We move on to item 4 on the agenda this afternoon, which is a statement by the Minister for Health and Social Services: strategic assistance for Betsi Cadwaladr University Health Board. And I call on the Minister for Health and Social Services, Vaughan Gething.

Thank you, Deputy Presiding Officer. I want to update Members today on the progress that Betsi Cadwaladr University Health Board has made to address the issues that led it to be placed in special measures in 2015. Together with my officials and the health board, I remain focused on the work to secure ongoing sustainable improvements.

The heath board has recently submitted a comprehensive and balanced account of progress during the period of special measures escalation. This shows genuine progress but also insight and acceptance of areas for ongoing action and improvement. Areas of progress include the ability to drive improvement to lift some services out of special measures. Maternity services and out-of-hours services have both achieved this and are now part of the board’s ongoing improvement drive. Measures of quality, such as responding to concerns and infection prevention and control, demonstrate that historic performance issues have been addressed. The board now has a more structured approach to continuing assurance and improvement. 

It is important to recognise the positive and sustained response to COVID-19 from the health board in the most difficult of circumstances. This reflects the improved resilience and ability to deliver. The health board has provided an honest assessment of areas for ongoing action and improvement that coincide with the views of the recent meeting of tripartite partners, including: the need to further improve leadership and governance; the development of a long-term integrated clinical services strategy; further strengthening leadership capacity within mental health to enhance stability and resilience; the development of a robust three-year financial plan to meet its financial duties as part of the integrated medium-term plan; the need to finalise and implement a revised accountability and performance framework, and deliver improvements in performance, particularly in the acute sector.

Whilst many other health organisations have related issues to address, as Members are aware, they are more long-standing for north Wales and performance is disproportionately poor in respect of high-profile areas, such as referral to treatment and accident and emergency, demonstrating a need to enable recurrent and longer term solutions. To address these long-standing challenges, I have decided that a different approach for the next phase of improvement is required. I will, therefore, provide strategic longer term funding for key service and performance issues. This will enable the health board to move away from short-term actions and make progress on medium and longer term planning that translates into an approvable plan.

I have already confirmed the position on NHS historical deficits and cash support that will benefit the outlook for the health board. To enable further progress, I am today announcing a package of strategic assistance support for the next three and half years. This assistance will provide a different set of parameters that will enable the health board to reset and plan sustainably for the future, to meet the health needs of the people of north Wales. It will include: cover for the deficit of up to £40 million a year; funding to improve unscheduled care and build a sustainable planned care programme, including orthopaedics, of £30 million a year; £12 million a year to support performance improvement and implementation of the mental health strategy in partnership; and support to build broader capability and capacity in the organisation.

The support for this strategic approach will be on the basis that the health board continues to build on existing partner relationships and fully engages with the public, staff, trade unions and wider partners. The essential first step will be to work in partnership to build a sustainable vision for the future, leading to a medium-term plan, focusing on prevention, physical and mental well-being, population health and, of course, primary and secondary care services.

I recognise this as a priority area for investment. It is therefore my intention to continue this support for the years 2021-22 through to, and including, 2023-24. It will involve a revised improvement framework and development of a maturity-matrix approach to assess progress. In addition, Members will be aware that I issued a written statement informing Members that I will establish a task and finish group to make recommendations to me on a proposal for a north Wales medical school.

This support that I'm announcing today will help to bring about transformation and innovation, leading to improved outcomes, patient experience and financial performance year on year. It is a clear demonstration of our growing confidence in Betsi Cadwaladr University Health Board's ability to further improve and deliver the high standard of services and care that the people of north Wales have every right to expect. Thank you, Deputy Presiding Officer.

Thank you, Minister, for your statement and for sharing an advance copy with us. Can I first of all, Deputy Presiding Officer, put on record a tribute to the staff in the NHS in north Wales, who I think have been doing an absolutely sterling job to be able to cope under some very difficult circumstances as a result of the COVID pandemic? It's not always easy, particularly at times like these, but they have stepped up to the plate and really are delivering on behalf of my constituents and the constituents of other representatives in this Senedd, and I want to applaud them for their work.

