the flow of private funding into the—. [Interruption.] You can heckle and try and support him from the sidelines—

Don't take any notice of them; that's the best advice I can give. Ignore them completely and carry on. 

Thank you. Just for the reference, £1.20 is spent on public services in Wales—provided by the UK Government—for every £1 in England. So, there's an obvious fault there, isn't there, when, clearly, there's less money being spent in England, and—[Inaudible.]—delivery? But, anyway, on with my question. This would encourage a greater voluntary contribution of the around £163 billion in non-pension assets possessed by each annual cohort of 65-year-olds in Great Britain. Now, the merits of the proposal may be a debate for another day, but at least, as I've said, they're looking at it. But we must acknowledge that something has to be done in Wales. Can you say yourself that the Welsh Government, and you as a Minister, are doing enough to do this, and will you also confirm to me how you have taken forward one, two or even more of the nine recommendations of the Finance Committee report, 'The cost of caring for an ageing population', especially No. 7, which highlights the need to engage with the public about the future funding of social care in Wales, and to have a national conversation? Have you taken those recommendations forward, and are you prepared to have that national conversation?

Well, I'd like to thank the Member for her latest interesting take and bring her back to reality. The undeniable challenges on social care exist right across the United Kingdom, including here in Wales. Within the significant reductions made to our budget by the UK Conservative Government that she supports and has campaigned for, we have made honest choices about the share in resources between health, local government and all other public services and money we spend on supporting the economy. If the Conservatives in the United Kingdom Government were really serious about fixing this issue, they would have done something about it. We've been promised a Green Paper, not a paper by Damian Green, to understand what the UK Government are going to do on this. It has been delayed again and again and again.

The Dilnot commission that was supposed to help take this matter forward was buried by the Conservative Government in the last term. The reality is we could have made more progress right across the United Kingdom if the UK Government had been a straight and honest dealer in this and actually taken action rather than kicking the can down the road. Here in Wales, we do have an inter-ministerial group that I chair on looking at the future payment for social care, and looking at how we generate more money to go into our social care system. And that is not a consequence of free choice to make at all, and if we want more resources to go in, there are difficult choices about where that money comes from and if we're prepared to fund that in a variety of different ways. 

I suggest that rather than just looking at it, the UK Government needs to recognise that they are responsible for the position on social care funding, and it comes back again to the choice on austerity. End austerity—there are different choices that every Government within the United Kingdom can make. End austerity, and your Conservative colleagues who run councils in England will have a different settlement, because don't take my word for it, but the choices that your Government across the United Kingdom has made have had even more serious consequences in England than any other part of the UK. They look on the way Welsh local government has been treated and they recognise there is a much better deal available for local government here because there is a Welsh Labour Government that has balanced our resources and prioritised local services. 

A very, very weak response from a Government Minister. You have just actually admitted to this Chamber that despite you having the levers, despite you having the resources financially, and despite you having the powers, you're actually waiting for a Green Paper from the United Kingdom Government. What happened to devolution? What happened to you taking the lead as a Government Minister and as a Welsh Labour Government? You've answered that question. But, anyway, I've got one more for you. [Laughter.]

There are 370,000 carers in Wales providing 96 per cent of the care in communities across Wales and they contribute more than £8.1 billion to the Welsh economy every year. Now, if just a small percentage of these hard-working carers stopped caring, health and social care services would undoubtedly submerge into a deeper crisis than I have mentioned. Therefore, challenges faced by unpaid carers in Wales must be addressed by you. For example, I am shocked, and I am sure other Members here would be, to learn— 

You do need to come to your question now. You don't need to preamble your third question. 

Many carers are unable to access appropriate breaks from their caring responsibilities in order for themselves to live healthy and fulfilling lives and to reach their own potential in terms of education and employment. What urgent steps are you taking to ensure that all carers receive the adequate breaks they require and that the full cost of replacement of respite care in order for them to live their own fulfilled lives is achieved? 

