Item 7 on the agenda this afternoon is a statement by the Cabinet Secretary for Health and Social Services on the publication of Donna Ockenden's governance review. I call on the Cabinet Secretary for Health and Social Services, Vaughan Gething.

Thank you, Deputy Presiding Officer. Last Thursday, the Betsi Cadwaladr University Local Health Board received the Donna Ockenden review of governance in mental health services in north Wales. This is another difficult report for the board, but the findings should not be a surprise to them. Donna Ockenden has drawn heavily on other reports, reviews and inspections of the board since 2009. The message is clear: the board must increase the pace of improvement and change. And I'm sure that no-one in this Chamber or outside will disagree with that. The board will also know how clearly I have set out my own expectations for the coming period.

However, I do want to place on record again how acutely aware I am of how difficult this period has been for individuals, families and patients affected by the original concerns. I have received correspondence from a number of the Tawel Fan families and my office is currently agreeing a time for me to meet to with them again, now that all of the reports are in the public domain. I also understand how the staff of the health board must feel about their health board being in the headlines again as a result this report.  My focus is now on moving the health board forward, learning from the past and putting the mistakes of the past behind them to secure real and sustained improvement.

There has been an improvement in mental health services in Betsi Cadwaladr since 2013. However, they still have a long improvement journey ahead of them. In her presentation to the board last week, Donna Ockenden herself highlighted areas of progress and in particular the work of the director of nursing and midwifery on managing complaints, concerns and safeguarding. However, it is important that the local health board more effectively communicate the improvements that are being made in order to rebuild the confidence of their population in their mental health services. I know that the chief executive recognises the need to do this and has now written an open letter that describes recent improvements in mental health services. Those improvements respond to both Donna Ockenden's and the Health and Social Care Advisory Service's recommendations. For example, there is now a completely new management structure in place for mental health services. 

I also know that Healthcare Inspectorate Wales's latest annual report was presented to the board last week. Rightly, it reported that there are still areas of continuing concern, but the report also noted that, overall, patients were happy with the care they received, staff felt supported, and there is good evidence of patient-focused care. It also highlighted that the health board had been open and responsive throughout its involvement with Healthcare Inspectorate Wales and, importantly, that the leadership has strengthened since 2013 and is more effective following fundamental changes to its structure.

Furthermore, the Wales Audit Office’s most recent structured assessment of Betsi Cadwaladr health board pointed to progress being made in addressing previous recommendations, and that strategic planning and operational arrangements are generally effective. However, the pace of this improvement must increase.

Going forward, the new chair will lead a renewed board with the recruitment of a new vice-chair and three independent members. There are also changes in the executive director team, including a recently appointed new executive director of workforce and organisational development, and imminent recruitment of a director of primary care and a director of strategy.

The board agreed at its meeting on 12 July to establish an improvement group to respond to both the HASCAS and Ockenden recommendations. The group will be chaired by the executive director of nursing and midwifery, and will provide leadership, governance and scrutiny of progress against the recommendations. I expect that group to regularly report to the full board. We are continuing to provide further intensive turnaround support for the improvements, with an initial emphasis on supporting improved governance and accountability, focused joint working with clinicians and partners to deliver sustainable improvements, all of which respond directly to issues raised in Donna Ockenden’s report.

It is also important to note progress made in other services, especially maternity services, which were de-escalated from special measures earlier this year. That demonstrates what the health board can achieve with focused leadership and action. But I am under no illusion. I recognise that the review reinforces what we already know about the position of the health board and why it was placed in special measures—it reflects the significant work still to be done.

It has been over four and half years since concerns were first raised regarding the care and treatment on Tawel Fan ward. The publication of Donna Ockenden’s report and the HASCAS investigation marks the end of a lengthy but necessary series of investigations and reviews. As I said earlier, the emphasis must now be on moving forward and increasing the pace of improvement. The staff and the public of north Wales deserve nothing less.

Can I put on record at the outset of my remarks my thanks to Donna Ockenden and her team for their work in compiling this very comprehensive report? Unlike the headline in the previous HASCAS report, published in May, this report has been widely welcomed and accepted by stakeholders, and I think that it's very important now that the National Assembly has the opportunity to consider both of these in a full Assembly inquiry at some point in the future. As part of that inquiry, I think we need to look at the effectiveness of the action that's been taken under special measures to date. 

