Betsi Cadwaladr University Health Board special measures framework, March to December 2023

On 27 February 2023, Betsi Cadwaladr University Health Board was escalated to special measures. This significant decision followed the tripartite group of Healthcare Inspectorate Wales, Audit Wales and Welsh Government officials’ meetings in November 2022 and January 2023 to specifically discuss concerns about the service delivery, quality and safety of care and organisational effectiveness at Betsi Cadwaladr University Health Board. The escalation to special measures reflects serious and outstanding concerns about board effectiveness, organisational culture, service quality and reconfiguration, governance, patient safety, operational delivery, leadership and financial management.

The chair, vice chair and independent members of the Board agreed to step aside, and a number of direct appointments have been made to ensure board stability over the coming 12 months. A new chair and some independent members have been directly appointed by the Minister for Health and Social Services.

On 8 June 2015, Betsi Cadwaladr University Local Health Board (the health board) was placed in special measures due to failings in service delivery, organisational effectiveness, and the quality and safety of care in a range of areas, including the provision of mental health services, maternity services and primary care including out-of-hours services.

On 3 November 2020, a package of strategic support for the Board was announced. A special meeting of the tripartite group was held on 13 November 2020 to discuss progress made by the Board. It recognised the Board had made progress in some of the areas that were previously of concern and noted that the health board delivered a coherent and comprehensive response to the pandemic, demonstrating improved engagement with partners. A decision was made to de-escalate the health board from special measures, and they were placed in Targeted Intervention (TI) in November 2020 for the following areas:

• mental health (adult and children)
• strategy, planning and performance
• leadership (including governance, transformation and culture)
• engagement (patients, public, staff and partners)

In May 2022, following patient safety, governance and assurance issues highlighted through a number of serious incidents and inspections, a decision was made to widen the targeted intervention status at Betsi Cadwaladr University Health Board to include:

• Ysbyty Glan Clwyd – patient safety, governance, leadership, operational oversight, clinical safety governance including record keeping, incident management, team working, reporting concerns, and consent 
• Vascular Services
• the Emergency Department at Ysbyty Glan Clwyd

In addition to the strategic support announced in November 2020, the extension of TI measures in May 2022 saw an increased support package targeted at the health board with a particular focus on Ysbyty Glan Clwyd.

Over the last 12 months, a number of concerns have been raised encompassing board effectiveness, organisational culture, service quality and reconfiguration, governance, patient safety, operational delivery, leadership and financial management within the board. There was sufficient evidence to indicate that significant and timely improvement was not happening under TI and further escalation was considered necessary and appropriate in these circumstances. A major consideration was concern about the unitary board’s effectiveness to develop and implement change and improvement.

The Minister for Health and Social Services took a decision to invoke the NHS Escalation and Intervention Arrangements (2014) which sets out the process for taking action on serious concerns (annex 1) and raised the escalation level of the health board to special measures.

Special measures are the highest level of escalation in the NHS Wales escalation and intervention framework. There are a number of areas of concern that resulted in the special measures status of the organisation. Each of these will receive directed intervention, support and de-escalation planning. The intervention plan for each domain will report into the overarching special measures process, this will incorporate areas previously subject to the targeted intervention status.

The domains 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 services

The following outcomes have been agreed for the stabilisation phase of special measures:

• a well-functioning board
• a clear, deliverable plan for 2023 to 2024
• stronger leadership and engagement
• improving access, outcomes and experience for citizens
• a learning and self-improving organisation

There will be ongoing oversight from Welsh Government of priorities set out in the planning framework, performance framework and outcomes framework through the performance management arrangements of Integrated Quality, Planning and Delivery meetings (IQPD). The monitoring and governance of special measures is a separate, but related monitoring process.

The complexity and scope of work in the domains is such that there will be four levels of the process to support de-escalation:

• Discovery, from March to May 2023
• Stabilisation, commencing in June 2023
• Standardisation
• Sustainability

The mandated support and special measures intervention is led by Welsh Government’s Escalation and Intervention Team, supported by the NHS Wales Executive.

