The following amendment has been selected: amendment 1 in the name of Rebecca Evans.

The next item is the Welsh Conservatives' debate on Betsi Cadwaladr University Health Board. I call on Angela Burns to move the motion. Angela Burns.

Motion NDM7058 Darren Millar

To propose that the National Assembly for Wales:

1. Notes that 8 June 2019 marks four years since the Betsi Cadwaladr University Health Board was placed into special measures.

2. Further notes that ministerial oversight of special measures arrangements at the Betsi Cadwaladr University Health Board has consistently been with the current health Minister.

3. Regrets that the Betsi Cadwaladr University Health Board still has significant improvements to make in its mental health services and its governance, leadership and oversight, in spite of spending longer in special measures for these matters than any organisation in the history of the National Health Service.

4. Calls upon the health Minister to accept his responsibility for failing to deliver the required improvement at the Betsi Cadwaladr University Health Board over the past four years and resign.

Motion moved.

Diolch, Llywydd. I'm grateful to have the opportunity to open this debate today marking an anniversary that none of us wanted to see. Minister, you and your predecessor, now First Minister, have presided over four years of Betsi Cadwaladr University Health Board in special measures. Not only has this board spend the last four years under the management of your Government, but, as we heard in yesterday's statement, we do not seem to be any closer to a clean bill of health being declared and the health board being able to stand on its own two feet once more.

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

Residents of north Wales, under the care of Betsi Cadwaladr, are spread across a huge area of the country, making up 23 per cent of the entire population of Wales. Despite this scale, patients suffer the worst A&E waiting times in the country, the highest number of reported patient safety incidents and an almost crippling shortage of GPs, midwives and community nurses.

Now, the Welsh Conservatives have brought this debate forward on the week of the fourth anniversary not to further demoralise the hard-working staff who are under considerable pressure, but to try and get some tangible answers as to what progress has been made in the last four years, whether lessons have been learnt, and most importantly, whether the reasons that were given for these special measures have been addressed.

The statement provided by the Minister yesterday on this same subject painted a far rosier picture than the reality of patient experiences and what we hear from staff. Whilst I accept that some positive actions were taken and improvements have been made, yesterday’s statement seemed to correspond more to a health board that had only recently entered supported status, and not one that’s been in special measures for four years—the longest period that any board or trust has been in special measures for concerns around their services, leadership and governance arrangements anywhere in the UK.

I want to revisit 8 June 2015, four years ago, when the board was initially placed in special measures by the health Secretary of the day and his deputy—today’s current Minister for health. The written statement, issued by the Welsh Government, centred around the following aspects of the board’s operation: governance, leadership and oversight; mental health services; maternity services at Ysbyty Glan Clwyd; GP and primary care services, including out-of-hours; and reconnecting with the public and regaining the public’s confidence. I was hopeful that the statement yesterday would provide some answers to those initial concerns, and perhaps recognition and a little humility from the Minister for health that these reasons for special measures have still not been resolved. What the people of north Wales really want to know is whether their health board has turned the corner, and, Minister, from all the evidence available, the short answer is 'no’.

The past four years have seen 13 written statements by the Welsh Government, three external investigations, and millions of pounds of taxpayers’ money invested in the board. Maternity services did emerge from special measures in 2018, but only after a reversal of the decision to close the services provided at Glan Clwyd in July 2015, which managed to unite politicians from across the Chamber, given the foolishness of the health board’s plans and, of course, consequently, it did a great deal of damage to the public reputation of the health board.

Out-of-hours care followed maternity services, and this is to be welcomed, although you must recognise, Minister, that out-of-hours care is not stable given the shortage—the chronic shortage—of GPs in north Wales. And the GPs are saying this, not just me.

However, mental health services and financial governance remain in special measures, and a report from the Assembly’s Public Accounts Committee stated that the senior management team admitted that the board would not be on a truly transformational journey by 2020.

When it comes to the fifth reason for special measures—reconnecting with the public—then it is much harder to judge. Given the years of spin, confusion and poor consultation exercises, the wounds will take much longer than four years to heal between the board and the public. As, again, the Public Accounts Committee identified, placing the board in special measures has become the new normal. Progress is unacceptably slow and the Welsh Government intervention has had little practical impact.

Minister, progress has been made in some aspects of the failings of this health board, but some of the original issues remain unresolved. In your statement yesterday, you said, and I quote:

'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.'

So, on the one hand, you say that there’s been headway made, but with the other hand, there are new problems rising rapidly, with no obvious solutions in place. It’s concerning that it’s taken four whole years for these issues and concerns to be identified.

Now, my colleagues will focus on some of the more specific aspects of the failings of the management of this health board, but I want to turn my attention to what special measures or Government intervention actually looks like in Betsi and what it should look like. Because under your stewardship, Minister, five of seven Welsh health boards are working under some form of Government intervention. Now, Betsi Cadwaladr obviously gets the most attention due to the length of time it's been in place, but we should not ignore what's happening in other parts of the country.

What is not clear to many outside of this Chamber is what happens when a health board is placed under special measures. In Wales, the Welsh Government, Healthcare Inspectorate Wales and the Welsh Audit Office work together to identify and respond to serious issues that affect services, quality, safety of care and organisational effectiveness. Actions can, but not always, involve placing key individual specialists or people with turn-around experience to provide support settings, actions, milestones and an improvement framework. Welsh Ministers are also able to suspend or remove powers and duties from Members of the health board, or to direct a health board to ensure that functions are performed by a specific person.