It's been over five years now—we're into the sixth year of the special measures regime here in north Wales—and many people are very unhappy that it's taken this long to try and sort the problems out there. We know that the Welsh Government announced, when the health board went into special measures, that there would be a suite of 100-day plans to try and turn performance around. Well, it's actually feeling a little bit more like the 100-year war in terms of making progress there. The Minister alluded to the fact that the maternity services and GP out-of-hours services have both been taken out of the special measures regime, and I welcome the fact that they've been taken out, but we must not forget that it was as a result of the public marching on the streets that we saw the improvements in those maternity services and the security of the maternity services, particularly at Glan Clwyd Hospital, the hospital that serves my own constituency and, indeed, the constituents of yours, Deputy Presiding Officer. 

In terms of leadership as well at the health board, we've had something of a revolving door. We've seen chief executives come and go, we've seen finance directors come and go, we've seen mental health leaders come and go, and it really has been a little bit of a shambles. So, I really do hope that the new incoming chief executive, when she arrives in the new year, will be someone who is able to stick around, really get to grips with these problems and deal with them once and for all.

Now, if I can also take the opportunity today to really welcome this additional investment in north Wales from the Welsh Government. I have always said that I think that there's been a structural deficit, which the organisation in north Wales inherited when it merged with the other health organisations in the region, when it was set up. I do believe that the additional £40 million a year over the next three years will help it to get to grips with some of those problems that it's not been able to get to grips with because of a lack of resource and funding. Can I ask the Minister whether this funding of £40 million is an acknowledgement that there's a structural deficit, and if it is, whether that's something that will continue beyond these three years? We know that structural deficits have been identified in other significantly sized health boards—Hywel Dda in particular—and that funding was made available on a permanent basis there, and I do think there's a case to make this additional £40 million available on a permanent basis rather than just for a three-year period. 

Again, I welcome the £30 million that's being made available to try to help performance in terms of emergency services, and indeed to get to grips with the referral-to-treatment time waiting lists as well, but again, I'm not sure whether £30 million will actually completely deal with that problem or eradicate it. I know that the health board has got proposals that it's bringing forward that will require some capital investment in order to get to grips with some of these issues, particularly with referral-to-treatment times, which have absolutely spiraled out of control over the past few months because of the pandemic, but were already in very, very bad shape even prior to that, with people waiting for two years typically for orthopaedic surgery. So, can you tell us, Minister, in addition to this resource of £30 million to support unplanned and elective surgery, whether there will also be some additional capital investment that you'll be able to make in things like robotic surgery, which we don't have at the moment for urology patients in north Wales, and indeed in terms of helping to clear that backlog, perhaps with diagnostic and treatment centres that are separate from the services currently provided on our existing hospital sites?

And just finally, if I can turn to the mental health part of the statement today, obviously we know that there have been serious concerns about mental health services in north Wales for some time. We've seen some poor judgment used by the health board with 1,600 patients that were discharged from primary care services. I know that there's going to be some change—and there has been some change—in the leadership of the mental health directorate within the board, but it is obviously essential that we can have some confidence going forward that these services are an absolute priority. The Welsh Government has obviously taken a decision to invest in a new mental health unit at Glan Clwyd Hospital, which I'm very pleased to see and which is now in train, but I am concerned that obviously it's not just money on buildings that's required here; we do need to change the culture within the health board to make sure that people can get the services that they need. How confident are you that you'll be able to secure the sort of turnaround leadership for our mental health services in north Wales that we so desperately need to see? Thank you, Presiding Officer.

Thank you for the questions. I'll start with your final point on mental health. The health board has its own strategy that it has developed together with partners outside of the health service, 'Together for Mental Health in North Wales'. That sets out an approach to continuing the transformation and improvement of mental health services and we've had good feedback from partner organisations that the health board really did look to co-produce that strategy, and that's come about because of the change in leadership that took place after special measures were introduced. So, there has been progress and improvement in mental health services and the money that I have announced for the next three and a half years is to further drive that improvement forward. We'll continue to measure and monitor the progress; it's a key factor in all the tripartite conversations that take place between, as the Member will know, Healthcare Inspectorate Wales, the Wales Audit Office and the chief exec of NHS Wales, not just to consider north Wales, but each organisation when considering their escalation status.