A number of independent advisors have been appointed to form a health board improvement and support team. More will follow if required, but will be agreed with the health board. This team will, subject to their own individual skills, backgrounds and experience, undertake the following:

• provide advice about board governance and board effectiveness
• offer mentoring and support to the Board and as agreed individual board members
• provide specialist HR support to the new chair and the Board to review the organisational structure, the associated size and content of portfolios and relevant delegated arrangements supporting these portfolios; while helping quality assure the underpinning systems and processes
• provide advice and support in helping the Board to understand where an increase in capacity and expertise for clinical service planning within the organisation is required to ensure the development, implementation and embedding of the clinical plan
• provide support to help improve operational performance and deliver the agreed transformational change needed; there are operational and delivery priorities, governance processes to improve and manage, estate risks to mitigate and a recovery/turnaround plan to develop

It should be noted that this list may increase or change as the advisors gain further understanding of both challenges and opportunities as this work progresses. It will be necessary to provide advice, particularly in individual portfolios, of how the work is prioritised initially.

The independent advisors will not be responsible for any day to day operational or management functions. The advisors do not have a responsibility to determine potential breaching of professional regulatory standards or performance issues. If any information is to arise which might lead to such concern, this will be escalated via the Welsh Government Escalation Team through agreed pathways and a feedback process developed to ensure that the concern has been properly assessed and a decision on the actions required has been made. Consideration in the pathways will be given to external notification where determined by a statutory requirement.

In order to support the health board to address the issues identified effectively and to deliver the required improvements, the following measures will be put in place:

• a programme of in-depth support for the chair and independent members
• officials to work with the new Board, supported by an independent team known as Independent Advisors to provide expertise to the organisation, to work with the executives to determine how best the executive team is shaped and who is best placed to discharge the relevant executive duties recognising that a number of executives will have statutory and accountable roles reporting to external organisations
• investigations commissioned regarding patient care, interim appointments and tender waivers
• consideration to be given to strengthen the functions of the three Integrated Health Communities (IHCs) to ensure effective influence across clinical and corporate services
• officials to work with the executive directors to review the scope and breadth of responsibilities, review the effectiveness of the structure and to secure professional support to enable the Board to recalibrate the way it works, and how it leads the organisation to ultimately deliver high quality, safe care and experience for patients and their families/carers; whilst additionally strengthening the recognition of the organisation as attractive in relation to the retention and recruitment of staff
• priorities for the discovery and stabilisation phase of special measures to be agreed and support for these priorities agreed with the Improvement and Support Team (Independent Advisors)

The following principles will guide all special measures actions and interventions:

• patients first; everyone using services should expect to receive consistently high standards of care and treatment
• staff empowerment; ensuring that they have the right working conditions and resources to support their own wellbeing and deliver the best care and services possible and sharing of best practice
• a quality and safety ethos that drives everything
• delivers services that improve the health of the population and works to reduce heath inequalities in collaboration with partners based on trust, respect and learning
• has strong, compassionate leadership supported by robust and effective governance systems
• provides safe, high quality urgent and emergency and planned care services

The following statements set out the core values and behaviours of the escalation:

• patient focused; decisions, recommendations and actions will be driven primarily by safety, quality and patient experience considerations
• valuing people; a well led, highly motivated and appropriately engaged workforce is a fundamental requirement for the delivery of safe, high quality, patient centred services
• open and transparent; subject to the constraints of patient confidentiality and data protection, work will be conducted and decisions will be made in an open and transparent manner
• inclusive; engage with staff, patients and stakeholders involving them actively in the oversight and improvement process
• collaborative; within an environment of robust scrutiny and challenge, to work collaboratively with the health board to optimise the improvement process and avoid unnecessary bureaucracy, duplication of effort and resource

Discovery and stabilisation

Agree and deliver board priorities

The following section sets out the focus of activity for the Board for the first 9 months of special measures between March and December 2023. A number of these areas will continue beyond December 2023 with a more in-depth focus where required.

Stabilise the Board

• Review of board governance, including committees.
• Review of key decisions to be taken prior to March 2023 and between April and September 2023.
• Engage, provide national and local induction and development of new Independent Members (IMs).
• Secure the nomination and appointment of the local authority, university and trade union IMs.
• Make a number of additional short term direct appointments, as appropriate, to the Board before starting a campaign for new members.
• Recruit a new chief executive.
• Respond to part 2 of the Geraint Evans Report.
• Commission board support programme and board development.