In Scotland, their special measures encompass a five-stage process, ranging from surveillance to formal recovery plans, with the ultimate sanction, at stage 5, for the Scottish Government to dismiss or appoint senior leadership of a board, such as they bravely did in NHS Tayside in 2018. In England, there are five types of action that can take place, ranging from the appointment of improvement directors to the removal of freedoms that some NHS foundation trusts have compared to other NHS organisations.

An innovative approach in England has been the buddying system, which acknowledges that some trusts in special measures can suffer from insularity, therefore it is essential that trusts look outwards as they seek to improve their quality. This was first introduced in 2013 and recognises how trusts can understand how other trusts approach their operations. They can learn, they can benchmark, and quality improvements come through. Buddying with another trust has often proved very valuable, but it does require commitment from both parties. It helps to define the specific terms of reference for the relationship, for example a specific clinical areas or speciality.

There are a number of case studies I would love to raise with you demonstrating best practice, because the length of time it's taken to introduce some of these measures makes me realise that you have not gone out and looked at best practice around the UK. I just want to highlight the case of one, Wexham Park Hospital in Slough, where problems were identified in 2014. The Care Quality Commission described a culture of 'learned helplessness', and I think we can say that identifies closely with Betsi, and changing this was made a priority for the new leadership team. The focus was on putting patients at the heart of everything, asking staff to treat them as if they were their own family members. An external view of what looked good helped to change and challenge ingrained behaviours, allowing the hospital to make significant change to the culture in a relatively short space of time. 

I'm not saying that all the answers lie over the borders, but I do want to ensure, Minister, that you look at the best practice that is out there to acknowledge that there are other systems in place. I also understand that in Wales we couldn't possibly buddy up because we'd only have two health boards and they would crash under the weight of the five. But we could ask Scotland and we could ask England for their advice and support.

Yesterday, in your statement, you acknowledged that a transformation team was needed, and this is a point I've made on repeated occasions. I acknowledge that you've finally decided to engage PricewaterhouseCoopers to help deliver substantial financial improvements, and, again, I applaud this. But why has it taken so long—four years? 

I'm not just going to say to you how awful I think this whole process has been managed. I want to give you some help. This is what the Welsh Conservatives would do: we would draught in help from experienced change managers working in the NHS throughout the UK to help drive those changes forward. We would implement robust and independent consultation and feedback events to engage and empower staff, to help them identify areas of concern free from external pressures. We would underpin the areas that have shown such devastating failures of performance and provide them with day-to-day management support and funding to improve.

We would look at rationalising the management structure, devolve the power to the lower levels of management so decisions can be made quickly, and green shoots of promise can be encouraged to grow and people feel empowered to make the difference that's so desperately needed. And—something Welsh Government seems so reluctant to do in so many health boards—we would review the core competency and skills of senior management to ensure that the right people are in the right jobs.

Minister, I would like to close my contribution—. Chamber, I would like to close my contribution with a little bit of reflection. It's disheartening to remember that this struggling health board is named after Betsi Cadwaladr, a famous nurse who treated the wounded soldiers of the Crimean war. Born in north Wales, her courage on faraway battlefields inspired visions of a legacy of health provision for the people of her homeland. I only hope that, in her memory, it won't be long before the spirit of her legacy can be properly honoured again. The staff of the health board have this spirit. They just need the leadership to fully release their potential. Perhaps through proper leadership, which borrows just a little of Betsi's famous courage, this vital resource can be restored again for the people of north Wales. And, Minister, if you do not have the courage to provide this leadership, then make way for someone who does.

Thank you. I have selected the amendment to the motion, and I call on the Minister for Health and Social Services to move formally amendment 1 tabled in the name of Rebecca Evans.

Amendment 1—Rebecca Evans

Delete points 2, 3, and 4 and replace with:

Recognises the progress made in the initial areas identified as concerns in 2015 and the continued focus and improvement required for de-escalation.

Notes that any decisions on changing the escalation status of Betsi Cadwaladr University Health Board will be taken after receiving advice from the Wales Audit Office, Health Inspectorate Wales and the NHS Wales Chief Executive.

Amendment 1 moved.

Formally.

For over 154,000 people in Flintshire and over 675,000 people across north Wales, Betsi Cadwaladr health board provides life-saving operations, cares for our most vulnerable and elderly, supports our friends and families through the trauma of death, whilst also supporting mothers and fathers bringing new life into this world. So, Deputy Llywydd, I'd like to start by acknowledging that and thanking every single NHS staff member across Wales, across the UK, for their work and the leadership they show in their communities, as well as the part they play in the health and social care service.

I know, as other Members across this Chamber who represent north Wales will know as well, that the care that many of our constituents receive from the health board is up there with the best. When I speak to certain patients and my own constituents, many tell me that they have received excellent care and of the professionalism of the staff members. But I also have too many who turn to me for help having been let down. Firstly, I think the health board has made some very positive steps by recognising the risks to its performance, namely the failure to maintain the quality of patient services, maintain financial sustainability, develop plans and reconnect with the wider public.

When constituents get in touch with me, it's more often than not relating to GP out-of-hours, primary care services, mental health services and ambulance response times. So, touching briefly on primary care, I know that, in my constituency, the issues are recognised and that more does need to be done to ensure a sustainable primary care workforce. Equally, on GP out-of-hours, I know there has been significant investment and that performance is comparatively good when viewed with the rest of Wales, but Members for north Wales will also know that several challenges remain in relation to the workforce, performance, risk management and finance of such services.