You said in your statement, Cabinet Secretary, that it's another difficult report for the board, and that of course is absolutely the case. The report is a litany of failure, it lists a catalogue of problems at the health board, including governance and management systems that were flawed from the outset; delays in appointing staff to clinically essential posts; staff who describe, in their words, being exhausted, depleted and unheard, working in a dangerous working environment; an estate that isn't fit for purpose, posing a risk to patient safety; and a complaints procedure that isn't working; and an organisation that doesn't learn from its mistakes or implement agreed action plans. 

But of course it's not just a difficult report for the board, it's also a very difficult report for the families of those affected by the failings of care on Tawel Fan. I have to say, many of those families remain absolutely baffled by the overall conclusion of the HASCAS report that was published back in May. Some of them are still waiting for their individual patient reports about their family members. I ask you, Cabinet Secretary, given that you've made very little reference to the families in your statement today: when will they receive those individual patient reports? At what date can they expect some closure on some of these issues?

And of course it's not jut a difficult report for the board and for those Tawel Fan families, it's a very difficult report for you too, or it certainly ought to be, because you've been responsible for the oversight of the special measures arrangements at the Betsi Cadwaladr university health board from the day that those special measures started, in your previous capacity as Deputy Minister for Health and now as Cabinet Secretary. It's very clear from this report, this is not a historic document; this brings things right up to date to the current time. It's very clear that those special measures are not working. You can try to pass the buck back to the health board, as no doubt you've already done today in your statement.

We were told initially that we had 100-day plans to turn the health board around. Well, it didn't even veer one inch to the right or the left in an attempt to turn around, and this report seems to demonstrate that. It's now been more than 1,250 days and I think that lots of people in north Wales have lost confidence in your ability and the ability of your Government to have special measures that mean something and actually deliver the pace and progress of change that we need to see. I know that you say on a regular basis that you've made your expectations clear. I'm fed up, frankly, of that line, and so are people in north Wales. A weekly rant, an e-mail from an ivory tower in Cardiff Bay is not going to deliver the change that we need to see in patient care in north Wales. We need more action not words, apologies not excuses, and accountability not an avoidance of responsibility.

So, I ask you today: will you apologise for the failure of special measures to date? Do you accept some responsibility for the failures outlined in this report? Because some of them have been failures that we've seen on your watch while this board has been in special measures. It was put into special measures, in part, to deliver the outcome of some of the recommendations in the individual investigations and reports that have been undertaken by various bodies. They clearly haven't done that, because the report says that very, very plainly.

People still find it absolutely astonishing that not one person at the health board has been sacked as a result of the failings that have been itemised in this report. Yes, we've seen some changes in the senior leadership team. We've seen some of those executive team members change. But, some of those senior managers are still employed by the board, including some of those who were in a position to be able to change things at the board. One individual, for example, the former chief executive, has recently been appointed as the board's turnaround director. Can you believe that? A turnaround director. You couldn't make these things up. It's a disgrace.

We know that patients have come to harm. Some patients, as well, when you go back through this report, have actually died as a result of the failures in governance and leadership at this board. And, frankly, I think that those responsible should never work in the national health service again—ever—and I think it's your job to determine that there is action taken to deal with that accountability issue. I'd be grateful if you could tell us what you're going to do—

Are you winding up now, please?

—to deal with that.

Are you winding up, please?

You will be aware, Cabinet Secretary—. I will, Deputy Presiding Officer, in a second. You will be aware, Cabinet Secretary, that, as a result of the Corporate Manslaughter and Corporate Homicide Act 2007, organisations can be found guilty of corporate manslaughter as a result of

'serious management failures resulting in a gross breach of duty of care'.

Many people in north Wales—people in this Assembly too—are concerned that the Betsi Cadwaladr health board is guilty of just that. 

So, can I ask you: will you be referring the contents of this report to the police and to the Crown Prosecution Service for them to be able to consider whether there is a case to answer in terms of corporate manslaughter and corporate homicide, because I think that there may be justice in doing just that?

Can I ask also about estate—

Please—[Interruption.] Excuse me, from a sedentary position, I don't need any help, thank you, and I'm asking the Conservative spokesperson to wind up. He's had longer than the Minister took.

I will wind up. And I think it's regrettable that we don't have more time, frankly, in a Government debate to be able to consider some of these issues this week, but no doubt we will return to it—we'll probably have to return to it in opposition time. 