Review organisational structure

• Determine how best the executive team is shaped and who is best placed to discharge those executive duties.
• Determine how the governance team should be shaped to ensure the provision of robust advice and support to the board and wider organisation.
• Review operational model.
• Consideration to be given to strengthen the functions of the three Integrated Health Communities (IHCs) to ensure effective influence across clinical and managerial services and sharing of learning and improvement between IHCs.
• Review the scope and breadth of responsibilities, review the effectiveness of the structure.
• Review of interim posts and recommendations to replace these with permanent personnel (subject to agreeing to appropriate corporate and operational structures).
• Review workforce strategies and plans, including medical, nursing, Allied Health Professionals (AHPs) and ancillary workforce amongst others. Consider how a flexible workforce can work differently and give consideration of new roles that may be required outside the more traditional boundaries.

Culture, leadership and governance

• Review of future board governance, processes and decision making, including the need to ensure appropriate impact assessments are undertaken and the Duty of Quality is considered.
• Agree the required skills profile of the board to inform the recruitment of substantive board members.
• Respond to Audit Wales, Board Effectiveness Review.
• Ensure the health board discharges its responsibilities with regard to the production of the annual accounts and required governance reports for 2022 to 2023. (See also finance and planning).
• Agree the approach for determining the internal audit plan for 2023 to 2024, ensuring the flexibility to respond to known and emerging risks.
• Review Stronger Together, ensuring focus on organisational culture and next generation leadership.
• Values and behaviours review, board to ward focus.
• Review of clinical leadership at all levels / capacity and capability / multi-professional working / empowerment of more junior staff / identifying change champions.
• Talent development programme (grow your own).
• Review arrangements for raising concerns within the health board to ensure staff feel able highlight their concerns and have the confidence they will be acted upon.

Finance and planning

• Stabilise and complete 2022 to 2023.
• Decision taken as to the 2023 to 2024 approach to planning.
• Understand the drivers behind the financial deficit and take appropriate decisions.
• Agree capital investment priorities.
• Review contract management skills and audit a number of contracts to ensure correct procedures in place.
• Complete the end of year financial position and accounts.

Clinical service planning and engagement

• Response to Vascular Quality Panel Review, consideration of the future vascular clinical services model.
• Overview of the approach taken in developing the regional treatment centres and approach to regional service delivery.
• Review of the clinical delivery models in place for urology, ophthalmology, oncology, mental health, Child and Adolescent Mental Health Services (CAMHS) and dermatology and other services (as requested by the Board in case of clinical risk) if required.
• Develop and agree a methodology for wider clinical services review to include primary care services.
• Preparation and implementation of Duty of Quality and Duty of Candour.
• Ensure the requirements to respond to and develop quality statements are considered.
• A review of clinical leadership at all levels / capacity and capability / multi-professional working / empowerment of more junior staff / identifying change champions and empower local leadership models.

Review of patient care and safety

• Deliver and consistently implement a policy for consultant job planning and appraisal management.
• Undertake an investigation into patient safety concerns in line with serious issues raised.
• Review current systems and procedures to ensure high quality care, consistent with the Duty of Quality guidance.
• Design an organisational approach to learning from patient safety and ensure the principles and requirements of the Duty of Candour are embedded.
• Assess and advise on the implementation of an effective quality management system linking quality control, assurance, planning and improvement in line with duty of quality requirements.
• Ensure an integrated system of adequately resourced clinical leadership.
• Ensure a high level of sensitivity to feedback and good relationships and communications with public and patients.

Operational performance and delivery

• Planned care short and medium term recovery plan with clear trajectories.
• Mental health and CAMHS recovery plan with clear trajectories and the development of a clear operational model. 
• Transformation support embedded within the urgent and emergency care teams in each DGH, clearly defined plan and improvement trajectories. Each site learning from the others.
• Clear plan and approach for Orthopaedics, Ophthalmology and regional treatment centres.
• Review into the out of hours challenges and opportunities.
• Implementation of relevant Getting It Right First Time (GIRFT) best practice and theatre productivity.

