We now move on to item 5, which is a statement by the Minister for Health and Social Services, which is an update on Betsi Cadwaladr University Health Board. I call on the Minister for Health and Social Services, Vaughan Gething.

Thank you, Deputy Presiding Officer. Betsi Cadwaladr University Health Board was placed into special measures in June 2015. The significant concerns at the time centred on leadership and governance, maternity services, mental health, re-connecting with the public and primary care out-of-hours services.

Progress has been made in each of these areas. Maternity services and primary care out-of-hours services have both been de-escalated and are no longer special measures concerns. The health board has met a number of the expectations set out in the special measures improvement framework to be achieved by April this year. There have been improvements in governance and quality processes, board leadership, mental health services, engagement and partnership working, and achieving sustainable hours in general practice.

David Jenkins, the independent adviser to the board, has provided assurance that board oversight and scrutiny of delivery and performance has improved markedly. He also reports the board is now setting clear expectations and providing constructive challenge. The chair has brought new impetus with more active and constructive participation in partnership working arrangements.

Quality improvement has been a key driver for the health board under the clinical leadership of the executive director of nursing and midwifery. Concerns-related data is now available at ward level following the roll-out of the harms dashboard and harm summits to promote shared learning. There's also been significant improvements in infection rates, including a reduction of more than 50 per cent in MRSA rates. 

I've been pleased to see that recent Healthcare Inspectorate Wales reports on mental health, together with feedback from Emrys Elias, the independent adviser on mental health services, have provided independent assurance that improvements have been made to the quality of care provided, the commitment of staff, and access for patients.

Like all health boards, Betsi Cadwaladr University Health Board is collaborating with partners through local primary care clusters to transform local services. The health board is achieving positive results with fewer GP practice resignations, managed GP practices moving back to general medical services contracts, and all trainee GP posts in north Wales filled for the first time.

The special measures oversight has, however, identified other concerns across the whole system to deliver the progress needed in finance, planning and waiting-time performance. The health board has not met the expectations set out in the framework in these areas. The health board faces a significant financial challenge, but also opportunities to improve on its financial position. This has been supported by local assessments of financial opportunity and benchmarking. In 2013, a Deloitte's benchmarking exercise identified potential efficiency savings ranging from between £85 million to £125 million. A further internal benchmarking exercise in 2017 estimated an even higher level of potential saving. It is simply not acceptable that little or no progress has been made in pursuing these opportunities.

To make the required progress, I have agreed support that PricewaterhouseCoopers works alongside the health board during the first quarter of this year to improve its planning and approach to deliver sustainable financial improvement. This will help to ensure it has a more robust plan for 2019-20 and a basis for sustainable financial planning for the future. I also recognise the need for additional high calibre turnaround expertise and officials are already working with the chair of the health board to take forward the Public Accounts Committee's recommendations in this area.

The future success of the health board beyond special measures in delivering timely, high-quality services within the resources available will depend upon its ability to develop a sustainable clinical strategy. A clear strategy is necessary to underpin the board's wider vision of providing care closer to home with an increased focus on improved population health and well-being. This is also the clear view of the Wales Audit Office. Without an appropriate clinical strategy, the board will struggle to sustainably address its poor performance in planned and unscheduled care. It is also likely to remain overly reliant on locum and agency staff in trying to maintain services with associated service quality and cost implications.

Whilst the clinical services strategy is developed, I will be providing more focused support to deliver progress in waiting times, specifically in orthopaedics, urology, endoscopy and child and adolescent mental health services. To secure sustainable improvements in orthopaedic services, I have asked the NHS chief executive to intervene to ensure progress is made. Support will be provided to invest in community musculoskeletal services, expansion in the number of orthopaedic consultants with a further six posts, and to finalise the capital design and procurement process for the capital schemes across the three main hospitals.

The additional recurrent funding that I announced last July has supported increased capacity, capability and resilience across the three main hospitals. I expect the 90-day improvement cycles in unscheduled care to maintain improvements in patient flow and to start to demonstrate a sustained positive impact on other unscheduled care targets.

