Questions now from the party leaders. Leader of the Welsh Conservatives, Andrew R.T. Davies.

Thank you, Presiding Officer. First Minister, if I could draw your attention to something that you are responsible for, which is the health board in north Wales and the Royal College of Surgeons report into vascular services last week that revealed that the majority of clinical documentation was unreadable or absent, that communication and care planning was non-existent in some cases, and that, in one instance, an amputee's wife had to carry him to the toilet after he was sent home without a care plan, is any of this acceptable, and, if it's not, will you apologise?

I do not regard any of that as acceptable, Llywydd; of course I don't. The findings of those 44 cases that were reviewed by the Royal College of Surgeons are very disappointing, and they are—as Andrew R.T. Davies illustrated in his answer—errors that were made by clinical staff failing to observe what seem to me to be basic standards of professional practice. When you read that there were deficiencies in record keeping, in consent taking and follow-up of cases examined, then all of us are right to be concerned and to be disappointed, and it is for the health board now to ensure that the necessary standards of professional practice are consistently delivered to the people who depend upon that service in north Wales.

Sadly, First Minister, I didn't hear an apology from you there, which I asked you to give to the people of Wales, and in particular the people who have that health board serving their needs, and the staff as well, who feel let down, because, obviously, you—as First Minister and health Minister—had this health board in special measures for seven years. Also, your Deputy Minister at the time, Vaughan Gething, had special responsibility for the health board in north Wales, and so I'd ask you again, please, if you accept that these findings are unacceptable, that you make an apology for the time that you held the strings on the governance and accountability within that health board. You can't go on constantly delivering, saying that promises are going to be made and improvements are made time and time again when (a) from your lack of apology today, you don't seem to accept any accountability for the problems that arose that this report uncovered, and, importantly, the constant merry-go-round that we as Members constantly see reports like this coming out of the health board area. So, I do ask you, as you had this health board in special measures, and you are First Minister, and, previous to that, you were health Minister, to apologise for what has gone on in this health board.

Llywydd, I have no difficulty in apologising. I don't share the same standards as the Conservative Party, where the Prime Minister refuses to apologise time and time again for the things for which he has been so directly responsible. I have apologised in the past for the failings of the health board in north Wales, and the Welsh Government has taken a series of measures to assist the health board to make sure that the services people get are of the standard that they are entitled to receive.

In relation to vascular services alone, the Welsh Government has made a substantial investment in the physical infrastructure of the service at Glan Clwyd Hospital, and, as a result of the funding that the Welsh Government has found for that health board, there are six additional consultant vascular surgeons, an additional consultant interventional radiologist, four vascular junior doctors, extra vascular specialist nurses, and a dedicated 18-bed vascular ward. The Welsh Government has done everything we can to support the board in making good for some of the deficiencies that had been identified in it. It is very disappointing to learn that in this service there are still standards of professional practice that do not match the standards that people are entitled to expect from those who are directly responsible for that clinical care.

My colleague Eluned Morgan set out in her written statement on 3 February the measures that will now be taken, and that includes oversight of the service from a large vascular service outside Wales to make sure that there is both oversight and multidisciplinary support. She said in that written statement as well that she had asked that vascular services are discussed at the next tripartite meeting of the Welsh Government, Healthcare Inspectorate Wales and the Wales Audit Office. That meeting will be taking place on Friday of this week.

Well, I asked you for the second time to apologise and you said that you had difficulty to apologise. I'm sure the lady who was carrying her husband to the toilet will regret the fact that you have difficulty in apologising for the lack of care plan that was put in place. I'm sure you will find it really—[Interruption.] I'm sure that the patients—22 that are numbered in this particular document—that you have responsibility for, have their records missing or unable to find any care plans put in place for their future well-being—. And it is a matter of regret that, during the seven years that you were in charge of the health board directly here from Cardiff, because of special measures—I might add the longest public body in special measures in any part of the United Kingdom—you, again, have felt unable to apologise when this report has come out.

You have tried special measures, First Minister. Since its formation in 2009, there have been four chief executives, six chairs and now we have targeted intervention and still we're getting reports like this. At what point are you going to accept that, instead of trying the same thing over and over again and getting the same results, Betsi needs radical reform and restructuring so we can see change for the people in north Wales and delivery of a service that stops reports like this being published and we have to debate them here in this Chamber?

Llywydd, it may be because I'm taking part remotely that what I said wasn't able to be heard sufficiently well. What I said was—

If I may help you, First Minister, I certainly heard you say that you had no difficulty in apologising. So, it may have been misheard elsewhere, but that's certainly my recollection of what you said.

Well, Llywydd, that is exactly what I did say, that I had no difficulty in apologising, and I'm sure the leader of the opposition will recognise that. I'm afraid I just cannot agree with him that the best way in which services for people in north Wales could be strengthened, in the way that I think right across the Chamber we would wish to see, would be to embark upon the turmoil of a radical reform and restructuring of services. If anything was guaranteed to divert attention away from care at the front line of the sort that needs to be put right in vascular services, it would be to plunge the organisation into that sort of internal turmoil. I can assure him that at various points when this has been suggested, this has been rehearsed inside the Welsh Government and with professional advisers and with other bodies, and every time the conclusion is reached that this would be the opposite of a recipe for improvement. It would just guarantee that, for several years ahead, instead of focusing on the things that need to be done, people in north Wales in the health service would be focused on organisational matters, rather than on the standards of clinical care.

On behalf of Plaid Cymru today, Rhun ap Iorwerth.