Members will also know that I've spoken a lot about new technology and how that can assist our public services in the future. Deputy Llywydd, I genuinely believe that if we are bold and brave enough, Betsi Cadwaladr is well placed to lead on the new technology, and will benefit from doing so, whether that is letting them lead on certain technological trials or by using more online services to reduce the pressure points within the GP services.

On mental health, which is, of course, one of the most personal issues for me, I know the significant scale of the ongoing challenge to improve those services across north Wales. The Minister will know that, since I was elected, I've had a lot of casework on mental health, and I particularly look forward to his reply to my recent query on the availability of dialectical behaviour therapy in north Wales, something that will help many of my constituents.

Finally, on the issue of the health board's make-up as it is—because I know this has been a controversial topic of discussion in the past, but, from the correspondence I continue to receive and the meetings that I have had, I believe it would be wrong to shelve completely the idea of reorganising Betsi Cadwaladr. For me, any change needs to weigh up the evidence—not political, but clinical, and led by professionals. At the same time, we need to make sure that any such changes wouldn't have unintended consequences or impact on the difficulties it already faces. Ultimately, our goal should be ensuring Betsi Cadwaladr health board gets out of special measures and regains the confidence of those who feel let down.

I'll finish my contribution shortly, Deputy Llywydd, but I'm also very keen to ensure that patients across north Wales, particularly my constituents, continue to be able to receive cross-border services, just as we are happy to welcome English patients to Wales. But I want to take this opportunity to say thank you for bringing everyone together, because we shouldn't be using the health service and debates about the health service as a political football, but we should speak openly and honestly about the issues whilst respecting the hard-working NHS staff. That is the way I see change and it's the way we all need to see change. Diolch.

May I express my gratitude to the Conservatives for bringing this motion forward today? This is not, as Angela Burns has said, a situation that any of us would wish to find ourselves in, and this impacts, of course, very directly on a great many of my constituents in the west of the Betsi Cadwaladr area.

I'm really concerned that we get from this Minister a lot of complacency, a lot of 'everything's going to be all right'. I've been looking back through the six-monthly reports—they are full of assertion and they are not very full of evidence. And I just want to highlight a number—very briefly—of issues that are publicly evidenced. Waiting times have not improved since special measures were introduced and have only shown improvements in early 2018, when it was highlighted as an issue in Plenary again. The A&E system still consistently performs worse than the Welsh average, and the performance of two poorly-performing hospitals drag down the performance of a good one. Cancer waiting times show that, at the start of special measures, Betsi was actually performing better than the Welsh average and now performs worse than the Welsh average and there's been a 5 per cent decrease in the number of GPs in the Betsi Cadwaladr area over time, though I do accept what the Minister said yesterday about there being alternative services directly employed by the local health board being put in place to address some of those issues. Now, the Minister appears to be expressing some scepticism about this, but I'm basing this on publicly available figures, and if he's got other publicly available figures that tell us something else—other not publicly available figures—I urge him to put those in the public domain so we can see where this so-called progress is coming from and who is delivering it.

After four years, we need to have from this Minister some real understanding about why he thinks delivering change in Betsi Cadwaladr has been so difficult. Why is it so intransigent? What is going wrong there? Now, if I was to hear from the Minister today, 'These are the issues that I'm facing', 'These are the things that I cannot shift', 'These are the things that we need to build political consensus, perhaps, to deliver and change', then I would be the first person in his corner, because Jack Sargeant, of course, is quite right when he says that nobody wants to play any kind of political game with the NHS, but the reality, of course, Deputy Presiding Officer, is that issues surrounding the NHS are highly political: how the NHS is funded, how it is managed, is highly political, and here, in Wales, we have established—we legislated in 2009 for a system that made the system accountable to the Minister. I remember the then Welsh Minister, Edwina Hart, saying that the decisions about health in Wales needed to be made by the people that the people can sack. Now, at that time, the Conservative spokesperson, Jonathan Morgan, was of the view that we should continue to have a more hands-off approach. That was not the decision that this place made. It's a perfectly respectable position; not one that I shared at the time. So, the Minister is clearly totally accountable for this, and he needs to explain to us why things have not moved on.

Now, of course there's been some improvement; if you'd have left the system entirely alone for four years and done absolutely nothing there would have been some good people in some good places who would have been able to achieve some positive change. And, of course, as others have said, and we must acknowledge this, across that system—and I hear this weekly from constituents—there are really good people on the front line who are working their socks off. There are also some really good front-line managers who are doing innovative things, for example, co-operating with social services in Gwynedd. But, at the top of the health board, there is obviously something seriously wrong, and I believe that there is a cultural problem.

I wonder how invested the senior leaders in that health board are in delivering change. Now, it does worry me that six of the people leading that health board—not on the board side, but professionally—don't even live in this country, never mind in the area that they serve. Now, obviously, you wouldn't want to start discriminating against people on the basis of where they live, but, when you have such a high percentage of your management team whose families, whose children, whose neighbours are not directly affected by the decisions that they make, I think, potentially, you've got a problem. We used to, in the public sector in Wales, very often appoint senior leaders—I'm thinking particularly of chief executives of local authorities—on the basis that, 'We welcome you from wherever you come, but we expect you to come here, we expect you to live here, we expect you to invest in this community'. And Betsi is full of senior leaders who have not done that.