Just one final question from me, given that my time has run out, and that is about the estate issues that are referred to in this report. I know that one of the issues that was reported to us in the letter—the open letter—from the Betsi Cadwaladr health board was the need for some capital improvements to be made in north Wales. I know for a fact that bids have gone in to the Welsh Government—some of them 18 months ago—to make some of the improvements that are necessary, and yet you have failed to be able to respond to those bids. You've not even said 'no'—at least if they had a 'no', they would be able to look at other ways of trying to make some of these improvements. Why on earth can't you pull your finger out and make some decisions on these matters so that we can make the progress in north Wales that is absolutely required so that we can get the improvements in place that patients deserve?

Cabinet Secretary—[Interruption.] Sorry, if I hear any more comments like that, I will suspend the proceedings until people are listening quietly. I will not have sedentary comments from people who are not taking part in this debate. Cabinet Secretary.

I recognise the range of comments and concerns the Member has consistently made throughout the course of special measures and the initial Ockenden report into the Tawel Fan ward. Dealing with what I think were the questions, as opposed to the broader comments made, at the outset I recognise the very difficult position that families are in. This has been a long road travelled, and I understand why closure is incredibly difficult for families—I've recognised that on each and every occasion I've been in this Chamber, and I did so at the start of my statement today.

The family reports from the previous Health and Social Care Advisory Service report are not the subject of today's statement, but you asked about it—I will chase up again the process for those being provided, but dates are supposed be agreed between HASCAS and families for individual reports to take place. If any Member has any evidence that there has either been no contact or that unobtainable dates are being provided, I will happily take that up with the health board to make sure that HASCAS themselves are providing a range of dates to make sure that those individual reports for families can be provided and the information that people will, of course, want to see.

You talked more broadly about responsibility and your consistent call for people to be sacked. I'm very clear that I have responsibility for the whole of the national health service—what it does well and, equally, what it does not do so well. Of course, much of the time in this Chamber is spent talking about and responding to points where the health service goes wrong, and this is an example of where the quality of health and care has not been what any of us would wish to see.

I couldn't be clearer about my disappointment in the pace of improvement during special measures or the need for further improvements to take place. That is why we are providing increased support to those areas of challenge with the health board—the additional capacity at an operational level and the additional capacity we're looking at again in responding to the recommendations laid out in this report and, indeed, the HASCAS report.

The action plan has to be real and to be deliverable, because you will know as well as I do that in Donna Ockenden's report she suggests coming back in what she refers to as quarter 2 next year, so roughly the middle of the summer next year. So, in approximately 12 to 15 months, there will, understandably, be a need to return, but in any event the health board themselves have acknowledged that they need a proper plan to respond to. I expect them to come back to their board on a regular basis to update them in public about the progress that is or is not being made in responding to the recommendations in this report and the HASCAS report. 

It is not for me to refer this report to the police or the Crown Prosecution Service. They are well aware of the content of the report—how could you not be within north Wales? It is for them to decide whether there is a case to answer. It is not for me to decide that there is a case to answer for corporate manslaughter. I would caution Members on not taking an approach that is to use the most intemperate language possible about what are very difficult circumstances for families and staff within the health board. I do not apologise for not acquiescing to the demand the Member made at the outset, four and a half years ago, to immediately dismiss people without any process. That would have been the wrong thing to do then; it is still the wrong thing to do now. The health board, as the employer, must take through a proper process with their employees, and if there is disciplinary action to be taken then they should take it. 

On your broader point about capital funding, the letter from the chief executive sets out a range of funding that has been provided and has been made use of to improve the environment, specifically within mental health services. And anything else that comes in I expect the Government to respond to properly. [Interruption.] I'm not aware of the individual matters that the Member refers to. If he wants to write to me with detail, I will happily respond to him and make other Members aware of the response. 

But, in terms of where the health service is, you made this point that not one thing has changed about the health service and has not got better, and yet maternity services have been de-escalated, and yet we see real excellence in the provision of healthcare in a range of areas across north Wales. [Interruption.] I think some temperance—

Sorry. Sorry, Cabinet Secretary. Darren Millar, if you can't keep quiet from a sedentary position—. You have now had several interventions from a sedentary position, and sighing from your backbenches does not help you either. Sorry.  

There are several areas of excellence and high quality being provided within north Wales, and I do think that there is room for temperance and responsibility in the way that we address healthcare services in every part of the country, and that includes the scrutiny that could and should be provided to an area of continuing concern that I do not seek to hide from at any point whatsoever.  