In terms of the other questions, it's positive to hear Darren Millar welcome today's investment decision. On the suggestion that there is a structural deficit of £40 million, that isn't where we are. This is a recognition of the fact that we need to enable the health board to be able to move forward and to plan for the future. They have made more progress in becoming a more efficient organisation, so they have made progress in their financial management, but to allow them to get on with the longer term planning they need to do, we are resolving some of the issues. And in reference to Hywel Dda, we did give significant support to Hywel Dda in a multi-year package that allowed that organisation to move forward, and it is now positively in a better position than it was three to four years ago. So, the choice we made there has paid dividends not just for the leadership of the health service, but, much more importantly, for the staff and the public that they serve, and we're now in a position to make a similar investment choice over a multiple number of years for the people of north Wales.

We have already undertaken a review of the allocation formula to update the Townsend formula, and so we're in a position where we're going to use it for future allocations in the general formula, and that will reflect the assessment of need that exists in different parts of Wales. That looks at a range of factors, and we've had engagement with the Health, Social Care and Sport Committee previously about that review, so you can expect to see the growth in healthcare change in line with that updated allocation formula.

In terms of your point about capital, it's already the case that the health board are developing plans for a diagnostic treatment centre and a range of other service areas, but, as with every health board, we have a business case assessment process, we need to review that on a case-by-case basis and see that as part of the overall plan for the organisation. So, I do anticipate that some of the service transformation may well require capital moneys to be spent. But, actually, we've demonstrated our willingness to spend significant amounts of capital on the health service in north Wales. You'll recall the recent report into the significant money spent on Ysbyty Glan Clwyd, but on other projects too. That has highlighted improvements we have made in our business case assessment process and we need to continue doing that. So, I'm not in a position to give an open-ended commitment to capital, but, as I say, there's a recognition in making this decision that there may well be a need to have capital spending to go alongside the service improvement plans and the money that I've allocated on a revenue basis for the next three and a half years.

Thanks to the Minister for this statement today. The first thing I will say is I'm very pleased when I hear of any improvements that are being made in the performance of health boards, wherever that might be in Wales. But I must say, this does read largely like any one of the statements that we have heard over the past five and a half years since the board was put into special measures. I think there must be a template somewhere that has been fetched off the shelf; again, some improvements have been made, but there are still major issues that still need addressing with Betsi Cadwaladr, and I'm not seeing in this statement, certainly, the evidence even to back up the claims that real improvements are being made, so I'd appreciate some more clarity on what is happening. And of course, when you do hear of major issues still in referral-to-treatment and accident and emergency, we're talking about hugely important elements of the health board in the north that are problematic five and a half years on from going into special measures.

I've made my position clear: I think there has been enough of an opportunity to try to turn things around for Betsi Cadwaladr. I think it's time for a fresh start with a new structure for health in the north. I know far too many health workers in the north; I respect them and the work that they are doing in difficult circumstances, and the messages I get from them saying, 'Thank you so much for saying that we need a fresh start.' That's my belief. But, for the time being, of course I welcome additional funding. I also question whether it makes sense to put a time limit on some of the fundamental increases that are being suggested here, and I ask the Minister: does he think now, following the review that has led to this statement today, that there has been a basic error in setting the baseline for funding the health service in the north of Wales? I'm certainly of that opinion and would like to hear the Minister's latest thinking on that.

Finally, we have news of a task and finish group to make recommendations on a proposal for the north Wales medical school. If the good people of Ynys Môn decide that they don't want me to represent them in the Senedd after next May, that is probably the one campaign that I'll be very pleased that we were successful in—in making sure that we move towards the introduction of undergraduate medical training at Bangor University. Let's not dither too much now. I know this Government likes its task and finish groups, but let's make sure that this is a group that decides on the detail of how we move ahead with the establishment of a full medical school for the north of Wales. We need it for the future of the workforce here in the north, and it's something that hopefully we can all agree needs to be pursued now with some urgency.

I simply don't agree with the opening statement that the Member makes that this reads like any one of the statements in the last five and a half years. There have been various points in time where statements over the last five and half years have been much more downbeat about where we have been. The fact is that, at various points in time, maternity and out-of-hours have come out, which shows that this has been progress over time. We've also had challenges over financial management and performance over this time, so it just simply isn't the case that we're taking a statement off the peg. And it really doesn't reflect the tripartite escalation statement that was introduced, where the external views of HIW and the Wales Audit Office were taken account of, and their assessment is that the health board has made real and definable progress. 