When I raised the question yesterday with the Minister about whether he believed the senior leadership understood the communities they were serving, I was profoundly disappointed that he dismissed that as a concern. But it seems to my constituents and the constituents of other colleagues that the decisions are being made by people who don't understand the nature of the communities, who don't understand the geography, and maybe that is something that is at the root of all of this.

I see my time is up, Deputy Presiding Officer, and I'll bring my remarks to a close. But I'd associate myself with what's already been said about the need to have performance standards for managers, to have core competencies, to have a register of NHS managers, off which they can be kicked, as doctors and nurses can, if they don't perform, because I believe this is a cultural problem across our NHS. The Minister has got to take some responsibility for this. If he wants our help, he can certainly have it, but, as it is, he dismisses our concern and it's not good enough.

Self-proclaimed 'party of the NHS', Labour, is responsible for just seven health boards in Wales, and it is shocking that five of these are in special measures of some kind. The largest of these, serving around 1 million people, Betsi Cadwaladr University Health Board in north Wales, will not be celebrating the fact that next Saturday it will be four years since it was placed into special measures. Ministerial oversight of these special measures arrangements have been with the current Minister. No Conservative Prime Minister has ever cut a NHS budget. Under Labour, however, Wales was the only UK nation to see a real-terms decrease in identifiable expenditure on health between 2010 and 2016.

Betsi Cadwaladr entered special measures after horrific reports emanated from the Tawel Fan mental health ward. The Welsh Labour Government had failed to heed the warnings of the Ockenden—or has failed to heed the warnings of the Ockenden—review of this and consistently ignored the concerns of families involved. It may have met them—continued to ignore them. The Welsh Government instead relied on the 2018 Health and Social Care Advisory Service review, which was described by the families as a cover-up.

In January, Donna Ockenden said she had seen insufficient progress in improving mental health services and revealed that staff had told her that services were going backwards. Her 2018 review was repeatedly informed that, from the health board's birth in October 2009, there was very significant cause for concern in the systems, structures and processes of governance underpinning a range of services provided by Betsi Cadwaladr.

Speaking here in May last year, I asked the health Minister why the conclusions of the HASCAS report, commissioned by Betsi Cadwaladr, did not stack up with the findings of Donna Ockenden's 2015 report, which the Welsh Government had accepted, or with the Healthcare Inspectorate Wales report, or dementia care mapping work, both in 2013, the year that the health board states that it was alerted to serious concerns regarding patient care on the Tawel Fan ward. In fact, I had highlighted concerns with them and the Welsh Government in 2009.

While front-line staff are working incredibly hard, last month the Public Accounts Committee found that the Welsh Government's intervention with the board has had, quote, 'little practical impact'. The North Wales Community Health Council stated that it totally agreed with the report's recommendations and referred to a letter sent to the health Minister in which they stated there is a belief among its members that special measures is now the new normal and appears to have lost its impact. The Welsh Government's A&E target to see 95 per cent of patients within four hours, in place since 2008, has never been met. So, the latest figures show that Betsi Cadwaladr remains the worst-performing in Wales. Wrexham Maelor Hospital's A&E department only saw half of its patients within four hours.

In January, the north Wales coroner, John Gittins, stated that ambulance hold-ups, staff shortages and the difficulty of getting speedy A&E care have contributed to numerous deaths and may claim more lives. Last month, a senior consultant, Ian Smith, told the coroner's inquest into the death of Megan Lloyd-Williams at Glan Clwyd Hospital that it was over two years since he had highlighted a gap in geriatric care and treatment at a similar hearing, but nothing had changed, despite assurances that improvements had been made. How familiar that rings. Following that inquest, the coroner gave the health board until the end of this year to make improvements to its orthopaedic care.

In March, North Wales Community Health Council wrote to the Minister expressing their disappointment with the Welsh Government response to the NHS Wales GP performers list options paper, stating that the difficulties in north Wales had been present and increasing for at least five years. There is no question about if or whether the difficulties in recruitment and retention will continue. They added that the other ways tried by Betsi Cadwaladr to address the recruitment problem were, quote, 'not as successful as have been reported'. They're now working with community health councils across Wales to review experiences of people having to stay too long in hospital when they're well enough to leave. Is it any wonder, therefore, that this thin-skinned Labour Government is now seeking to replace community health councils with a centralised body that they can control?

Only last month, the Royal College of Physicians stated that only 43 per cent of advertised consultant physician posts in north Wales were filled last year. The health Minister's repeated statements that he expects to see action—we've heard it today, we heard it four times yesterday—have become hollow. He needs to accept his responsibility for failing to deliver the required improvements at Betsi Cadwaladr University Health Board and honourably resign.

As we’ve heard, special measures was to be a temporary measure for Betsi Cadwaladr University Health Board. Now, four years later, they are still in special measures. I can tell you, Minister, that the people of north Wales don’t consider those measures to be temporary and the people of north Wales don’t consider special measures to be special in any way whatsoever, because, as the community health council in north Wales has said, the special measures are now the new normal in north Wales.

The health council believes, and I agree with them, that direct management by Welsh Government of the board has lost its impact. There is a lack of confidence among the residents of north Wales in the way in which the Government is seeking to deal with this situation, and, indeed, as a result of that, in the ability of the health board to provide the care that the public in north Wales wish to see, expect to see, and have a right to receive.