I expect to see significant action and progress on the outstanding concerns so that people in north Wales are assured the focus remains on making the improvements necessary beyond special measures.

I'm shocked, actually, by this statement. When you read it, if this was a health board that was going into special measures now, or had been in special measures for six or eight months, I could accept a lot of what you were saying, that it's still a work in progress, but we are talking about four long years.

I had a nice little list of things I was going to ask you about what we should be doing, or what you should be doing in Betsi Cadwaladr, but actually out of your statement leaps one absolutely shocking commentary: 'without an appropriate clinical strategy'. I would've thought that was absolutely the fundamental core business of a health board: to have a clinical strategy that delivers for their patients, that delivers for their areas, that enables their staff to do the job that they have trained to do and wish to do. For you to stand here, Minister, after four years and say that Betsi Cadwaladr health board still do not have a robust and agreed clinical strategy is truly shocking. And, therefore, I'm not surprised that the many other improvements that this health board seeks to implement and needs to implement have not been able to be implemented, because unless you have a plan, you don't know where you're going, you don't know where you're coming from and, above all, you don't know whether or not you've achieved the goals you've set out to achieve. So, this I find absolutely shocking and I would like to have much more detail from you about this clinical services strategy, about who is going to put it together, when you would hope that it will really—and I mean really, not the timescales here—be implemented, and how you're going to ensure that it is a clinical strategy fit for the people of north Wales.

The other comment that you make is that, finally—and I have mentioned this to you, and we can check the Record so you know it's there—I've mentioned to you many, many times before that transformation is a skill, it isn't a blind science, it is not an art, it is an absolute management skill, and to truly transform something in trouble, like this organisation, you need new boots on the ground, and I've asked you again and again and again: when are you going to put new boots on the ground? I am pleased to hear that you're now finally going to bring in an outside organisation to help this health board, but, again, it is four years too late and, to be frank, I would've thought that just a tiny bit of humility from the Welsh Government on this subject of this very troubled organisation would've gone a long way.

I have a couple of very quick additional questions to ask, Deputy Presiding Officer. Minister, last summer, you published a special measures improvement framework that set out milestones for the board to meet by September 2019. Now, are you really confident that these have been met, or are in the final stages of being met, or do we have to wait for this clinical services strategy? What progress has the board made with implementing the Ockenden and Health and Social Care Advisory Service reviews from last year and how confident are you that mental health services have improved, then, because I note that your statement talks about CAMHS, but it doesn't actually talk about adult mental health services? You've mentioned NHS England's experiences with trusts in special measures previously—what best practices have you looked at to bring forward to help move this trust forward?

And, finally, I have lots of questions, but I'm very aware that the Welsh Conservatives tabled a motion last week to talk about the fourth anniversary of Betsi Cadwaladr being in special measures tomorrow—so I'm not entirely surprised, I suppose, that this statement has popped out of the blue today—but, again, in your statement, you do mention that you have stemmed the losses of general practitioners. But let's be very, very clear: there are precious few general practitioners now left in north Wales. What do you believe the 'Train. Work. Live.' policy is delivering there? Do you think it's keeping up with that demand, especially as training places for GPs are now oversubscribed? And do you think that, given that we have such a dearth of general practitioners—there's a real shortage in north Wales of GPs—and are you confident that Betsi's out-of-hours care will be fit for purpose in the coming years? The rest of the commentary I have on this statement and on Betsi in general and on the Welsh Government's handling of this poorly performing health board I will reserve until tomorrow afternoon.