Special measures intervention

There will be a number of interventions to deliver on the actions needed for stabilisation, co-ordinated by the Welsh Government and supported by a team of independent advisors and the NHS Wales Executive as set out below:

• 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 services

Programme and project support for each domain will be provided by the health board and supported by the transformation team. The key actions and work per domain for the stabilisation stage is outlined below: 

1. Board leadership, values and cultures

• Support, mentor and develop independent members and executive directors.
• Agree and support a board recruitment programme, ensuring board members receive the required induction on appointment.
• Agree a long term board development programme which takes into account the need to plan for changes of personnel during this period.
• Agree a framework of objective setting for executive directors and independent members (taking into account the objectives agreed by the minister with the Chair).
• Develop a values and behaviour framework.
• Review Stronger Together, with a focus on organisational culture and next generation leadership and advise on a cultural change programme.
• Support a cultural change diagnostic.
• Consideration to be given to strengthen the functions of the three Integrated Health Communities (IHC)s to ensure effective influence across clinical and managerial services.
• Review what has happened since the last special measures support programme.
• Develop conditions for sustainability and special measures evidence and action log.
• Support the development of the special measures structure and framework.

2. Board governance

• Consider the Audit Wales Review of Board Effectiveness and the implications for the health board and for the Executive Director Team.
• Develop a cohesive response and strategy in response to the Audit Wales Review.
• Agreeing Board forward look, priorities and key decision points.
• Undertake a review of the Office of the Board Secretary, board committees and governance processes.
• Develop and embed a process for the good management and delivery of board business.
• Review and ensure the Board has agreed risk management processes and procedures to inform the health board's risk profile and risk appetite.
• Review key organisational risks and consider if appropriate mitigations are in place taking into account the health boards risk appetite.
• Support for special measures programme development.
• Ensure appropriate governance is in place, particularly with regards to providing appropriate scrutiny of performance, leadership style and practice.

• To establish an independent HR team and function that can respond to a number of critical workforce/HR based issues.
• Stabilise the health board workforce team and assess whether it has capacity and capability to deliver it's functions.
• To provide support to the deputy workforce director.
• Ensure effective governance and accountability with the Remuneration and Terms of Service Committee. 
• Agree and implement arrangements for handling the Ernst and Young review of year end and counter fraud investigation and ensure that action is taken.
• Ensuring that there are suitable processes in place to resolve a number of grievances currently on hold.
• Reviewing and improving staff engagement and communications.
• Review of operational structure to be undertaken with the governance and leadership leads and presented to the Board. Actions then to be taken in accordance with that decision. 
• Assessment of effectiveness of the following:
  • key workforce policies, processes and governance arrangements
  • employee wellbeing services
  • learning and development activity including compassionate leadership
  • workforce information systems and planning
  • culture / values / behaviour
  • staff side relations
• Support the recruitment of a new workforce director.
• Review key medical and nursing gaps and capacity for all clinical groups making recommendations for the future.

The four areas to be covered in this portfolio are:

• financial governance
• resource allocation and utilisation (linked to this outcomes)
• the financial control environment (including grip and control)
• maturity of the finance function (including capacity and capability)

As a minimum this will require:

• review of interim staff and appointments (process and governance)
• review of contract arrangements and contractual management capability
• review key organisational risks and consider if appropriate mitigations are in place
• review and agree capital investment priorities in light of current estate risks
• review forward work programme for the Finance and Audit Committee providing recommendations of the way forward and immediate decisions that need to be taken
• having produced a trajectory and action plan for returning the organisation on an initial basis to an agreed outturn deficit position
• clarity on what the drivers are and where the deficit is in service and workforce terms; have a clear strategic narrative to inform the organisation's plan and national priorities, with clarity on any choices to commit recurrent resources
• to demonstrate a focus on recurrent solutions and not reliance on non-recurrent measures resulting in impacting underlying deficit
• having a clear assessment of where the organisation’s cost base is changing and why, ensuring overall baseline alignment in service and workforce terms being consistent and follows from the underlying assessment; ensure that cost drivers are well understood, evidenced based, with a realistic cost growth assessment including cost mitigation
• having savings and efficiency plans, supported by realistic and deliverable plans, with a clear risk assessment and actions being taken to mitigate those risks to give confidence in an overall level of realistic savings delivery
• working within a live ongoing opportunity framework, which is continually updated and refined linking into efficiency and productivity agenda

1. Clinical Leadership and Capability 

• Support the health board in its response to the recommendations from the Vascular Quality Panel Review, the wider work on vascular services, and the Sustainability Audit in relation to the consideration of the future vascular clinical services model.
• Review the urology service model, clinical leadership, capability and consider options in line with the RCS for service configuration.
• Consider the dermatology pathway, making recommendations for a future delivery model.
• Assess patient risk within the ophthalmology pathway, assess whether the clinical risk is being well managed and options for an improved clinical model.
• Review commissioning arrangements for conditions of concern such as plastics, oncology and so on, supporting and advising senior clinical staff on taking a coherent and systematic approach. 
• Review the clinical approach for regional delivery models including the regional treatment centres.
• Reassess the clinical strategy and support the immediate development of a clinical plan to lead future planning and investment decisions.
• Review the clinical network arrangements.
• Support the development of a policy for job planning for consultants, specialty and specialist doctors and where appropriate for other senior clinicians.
• Ensure an integrated system of adequately resourced clinical leadership.