This new normal, of course, represents an ongoing financial crisis, it represents recruitment problems, failures in long term planning, particularly in terms of the workforce, GP services collapsing, an over reliance on locums and agency staff, and a failure to deal with complaints in a timely or appropriate manner. Increasingly too—and this is something that I have raised in this place in the past—there is more and more involvement of the private sector in health services in north Wales. I’ve raised in the past the campaign to prevent the privatisation of aspects of the dialysis service in Wrexham and in Welshpool, including transferring staff from the national health service to the private sector, and now, of course, we are facing the privatisation of pharmacy services in general hospitals across north Wales.

People are complaining that Donald Trump is going to be a threat in privatising elements of our health service in Wales—well, perhaps we need to look closer to home when it comes to that particular agenda. I do hope that the Government and the Minister will have the honesty, when they do condemn the privatisation of health services in England, to be aware of what is happening on their watch in terms of similar services in Wales.

I am going to refer to the case of one constituent of mine who is 90 years old, living in Flintshire. She went to hospital very recently after a fall in her garden. She’s now well enough to return home but she will need some support of course. Her family clearly want her to return to her home having spent 10 days in Ysbyty Glan Clwyd and more recently in Holywell Community Hospital. But, there are no care packages available to allow her to return home. The family are therefore in a quandary. Do they leave her in the community hospital where clearly she is becoming demoralised, or do they pay privately for a care package that will cost a total of £210 a week?

I highlight this because back in 2012, Betsi Cadwaladr home enhanced care packages—I’m sure you will all remember the HECs, as they were called. The aim was to help people out of hospital and back into the community, and the claim made at that time was that patients would be able to see consultants in their homes and that would replace the community hospitals that were being closed across north Wales as part of a radical restructuring and centering of services across north Wales. But the truth is that even support workers aren’t able to visit patients in their homes now, never mind anyone else. There is too much demand for the service and they can’t meet that demand.

Now, it’s not the front-line staff who are to blame here. They are doing their very best despite the circumstances and difficulties. The problem, I fear, is senior management who have made these poor decisions, which have led to the health board reaching this point and have led to special measures. And of course one of those was appointed to be responsible for turning the board around, which raises further questions.

But unlike doctors and nurses who occasionally make errors in their work, there’s no way for health board managers to be held to account. If it’s right for nurses and doctors to be struck off—we’ve said as a party that should also be the case for senior managers. In north Wales, we’ve been through three chief executives and three chairs and there’s a feeling of shifting the deckchairs whilst the ship is sinking. The one consistent factor throughout that period of course is that you, previously as Deputy Minister, were responsible for the day-to-day running of the health service and the situation in Betsi Cadwaladr. So, rather than changing chairs and chief executives, isn’t it true that you are the one who should resign?

Caring for the health and well-being of the population of north Wales should be the fundamental aim and purpose of the Betsi Cadwaladr University Health Board, and I bear witness to the fact that, as regards front-line staff, they work hard every day with their hearts and minds, trying to deliver just that. Four years ago, however, the board was placed in special measures as a result of significant failings. On 8 June 2015, our now First Minister declared that this significant decision reflected serious and outstanding concerns about the leadership, governance and progress in the health board over some time and that a thorough and balanced assessment would taken place on areas of concern to form the basis of actions to be taken as a result of those special measures.

Those actions have been guided by you, Minister, from your time as Deputy Minister and your statement on 14 July 2015 to this debate today. Nearly 48 months represents the longest time any organisation has been in special measures within the history of the NHS. This is double the length of time Vaughan Gething AM initially claimed it would be. So, after 1,460 days of your direct control, I and many of my constituents and many Members here today in this Chamber would have expected the health board to be back in good health.

However, after 13 written statements and three external investigations, the situation today is still alarming. North Wales mental health services have still not been de-escalated, and seem a long way from reaching so. Shockingly, Donna Ockenden has reported that she's seen insufficient progress, and it was revealed that staff believed that mental health services were going backwards. Only last month, the Public Accounts Committee—and I thank the Chair and his team for this—outlined key concerns about the delivery of the board's mental health services, including an insensitive release of the HASCAS report, which let down the families of Tawel Fan patients, insufficient progress on implementing the recommendations of the HASCAS and Ockenden reports, lack of engagement with the North Wales Community Health Council and correspondence from BCUHB staff in which they, the front line, explain that staffing was worse, they were exhausted, and they do not expect positive change in the foreseeable future. Minister, you should—I'm sorry—hold your head in shame at these findings, and the fact that on Donna Ockenden's offer to help—that you declined this.

Actually, you have overseen the development of a monetary migraine also. Betsi Cadwaladr board has just recorded the biggest deficit of all Welsh health boards at the end of 2018-19—the only board to increase its debts between this period—and has only managed to make 85 per cent of its savings target by March. The accounts at Cadwaladr seem to be spiralling out of control, with major pressures from all directions: £900,000 has been spent on just eight health legal cases, Cardiff are demanding that the board pay back £1 million for failing to hit waiting time targets, and a shortage of front-line staff saw £34 million spent on agency staff in 2017-18. Clearly, the health board still has significant improvements to make in spite of special measures.

