Betsi Cadwaladr University Health Board special measures: progress report April to June 2024

On 27 February 2023, the Minister for Health and Social Services raised the escalation level of Betsi Cadwaladr University Health Board (BCUHB) to special measures, following serious concerns about board effectiveness, organisational culture, service quality and reconfiguration, governance, patient safety, operational delivery, leadership and financial management.

Four progress reports have been published to date, reflecting on the progress made over the first 12 months of the current special measures escalation, including lessons learned, and improvements and challenges that have been identified.

In the year one progress report, published in February 2024, we concluded that Betsi Cadwaladr University Health Board had stabilised as an organisation and had started to put in place the building blocks to become a sustainable organisation. We also recognised that the steps and processes put in place by the board and executive team were starting to have an impact, but that further effective team working and leadership would be required to build upon these in the coming 12 months.

The health board presented its own report providing its reflections on the first 12 months of the special measures escalation to its board in March 2024. It is also providing additional updates for the public via its website. 

In May 2024, a refreshed special measures framework, including de-escalation criteria, setting out clear priorities and expectations across six domains for the next phase of the current special measures intervention was agreed between the Chief Executive of NHS Wales and the Chief Executive of Betsi Cadwaladr University Health Board.

The health board remains subject to considerable oversight as part of the special measures escalation, including:

• a quarterly special measures improvement forum with the board, chaired by the Cabinet Secretary for Health and Social Care with the Minister for Mental Health and Early Years in attendance
• monthly meetings between the Cabinet Secretary for Health and Social Care and the Chair of the health board to assess progress against the chair’s objectives, including delivery against the health board’s agreed special measures response plan
• quarterly all-age mental health assurance meetings with the health board, chaired by the Minister for Mental Health and Eary Years
• a quarterly special measures assurance board, chaired by the Chief Executive of NHS Wales to review progress against the special measures framework
• health board and Welsh Government meetings to track progress including, but not limited to, monthly cancer and eye-care meetings; monthly integrated quality, planning and delivery meetings; a Joint Executive Team meeting held twice a year; and finance, quality, planned and unscheduled care touchpoints on a regular basis
• regular visits to health board settings by the Cabinet Secretary for Health and Social Care, the Minister for Mental Health and Early Years and the First Minister

This report sets out the progress the health board has made over the last quarter (April to June 2024) against the agreed special measures priorities. The focus over this period has been the health board’s response to the serious issues that resulted in its escalation to special measures, developing and building the board, rebuilding trust and confidence and putting in place firm foundations for the future.

Governance

The health board now has a full complement of independent members, supported by a new Executive Director of Governance, who was appointed in April 2024, and will provide the leadership capacity and capability required to strengthen corporate governance across the organisation. This has allowed the health board to strengthen its governance processes across eight board committees and three board advisory groups, which are now fully operational with regular reporting to the board. In line with the recommendations of the review of the Office of the Board Secretary, the terms of reference for each of these groups have been refreshed.

Board awareness and consideration of the quality, safety and experience of services across the organisation has been improved through the introduction of a report on quality at each board meeting. A citizen experience report has also been introduced and will be presented to board meetings on a quarterly basis, together with a patient experience story, to give the board insight into current issues and provide an opportunity for learning and development of patient centred services.

Board development sessions happen on a regular basis and support the independent members to learn more about particular areas of the health board’s work. The health board has published its approved Board Development Plan for 2024 to 2025.

The health board has made good progress in implementing the recommendations of the review of the Office of the Board Secretary and expects to be able to conclude its response to the outstanding recommendations by January 2025.

Quality of care

The board approved the health board’s approach to a Quality Management System (QMS) in May 2024. The QMS will be supplemented by an implementation plan, and a QMS hub that will interactively guide and assist individuals, teams and departments across the organisation to develop their quality management assessment and improvements.

The focus is now on the implementation of the QMS. The board has agreed to use the QMS tool for vascular and urology in the first instance. These are two services that have quality issues that are well recognised and are at different stages of the development journey.

The health board is making good progress in developing its quality governance process and systems whilst dealing with serious legacy issues that must be addressed at pace. This includes cases highlighted by HM Coroners and the Public Services Ombudsman for Wales, including failures to act promptly with the complaints process; insufficient or ineffective strategic planning and support being undertaken; the timeliness of health board investigations and the continued reliance on paper patient records.

The health board has completed phase one of its learning from investigations programme, which saw a review of its investigation processes and embedding of learning across all parts of the organisation. This has informed the development of a new integrated policy for investigating incidents, complaints and mortality, which will incorporate patient or family involvement from the start and includes staff contributions throughout.

A project is also underway to provide assurance on the quality of investigations, embedding of learning and supporting evidence for previously completed investigations. A presentation about the learning from regulation 28 / prevention of future deaths reports was shared at the health board’s Regulatory Assurance Group in April 2024 and training sessions took place in May 2024.