2. Quality Management – clinical governance and patient safety

• Review current systems and procedures to ensure high quality care, consistent with the Duty of Quality guidance.
• Undertake an investigation into patient safety concerns in line with serious issues raised.
• Review data surrounding incidents complaints, datix, never events to establish any patterns.
• Investigate the extent to which learning is taking place.
• Overall review and assessment of clinical governance.
• Assessment of clinical staff capability and overall wellbeing.
• Assess and advise on the implementation of an effective quality management system linking quality control, assurance, planning and improvement.
• Review how patient experience is being used to support quality management.
• Undertake oversight of the putting things right process including putting things right compliance, inquests and claims management, complaints and serious incidents and external investigation processes.
• Review safeguarding arrangements.

To provide support to the health board to improve in a sustainable manner as follows:

• improved planned care performance against an agreed trajectory maintained over six months and performance improvement noted in line with the plan with a clear trajectory to achieving the ministerial priorities for 2023 to 2024
• improved adult mental health, CAMHS and neurodevelopment delivery with performance against an agreed trajectory maintained over six months and performance improvement noted in line with the plan with a clear trajectory to achieving targets for part 1 and 2 local primary mental health support greater than 80%
• consistency in urgent and emergency care over the next six months as highlighted in 4 and 12-hour performance and delivery of the Integrated Commissioning Action Plan (ICAP) actions, including improvements in 4-hour ambulance handover trajectory
• evidence of actions implemented from identified within the speciality reviews, opportunities assessment and improvement plans and performance sustainably improved over six months

The NHS Wales Executive will support a performance deep dive, highlighting areas of concern and particular areas of focus. This will require a response from the health board and progress against that action plan will be reviewed monthly through a SM meeting chaired by Welsh Government. In support of that action plan the following interventions are planned:

• urgent and emergency care, ensuring that recovery and improvement plans are in place to help improve performance so that all patients receive safe, timely care
• planned care will involve work from the NHS Wales Executive via the Planned Care Improvement and Recovery Team to support transformative solutions and pathways and the Delivery Unit to work with the health board so that the health board is able to understand demand and capacity requirements for planned care across the whole of the health board
• orthopaedics service transformation and approach
• support for the development of the regional treatment centre 
• mental health, CAMHS and neurodevelopment performance

The health board has indicated that it will be unable to submit an approved organisational plan in line with its statutory duty under the Finance (Wales) Act 2014.

For 2023 to 2024. The health board was not able to submit an Integrated Medium Term Plan (IMTP) in 2022 to 2023 that could break even over a rolling three-year period.

To support the health board with its planning, Welsh Government will arrange an independent review of Betsi Cadwaladr University Health Board’s integrated planning arrangements. The independent review will undertake:

• a rapid peer review of integrated planning capacity and capability within Betsi Cadwaladr University Health Board both in terms of IMTP strategic and operational planning
• a rapid peer review of the organisation’s approach to developing its IMTP and the associated decision-making mechanisms 

This will include reviewing and making recommendations on the following areas:

• an assessment of whether the health board has access to sufficient planning capacity and capability for strategic and operational planning
• IMTP development process including the triangulation of plans to operational, workforce and financial inputs
• IMTP development stakeholder engagement and input
• IMTP development decision making process and governance
• clearly define areas of support and improvement
• identify areas of good practice 
• make recommendations to implement robust processes, structures and reporting arrangements for the development of annual plans / IMTPs

Capital planning processes are excluded at this time.

Aims and objectives

• To provide findings and recommendations against each part of the scope.
• To report to BCUHB within a four-week period of the independent review being commissioned to support with the development of the 2023 to 2024 planning cycle. The intention is to provide real time advice to the development of the university health board’s Annual Plan for 2023 to 2024, whilst also future proofing for the development of sequent plans and IMTPs.