The Minister's poor management is having a negative impact on staff, and I have it on good authority that your intervention is actually causing some of the problems there now. It is indicated by the fact that sickness absence from October to December 2018 is up on the same period in 2017. Sadly, the situation is directly impacting on my constituents. Almost every day, I am receiving new complaints and having to resort now to having weekly appointments with the chair's office—the new chairman—who is working really hard to oversee my collection of constituent concerns. You know what the problems are: referral-to-treatment times no better, the highest number of patients waiting more than four hours at A&E, and serious staffing gaps. Clearly, any reasonable person cannot but agree with the Public Accounts Committee's findings that special measures has become a normality and that Welsh Government intervention has had little practical impact.

The residents of north Wales, and certainly my constituents in Aberconwy and my other colleagues—they deserve better. The health service in any nation must be considered as its ultimate priority, and how disappointing that the First Minister himself cannot be present for such an important debate today. As we seem set for yet another 12 months of special measures, we have no sustainable clinical strategy in place. It is time for the First Minister and the Welsh Government to be collectively held responsible. But I hold you responsible, Minister. I will echo my colleagues' concerns. Please do not bring the name of Betsi Cadwaladr in vain, and please, Minister, if you are—. You're shaking your head now. If you remain in denial as to just how bad things are, please do us all a favour and make way for someone who might—just might—be able to turn that situation around. Thank you.

I thank the Welsh Conservatives for tabling this debate today. The state of the NHS in north Wales does leave a lot to be desired, and Welsh Labour must accept blame here, because the reforms over the last 20 years have directly led to the situation in Betsi Cadwaladr.

As my colleague Mandy Jones pointed out yesterday, this health board has been in special measures for nearly half of its existence. The fact that there has been a slow pace of change and limited improvement, given that nearly four years have passed since the health board was placed into special measures, is not only deeply concerning to the Public Accounts Committee but indeed to us all. However, I don't believe calling for the current Minister's resignation is the right answer, and the fact that success in delivering improvements in healthcare in north Wales has been limited points to a more structural problem than which Government Minister is in charge. It clearly indicates that the current local health board system is not fit for purpose, and while the issues are most keenly felt in north Wales, most of Wales's health boards are in some form of escalation and intervention arrangement. What must happen now is not a change of Ministers but a change in approach. Welsh Government need to accept responsibility for the mess they have created and take immediate action. 

We all know the challenges facing the NHS in the coming decades, and if we don’t have the right governance structures in place, the problems we see in Betsi today will pale into insignificance. So, we need to end ministerial appointment to health boards. Health boards need to make clinical decisions, and not political ones. We need to strengthen Healthcare Inspectorate Wales and ensure that it too is free from political interference. HIW should have the power to intervene and give direction to health boards when problems are identified. And we need to ensure that problems are identified early on. This means introducing a no-blame culture to identify mistakes and ensuring every person working in the NHS or with the NHS has a duty to disclose.

We need to make urgent and significant progress in ensuring our NHS has the right structures in place to meet the needs of patients in every part of Wales, now and in the coming decades. While the current minister shares some of the blame for the problems in Betsi and across the NHS, I truly believe he has attempted to address some of the problems that have been in existence prior to his being handed the health portfolio. And if blame is to be cast, then predecessors must also accept a portion of that blame equally, and not allow one person to be used as a scapegoat. So, blame is sometimes direct, and other times indirect regarding the current messy governance arrangements.

I urge the Minister to accept that mistakes were made and to take urgent steps to rectify them. This is how we will address the problems. A change of leadership may only exacerbate them now. Minister, I am confident that you can deliver the necessary changes, but it is urgent that you act now. 

I think it's fair to say that the ongoing governance and management problems at Betsi Cadwaladr University Health Board since 2013 must, without a shadow of a doubt, be an enormous source of deep regret and embarrassment for the Welsh Government. Despite several reviews and reports being conducted over the past four years, progress has been dreadfully slow, financial management has been ineffective, and most importantly, concerns over patient care still remain. The staff and medical professionals in north Wales who are working hard under very difficult circumstances deserve proper and appropriate leadership and support from the Welsh Government.

As Mark Isherwood and Janet Finch-Saunders said earlier, only a few weeks ago the Assembly's Public Accounts Committee published the latest in a string of reviews into the governance arrangements at the health board. That cross-party report concluded that Welsh Government support has been insufficient and that actions had little practical impact on changing the health board's performance. After four long years of the health board being placed in special measures, the Welsh Government has simply continued to preside over a service that is continuing to let some patients down. Now, in giving evidence to that inquiry, Mark Thornton, the chair of the North Wales Community Health Council, shared their frustrations by comparing the Welsh Government's inaction with action that had been taken across the border. He said that, and I quote,

'They seem to have a slightly different approach in that they actually bring much more resource, expertise, whatever's needed to actually set a health board onto an even keel and provide a stable platform for a health board to make the improvements required to come out of special measures. As far as we're aware, the health board was provided with some expertise in terms of the special advisers, but certainly initially at least we didn't see a lot else.'

Now, those aren't my words, or even the committee's words, but the words of the community health council in representing local patients. The evidence they gave to the inquiry is damning. Despite the Welsh Government knowing of the ongoing governance and financial difficulties of the health board, it seems to me that the CHC believe that rectifying the matter is simply not a serious priority for the Welsh Government. As a result, patients is north Wales are continuing not to receive the health service they deserve, particularly when it comes to mental health services, as Jack Sargeant said earlier.

The reality on the ground is that whilst report after report criticises both the health board and the Welsh Government, real people in north Wales are simply not receiving the care they need and deserve. As Angela Burns said earlier, there's also a real question here about humility and the Welsh Government's handling of the whole situation. In responding to the Public Accounts Committee, the Welsh Government said that, and I quote:

'We also recognise the further progress and action must be delivered to tackling long standing issues and will work alongside the Chair and the leadership team to ensure turnaround and de-escalation from special measures.'

