Turning to spokespeople's questions, and the first is from Angela Burns, the Conservative spokesperson.

Thank you very much, Deputy Presiding Officer. As a result of serious concerns about the quality and safety of care within maternity services at Cwm Taf, you commissioned an investigation into the provision of those maternity services. You asked the Royal College of Midwives and the Royal College of Obstetrics and Gynaecologists to undertake the investigation. This they did in January of 2019, and the royal colleges subsequently produced a report that the Welsh Government published on 30 April. It is a damning report. During the investigation, the royal colleges were so alarmed that they took the highly unusual step of making interim recommendations designed to secure immediate improvements in patient safety. The investigation found a service that was working under extreme pressure and under sub-optimal clinical and managerial leadership. The maternity services, Minister, were already in enhanced monitoring, warning bells were ringing, the field work on the unpublished colleges' report had been undertaken some eight weeks earlier. Therefore, do you think it was appropriate that you agreed Cwm Taf's integrated medium-term plan on 27 March?

'Yes' is the straight answer, because it's important that there is a plan and the plan itself makes sense. And having had the interim step from the joint royal colleges' report, of course I considered the matter fully, and whether it would be better or not to not approve that plan. I believe it's the right thing for the organisation, and I believe their capacity to deliver and continue to deliver in other areas should continue. But, of course, there is heightened scrutiny. So, I did take the step to raise the escalation status of the organisation, the targeted intervention. And as for the improvements on maternity services, well, Members in this Chamber have heard me say on more than one occasion, openly, where we are on the journey of improvement, with the work of the independent oversight panel, and that, indeed, the changes that the recent governance review recognised have taken place under the new leadership within that organisation.

Let's be clear: Cwm Taf was already struggling. There were reports from Healthcare Inspectorate Wales in 2015, which raised concerns about the quality of patient experience, the delivery of safe and effective care, and the quality of management and leadership. There was a report by the workforce and organisational development team in 2016, which identified significant issues, including the perception of a blame culture and a lack of time. There was a 2017 Wales Deanery visit that highlighted six areas of concern. There was a 2018 General Medical Council survey, which highlighted concerns, a 2018 Healthcare Inspectorate Wales report, which highlighted concerns, a 2018 internal report by the associate medical director, which produced a governance review and an implementation plan that wasn't implemented. May to September 2018 saw three deep dives into reported and unreported incidents on Datix, including the discovery of all those stillborn deaths, a September 2018 internal report by a consultant midwife that was ignored, a 2018 report by the Human Tissue Authority, which identified concerns in a number of areas throughout the health board, including maternity services. And a 2018 report by the Wales Audit Office, raising concerns over quality and governance arrangements. Minister, you did not sign off on the IMTPs of Hywel Dda University Health Board, Betsi Cadwaladr University Health Board, or Abertawe Bro Morgannwg University Health Board. So, can you explain to us what was so different about Cwm Taf that, despite all the foregoing, you felt you could agree their IMTP?

Well, I think it's important to recognise that, in the reports that the Member has quoted elements from, there are also a wider range of positive reports about the activity of the health board. Trying to recast in a wholly negative light the activity of the former Cwm Taf health board is not something that I think is either fair or balanced. The honest truth has been set out, in both the recent governance review, and indeed in the joint royal colleges' report that I intervened on and commissioned. Some of the areas that the Member has referred to were actually dealt with in my statement in autumn of last year, in requiring further improvement. So, far from the Government looking askance and ignoring the issues, we have intervened, we have taken steps and measures. And I look forward to further progress being not just made by the health board, but actually the independent oversight and assurance we will get not only from the independent oversight panel, but from the work both of the Wales Audit Office and Healthcare Inspectorate Wales. And more than that, in my recent visits to meet people in maternity services, I met staff on both sites; it was an honest and an open conversation, and a much more public one. And I'll be going back to meet families before the end of the calendar year, as indeed I promised to do. I think a balanced view is the one that I took when I approved the plan, and it's still the right thing for that plan to be approved today.

Well, let's be clear—the five operational objectives that provide a framework for Cwm Taf's IMTP plan include: to improve the quality, safety and patient experience, and to provide strong governance and assurance. Now, Dai Lloyd has already raised the evidence that we had from the director of community mental health and primary care at Cwm Taf over Parc prison. We're not questioning the fact that, in fact, G4S are supposed to be the ones running the community services; what he has responsibility for is governance, to ensure that those services are being delivered. And yet, his response to most of the committee questions was, 'I don't know. I don't know. I don't know', despite the fact that they've had that prison, not only in their care since the beginning of this year, but there's been an 18-month lead-in to it. So, it's all about the governance, and this has been brought out again by the joint Wales Audit Office and HIW report, which absolutely slates the lack of governance and audit control within this health board.