Thank you. Rhun ap Iorwerth. 

Diolch, Dirprwy Lywydd. I'd also like to place on record my thanks to Donna Ockenden and her team for preparing and publishing this most recent report. I thank the Cabinet Secretary for the statement too, but I'd like to place it on the record that I have requested in Business Committee that we have a debate on these matters. We are at a point where we need a debate and, for people watching this discussion today, it's worth pointing out, for people who aren't well versed in how the Assembly works, that the difference between a statement and a debate is that in a statement we have limited time; in a debate we have additional freedom to not only have more time to question the Government, but also to put down amendments to motions, and to hold a vote on matters. So, I look forward to having that debate in due course. 

You will not be surprised to hear that I find the content of your statement today disappointing. There seems to be very little recognition that Ockenden's report highlights the failure to implement recommendations of report after report, including the period, of course, in which Betsi Cadwaladr has been in special measures. And, just as Einstein told us about the chances of getting a new outcome when you keep on trying the same thing time and time again, here we have another statement from you in which you place the emphasis and responsibility for change, or for delivering change, on the board itself. We need a new approach from Government. 

I want to highlight one issue in particular raised by a constituent of mine to illustrate how little, it seems, has changed. She writes, 'I found myself unexpectedly in the position of being a whistleblower in Betsi Cadwaladr some 18 months ago'—that's in a period, of course, when you are running the board—she goes on, 'after my initial attempts to discuss my concerns to a senior manager were rebuffed. Since I took this fateful step last year, I've encountered endless obstacles and difficulties. Those difficulties include complaints going missing, transcripts of meetings being falsified, investigators being appointed who were either not clinically competent, didn't hold sufficient authority or who were too closely connected to persons named in the concerns, and one investigator actually worked part of their job in a subordinate role to a named person.' Remember that the focus on improvements put in place after the Tawel Fan scandal surely should have put an end to this culture of disbelief in whistleblowers and bullying those who raise concerns. Now, isn't it the case that what we have here is a health board that really didn't work from the word 'go' and, it seems, still doesn't work now, three years into your running of it? Isn't it now time to acknowledge perhaps that this is a health board with a reputation that is toxic and beyond repair, that we need a new model for delivering health and care in the north of Wales?

Let me finish by asking what your role is here. Do you agree that the buck stops with you as Cabinet Secretary for health? If you agree with that, do you see that failings have continued during the period in which you have been in charge? Do you agree with that? And, if so, what response can patients and their families expect from you in light of the fact that you have failed to address the problems within Betsi Cadwaladr?

Thank you for the questions. Your point at the outset about a debate or a statement is a matter for people in this place to decide how they wish to use their time. What I would gently point out to the Member is that in a statement the Minister has to respond to a series of questions from a wide variety of people; a debate is an opportunity to simply respond to one debate. There are choices to be made and in reality there would have not have been the time to come to this place with a debate today, but I asked for a statement to be added, recognising the significance of the issue. 

In terms of your point about implementing recommendations, I think I've dealt with that in response to Darren Millar, but also in my opening statement about needing to implement recommendations and also the upfront recognition that we are in this place because we have not had the level of improvement required and we have not implemented all of the previous recommendations that have been made. There have been challenges in the leadership and direction of this health board over a period of time and that is recognised and I have confidence in the renewed leadership that is about to be provided again to particularly address the challenges that HASCAS and the Ockenden report have highlighted yet again.

You mentioned a specific complaint with a range of details that of course I'm not aware of and can't respond to, but if you do write to me then I will ensure that those matters are taken up. I would not try to stand by or defend the suggestions of poor practice that you have suggested, but I can't really respond unless I'm aware of the specific complaints. 

When you talked about a new way of delivering healthcare, I'm not sure if you were talking about a suggestion that Betsi should be broken up or renamed. It would be helpful to have clarity, but no independent organisation who's gone through in the last few years has suggested that the answer to improving healthcare in Wales is to have more than one health board again within north Wales. I believe at this point in time that would be a distraction and our challenge is making sure that Betsi actually works, and I take on board my responsibility for doing so. There is no escape from that in this particular role and I do not attempt to do so. I expect to be here to answer questions, I expect to answer questions in committee, and I'm committed to do so.