Nowhere, nowhere in that statement is there a genuine apology to those families in north Wales who, in the past four years, have suffered. Nowhere in that statement does the Welsh Government come forward with concrete action or take any leadership of the situation. Instead, the Welsh Government just dusted off its regurgitated 'We'll work with the heath board' statement. Well, that is simply not good enough anymore, and it’s simply not going to wash with people in north Wales who've heard this all before.

It should be a matter of regret for all Welsh politicians that there’s a part of Wales that will shortly be entering its fifth year of being placed in special measures, and yet the Welsh Government seems settled on special measures being the new norm for healthcare services in Wales. What will it take for the Welsh Government to show some leadership and commit to fully addressing this crisis? And in the meantime, how many patients will have to suffer? If the Welsh Government does not make real progress in the immediate future, then people in north Wales will feel let down by a Government that they will see as just being too Cardiff-centric. And can you really blame the people of north Wales for feeling that way?

Dirprwy Lywydd, today’s debate gives the Welsh Government an opportunity to change the record and come forward with a concrete strategy that provides a real commitment to the people of north Wales that it will finally get a grip of this issue. And hopefully, the Minister will show a little humility to those people for the catalogue of failings that he and his Government have overseen.

At the start of this year, Donna Ockenden told the Minister directly that staff had told her that services were going backwards. Fast forward to two weeks ago and a report endorsed and signed off by every party in this Chamber concluded that it is apparent that the Welsh Government's interventions have had little practical impact. Therefore, it's time that the Welsh Government steps up and finally accepts responsibility for the failures that have taken place while Betsi Cadwaladr has been in special measures, and make this matter an urgent priority. And so I urge Members to support this motion, and I call on the Welsh Government to start delivering a service in north Wales that’s actually fit for the twenty-first century.

Can I now call the Minister for Health and Social Services, Vaughan Gething?

Thank you, Deputy Presiding Officer. As the motion laid notes, on 8 June it will mark four years since Betsi Cadwaladr University Health Board was placed into special measures. My statement yesterday recognised the need to use the anniversary as an opportunity to reflect on the reality and the pace of progress to date, but also the actions still outstanding. I also mentioned yesterday a range of actions already being taken with regard to finance, performance and turnaround. I do want to deal at the outset with one other point made about the First Minister’s absence today, in particular remarks made by Janet Finch-Saunders, and as most Members will be aware, the First Minister is not here today because he is exactly where he should be, at the D-day commemorations in Portsmouth.

Four years ago, the special measures framework required improvement across a range of areas: governance; leadership and oversight; mental health services; maternity services at Ysbyty Glan Clwyd; reconnecting with the public; and general practice and primary care, including specifically out-of-hours services. In the statement I gave yesterday, I set out the areas in which improvement has already been made. I also outlined those areas in which the health board has not made the progress that we expect, and further action is plainly required.

On two of the significant areas of concern set out in 2015—maternity services and GP out-of-hours services—improvements have resulted in the de-escalation of those areas from special measures. It’s important to recognise the good practice, innovation and improvement that staff across Betsi Cadwaladr University Health Board have delivered. And on one point of agreement across speakers, it is to recognise the dedication of our staff within the national health service delivering front-line care in each and every one of our communities.

In 2015, though, we and the people of north Wales had significant concerns about, for example, infection rates, access to therapy services and timely access to treatment for people on the cancer pathways, and in each of those areas, there has been real improvement. Today, we've heard of other areas in which Betsi Cadwaladr should develop their services to improve outcomes and experience for the people of north Wales—areas of concern, of course, that go beyond special measures that we could discuss in any particular part of public service. The challenge is not to wipe those away, but to focus on improvement in every area and to understand what Betsi needs to do to move beyond special measures. It is important to note that the health board is stepping up to take the action necessary to deliver improvement. The view of the independent advisor is that the board is now better placed to do so and in particular that the chair has brought new vigour and drive to real leadership and improvement.

In relation to the areas for improvement covered under the special measures arrangements—[Interruption.] I'll happily take the intervention. 

Thank you. The Public Accounts Committee report into this has been mentioned by a number of Members, and recommendation 1 of that report was that, if things are to be turned around, we do need to have more specialist external staff brought in—external advice brought in—to assist the board, in addition to the turnaround director, or whatever else they have done. What progress have you made in making sure that that additional support is put in place?

I did manage to go over some of this yesterday, but we're already working together with the chair to look at the finance function with external expertise being brought in to help, the appointment of a new finance director and thinking about the team that needs to go around that person to deliver the function—and not just a person, but a turnaround function. So we're already taking seriously the need to have external help and opportunities for improvement within the organisation. 

I, myself, though am obviously frustrated at the progress in a number of areas, and I recognise that a whole-system integrated approach is required if improvement is to be sustainable. I outlined yesterday the renewed focus that is required on planning, financial management performance, mental health, planned care and unscheduled care, and I also outlined the further support that is being provided to the board to help deliver improvement. I've written to the chair of the board to set out expectations for this autumn, to confirm that there will be an annual plan with performance trajectories for 2019 by the end of summer to progress the development of a sustainable clinical services strategy, in partnership with clinicians and wider partners; to have an agreed financial plan, including identified savings, efficiencies and opportunities to be taken by the health board throughout this year; and to have sustainable, improved performance in areas of quality, mental health, unscheduled care and planned care; and to make real and sustained progress is delivering the mental health strategy and actions agreed in response to the HASCAS and Ockenden recommendations. There is already a functioning stakeholder group to provide real oversight and challenge to the progress that is being made. 