Thank you for the comments and questions. It's good to see you back in the Chamber, Angela; we have missed you. I should point out—and you haven't been here for some time, and I really am pleased to see you back—we've had this on the business statement for some weeks that I would be making a statement today; it hasn't been produced as a strategic attempt to try and spike the debate tomorrow, and it's entirely appropriate for the Government to be making a statement in the week of the fourth anniversary of this health board going into special measures. It is an unusual length of time. The Medway NHS Foundation Trust in England was in special measures for just under four years, Barts Health NHS Trust in England was in special measures for just over four years on quality grounds and is still in special measures on financial grounds. So, it is unusual within the UK setting, and we've never tried to hide from the fact that that is the case. I've said before, and I say again at the start, before dealing with your points—to come out of special measures, the health board has to show not just progress, but show a level of confidence about its ability to sustain that progress and still continue to improve. And the framework that I've set out previously has been designed to show clearly the areas it needs to improve upon, and show real and sustainable progress. But the independence of the advice that I receive before I then have to make a choice—it's not someone else's choice; it is still my choice—comes from that tripartite process involving the NHS Wales chief executive, the Wales Audit Office and Healthcare Inspectorate Wales. The points that I've made on the progress that has been made come from the independent sources around the board, not the board marking its own homework. So, the points that you make about mental health services and out-of-hours—out-of-hours is no longer a special measures concern because of the advice that we've had about the sustained improvement that has been made. Indeed, the comments that I made in my statement, not just about CAMHS but about adult mental health services—again that comes from the feedback both from NHS Wales Informatics Service alliance and also Healthcare Inspectorate Wales, and I pointed that out in my statement too.

On your broader point about when we'll see the progress, well, actually I can't tell you now where exactly the board is, given that I'm waiting until autumn 2019 to see how much progress has been made against the framework. That's what I said—I'd form a judgment on the work that they've done, but, obviously, the progress they've made through that time will be considered when the tripartite escalation meeting takes place in its normal time frame over the summer.

Now, when it comes to leadership, there has been a significant change in the executive team, and indeed in the independent board members, since the health board went into special measures. The chair and the vice-chair are different, and I think there are six different independent members and eight different executive members. So, it's been a real turnaround. We've now seen that the finance director has left the organisation. We're recruiting a new medical director, and that's a key post for, actually, the ability to deal with the clinical services strategy. Because, actually, in west Wales what we've seen is that having a strategy is not something that is done in a quick and easy manner—you have to bring your staff and the public with you, and even then, with lots of investment and time to do so, it is something that is still controversial, where people always have a view on whether they want to see that happen, because it requires you to look at the way you deliver services now and the way you want to deliver services in the future, and that requires change and reform. But without that, the board will only be able to go on on a year-to-year basis, so it's a longer term objective that they need to make progress towards. But on the progress they do need to make in the here and now—on turnaround, we are looking to have new people come in. That's what I signalled in my statement. The Public Accounts Committee have made clear their view, and, in fact, it's a fortunate coincidence in terms of the position the Government and the health board are already in. The chair had recognised that already. There've been conversations with Government on improving the turnaround function, having external advisers' support to do so, and the Public Account Committee recommendations reinforce the need to do so.

Your final point was about general practice in north Wales. I'll have more to say generally about general practice and our ability to train and recruit staff in general practice in every part of Wales, but in north Wales the picture is much more positive. We have not just filled all three of the training schemes in north Wales—we've overfilled two of those, and I've announced earlier this year that there is the capacity to overfill across Wales by at least 24 places. I'm looking to reset our ambitions and our capacity to have GP training here in Wales, following advice we've had from Health Education and Improvement Wales, but I'm making a statement on that in the coming weeks, before summer recess.

I'd also like to begin, as the Minister has done, by welcoming Angela Burns back to the Chamber. We have certainly missed her contribution here and on the Health and Social Care Committee. It's good to see you looking so well.

I begin by associating myself with much of what Angela has said in her introductory remarks; there's no need for me to repeat them. But I am a little bit surprised that, in his response to her, the Minister refers to examples of health institutions in England that continue to be in special measures for a very long time. Now, it's my understanding that we have a very different system here in Wales, a system that I think the Minister would probably agree with me ought to be better, and a system that very certainly does give the Welsh Government much greater control over health institutions in Wales than the English Government has over institutions in England. So, I would put it to the Minister that it is little comfort to me, I am afraid, for him to tell me that there are institutions in England that are doing just as badly under Conservative Ministers in their attempt to recover, as the Betsi Cadwaladr board is doing or not doing under him.

I am grateful for the opportunity that we'll have to discuss these matters in more detail under the motion that the Conservatives have tabled tomorrow. A couple of the points that I want to raise with the Minister—I wouldn't necessarily expect him to have the facts at his fingertips today, in the point of quite a general statement, but I would be grateful if it was possible, perhaps, for some of those points to be referred back to when he responds in the Conservative debate tomorrow.