The health board is also focused on improving its process for responding to and learning from nationally reportable incidents (NRIs). All NRIs are subject to a 'make it safe' rapid review, and in some cases a Rapid Learning Panel (led by a clinical executive or deputy) and further investigation. The learning and actions from each are recorded on the Datix Cymru incident management module. Learning forms are drafted for each investigation and are submitted to the NHS Executive to provide assurance on learning and actions.

Performance and outcomes

There has been a reduction in the number of long waiting times for patients, at both the outpatient and treatment stage since February 2023. Between February 2023 and June 2024, the number of RTT orthopaedic patient pathways waiting more than 104 weeks has reduced by 48.0%, the number of pathways with total waits more than 104 weeks has reduced by 4.7% and there has been a 19.9% reduction in the number of pathways waiting more than eight weeks for their diagnostic tests over the same period. Cancer performance remains variable, impacted by challenges in services such as urology and dermatology.

There is a real focus within the health board on eliminating long waits for planned care with a commitment to treat in turn, implement efficiency measures and improve productivity.

Performance against the various mental health measures for people under the age of 18 has improved, with 79.6% of assessments completed within 28 days in June 2024 compared to 57.8% in February 2023, and 41.6% of interventions starting within 28 days in June 2024 compared to 26.8% in February 2023. Despite this improvement, performance remains below the target of 80% for each of these measures. For adult mental health, performance for interventions completed within 28 days remains above target at 82.4% in June 2024, and there has been an improvement for assessments completed within 28 days at 74.7% in June 2024.

The health board continues to work closely with colleagues across the health and social care system, Welsh Government, the Welsh Ambulance Services University NHS Trust, the national Six Goals Programme and the NHS Executive to improve operational delivery of urgent and emergency care services and the safety and experience of patients. However, performance for urgent and emergency care remains a significant challenge.

Leadership, capability and culture

Work around culture and developing compassionate leadership is progressing across the health board. Progress in this area is being monitored by the health board’s People and Culture Committee. A leadership conference addressed by Professor Michael West, an expert in compassionate leadership and Henry Engelhardt, former CEO of Admiral Insurance was attended by around 250 people from across the health board and was well received.

A senior and executive director recruitment programme has commenced including:

• executive director of allied health professionals and health science, starting in post in August 2024; the post holder will be the executive lead for mental health and learning disabilities
• director of commissioning and performance starting in post in October 2024
• interim integrated health community director (central) starting in post in August
• interim executive director of public health is in place

The health board is working with an executive search partner to recruit substantively to the posts of executive director of workforce and organisational development and chief operating officer.

The health board is starting to demonstrate how it develops and identifies opportunities for organisational learning and reflection. This includes learning from inquests, learning from medication errors and learning from investigation report writing standards. The learning from medication errors included the importance of learning from human factors and its importance to integrate into patient safety reviews. Organisational learning has been disseminated across the organisation with regards to the safe administration of transdermal patches using the seven-minute briefing approach.

Financial governance and management

A review of contract and procurement management was commissioned by the health board and undertaken by the NHS Wales Shared Services Partnership (NWSSP) Internal Audit Service. The report developed 24 actions for consideration by the health board, NWSSP Procurement Services and the Welsh Government.

Significant progress has been achieved in addressing the issues raised. Of the 13 actions for the health board, 11 are completed, with the remaining two underway.

The health board’s year-end out-turn position for the 2023 to 2024 financial year was a deficit of £24.347m. This was £4.347m higher than the target control total of £20m set in 2023 to 2024. The health board made progress in-year against its original plan, but it was one of three health boards that did not deliver on the target control total set by Welsh Government.

The health board has a planned full-year deficit of £19.8m for 2024 to 2025, which is a £4.6m improvement from the 2023 to 2024 year-end out-turn position. This is based on assumed delivery of an annual savings target of £48m.

The health board held an Extraordinary Board meeting on 10 July 2024 to discuss its annual report and accounts for 2023 to 2024. The board also considered the Auditor General’s report on the accounts, in which the Auditor General concluded that the accounts gave a true and fair view on the health board’s finances.

The Auditor General has, however, indicated a qualified regularity opinion on the accounts as the health board:

• did not meet its financial duty to break-even against its revenue resource limit over three years 2021 to 2022 to 2023 to 2024
• incurred irregular expenditure and breached its standing financial instructions in making payments to a former interim executive member of the board at a higher rate than the Welsh Government’s approved salary for the role; the approval of the board and Welsh ministers was not obtained, contrary to the requirements of the health board’s Standing Financial Instructions (SFIs)

The Auditor General has noted that the health board is now strengthening its controls and governance arrangements accordingly.