In terms of the additional support that you asked, I've put in more intensive support for a team to work alongside the health board, and that will provide additional capacity and capability in key areas, including the delivery of planned and unscheduled care and of course the work on financial turnaround. That also means that I've put in an increased level of support for the performance delivery and finance delivery units as well. So, I expect confidently that I'll have an opportunity to respond to the Chamber again in the future and that will continue to be the case until real and sustained improvement has been achieved.

Thank you for your statement, Cabinet Secretary, but I'm not particularly encouraged by it. I note that, in the first paragraph of your statement, you say that the Ockenden report is another difficult report for the board and that the findings shouldn't be a surprise to them. I agree with you on that point, but Betsi has been in special measures since 2015 and your Government have had control of the NHS in Wales since 1999 by virtue of being in Government in Cardiff Bay and are ultimately responsible for its failures. So, if this is a difficult report for the board of Betsi Cadwaladr, it's an even more difficult report for you, Cabinet Secretary.

Just reading the report's executive summary left me with my head in my hands in despair. There is an account of failure on practically every page, and the report provides a snapshot of an NHS in north Wales that is a shambles due to mismanagement. There are accounts of lessons not being learned and staff being stretched to breaking point by an irrational reorganisation that left them covering a vast geographical area.

The Ockenden report also reflects some of the comments that were made in the 'Mind over matter' report debated recently in this place that recommendations to the board have not been implemented. The same problems keep being repeated and have been since 2009. So, do you agree with me that it is the decisions of the board, and you and your Government, that have led to this unprecedented, woeful and utterly shameful situation and that you owe a huge debt of gratitude to the front-line staff who have been badly let down by you but continue to care enough to produce improvements that you can then trumpet as a success? Will any board members be removed if they fail to deliver on the expectations of improvement that you promise to place on them? And would you agree that, if someone is recruited to a job they fail at, the recruiter has to take a large part of the blame for mistakenly believing they were suitable and then even more culpability for the problems it causes if they don't remove that person or persons?

You've mentioned improvements, and I won't deny that there have been improvements. But improvement at Betsi Cadwaladr is proceeding at a glacial pace to say the least. You're saying that you will continue to give ongoing support to Betsi Cadwaladr, and my question to you, Cabinet Secretary, is how this support will differ from that which is already being provided, because previous support and interventions don't seem to have borne sufficient constructive fruit. The Ockenden report points to failures and warnings of the same since Betsi's creation in 2009. True, the board needs to shoulder its fair share of accountability for the failures and shambles that are reflected in the Ockenden report. However, you as Cabinet Secretary are responsible for managing that board and have to accept accountability for your own failure to bring Betsi out of special measures and back on the road to excellence. Will you do that? Anything less than the full and proper implementation of the board's recommendations, rather than the mealy-mouthed 'accept in principle' with which you greeted many of the recommendations in the 'Mind over matter' report on the state of children and young people's mental health service provision in Wales, will be a gross dereliction of the duty of care that you owe to the people of north Wales.

You said in your statement that you're acutely aware of how difficult this period has been for families and patients affected by the failures highlighted by the Ockenden report, but I'm sure that they would find far more comfort in you resolving the problems at Betsi than they will from your mere words. So, finally, without using the term 'lessons have been learned', please can you tell me what new actions that differ from those actions you've taken so far you will be undertaking to drastically improve the outcomes at Betsi Cadwaladr? Thank you.

Thank you for the series of questions. I think I've dealt with the similar questions that have been asked about responsibility, which I accept for the national health service when it goes well and, indeed, when there are challenges too. Other people have asked about the same point about not just the scrutiny but actually additional support around the board, which I think I've dealt with in the last two questions by giving particular detail of the additional support and what that amounts to.

I just want to make two points in answer to the other broad questions that have been asked. On this point about special measures, special measures will continue until the health board has made real and sustained improvement. It will not end at a point that is convenient for me. If special measures were a construct simply to make a politician's life easy, then there would be little point in having them. The special measures engagement and the improvement framework—we have the independent advice from the Wales Audit Office and Healthcare Inspectorate Wales, and indeed the role that the chief exec of NHS Wales plays. When they give advice that the health service in north Wales can be de-escalated, that is when it will take place, and not before and not at the convenience of a politician.