Thank you for the question on carers—an important subject on which there is some cross-party agreement that we need to find a better deal on. The Social Services and Well-being (Wales) Act 2014 provides rights that do not exist in other parts of the United Kingdom. Our challenge is how we work with our partners and make sure those rights are realised. There is no lack of focus on carers and, indeed, the Deputy Minister is leading work with carers on implementing a better deal for them here in Wales.

I actually think the problem with this set of questions is that when you talk about powers, levers and resources that already exist, actually the undeniable truth is we have only recently had powers over changing our income. We have not had the resources. That's a point I've continually made about austerity and your failure to take any kind of responsibility for the choice that you have actively campaigned for in three successive general elections. It is a Conservative choice, it is a Conservative creation—the crisis that we see across public services right across the United Kingdom. 

The challenge in this exchange is that, unfortunately, Llywydd, I just don't think the Member understands what is actually happening within the country, and let's just leave it at that. 

UKIP spokesperson, Neil Hamilton.

Diolch, Llywydd. The Minister will know that in the years 2017-18, 100,000 ophthalmology patients' appointments were cancelled, often at very short notice, and that figure was a rise of 5.5 per cent on two years before. Those who have been waiting for twice as long as they should for a follow-up appointment were 35,000 in December 2018, up from 15,000 in April 2015. The latest figures that I have been able to find for those people who go blind whilst waiting for treatment in Wales is 48. That was back in 2014 in a Royal National Institute of Blind People report. Is it not a scandal that a single person in Wales should go blind whilst waiting for treatment by the NHS? 

This is an area in which we've actually changed measures, and the difference between measures and what happened in the service actually matters. We were measuring a referral-to-treatment target that didn't actually take account of the clinical priority of patients. So, we had a blunt measure that didn't take account of how the service should act to actually deal with the potential clinical harm. So, one of the things that I have done is that I have now worked with the service, together with the Royal National Institute of Blind People, and we have new measures in place that actually take account of clinical priority. So, some people will wait longer, but we will prioritise those people in the greatest need to avoid the prospect of people actually suffering avoidable sight loss. It's a deliberate choice that we've made, and I believe the health service and the people of Wales will be better off for it, and it enjoys the widespread support of both clinicians and the third sector.

Well, better late than never, I certainly acknowledge that, but there is still a very long way to go. The Minister will know that the Public Accounts Committee has been taking an interest in this area, and recently we took evidence form Aneurin Bevan health board, which noted the need for improvement on its current 62 per cent performance of risk 1 patients being seen by the target date or within 25 per cent in excess of the target date. Risk 1 is defined by the RNIB as a risk of irreversible harm or significant patient adverse outcome if the patient target date is missed. These delays are really intolerable, are they not? 

If you look at the follow-up appointments in certain health boards, there is a very significant disparity between performance. In Abertawe Bro Morgannwg, there were 5,000 people waiting twice as long as they should do for follow-up appointments—that's four times as many as two years before. In Cardiff and Vale, 10,000 people are waiting twice as long as they need for eye appointments. That's four times the position two years ago. This is something that calls for the most urgent action possible from the health Secretary, and perhaps he could tell us what, in practical terms, he's now going to do to sort the problem out.

Well, the new measures themselves are not simply an answer in themselves. They are actually about how we organise and run the whole system. It's about actually ensuring that we're able to transfer care into community-based services wherever possible, and actually Aneurin Bevan have been leading on a range of that work, to provide greater time and capacity within hospital-based services for people who need to be seen by a hospital-based clinician. So, it's about re-engineering our whole system. And actually if you talk to people within the service, and if you talk to people across the system within the United Kingdom, they recognise that we're doing the right things here in Wales and there is a challenge about how other parts of the UK catch up with what we're doing, both in local treatment within the community as well as more priority for the right people to be seen more quickly within a hospital system. That means different measures that accurately reflect what matters to the person and what should matter to all of us to make sure that the right care is provided at the right time and in the right place.