The health hoard continues to make progress, with support from the financial planning and delivery team of the NHS Executive, on the special measures finance action plan, with a key focus on:

• continuing to strengthen financial governance and control arrangements
• ensuring a robust and deliverable financial plan is in place to achieve the forecast position in 2024 to 2025
• translating opportunities into savings in support of financial delivery in 2024 to 2025 and on a recurrent basis
• ensuring clear plans are in place to utilise resources to deliver on improvement and performance priorities.

Planning and service transformation

An independent review of integrated planning in the health board, has been completed. The health board’s action plan and management response to the review was approved by its Performance, Finance and Information Governance Committee on 30 April 2024.

The health board has reported many elements of its action plan are already underway, including stakeholder engagement to support planning process redesign, access to diploma level education to support and develop planning capability, and an initial review of corporate planning capacity and capability. A number of task and finish groups will also be established to oversee specific areas of work, and progress will be reported in line with the agreed special measures framework requirements.

The health board was unable to submit a balanced integrated medium-term plan (IMTP) for 2024 to 2027 in line with section 175(2A) of the National Health Service (Wales) Act 2006 (as amended by NHS Finance (Wales) Act 2014) and in accordance with the NHS Planning Framework. It has submitted an annual plan for 2024 to 2025. This is the first plan developed by the health board under the leadership of the new chair and chief executive, supported by a substantial change in board membership and signals a clear ambition to move beyond the challenges that have led to special measures escalation to a position where the health board can operate sustainably to deliver high quality services.

The health board has committed to initiating and progressing development of its Clinical Services Strategy and Clinical Plan in 2024 to 2025. This will be supported by a focussed discussion at the board development session in July 2024.

Fragile Services

Mental Health

Child and Adolescent Mental Health Services (CAMHS)

Child and Adolescent Mental Health Services (CAMHS) and neurodevelopment improvement plans have been developed and agreed by the health board’s executive team. All areas are now delivering some extended hours and the focus will be on developing this into a sustainable model.

An initial draft service model proposal for neurodevelopment has been developed to support the move from a diagnosis-focussed model towards a needs-led model, to better meet the needs of families and children. A workshop is planned for September to seek regional feedback, which will be followed by a wider engagement plan with other health board colleagues, local authority, education and third sector colleagues to seek opinion before proceeding.

Royal College of Psychiatrists review of mental health reviews

The final report from the Royal College of Psychiatrists review of mental health reviews was presented to the Board on 30 May 2024, at which the health board committed to prepare a detailed response plan setting out actions and timescales in response to the review’s findings for consideration by the board at its meeting in July 2024.

The college found there was good or strong evidence for implementation in relation to 37 out of a total of 84 (44%) recommendations in the four external reports. There was some evidence for implementation in relation to nearly half (41; 49%) of the recommendations and little or no evidence for six (7%) recommendations.

Mental health inpatient safety

The final report from a joint safety assessment of mental health inpatient settings, undertaken by the National Collaborative Commissioning Unit (NCCU) and the NHS Executive has been published on the health board’s website, along with its management response. These were discussed at its board meeting in November 2023.

A follow-up assessment was undertaken six months later to gauge the extent to which actions identified by the review had been embedded. The report from the follow-up assessment was formally shared with the health board in May 2024.

The health board has established an NCCU inpatient safety delivery sub-group to provide oversight and ensure there is progress against its action plan, and that evidence of this progress can be demonstrated. An NCCU post action plan report is being developed, capturing the work that has been delivered as part of the review. This will provide the basis for the health board’s response to NCCU and NHS Executive in August 2024.

Vascular services

The Welsh Government, working with the NHS Executive and the health board, as part of the special measures intervention, commissioned a two-part assurance assessment of the quality of vascular services and other related services, to assess the extent to which recommendations from previous reviews and reports have been implemented sustainably.

Part one of this assessment focussed on the health board’s amalgamated vascular improvement plan to ensure it adequately reflected recommendations and escalations from previous reviews of the service. It also considered the clinical governance mechanisms in place and their effectiveness in relation to vascular services. The assessment and final report from this work were shared with the health board in October 2023 and highlighted an overall improvement in the quality and safety of the vascular service.

Part two involved an assessment by the vascular quality review panel of 40 case notes aligned to a number of different vascular procedures undertaken between 1 August 2022 and 31 July 2023. The final report from this assessment was shared with the board in March 2024. The panel found 38 out of the 40 procedures undertaken during this period were considered to be acceptable. Ten recommendations for further improvement were identified from part one, and 17 recommendations from part two.

A progress report on the improvements being undertaken in vascular services in North Wales has been prepared for consideration by the board at its meeting in July 2024.

Conclusion

The special measures framework provides clarity in our expectations in terms of the priorities and milestones the health board must achieve as we move into the next phase of the special measures escalation.

We continue to work with the health board through our oversight and assurance arrangements, to ensure the required improvements related to outcomes, performance, clinical fragile services and quality and safety are accelerated, and that the necessary systems and structures are in place to ensure these improvements are sustainable.