I'm going to structure my questions as briefly as I can, Dirprwy Lywydd, because I'm aware that we've had a long afternoon already, around the five aims, the five issue, that brought Betsi Cadwaladr into special measures in the first place, and the first of those is governance and leadership. I wonder if the Minister shares my concern that, this far in, financial issues are still in such a grave and, I would say, parlous state in the board. I hear what the Minister is saying about the steps that he and his officials are taking to attempt to improve this, but, four years in, I am concerned that the problems must have been pretty deep-rooted if he hasn't managed to improve them yet. Specifically, I'd like to know a little more about the cost of all of this, and particularly the intervention of PricewaterhouseCoopers. I welcome that he's bringing external expertise in if that's what's needed, but that, of course, will not necessarily deliver sustainable change unless something is being done at the same time to build up the financial capacity and financial planning capacity within the board itself. So, again, I'd be grateful to hear from the Minister what steps he and his officials are taking to ensure that that financial capacity is built up, not only at the top where it's obviously crucial, but further down the health board where people are accounting for smaller units, because there is the saying in Welsh: diwedd y gân yw'r geiniog—at the end of every song, there's always the penny to pay. And in the case of Betsi Cadwaladr, unless the financial issues can be resolved, other issues will continue to be a real challenge. I would agree with everything that Angel Burns has said about the need for a plan, but, again, we can return to that tomorrow.

So, I'll turn briefly to mental health. Now, the Minister will be aware, because of correspondence that I've shared with him, about some real concerns that are continuing to be brought to me by constituents who live in the Betsi Cadwaladr area about aspects of adult mental health services. He mentions some clear improvements. He was provided independent assurance that clear improvements had been made about the quality of care provided, commitment to staff and access to patients. I profoundly hope that he's right about this this. Some of the evidence that's come in to me, albeit anecdotal, suggests that he may not be entirely right about that, and so I'd be grateful if the Minister can tell us either today or tomorrow: what are the matrixes that are being used to judge those improvements? What's the baseline? How are we judging that improvement? And where is the voice—in making judgments of that improvement—of patients, patients' families and carers? I think that's absolutely crucial.

The Minister mentions in his statement that there is further work to be done around access to child and adolescent mental health services, and, again, I'd be grateful for some detail, either today or tomorrow, about what exactly those improvements are, because, again, certainly, my constituency case load suggests that there are terrible issues with regard to access, and I've got a particular concern about access to services through the medium of Welsh, which is absolutely imperative in this area. And that's not about, simply, a person's right to receive services in their own language, but we know that people are more likely to recover, particularly around mental health areas, if they do have those service available to them.

I want to refer now to aim 4—the GP services and out-of-hours—it's good to hear that the Minister is confident that he has been able to de-escalate those. Again, I would share some of the concerns that Angela Burns has raised about the long-term profile, but the Minister has already said, of course, about the issue around training places and that is very positive to hear. I wonder, given that we haven't been able to find any public, published statistics on out-of-hours availability—and it may be that my research in this has been inadequate—whether the Minister can provide us with some more detailed information about how and on what basis he is actually confident that the out-of-hours availability has improved, because we obviously know that the knock-on effect into secondary care, if the primary care out-of-hours service is not sustainable, is serious.

I would like, then, in that context, to briefly refer to the difference in performance around emergency care in the hospitals across the area. Is the Minister confident that those disparities are being effectively addressed now by the board, and can he tell us a little more about how that is happening and when he would expect to see the other hospitals in the area coming up to the standard of Ysbyty Gwynedd?