And I do have to take issue with your characterisation that the NHS in north Wales is a shambles. There is much to be proud of about the health service within north Wales. The language that you used in a broad-brush way to attack the whole service and what it achieves and then to say that you provide praise for front-line staff—you can't do both at the same time. Those same front-line staff who are achieving all therapy services being delivered within target, those people who are delivering the new and improved models of care to deliver more care at home, those health service staff who are delivering on a significant basis much better cancer performance within north Wales compared to colleagues across the border are the same people that you are suggesting are not doing their job in other areas. Now, there's a challenge here. I'm uniquely responsible for things that go wrong in the service. Now, that happens, that's the responsibility that goes with the role, but I'm looking for real and sustained achievement, not to make my life easy, but because it's the right thing to do for staff within north Wales and, crucially, it's the right thing that people in north Wales expect, and they deserve exactly the same high-quality care that every other part of our country does as well.

Well, let's try again. How do you respond to the statement by Donna Ockenden that,

'Staff are frequently commented on in a positive way. The good practice seen is often despite (rather than because of) any specific interventions by either the CPG management team or the BCUHB Board over the timescale, particularly from 2009 to 2016'?

How do you reconcile the statement in the letter to north Wales Assembly Members from the health board, received today, that,

'many of our current challenges stem from historic issues. There is much work to do to embed improvements across the...organisation but we are absolutely committed to increasing the pace of change for the good' with the Donna Ockenden review statement that,

'As recently as the end of 2017 actions promised following reviews and inspections in previous years were found not to have been carried out by BCUHB'?

You conclude your statement by saying it's been over four and a half years since concerns were first raised regarding the care and treatment at the Tawel Fan ward. Why do you keep repeating that when I've repeatedly stated—most recently here in May—that I represented constituents in 2009 alleging that treatment of their loved ones in the unit had nearly killed them, and that they were now worried about the treatment others may receive in the unit, and that Donna Ockenden

'found that the systems, structures and processes of governance, management and leadership introduced by the...Board from 2009 were wholly inappropriate and significantly flawed'?

Will you now address the question I put to you in May after the HASCAS report over why the findings of the HASCAS report appear to completely ignore the absolutely contradictory findings of previous official reports by Healthcare Inspectorate Wales in 2013 and the dementia care mapping in October 2013? How do you respond to concerns raised by the chief executive of the community health council in correspondence to the health board that there had been a serious data breach in relation to one of the patients, which had occurred when the health board supplied the relative with his mother's medical records and the community health council added that this is an all too common occurrence when BCUHB supply medical records to its clients? This was last month that that was written. And my very final question, in relation again to the letter received from the health board today: it says that the board will establish a stakeholder group—which seems rather late in the day—to help the improvement group understand and take account of the impact on stakeholders by providing a forum that enables a more in-depth assessment to be made whilst at the same time providing a means of identifying emerging stakeholder-related issues that need to be brought to the attention of the improvement group. Why, after all these years, are they still completely failing to understand and completely ignoring the issues identified by the Auditor General for Wales in his valedictory letter to the Chair of the Public Accounts Committee that we have to start doing things differently by designing and delivering services with patients and communities because, if we don't, we're going to continue making the same mistakes?

I recognise some of the comments that you've made about the historic nature of some of the challenges that the board faced at its inception in the way it was organised. That was set out in the Ockenden report we're discussing today, and, indeed, that was set out in the HASCAS review, and it's been really clear that the structure that was implemented at the time was not implemented in an optimal way and caused real challenges in the way that health and care were delivered in a range of different areas. That definitely affected mental health services. So, some of this has been about reorganising the structure of delivery. There's more to do within that. I will return to that later in responding to your final point.

I think it's important to recognise the improved leadership that has been delivered by the director of mental health and the need to deliver a different culture within the service that is provided, and that is work that is continuing and it must be part of the response to both the Ockenden report and the HASCAS report. Indeed, Healthcare Inspectorate Wales have commented positively on the improvements in the structure that is now permanent and they recognise that is fit for purpose. Indeed, Donna Ockenden herself comments that the structure is significantly improved. 

I don't accept your characterisation that the conclusions of the HASCAS report are somehow to be disbelieved or put to one side. I think they are consistent with the findings in the Ockenden review. Neither report is a positive report for the health board; they have both spelt out real and significant challenges that still have yet to be properly addressed. That is why we're in this position and why I'm making yet another statement on mental health services within north Wales.