In your Cabinet paper, on 27 March, you said that all of the IMTPs of all of the health boards had been subjected to a robust assessment process. How, Minister, did you or your officials not pick up on this tsunami of concerns? Is the reality that, for the last few years, Cwm Taf has been held up as the grade A health board, the lodestar, the ones that all other health boards should try to emulate, and it couldn't be allowed to fail? Because there is beginning to smell a systemic issue throughout this health board. And before you come back with some quick quip on this, I'd like to remind you that even the maternity services oversight panel interim report is very clear, as is David Jenkins very clear about the fact that this is a cultural change that has to happen throughout the whole health board, that there are systemic issues, and the governance arrangements, if nothing else—which is one of the things in that IMTP that they waxed lyrical about, and say is absolutely spot on—are poor. Their audit committee hasn't met for ages, to discuss some of these issues. So, Minister, I'll just ask you this: did you look at Cwm Taf's performance robustly and dispassionately? Did you look but did not see? Did you look, did you see—did it not matter?

I think that's an appalling way to finish a question—as if it does not matter. Everything that I do in this job and the choices I make are about people in Wales who work in our service, people in Wales who need the health service. Far from there being a tsunami of unanswered concerns—. And, again, the overstated nature, in terms of the language you're using, I think really doesn't do you any credit, Angela Burns—[Interruption.] The reality is that having understood, following the joint report commissioned by the royal colleges, the nature of the concerns that existed, every organisation has looked again across the NHS at what it is doing and why. And if you look at the previous Wales Audit Office governance reviews, they don't reveal the same level of concern, and the detailed work they've done together with Health Inspectorate Wales doesn't reveal either.

There is a requirement for cultural change, and I've been very, very open about that and about the expectation that not just needs to take place but to be evidenced and to be felt by staff and the public. And, indeed, the new leadership in place within the health board, not just the interim chief executive, but the different approach being taken by the wider team, including independent members, is part of that as well. I'm looking forward to there being real evidence on where the health board is, and I will absolutely make choices about each and any NHS organisation dispassionately and with the interests of the public in mind.

Thank you. Plaid Cymru spokesperson, Helen Mary Jones.

Diolch, Dirprwy Lywydd. Minister, I'm really keen to understand why it was that the seven previous reports into the issues at Cwm Taf hadn't raised concerns with you, hadn't brought you to the point where you eventually did take the action that you took. And I have to bring you back to the question of the integrated medium-term plans, because there were some plans that you chose not to sign off, you chose to sign off the Cwm Taf plan—only a month after that, the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists report was made public. When were you aware, Minister, of the content of that report? And can you explain to us—? You've said to Angela Burns that you thought it was appropriate to sign off the plan, but can you explain to us, because I didn't really hear you answer Angela Burns in that regard as to—? Did you know what was in that report? You'd commissioned that report, you knew there were problems—did you know what was in that report before it was published, before you signed off the plan? If it was appropriate for you to sign off that plan, why was it inappropriate for you to refuse to—? Why did you refuse to sign off other plans for health boards where, apparently, there certainly were difficulties—don't let us talk about Betsi Cadwaladr—but, for whatever reason—? I suppose what I'm trying to get to, Deputy Presiding Officer—forgive me—is things were obviously in part of Cwm Taf in a very serious state. You chose to sign off their plan. Things in other health boards were—there were clearly other difficulties: you didn't sign those off. Could you please give us a bit of insight into what was the thinking behind saying, 'Yes, we'll sign off Cwm Taf's plan, but we won't sign off these others'? What were they doing, or failing to do, that was so terribly wrong that made what was going on in Cwm Taf appear comparatively acceptable?

When you sign off a three-year plan you have to understand the nature of the narrative, what's being proposed and whether there's the ability to deliver on the change that is being described within that plan. And having a strategic direction is actually really important for organisations, regardless of their escalation status. And it's part of the challenge in north Wales that they've been living hand to mouth for far too long and they'll need, even if they don't move into normal monitoring, to have a plan for the future. It is part of the challenge they're facing. In Hywel Dda, they recognise that until they have further traction on their financial challenges, they're unlikely to have a three-year plan that the board can sign off and actually expect to be approved here.