And, finally, in terms of the fifth objective, which, of course, was restoring confidence of the local population—I hope the Minister will take from me as one of the representatives of the local population that there are still real issues with confidence. And one issue that's of particular concern to me is of my constituents in the west of the area who feel that the current board does not understand their communities, does not speak for their communities, quite literally does not speak their language, and that is important in itself. And when services are being 'rationalised', they are being rationalised on the basis of where the hospitals are, not on the geography of the whole community. I would like, in all good faith, to ask the Minister to have some discussions, or appropriately for his officials to have some discussions, to ensure that when services, planned services are taken—. Services—. Plans to change services—it's been a long afternoon, Dirprwy Lywydd. When plans are being considered by the board, that they do take into account the whole geography of the region and not just where the hospitals in the region lie. Because there is a sense, and I'm not saying that it's justified, but it comes across clearly to me when I'm in that part of my region, that, when we're talking about moving services, we're moving them to a central point in terms of where the hospitals are, not a central point in terms of where the people live. And in terms of restoring that confidence, Minister, which was one of your aims as you took the board into special measures—in terms of restoring that confidence in the west of the region, it's absolutely crucial that those people need to have a sense that the board and that you understand the geography of the area well enough to know that it's a very, very long way away from Dolgellau to Wrexham. Thank you, Dirprwy Lywydd.

Thank you for the comments and questions. I think there was a slight misunderstanding at the start about the comments I was making about four years. I was making the point it is an unusually long period of time to be in special measures. I'm giving two and only two examples of health organisations that have been in special measures for a similar period of time. It's not a badge of honour; it's a marker of how unusual it is to be in special measures for this period of time. 

In terms of the comments about the various areas that led to the health board going into special measures, I think it's undeniable that there has been a significant improvement in leadership and governance. That is not just the view that I take in my ministerial office, it is not just a view provided by David Jenkins in his work around the board, it's also the view we have from independent commentators, from partners, from engagement with the health board, and it's not just about the new impetus the new chair has provided, although that has been a very visible step forward in the leadership of the organisation, but it is the visible scrutiny within the organisation about decision-making choices, and that is a good base for them to move forward upon. 

I don't think there's a direct link necessarily between leadership and governance and finance challenges. The progress we've seen in the last year has actually highlighted some of the unacceptable performance in the finance function of the health board, and I'm looking for a new amount of work to be done around the finance function, that's why I have supported the chair's request for the additional work around PricewaterhouseCoopers, but it's also why the NHS finance delivery unit are engaged and involved around the board as well. So, it's not a laissez faire, just go and make it work approach, but we do expect the board to have a different approach and a different achievement in terms of finance function. It was not acceptable. It was the only board within Wales that was not able to live within its control total in the last year. It overstepped that. I expect it to make progress to live within the control total within this year. I then expect it to move on to a position where it lives within its means and not within a tolerated deficit. 

In terms of access in mental health services—again, this comes directly from work done by the healthcare inspectorate, it comes from the work of the independent adviser, Emrys Elias, who I referred to in my statement—there has been a real improvement in access times in both CAMHS and adult services. That does not mean the service is perfect. It does not mean that you or any other representative within north Wales will not have people come to you with legitimate stories where they're still waiting too long. But it does show that real improvement is being made, and it's the further amount that still needs to be done, but the scale of that has significantly reduced over the period of time within special measures. Indeed, the health board has had some praise for the way in which it's involved service users in redesigning the mental health strategy in a way that simply did not happen in the past. That is part of the base upon which I think there are good grounds for further improvement within mental health services. 

On out-of-hours, they were de-escalated quite a long time ago now. In fact, before you returned to the Assembly, out-of-hours services were de-escalated as a concern and are on a par with other services across the rest of Wales. I'm actually looking at the roll-out of 111 as part of our out-of-hours services, and also the role that may play as a model for some of our in-hours services as well. So, we're looking to transform and change the way that part of our system actually works, not just within north Wales but beyond that too. 

On unscheduled care, the 90-day improvement cycles are the key improvement method currently being used within the health board. It's stabilised; in fact, there has been some improvement, but actually the challenge is over the next quarter to see much further improvement, because if every part of the health board performed at the same level as Ysbyty Gwynedd, that would mark a significant improvement on where the health board is overall now. But, actually, the whole organisation still then needs to move further and beyond that too. That's partly about models and ways of working, is about the clinical leadership, but it's also about the services outside of emergency departments too, and the link into social care and the linkage across the whole system and, actually, the improved partnership working provides a much better basis to do so as well. 