In order to complete the independent review, the reviewer will carry out the following actions with regard to planning and transformation:

• review of documentation
• review of governance arrangements 
• interviews with key staff (internal) (to be identified) 
• interviews with key stakeholders (external) (to be identified)
• review of current 2023 to 2024 annual plan development process

• Strategic vision developed, strong and credible strategy and action plan for vulnerable services such as Mental Health, Vascular, and Urology.
• These services to integrate with corporate functions.
• Clear evidence that outstanding issues and recommendations from previous reviews, inspections and inquests have been completed and embedded as business as usual.
• Improvement plans are credible with a clear timeline and trajectory; there is evidence of meaningful progress against those elements of the improvement plan requiring short and medium term responses.
• Corporate governance, effective oversight and scrutiny of all vulnerable clinical services consistently being provided by the Board and the Quality and Safety Committee.
• Effective programme management structure is in place.
• Serious incident investigations being conducted on a ‘business as usual’ basis; all learning is routinely being identified and shared and there is evidence that this is driving improvements in care.
• Learning is routinely identified, shared and driving improvements in care.
• Executive, Board and medical leadership is visible, effective and permanent; there is leadership development support in place and the consultant body as a whole is actively engaged in driving forward service improvement.
• Evidence of positive shifts in culture in key areas such as joint working, multidisciplinary working and addressing the blame culture.
• Improving performance in line with requirements and expected standards.

Each domain team will produce:

• a plan on a page setting out key deliverables and timescales
• resources   
• agreed outcomes
• reporting criteria
• baseline assessment
• improvement trajectories 
• key actions
• a meeting schedule
• a monthly progress report

The first 3 to 6 months of this framework is focused upon scoping the issues and developing a range of solutions. Once agreed this framework will be updated to include key performance indicators and de-escalation criteria.

Strategic vision

Clinical plan and annual plan developed, agreed and communicated to the public; early actions delivered providing confidence that sustainable longer term continuous improvement is achievable.

Confidence and trust in the organisation improves.

Integrated performance and quality

Ensuring Betsi Cadwaladr University Health Board is a data-driven organisation that ensures data is understood and utilised in decision making at all levels. Demonstrating a strong link between ensuring quality and performance improvement. Quality and safety is embedded in everything the organisation does.

Culture change

There is evidence of positive shifts in culture in key areas such as multidisciplinary working and addressing the blame culture.

Structures and delivery

Ensuring all parts of the organisation are clear on accountability and expectations at all levels to ensure successful delivery. Empowering effective decision making and a constant focus on performance improvement.

Effective and functioning board

All independent members inducted, committees up and running operating to an agreed schedule with clear decision making points supported by a well-managed on-boarding system. Effective oversight and scrutiny of current service provision consistently being provided by the Board and the appropriate committee.

Responsive

Ensure that all recommendations from the Royal Colleges, Health Inspectorate Wales and other reviews are discharged and either verified or delivered or scheduled for delivery within the health board's longer-term improvement plan.

Learning and improving 

Effective investigations being conducted on a 'business as usual' basis; all learning is routinely being identified and shared and there is evidence that this is driving improvements in care. A culture of listening, learning and improving is embedded throughout the organisation based on early and rapid triangulation and resolution of issues from a variety of sources, including patient, user and staff feedback.

Stronger leadership and engagement

Ongoing development of leadership and management skills at all levels/professions to strengthen management maturity. The organisation is focussed on all aspects of strategic workforce planning and maximising the skills of its current staff. Continuation of embedding/demonstrating lived values and behaviours throughout the organisation. Demonstrate a greater emphasis on engagement. 

Programme management 

Effective programme management structure is in place, which defines objectives of the improvement work, has plans which show how the work is delivered and what barriers could impact on delivery of outcomes; structures have effective, open and transparent reporting, with effective board oversight. 

Clinical leadership

Clinical leadership is visible and effective; there is leadership development support in place and the consultant body as a whole is actively engaged in driving forward service improvement.

Strengthened clinical services

Such as vascular, mental health, urology, oncology and ophthalmology are supported by strong clinical leadership, an effective integrated improvement plan, project management structure and effective transformation support.

Improved access, outcomes and experience

Demonstrated by patient feedback, ambulance handovers, urgent and emergency care waiting times and access to planned care and mental health services.