The position in Cwm Taf was plainly different. Having had a three-year plan, having made progress on a range of areas, and the challenges about quality and some of the governance issues that have been highlighted—some of those were addressed through time with a range of criticism in the reports. But the idea that all of those issues were ignored or not highlighted or not considered simply isn't true. And in any of these judgments, it is a balanced judgment about what to do with and for that organisation. I made the judgment that I did. I think it was the right thing to do.

I actually think that having a plan in the here and now for Cwm Taf Morgannwg health board is actually really helpful about its future direction. But it does not underplay or move away from the challenges about quality and the ability to actually evidence that they are making the progress that they are plainly required to do, and indeed the heightened level of interest in and scrutiny of the organisation makes that very, very obvious. I have been open, and I will continue to be open about any choices that I make for any NHS organisation, including Cwm Taf Morgannwg University Health Board.

I'm struggling to understand this, and perhaps we're all suffering from general election fatigue and there's something the matter with my brain, but the Minister has just said that he was confident that Cwm Taf had the ability to deliver on that three-year plan that he signed off. Now, bear in mind, Deputy Presiding Officer, that this was before any of the interventions that the Minister has said will sort everything out. And let's be absolutely clear that the level of governance and management at that point, when he did that sign-off, was really, really poor. I still don't understand, from what the Minister has said, why he was happy to sign that off. Either he knew and he thought it could be overcome, or he didn't know, and that's a problem in itself, but he wasn't prepared to sign off those other plans.

Now, if we look back to the HIW and audit office report, they are being fairly clear that the Minister was measuring the wrong things. If these plans are only about the financial condition of a local health board, then let's call them that and let's deal with that, and I'm not for one moment saying that where local health boards are struggling with their finances, that shouldn't be addressed. But I cannot understand how the Minister felt that those individuals running that health board, who had allowed this appalling toxic culture to develop—and it's clear that it's not only in maternity services that that's really poor—when he signed off that plan, were in a fit state to deliver. That was long before he put his measures in. The measures he's put in may or may not work. I am just at a loss to understand that, and I want to know form the Minister whether he accepts that there are structural and systematic problems in the governance and leadership of the NHS that go beyond one health board at a time. 

Well, there's a range of questions in there, and, of course, I said before, you can't know what you don't know when you're making choices. I took measures to intervene in the health board once the report had been received and I then promptly published it. So, the intervention shows that we did act when the level of concern was there to do so. And indeed, putting in place an interim chief executive—that was an action that was fostered from the Government here as well. So, we've hardly been stand-off when it comes to the health board. And I don't think it is fair to put words into the mouth of HIW and the Wales Audit Office, in terms of saying that I or my officials were measuring or looking at the wrong thing.

If you look at the system reviews that have taken place within the national health service here in Wales, both before this term or at the start of this term with the parliamentary review, no-one has come up and said that there is a fundamental problem in the governance and structure of the health service here in Wales. Our challenge is how we make our structures work and how we hold each other to account in the different parts that are executive teams, independent members and, of course, in the scrutiny that I regularly face here as well. 

Now, ultimately, it will be revealed in the outcomes for people and in the facts and figures about what our health service continues to deliver. It is entirely possible to be a high-performing organisation and to get some things wrong. Our challenge is to recognise the scale of what needs to improve within Cwm Taf Morgannwg and to be open about whether that has happened or not and, if not, what further steps need to take place.

Well, well, 'you can't know what you don't know'. Well, Minister, you'd had seven reports before you signed off on that plan. You'd had seven reports from different parts of the health service that were telling you that there was a crucial service and that if you put all of that bad evidence together before you get the royal college's report, you can see that there are things seriously going wrong. 

I'm afraid that the Minister cannot stand here and say that he didn't know, or if he is telling us that he didn't know, then that takes us into a completely different area of competence, which is not where I want to go this afternoon. 

I think the Minister must accept—and it isn't us saying this; it is Health Inspectorate Wales and the audit office—that there are systematic structural problems with the governance, and Angela Burns is helpfully giving us the page reference—page 33. There are systematic problems not just in that health board. And isn't it time for the Minister to look again—to look at what the committee's report, which we discussed yesterday, said about some of the areas that the legislation that he's proposing will not address?

