BCUHB special measures - stabilisation phase: cycle 2 priorities

The second phase of special measures is stabilisation, which will last for approximately 9 months. This will be made up of three cycles. The first cycle commenced on 1 June 2023 and ended on 31 August 2023. The second cycle will run from 1 September 2023 to 30 November 2023.  

This paper sets out Welsh Government expectations for the second cycle.

The special measures framework sets out the reasons Betsi Cadwaladr University Health Board was placed in Special Measures on 27 February 2023. These relate to serious concerns about board effectiveness, organisational culture, service quality and reconfiguration, governance, patient safety, operational delivery, leadership and financial management. 

The framework sets out in some detail the improvements expected between March and December 2023 under the following eight areas of concern which are:

• Governance, board effectiveness and audit
• Workforce and organisational development 
• Financial governance and management
• Compassionate leadership and culture
• Clinical governance, patient experience and safety
• Operational delivery 
• Planning and service transformation
• Clinical vulnerable services

It also sets out five clear outcomes for the stabilisation phase of special measures:

• a well-functioning Board
• a clear, deliverable plan for 2024 to 2025
• stronger leadership and engagement
• improving access, outcomes and experience for citizens
• a learning and self-improving organisation

A review of cycle 1 was undertaken in the form of a workshop attended by members of the Board, Independent Advisors and Welsh Government officials held on 9 August, where it was agreed that the concerns and outcomes previously highlighted for cycle 1 should remain consistent for cycle 2. Whilst areas of progress have been made, it is still too early to consider the effectiveness and sustainability of these improvements. The following external reviews have concluded, and reports shared with the health board for consideration by the Board through their appropriate governance structures:

• Review of concerns raised around Betsi Cadwaladr University Health Board affiliated to patient safety.
• Safety Review of Betsi Cadwaladr University Health Board Mental Health and Learning Disabilities Inpatient Units.
• Rapid review of Interim appointments to executive posts at Betsi Cadwaladr University Health Board. 
• Assessment of key areas of workforce agenda (‘HR experts review’)
• Rapid review of the Office of the Board Secretary. 

The following reviews are underway and will inform priorities and actions for future cycles following completion and consideration by the Board through their appropriate governance structures: 

• Vascular services assurance assessment. 
• Executive team portfolio review.
• Independent assessment of integrated planning approach and process.
• Procurement and contract management (health board led).
• Operational model stocktake (health board led).

The work programme of the five independent advisors has concluded and their recommendations have informed cycle 2.

Governance, board effectiveness and audit

1.    Consider the recommendations of the Office of the Board Secretary Review. Develop and start to implement a clear action plan to enable and support effective governance processes across the organisation. Agree a clear and transparent forward plan for committee business supported by standard operating procedures that are accessible to all.

2.    Mentor and support the Board to ensure it can both constructively challenge and support the organisation in line with the requirements of special measures.

3.    Continue the recruitment of a permanent Board.

4.    Commission and start the delivery of a Board development programme. 

5.    Agree an effective scheme of delegation, that sets out the framework for delegation, decisions and accountability.

Clinical governance, patient experience and safety

6.    Develop, agree and start to implement an effective procedure/process for learning from incidents, patient and staff feedback, inspections internal audit and reviews, and begin to embed learning across the organisation.

7.    Consider the recommendations of the Review of Patient Safety Concerns, working with the NHS Executive to develop the required clinical governance processes, develop and start to implement a clear action plan in response to these recommendations.

8.    Develop and embed an approach and robust procedure to support the implementation of the Duty of Quality utilising the health and care quality standards to drive continual improvement to meet the needs of the population.

Workforce and organisational development

9.    Consider the recommendations from the Review of interim appointments, executive team portfolio review and HR processes report. Develop and start to implement a clear action plan in response to these recommendations – with an early focus on building sufficient capacity in the workforce team to deliver the plans. 

10.    Implement the learning and development framework.

11.    Continue to resolve outstanding respect and resolution cases including similar processes related to senior leadership. 

Compassionate leadership and culture

12.     Agree and start to implement a programme of work focussed upon culture, compassionate leadership, values and behaviours with a practical focus on driving change. 

13.    Implement a programme to stabilise and support the executive team and empower the senior leadership team.

14.    Continue and embed the agreed approach to build trust and confidence within the organisation and with stakeholders, including priority community groups.

Clinical fragile services

15.    Agree a mental health strategy, agree and commence implementation a CAMHS and neurodevelopment action plan to improve performance.

16.    Review, revise and implement clear improvement plans including but not limited to vascular (including enabling phase 2 of the vascular review), urology, ophthalmology, oncology, orthodontics, dermatology and plastics.

17.    Agree the clinical leadership arrangements for services across the organisation and commence implementation of the clinical engagement proposal.