Thank you, Llywydd. I am on the record stating that we should get rid of Betsi Cadwaladr health board unless they can return to the right path, and I'm afraid that the report that we've seen now does nothing to give us confidence in the future of the health board. Last week, in responding to a question from Mabon ap Gwynfor, the First Minister more or less accused us on these benches, and campaigners and local staff, of undermining vascular services in the north because of the way that we have opposed and raised questions about the process of centralising services. Having seen another damning report, does the First Minister now see that we were raising genuine concerns for good reason—that's what we were doing?

No, I don't agree with that at all, Llywydd. I recall the questions asked by Mabon ap Gwynfor and I recall the responses—the careful responses—that I gave to those questions last week. I still believe what I said a week ago. What has happened with the reorganisation of the service is something that was necessary. The way that it has been done isn't acceptable, but as Eluned Morgan said in her statement—these are the words of the Minister:

'I am also sure the situation has not been helped by relentlessly negative public discourse which has overshadowed any positive impacts of the service reconfiguration and had the potential to impact on staff morale. This is something that was noted in the first RCS report.'

Concerns were raised and opposition raised because we were worried about the standards of service. I could barely believe what I was reading in this report: treatment given that should not have been given, even amputation; treatment not given when it should have been given; an appalling lack of communication with patients and their families; and record keeping so poor that the royal college investigators couldn't even figure out what had happened to some patients or what discussions there had been about their treatment, or, indeed, whether the health board had even met its ethical and legal obligations in the treatment of patients. Far from being the fault of those of us who questioned the centralisation programme, this has been down to incompetence and mismanagement, and the board had to insist on pressing ahead with this investigation when senior managers were still saying, 'No, everything's okay.'

Now, there were real questions over whether Betsi Cadwaladr was ready to come out of special measures, very conveniently before the last election. I'm looking for an assurance this afternoon that vascular services in the north will go back into special measures with targeted intervention to sort out this mess. And will the First Minister, in reflection, now agree that the end of special measures then was premature?

Well, Llywydd, a number of points there. It's important to put on the record the fact that up to half of the 44 cases investigated by the Royal College of Surgeons long predate the reorganisation of the services; these are cases that span from 2014 to 2021. The Member, I think, does a disservice, again this week, in mixing up those two issues together. The way in which services have been redrawn, so that specialist services are concentrated in one place, was the right decision; that is not challenged in either of the Royal College of Surgeons' reports and, indeed, the royal college supported that plan. What is unacceptable and deeply disappointing is the neglect of basic standards of professional practice that are revealed in the report. 

I was the Minister that placed Betsi Cadwaladr into special measures. I remember being told by Members on the floor of the Chamber that that was convenient for political purposes, just as I'm used to other parties trying to claim that the decision to bring the board out of special measures was somehow politically motivated. It was, Llywydd, simply the result of the process that is in place.

I cannot give the Member the guarantees that he asks for this afternoon, because those are not political decisions. Now, he may think that he, as a politician, has the answers and that we should simply rely on his political judgment, but that is not the way in which those decisions are made in Wales. There will be a tripartite meeting. The tripartite meeting will make recommendations and then, indeed, it will be Ministers who decide whether and how to act on them. But that's how the system works. It's not by people designing solutions on the floor of the Senedd; it's by taking the expert judgment of that rounded tripartite meeting, and then Ministers taking the responsibility for acting on them.

But I fear that, sometimes, decisions are made without a deep understanding of the communities that they affect. Let's look at that principle of centralisation. I totally understand the arguments for developing centres that are able to have a bigger throughput of patients with the most serious illnesses. But (a) when we do that for rural areas, say, we have to think innovatively so as not to strip away core functions that are important locally, because whatever promises were made in relation to this particular centralisation, that certain services would be kept local, that's certainly not what has happened. And (b) if it's about better services, why on earth was that element of centralisation, which could have been beneficial, not developed around Ysbyty Gwynedd, where the quality of treatment was so high? I asked a Betsi Cadwaladr medical director why on earth wasn't it decided to centralise around Ysbyty Gwynedd. He told me he didn't know.

There are lessons here for all of Wales, I believe, First Minister, and that is that the principle of centralising has become more important than the quality of care in too many instances. Will the First Minister commit to having an investigation that's open and transparent, and independent, into what happened with vascular services in the north, so that all of Wales can be sure that those lessons, where centralisation does go wrong, are genuinely learnt?

Well, there are some aspects of what the Member said that I can agree with, Llywydd. We've just had the second independent investigation report published; I just don't see where the merit lies in piling investigation upon investigation. What we need is action on the basis of the reports that we now have in front of us.

The point that I feel I can agree with is when Rhun ap Iorwerth says that models that are developed by royal colleges and others have to be properly transferred into the Welsh context and can't be just picked up and dropped into Wales. When I was the health Minister, I was also responsible for a piece of work done about Bronglais General Hospital, in which these exact arguments were discussed—and discussed with the royal colleges—about the way in which services that could safely and properly be provided locally in a rural area could be safely and successfully deployed at that hospital. And I think that has been a successful set of actions that have followed that have added to the staff at the hospital and the capacity at the hospital. So, I agree that general trends in medicine, which are towards the centralisation of specialist services, have to be calibrated to the context in which they are being implemented, and we should do that in a way that works for us here in Wales.

Where I do depart from him completely is in his wish to try and reopen old battles over the way in which services were decided upon and configured in north Wales in the vascular context. The health Minister could not have been more direct in her statement about the distraction, at the very best, that that will be from the real job in hand, which is to make sure that the system that we now have works, and works properly, and does not have the very disturbing and disappointing aspects that were revealed in the report that the board itself had commissioned.