Isn't it time for him to consider a single, integrated, truly independent health and care inspectorate that can look at all these issues across the board? Is it not time for him to take steps to align the health and social care complaints procedures and make sure that they're rigorous and make sure, for all those families who were ignored again, and again, and again when they raised concerns in Cwm Taf, that that will not happen again. Isn't it time for us to have truly independent whistleblowing procedures for health and care services in Wales, because if the Minister believes there is one, he's probably the only person left in this country who does.

And is it not time, when it comes to quality of leadership—and this is so important—for the proper regulation of non-clinical NHS managers, including an agreed competence framework, consistent structures for training and development, and accountability procedures on a par with those to which clinical professionals are held? Will he today look at the seriousness of these issues and consider amending the quality and engagement Bill, as the committee has requested, to address all those issues, or, better still, withdraw and rewrite it, or does he expect us to believe that everything's fine?

Well, I've never tried to stand up and say, 'Everything is fine, look the other way.' That is just not the approach that I've taken at all. And I just don't think that an exercise in post-event justification is particularly helpful or useful in terms of taking forward our national health service.

The range of the issues that the Member raises—. She's entitled to have views that say she wants to reorganise parts of the health service. She's perfectly entitled to have those views, but in terms of trying to say that what is now required is to amend or withdraw the healthcare quality and governance Bill that the Assembly passed through Stage 1 yesterday I just don't think is the right thing at all. Because what the significance of what the Member has talked about is that this is entirely new legislation that takes us in a different direction, so in the parts on quality and candour that the Bill actually sets out—and we will go through the scrutiny of that Bill, through Stage 2, and I hope Stage 3 as well—that's a different matter entirely. And we've rehearsed before the issues around whether to have an entirely different management and registration system for managers within the national health service. I'm open-minded as to what the future could and should look like, but I'm practical about how we deliver that, and I don't think that a couple of speeches in the Chamber and a demand to change legislation is really an honest answer to how we could get there. 

Thank you. The Brexit Party spokesperson, Caroline Jones. 

Diolch, Dirprwy Lywydd. Minister, I was shocked to learn that, out of nearly 0.5 million calls to 999 last year, around a quarter of the calls were not serious. Welsh ambulance service staff were tied up with dealing with calls ranging from a stubbed toe to hiccups, instead of helping people in genuine need. The Welsh Ambulance Services NHS Trust has launched a campaign to encourage the sensible use of the ambulance service. Minister, what can we, here, in this Chamber do to support the Be Wise Save Lives campaign?

Well, the Be Wise Save Lives campaign sadly is run every year, or a version of it, because we regularly understand that there are people who don't make the best use of our emergency services and, in particular, in this case, the Welsh ambulance service. It's partly about equipping the public with information so that they can choose for themselves—the Choose Well campaign that we run each year—and it's also partly about asking people to have some common sense and to show some respect for the way in which they use the Welsh ambulance service. And all of us, regardless of our party perspectives, I think, could take some time to try to support and promote that campaign so that all of our constituents make better use of emergency services and those who are in real need of that emergency service are more likely to receive the help they will need at that point in time. 

Thank you for that answer, Minister. And, of course, as we enter the winter period, the pressure placed upon the ambulance service is enormous. We have seen record rates of sickness absence in the Welsh ambulance trust, putting more pressure on the service. Difficulty in accessing out-of-hours care continues to drive patients towards our overstretched accident and emergency departments, which has a knock-on effect on ambulance handover times. So, Minister, what steps has your Government taken to ensure the efficient handover of patients at emergency departments this winter in order to ensure our ambulance service is not stretched to breaking point?

Well, there is a range of measures that are already in place and  being introduced as part of the winter plans. Of the money that I previously announced, some of it went directly to health boards and some went to nationally directed services, and, indeed, £17 million was determined between regional partnership boards. Lots of it is about looking at the whole system. It's partly about taking pressure off the front door of an A&E unit, but it's much more than that. It is about keeping people well at home so that they don't need to go into an emergency department. It's also about getting people through and out of the hospital when it's no longer the right place for their care. And we are dealing with record demands being placed on our health service. It isn't just that October was the busiest month in terms of emergency department attendances but, for the ambulance service,  it was the busiest October ever, with the highest number of red calls ever—a growth of 35 per cent in the most serious calls to our ambulance service since the new clinical response model was introduced just four years ago. So, part of our challenge is delivering that capacity. I'll set out again in the future the measures that are already taking place and how that is helping us to try to deliver appropriate, compassionate and timely care even through the winter period.