In terms of your point about the geography of north Wales, I've been well aware of the geography of north Wales for some time. When I was a boy, going to different parts of Wales on holiday, my father was very keen to make sure we saw different parts of the country. We have this conundrum not just within north Wales but across the country. And if you think about the parliamentary review measures, some services will be specialised and concentrated, and we will ask people to travel further for better care. The counterpart, though, is that we'll also have more services being delivered in a more local setting. That requires us to invest in those local settings. So, in the recent past, we've invested in new models of care with significant capital. In Alltwen, in Towyn and Blaenau Ffestiniog, as examples, we're providing different services in a different and modernised way to deliver healthcare. So, you'll see both those things happen within north Wales and across the rest of Wales to deliver more care closer to home, but, for some services, they will be specialised and will deliver better care in fewer centres.

Mandy Jones.

Thank you, Deputy Llywydd. Angela, welcome back as well. We have missed you. It's great to see you. 

Minister, we are rightly proud of the NHS. We're envied by many other countries for having a health service that is free at the point of use. I'm sorry to be stood here today once again listening to a statement from the Minister whose first responsibility is oversight of NHS delivery and performance. In the case of Betsi, though, it's more than this. As the Welsh Government, you, Minister, have taken over the running of certain aspects of the health board's operations via special measures. This health board has been in existence for only 10 years, so that means it has not been performing as expected for at least 40 per cent of its life, so it seems to me that special measures is more like business as usual. I welcome the areas of improvement you mentioned in this statement. However, after four years, surely some sort of deadline for the ending of special measures should be forthcoming. Today's statement sounds and feels very similar to the last statement you made, and the one before that, and the one before that. We're getting really into this now. I'm interested to know when will you take decisive and positive action to make real change happen.

This statement is silent on the deeply concerning recruitment crisis for medical professionals and support workers in the region. And I wonder what analysis have you done as to the effect of the headlines around the health service in north Wales on recruitment. I think the recently published Public Accounts Committee report on governance lessons learned is really very concerning, in that it appears to me, despite numerous inquiries over the decades, that lessons are not actually being learned. More than anything, I'm concerned about the human cost of the challenge of this health board. Literally thousands of people are waiting far too long for surgery, well over the target times, whilst their health (1) deteriorates still further, (2) they are in pain, (3) they're not able to work, and (4) they're not able to look after their families. Please, Minister, please tell me and them how they can take comfort from this statement and have confidence in your stewardship of the Welsh NHS. 

Thank you for the comments and questions. I want to reassure not just the Member but the wider public that special measures are not business as usual. This is about seeing the health board improve and move beyond special measures. And, as I have said repeatedly, I'm not going to set an artificial deadline for special measures to end. That would be an act of convenience for me but absolutely the wrong thing to do for the public and for our staff. Coming out of special measures has to come on the basis of advice that allows me to say it's the right thing to do for the organisation. That advice from the Wales Audit Office, from Healthcare Inspectorate Wales and the NHS Wales chief executive is hugely important, otherwise our escalation process is meaningless, and it's simply about the convenience of action for politicians around electoral cycles rather than what is the right thing to do for the service and the right thing to do for the public.

In terms of the recruitment challenges we face, I've mentioned a number of these within the statement and in the conversation I had with Angela Burns about GP numbers and the work that we're doing. The success of 'Train. Work. Live.', compared to other parts of the UK, on GP numbers is a real positive for us as well. The fact that we're seeing a number of those managed practices that are now ready to go back as independent contractor models as well, that's a real positive—the fact that we're having a recruitment campaign around pharmacy, around nurses and around therapists as part of the allied health professions too, so we're being active in recruiting people, as well as the investment we continue to make in training the next generation of healthcare professionals here in Wales.

In a time of challenge, we continue to invest more in the training of not just doctors, with additional training places in north Wales as well, but in terms of other healthcare professions as well. So, I think we have lots to say, and within the statement, of course, I outlined the additional work that's being done on orthopaedics—the six additional posts that we're funding, the work that we're doing to make sure that there is a plan and not to simply wait for competing interests in north Wales to come up with a plan at some distant point in the future.