I simply don't agree with the Member on his plan to break up the health service in north Wales. I think that over the next term, to say that a health board that has dealt well with the COVID pandemic would then need to turn in on itself to consider how it would reallocate different jobs and services would be entirely the wrong thing to do. But the Member is entitled to his view and people will decide what vision they want for healthcare in north Wales and the rest of the country. 

On the point about the time limit and whether there's a fundamental error in the baseline, in answer to Darren Millar's questions I indicated that we have already reviewed the allocation formula. The Member should be aware of that, following his participation in the Health, Social Care and Sport Committee. I'm happy to circulate another note to that committee to confirm where we are with the allocation formula, if that's helpful to provide clarity. And in terms of the time limit, we took a similar approach in Hywel Dda, in Powys, indeed, before, but also with Cardiff and Vale and, indeed, Swansea Bay health board, where we provided moneys for a limited period of time to help deliver improvement. That 'something for something' approach has worked well in those areas, and so I don't think it's a mistake to provide a time limit indication for the length of time this strategic support will be available for. 

On the medical school, I think that the fact that we're able to take this forward, the fact that we had a much more worked through and credible proposal that was worked up between Bangor University in particular and the health board, but also with the buy-in and support from other significant partners in north Wales, is a real demonstration of the improvement in partnership working. It would not have been that long ago that you would not have expected north Wales partners to have come together to deliver a genuine north Wales plan with whole north Wales buy-in for a significant development like this. It's a good indication of improved activity from the health board and its partners, and I believe that bodes well for the future. And, of course, I want to have a returned view from a task and finish group that will allow me to make choices within this Senedd term, so we can actually provide some sort of plan for the future, but I will need to see what the recommendations of that task and finish group are. And, of course, I have already announced that, Deputy Presiding Officer, in a previous written statement.

I'd like to start this contribution by sending my condolences to the staff at Wrexham Maelor, who recently lost their colleague Wilbert Llobrera in a hit-and-run outside the hospital. My thoughts are with his wife and daughter.

I've mentioned before how special measures have clearly become business as usual for the north Wales health board. You denied them then, you will probably deny them again today. Out of interest, I have had a look at the published announcements relating to Betsi over the years of this Senedd term. In 2016, positive progress; 2018, escalation, review and additional support; also in 2018, £6.8 million to improve performance. And so it goes on.

I'd like to say I welcome this statement today and the use of the word 'strategic'—that's a new one, after all. However, I have little confidence that anything will really change. Just two questions to you for today, Minister—[Interruption.] Sorry about that. Two questions for you today, Minister: when will you try something fundamentally different to get this board on its feet and when will the people of north Wales get the service they deserve and pay for? Thank you.

Thank you for your comments, and I admire your ability not to properly swear when interrupted. In terms of the challenge that the health board faces, I think we should have more confidence in their ability to deliver. That comes from the tripartite review, and I wouldn't be making this significant and different approach in announcing an investment package of this sort over three and a half years if there wasn't more confidence they'll be able to make good on the plan they have. It's about the level of insight, understanding and acceptance of their need to improve. It's also the fact that partner organisations in north Wales are in a much better place in terms of their confidence in the health board. Nothing is perfect in any partnership or relationship, when it comes to it, as those of us who have other views on partnership working in other fields of life, partners need to come together to work through difficulties as well as coming to agree matters. They're in a much more mature place in north Wales, and they have done that over the last couple of years, so that's a good thing. There is more confidence. This is a fundamentally different approach. In terms of the point about when people will have the service they deserve, that is exactly the whole point of making this choice today and delivering this statement to the Senedd. I believe that people in north Wales deserve high-quality health and care services, and this is about enabling the health board to play its part with more confidence and a greater capacity to deliver the care that every citizen in Wales deserves. 

I do want to finish, Deputy Llywydd, by sharing my own condolences for the nurse from the Maelor who lost their life in a hit-and-run recently. It's a marker that there are always challenges, but we don't expect our staff to lose their lives in these circumstances. I know it's had an impact on friends and colleagues within work and outside as well. So, my best wishes and condolences to the family and all of those who are grieving the loss at this time.

The Llywydd took the Chair.

I thank the Minister.