I want to return to your final point as well, and that is your claim that, unless service users are involved—people who take part in the service—then we won't get the design and the delivery of the service right, wherever it is, including in mental health. And yet that is exactly what the new director of mental health has done, and been recognised for doing so, in designing the new mental health strategy for north Wales that deliberately took in and involved staff and service users, and, in taking that strategy forward, those same groups of people are being involved in what action should look like. I actually think that the new director of mental health and the approach that he has taken, which has been supported by the senior leadership within the health board, is one to be recognised, as indeed it has been by external partners as well. The challenge is not just saying there is a better approach now, but how that better approach leads to better outcomes and a consistent report back from staff and the public about the quality of the care they're taking part in.

Could I start by also thanking Donna Ockenden and her team for their work in preparing this report? I wish I could extend the same thanks to you, Cabinet Secretary, for your statement, but I fear that I can't. I don't feel able to do that, and I have to say that the tone is set in the first paragraph, isn't it? You just have to look at the second sentence,

'This is another difficult report for the board'

—not for the Welsh Government that has been in charge of Betsi Cadwaladr for the last three years, but for the board, and then you go on to say,

'The message is clear: the board must increase the pace of improvement and change.'   

Is it not a difficult report for the Government, then? Should the Government not increase the pace of improvement and change? Don't you see it as your responsibility? Don't you see it as your problem? Or, maybe, I think, that is part of the problem here, and something that you still are not addressing. And then we go on to the next paragraph—there are sympathetic tones and there's regret, of sorts here, and I'm not doubting that, but there is no apology, as has already been suggested. Do you not owe an apology to those whose lives have been a living hell over recent years because of many of these failings? And, having failed to respond to that request earlier, I would ask you again whether you would use this opportunity this afternoon to issue that unequivocal apology to those people who are out there suffering because of all of these failings.

Now, your statement emphasises that the Tawel Fan issues relate to the past, of course, and we need to learn lessons and move on. But, as Ockenden clearly shows, there have been numerous reports that have highlighted these problems, where lessons have not been learnt and those problems still persist. So, tell us, why should we have confidence in your and the Government's ability to learn those lessons this time, when you've patently failed to do so over the years? Ockenden tells us, if I may quote, that, 

'Medical and nurse staffing continues to be a concern' within older people's mental health to the current day.

'Clinically based nurses across OPMH in BCUHB described...staffing in 2017 as "very difficult" and as "constantly firefighting." Nurses also described staffing as "worse now".'

So, this isn't in the past. This is on your watch, under your control, with the board, of course, in special measures. So, will you not take a modicum of responsibility for the current situation, as described in the report?

The report also highlights the failure to investigate serious incidents and to deal with families' complaints adequately. As recently as October last year, a letter from a front-line clinical nurse who contributed to the governance review said, 

'"how would I feel about being a nurse? Vulnerable, unsafe, unsupported by senior management, as they are ignorant to the fact it happens—despite all the incident reporting. Why? Because they don’t go onto the wards anymore. They stay in their offices telling the heads of the trust we don’t have any issues, when clearly if they talked to the staff on the floor we no longer feel safe".

'The nurse also describes patients as "not safe as there are not enough staff" and "patients remaining without medication due to no doctors on wards". She added "money comes before staff and patient safety. I feel I am no longer a nurse but a prison guard trying to keep the wards and patients safe"'.

This is late 2017, just months ago—not 2015, not in the distant past. And this is two years into the Government's special measures. So when do you think you'll be able to give Betsi Cadwaladr a clean bill of health? You just said that you expect special measures to take as long as it takes. Frankly, how, therefore, do we measure your performance? Do we just keep coming back to these statements time after time after time?

Finally, if we don't see serious structural changes in the way that healthcare in north Wales is delivered, I fear that we will see further reports highlighting the same problems in coming years. If people in charge are unable to learn from the mistakes of the past, as clearly has been the case previously, we'll see this macabre groundhog day repeating itself. After almost a decade of lurching from crisis to crisis, isn't it time to draw a line under Betsi Cadwaladr university health board and consider whether it should be restructured? And if not now, then what will it take, and at what point will you accept that something has to change?

I'll start with your final point, because your colleague Rhun ap Iorwerth also talked about structure and restructure and what that might mean. I'm not clear at all what you're proposing in terms of the restructure of the health board, because we need to be clear about whether you're talking about more than one health board, how it would be achieved and how that would actually deliver better care. That's the challenge here: if you break up the current organisation, then the challenge that actually provides. And I don't believe that would deliver better healthcare, certainly for a medium period of time. The focus must be on improvement in the here and now.