So, intervention is taking place. There is more that has happened because of our intervention, and I look forward to seeing more happen at greater pace, because my ambition is for this health board to come out of special measures because it is the right thing to do, because it has made real and sustained progress with and for its staff, and with and for the people of north Wales it serves.

And finally, Darren Millar.

Thank you, Deputy Presiding Officer. Minister, can I thank you for your statement? I share your ambition. I want this to be a health board that has turned around in terms of its performance and to be the best-performing health board in Wales and, indeed, the whole of the United Kingdom, if at all possible, rather than consistently for many things—not all, but for many things—being at the bottom of the UK league table, and certainly at the bottom of the Wales league table.

I would ask you this fundamental question, though, and I think it's one that many people are starting to ask me, now, and that is: special measures—is it a help or a hindrance? Because I'm not sure the special measures arrangements in Wales, which are different than they are over the border in England, are working well. I think that—you know, the information and the feedback that I get from clinicians, from non-exec directors and others is that, sometimes, because of those special measures arrangements, it takes a long time to get decisions through the health board when, sometimes, there needs to be rapid action in order to sort things out. 

I was pleased to hear you make reference to the fact that you've recently signed off the investment in community musculoskeletal services, an expansion in the number of orthopaedic consultants and some capital investment around that. But it's taken over 18 months for that capital programme to be signed off by you, as a Minister, and I don't know whether that's a problem because your officials haven't brought it to your attention sufficiently well—I've no idea how your systems work within Government. But it's taken an extraordinary amount of time. And, of course, we know that the six orthopaedic consultants are largely because of the tragic circumstances that saw a regulation 28 prevention of further deaths order in relation to the Megan Lloyd-Williams case—the Flintshire lady, 77 years old, who broke a hip in September last year and ended up, unfortunately, passing away when she shouldn't have passed away had she got the quality of healthcare that she should have been provided. 

It concerns me that it takes an event like that—a 'never' event—where there's tragedy in a family and a lady losing her life in order to see people sign on the dotted line so that the plans for improvement can actually get the finance that they need. It's a concern to me that, for example, the national hip fracture database puts Glan Clwyd Hospital, Ysbyty Gwynedd—and I heard you saying that we should aspire to be everything like Ysbyty Gwynedd, but it puts that hospital as well, and Wrexham Maelor, in the top 10 worst performing hospitals on that database in the whole of the United Kingdom, out of 176 hospitals. That concerns me, and I want to see this situation turn around.

Now, there has been some progress; I acknowledge that. There was progress in maternity services, largely because 10,000 people marched on the streets in Rhyl—myself and the Deputy Presiding Officer included—to campaign for a new special care baby unit in north Wales. I'm delighted that we secured that investment—that was the right decision, and I fully supported the First Minister in making that decision.

I acknowledge that there has been some improvement on the GP front as well. I've seen it in terms of some of those practices that were at risk and no longer at risk. But, of course, we've still got a number of GP practices that have shut their doors once and for all, tens of thousands of patients having to face the upheaval of registering with new GPs or being transferred to new GPs. And whilst I accept that you've got some coming back into general practice, rather than being health board managed, the fact is that Betsi's got more health board-managed GP facilities than any other part of the country, and that still concerns me.

I took a visit to Wrexham Maelor Hospital yesterday to visit the emergency department, and I have to say a more dedicated team you will not find in our hospitals. But they were telling me about some of the pressures. When I arrived there, 10:30 in the morning, the longest wait in that department was 11.5 hours, and by the time I left it was 3.5 hours because of the hard work of people trying to make sure that people were getting the flow through the hospital. But I was concerned to hear that on some of the GP out-of-hours services, which you've taken out of the special measures programme, there were still gaps in rotas in parts of north Wales. Now, that's not acceptable. I can't understand how you seem relaxed about the situation with GP out-of-hours services, when they're telling me, the front-line staff, that there are gaps in those GP out-of-hours rotas. That concerns me. 