In moving our amendment, I noted that any decisions on changing the escalation status of Betsi Cadwaladr will be taken after receiving advice from the Wales Audit Office, Healthcare Inspectorate Wales and the NHS Wales chief executive. That is as standard under the escalation and intervention arrangements that we do have in place, so I won't set, as I've said time and time again, an artificial timetable for the health board to move out of special measures. It will be when real progress has been made and there is real confidence of further progress to be made. But it is simply not appropriate to suggest that five out of seven health boards are in a form of special measures. It is a deliberate using of the special measures label to cast doubt and throw mud over the rest of the health service. The intervention and escalation arrangements are there to highlight where improvement is required and not as an opportunity for mud-throwing over the health service. That goes back to a comment that Jack Sargeant made about not wanting to see the health board used as a political football, and of course it is an obviously political topic.

We spend half of the Government's money on the national health service here in Wales. Everyone has a view on the health service, and we should do, but we did hear then a series of nakedly political statements in the debate. Now, I accept that's the nature of business in this place. Politicians will have a view, and of course people will look to try to have political solutions to answers in this area. My job is to make sure that the health service is continuing to move forward. It is a public service—proud to be a public service. We are not privatising the national health service here in Wales. We are engaged in looking at practice within Wales for improvement, and across the United Kingdom too, in both our intervention framework and on the recovery and improvement within health services. This is not an insular service, only looking inwardly for improvement. I continue to be open to good practice, as, indeed, is our wider healthcare system, wherever it exists, especially across the United Kingdom.

I have been asked about reorganisation, and I know Jack Sargeant mentioned it in his comments, and I do want to say this, very simply: I don't see any objective evidence that reorganising Betsi Cadwaladr into two or three smaller boards would improve services or outcomes. I think the last thing that the health service in north Wales needs is another reorganisation, rather than a continued focus on improvement in its current setting.

I am far, though, from sanguine or complacent about the continuing challenges that we face. My focus will continue to be on improvement and moving Betsi Cadwaladr beyond special measures. I will continue to be honest and transparent about improvements made and improvements that are still, plainly, required.

Thank you. I call on Darren Millar to reply to the debate.

Thank you, Deputy Presiding Officer. As others have said in this Chamber, it's a very sad day, actually, that we're standing here four years after the Betsi Cadwaladr University Health Board was put into special measures, yet still this organisation has not made sufficient progress to come out of them. 

As has been said, a quarter of the population in Wales is served by this particular health board, but it's breaking records, and it's breaking them for all the wrong reasons: record-breaking poor performance when it comes to emergency departments; record-breaking waiting times for people waiting for orthopaedic surgery; and, of course, as we've already heard, a record length of time in special measures for those particular services and aspects of the health board that are in special measures.

You know, the front-line staff in our hospitals in Wales—in all of our hospitals, including in north Wales—are absolutely heroic. They are trying to do their best in difficult circumstances each and every day. I mentioned the fact that I had visited Wrexham Maelor Hospital on Monday, and I saw what people were having to deal with in the emergency department there.

They are amazing and incredibly talented people, but that doesn't take away from the fact that all of the evidence points to the fact that special measures in the Betsi Cadwaladr board are not working. They're not working. We've seen some improvement, yes, in maternity care, but that's because people marched on the street in order to secure those improvements—it was nothing to do with you, frankly, Minister. The reality is that unless we'd marched on those streets, those changes would have been implemented.

There has been some improvement, very lately, in terms of GP recruitment, or certainly training, in terms of securing more training. But, the fact remains that the GP out-of-hours services, which you have de-escalated, still have big gaps on their rotas on a frequent basis. I understand that one of the reasons why they are more able to meet their targets now is because if you phone the GP out-of-hours service, instead of having to get back to somebody within half an hour, as was previously the case, the target is now an hour. Well, of course, it's easier when you're moving the goalposts to be able to meet those targets, which is why you've managed to de-escalate that particular service. But, the Public Accounts Committee report, the Donna Ockenden comments and a whole host of other evidence point to the fact that these special measures don't work.

So, five out of seven health boards are in some sort of intervention or another, and that, to me, suggests that there's a systematic problem in the Welsh Government in terms of the way that it tries to bring improvement in our health service. It doesn't seem to learn from good practice and it doesn't seem to learn from its mistakes. We know that Cwm Taf, for example, recently entered into special measures, and one of the reasons it entered into special measures was because it repeated many of the mistakes that had taken place in Betsi Cadwaladr.

I've got to conclude. I will say this: I agree with the Minister on this one thing. I don't think we need reorganisation in north Wales. I do think that the name 'Betsi Cadwaladr' has been tarnished, and I think you ought to think about a change of the name of that health board in order to restore its reputation out there in the world. But you are the person who's been responsible for this ministerial oversight for the past four years. You've failed to turn this situation around, and the NHS seems to be slipping further into these intervention arrangements in all sorts of other ways across Wales. I think you ought to accept responsibility, carry the can and step down from office.  

The proposal is to agree the motion without amendment. Does any Member object? [Objection.] Therefore, we defer voting under this item until voting time.  

Voting deferred until voting time.