Financial governance and management

18.    Continue to stabilise the finance team and address capacity concerns.

19.    Continue to implement the financial governance action plan in response to the findings of the E&Y report and other concerns. This includes completing and finalising the end of year accounts for 2022 to 2023, and strengthening the financial control environment.

20.    Deliver an agreed efficiency savings plan that minimises the financial deficit in 2023 to 2024, understand the drivers behind the financial deficit.

21.    Undertake an assessment of the financial outlook for 2024 to 2025 including key cost drivers and opportunities.

22.    Undertake the review of procurement and contract management.

Planning and service transformation

23.    Make sustainable progress in delivering the Board-agreed annual plan, ensure there is an effective workforce plan in place that allows the health board to deliver the plan in an agile and effective way. Focus transformation and improvement activity on the areas within special measures to ensure sustainable and effective change.

24.    Embed urgent primary care centres as a core strategy for winter planning including immediate proposals for Ysbyty Glan Clwyd and take ongoing actions to ensure improvements across the three emergency care departments with a clear focus on Ysbyty Glan Clwyd.

25.    Participate in the integrated planning review and start the process for the 2024 to 2025 annual plan. Develop and commence a process with agreed timescales for the development of a clinical services plan.

26.    Agree a future operational model for orthopaedic services.

Operational delivery

27.    Improve access and experience as measured by elimination of 52 week waits at first outpatient stage, zero patients waiting over 156 weeks for treatment, zero 4 hour ambulance handovers and improved 4 and 12 hour emergency department waiting time performance.

28.    Design an integrated performance and risk-based framework based upon clear and accurate data and visible dashboards for performance, patient safety, quality and experience.

Welsh Government will use the following meetings to monitor performance against the special measures framework.

IQPD meetings

• IQPD meetings are scheduled monthly (apart from when there is a JET meeting). They are chaired by the Deputy Chief Executive of NHS Wales or their nominated deputy.
• They are used to assess performance against agreed trajectories, consider the overall quality and safety of services and to undertake deep dives on specific topics.
• Additional monthly planned care meetings are being held with each health board.
• Agendas will be circulated at least two weeks prior to the meetings. Health boards are asked to provide slides three days in advance of the meetings.
• These meetings have been extended for Betsi Cadwaladr UHB to ensure that there is a monthly check in on special measures. Whilst this will predominately focus on operations and performance, other issues will be reviewed as appropriate.
• This is an opportunity for the health board to keep Welsh Government fully updated and to ensure that there are no surprises.

JET meetings

• These meetings take place twice a year, chaired by Chief Executive of NHS Wales and attendees are expected to be part of the senior executive team.
• They will be used to scrutinise quality, planning, delivery and performance including assess the overall performance of the organisation against national requirements, its IMTP/annual plan and any accountability conditions.
• Agendas will be circulated at least three weeks prior to the meeting.
• The JET meeting that falls within cycle 2 will be the mid-year review. 
• Health boards are requested to provide slides ten days in advance of the meeting.

Other meetings 

• Challenged services across NHS Wales are subject to a monthly review meeting. Currently these focus on cancer, ophthalmology and planned care and are scheduled with all health boards.
• Other review meetings related to services of concern will be held. For Betsi Cadwaladr University Health Board, there are at present four clinical services that will have additional meetings. These are Mental Health, which has a quarterly meeting with the Deputy Minister, vascular services, plastics and ophthalmology. 
• They will be used to scrutinise quality, planning, delivery and performance including recovery plans, trajectories and serious incidents.

Special measures meetings

• The Minister for Health and Social Services will chair a bi-monthly Special Measures Improvement Forum.  This is a joint ministerial meeting, also attended by the Deputy Minister for Mental Health and Wellbeing.
• The Deputy Minister for Mental Health and Wellbeing will hold quarterly meetings with the health board to seek assurance on mental health.
• The Chief Executive of the NHS will chair a quarterly Special Measures Assurance Board.

Integrated Quality, Planning and Delivery meeting (IQPD) - 8 September 2023

Joint Ministerial Special Measures Improvement Forum - 13 September 2023

Cancer performance assurance meeting - 19 September 2023

Monthly Planned Care touchpoint meeting - 22 September 2023

Integrated Quality, Planning and Delivery meeting (IQPD) - 9 October 2023

Quarterly ministerial meeting on mental health (Deputy Minister Mental Health and Wellbeing) -  10 October 2023

Cancer performance assurance meeting - 16 October 2023

Joint Executive Team meeting (JET) - 26 October 2023

Monthly planned care touchpoint meeting - to be arranged

Special Measures Assurance Board    10 November 2023

Joint Ministerial Special Measures Improvement Forum - 20 November 2023

Cancer performance assurance meeting    24 November 2023

Monthly Planned Care touchpoint meeting - to be arranged

Integrated Quality, Planning and Delivery meeting (IQPD) - November (to be arranged)

Vascular touchpoint meetings - bi-weekly

Plastics touchpoint meetings - bi-weekly

Ophthalmology assurance meetings - to be arranged