You made reference to the change at the top of the organisation, and there has been a lot of change, but it seems to me that it's continuous churn. You know, the finance director's leaving, the medical director's also in the process of departing the organisation. We were informed by you in a statement in this Chamber just last year that a turnaround director had been appointed. Of course, it was one of the previous acting chief executives of the organisation, on whose watch a lot of this mess that we're trying to mop up had been caused. We said it was the wrong person for the job at that time—

Are you coming to a conclusion? Because you are the second speaker and you've had more than five minutes. 

I appreciate that, but I think it's very important for us to have some confidence, because we want to give our constituents confidence, that there are people who have the ability to turn the organisation around, and that your department has the capacity within it to cause the sort of sea change in this organisation that we need to see. I could go on about many other aspects—

No, I don't think you will. I don't think you will. 

I accept that. I know there's still time on the clock. But I would urge you and implore you to have a look at your internal systems and arrangements within the Welsh Government, because I'm not sure—I think they're part of the problem now. I don't think they are part of the solution. 

Minister, you have under five minutes to respond, because I will cut you off at 45.

Thank you for the series of comments and questions. I will endeavour to deal with all of Darren's comments and questions within the time allotted, Deputy Presiding Officer. 

I would gently say that the link to the unfortunate patient death that he described and the six additional posts—there is not a direct link to be drawn in the way that the Member tries to. Since my time at the start of this term as a Cabinet Member for health, I've had discussions with orthopaedic surgeons in varying and competing groups across the three sites, bringing them together with the health board to look at a proper plan for orthopaedics. The challenge is about getting to the point where we're able to get behind a plan to invest in the service that all the sites are actually agreeing with. Now we're in a better place, and that's why we're able to deliver increased investment in that service. We recognise it is absolutely required.

And capital choices do take time—the process that we need to go through to make sure we're investing in the right part of the service—and it's part of my frustration that we're not able to do that more quickly than we are. Actually, I don't think special measures is an answer for a delay in capital choices; it's actually about the health board having clarity in the choices it needs to make together with its staff, to have agreement on what it could and should invest in. And I'm keen to make sure that special measures is an aid to doing so, not a hindrance, because part of the challenge is whether an organisation feels that it can make choices that it really could and should do, and that's part of the challenge about having the special measures oversight to make sure they are continuing to make choices.  

On your point about maternity, the investment in the SuRNICC is of course welcome, but actually, the reason why maternity services came out of special measures was a significant cultural change in the way that department operated—a change in the leadership at midwifery level, in particular, and a change in the way that staff actually worked together. That was the biggest factor in improving maternity services across north Wales. That change has been sustained as well, and that's a real positive and it does show for the organisation that it has and it can improve services and sustain that improvement so that staff feel valued, and, actually, the patients, the people they care with and for, feel valued and receive better care as a result. 

On your points about general practice, I would just remind you again that no person has been left without a general practitioner, and it is almost always the case that the care is delivered initially from the same place they're always used to. We will see, though, a change in the way that general practice is delivered. It will mean that we'll have larger groups of general practitioners, other GPs working for other GPs, in much the same way that most lawyers are employed by other lawyers in law firms. But I do think we also need to see that as a positive to move people into a place where their care will be delivered in a local community but in a purpose-built and fit-for-purpose setting. That's part of what we're doing in investing in the primary care estate across Wales.

And I'm glad that you did go to Wrexham emergency department, because they are a committed group of healthcare professionals struggling and coping with real challenges that come through the door. It's much easier to be a politician, frankly, even in this job, than it is to go and work in an emergency department in any of our hospitals in any part within the United Kingdom, not just in Wales. And it really does highlight the challenges across our whole system, not just at the front door. That's why I place so much emphasis, in the conversations I've had with partners across north Wales, on delayed transfers of care, on that as a barometer for the health of the whole system, health and social care together, and why we do need to reform and restructure primary care to make sure we have more capacity outside of the hospital, so people don't need to go in there unnecessarily. That, I think, will significantly improve the way that people deliver care and, actually, the way that people can be proud of the care they deliver, and that people continue to value and have real faith and confidence in our national health service. And I look forward to the health board in north Wales coming out of special measures and continuing to demonstrate it deserves the confidence and support of the public, and is a service that all of us here should be proud of. 

Thank you very much.