I've talked several times over in response to questions that have been mentioned today about the additional support and intervention that is being provided to the health board, and I have apologised on a number of occasions within and outside this Chamber for the impact upon families where healthcare has plainly not been delivered to the quality that people expect and are entitled to expect. It has been the right thing to have these reviews undertaken over a period of time where they can have access to enough information to provide a significant and reasoned report upon significant evidence. I'm sorry it's taken the length of time that it has done, but it would absolutely have been the wrong thing for a politician to intervene to say, 'Provide this report more quickly.' That would be about meeting my interests, and not about the interests of the public who are receiving healthcare in north Wales, or the delivery of it.

In terms of the assurance to be provided, I've already indicated that special measures—. I've indicated an improvement framework for the next 18 months. That will be provided. The assurance will be provided by Healthcare Inspectorate Wales, the Wales Audit Office and the NHS Wales chief executive. That is not going to be delivered for my convenience; it will be delivered with an honest assessment of the progress that has been made, or not. And you will see from the previous reports on special measures that there has been no dumbing down of criticism or praise for where the service has moved. So, the essential honesty on what is happening is already there. I do take seriously what staff have to say, whether that is good, bad or indifferent, and when I visit healthcare facilities right across the country, staff are direct and honest with me, including when they think that things are not good enough. That has always been the case when I have visited north Wales too.

I would say that, in terms of visibility, I think it's wrong to say that the health board are invisible. Actually, Donna Ockenden herself recognises there are a range of key individuals who are visible. She calls for the rest of the board to have that same level of visibility. But in particular I'll make this point, as you mentioned a recollection from a nurse within the health board itself: actually, the nurse director has widespread praise within the profession, within north Wales and outside, and she is a very visible character. On every single visit that I have undertaken with her, she has not just been recognised by other nurses, but she has recognised those nurses herself and had a conversation with them, and the respect that is there is obvious. You do not always see that in every particular sphere, and I actually think that that level of maturity we require about expecting improvement, but about there being a reasoned way to do so—we do have to recover that in the way that we discuss these issues. That should not take away from the significance of the scrutiny that I fully expect to face.

We are out of time, but I will call Angela Burns. You are the third speaker in your group—I'll just give that gentle reminder. Thank you.

Thank you very much indeed. I do only have one question, but a very small preamble, which is that this report is the culmination of two and a half years of detailed work. Several thousand documents, some previously unpublished, have been reviewed by the team, 200 interviews with current and former staff and current and recent service users, across the six counties of north Wales, and it's four and a half years, as you yourself say in your statement, since the concerns were first raised. In that time, there have been three joint reviews of governance, in 2013, 2014 and 2017. Healthcare Inspectorate Wales have reported on the Betsi Cadwaladr health board, as well as the Wales Audit Office, the NHS delivery unit and various royal colleges. There has been targeted intervention since 2014-15, and special measures from 2015. I think it's an absolute disgrace that it has taken so long for this to turn around, and so my one question to you is: how much longer will you give them to make real, sustained improvement? Before you answer, I will tell you, as somebody who has run businesses that have been in awful trouble and tried to rescue them—some successfully, some not so—you can't just answer with, 'As long as it takes', because there comes a point when the critical mass spills over. You have to have an end game, and I'm not confident, Cabinet Secretary, that there is an end game of when you expect to see—your words, not mine—real sustained improvement. Because as Llyr Huws Gruffydd said, we shouldn't be having this discussion again.

As I have said, there is an 18-month improvement framework with a range of measures that we will test the health board against, and that won't just be my assessment; it will be the advice that is given by the chief exec of NHS Wales, the Wales Audit Office and Healthcare Inspectorate Wales. That assurance is not just the Government marking its own work or coming up with a convenient excuse or reason. So, every time they have that discussion, they provide advice, we provide a statement and we're open about what is said—both the good and the indifferent and the stuff where, actually, we're thinking we're not moving in the right direction at all. So, there will be openness and transparency, and if I think there are more measures that we should take, then I will do so, and I will be accountable for those measures. I will come to this place and I will announce them and I will answer questions upon them. There is no hiding, and I expect there to be—. Within the 18-month framework, there are measures there that are timed and specific, and I expect the health board to make real progress on doing so, as opposed to simply explaining why it hasn't managed to do so. If we cannot deliver that improvement, then it is understandable that people will not just have more questions, but expect further intervention within that health board to ensure that people really do receive the healthcare they are entitled to expect in north Wales and every other part of the country.

Thank you very much, Cabinet Secretary.