Betsi Cadwaladr University Health Board special measures: progress report July to September 2024

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

Five reports have been published to date, reflecting on the progress made against the special measures escalation. The reports recognise the improvements made and challenges the health board faces as it puts in place the necessary processes and systems to become a sustainable organisation.

Background

To support the health board on its improvement journey, a special measures framework, including de-escalation criteria was agreed with the board in May 2024. This set out the priorities and expectations across six domains between April and September 2024. This report reviews the progress against those priorities and is supported by the publication of the Welsh Government expectations until the end of March 2025.

Special measures oversight

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 Wellbeing 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
• quarterly all-age mental health assurance meetings with the health board, chaired by the Minister for Mental Health and Wellbeing
• 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 regular meetings to track progress
• a Joint Executive Team meeting held twice a year
• regular visits to health board settings by the Cabinet Secretary for Health and Social Care, the Minister for Mental Health and Wellbeing and the First Minister

Following the appointment of a full complement of independent members, and the director of governance, the health board has focused on strengthening corporate governance across the organisation. This includes:

• the full implementation of the governance and committee structure from April 2024
• board agreement of the terms of reference for all committees and advisory groups; the health board will continue to review and refine these in line with the principles of good governance
• publication of a corporate meeting calendar for 2024 to 2025, setting out key dates for board and committee meetings
• a chairs’ (of committees) advisory group established to promote cross-working of quality, resource, activity or outcomes between committees
• the integrated performance and accountability framework has been approved by the board and is being used to highlight issues and concerns to the board and its committees
• the performance, finance and information governance committee is undertaking oversight on key issues focussing on the detail and providing assurances to the board
• the integrated risk management framework has been approved by the board, setting out the key responsibilities, roles, and accountability arrangements

The review of interim appointments to executive posts at Betsi Cadwaladr University Health Board made 12 recommendations. The health board published its management response to the review in November 2023. This included an action plan setting out how it will address the seven recommendations for action by the health board, which related to strengthening internal processes and embedding a culture of compliance and improvement.

The health board’s remuneration committee has oversight of the action plan and monitors and approves all executive and senior appointments and receives regular reports on interims and compliance. The latest progress update was presented to the committee on 19 August 2024. The committee’s terms of reference were refreshed earlier this year as part of enhanced internal processes.  

The health board has made good progress in implementing the recommendations of the review of the Office of the Board Secretary with 97% (102) recommendations completed. Three actions remain in progress relating to the structure of the office of the board secretary. The organisation is currently undergoing a full structure review, these actions will be completed when the operating structure is finalised.

The board approved the health board’s approach to a quality management system (QMS) in May 2024. The focus is now on the implementation of the QMS, with the vascular and urology services as the two pathfinders.

The health board has approved and started the implementation of a new integrated concerns policy. This provides a framework to recognise, respond, learn and improve from incidents, complaints and mortality reviews.

The health board has been dealing with serious legacy issues, 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.

It 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.  

Over the last six months, the health board has focused on improving its processes and systems in response to complaints. It has created and implemented a revised process for consistent complaints handling. A new integrated concerns hub was operational from 1 September 2024. This supports the triangulation of issues, learning and complaint response times through tracking and monitoring learning investigations through a weekly executive-led oversight group.  

These revised processes have started to make an impact, with the percentage of complaints closed within 30 days rising from 33.3% in April 2024 to 58.9% by the end of September 2024. This improvement must now be maintained.

During July and August 2024, the patient and carer experience team received 8,793 feedback survey responses with 82.76% of respondents very satisfied with their overall experience of accessing services – this is the highest satisfaction level recorded in the last 12 months. 
 
Overall, the emergency department average satisfaction rating has increased by 4.23% from April 2024, with respondents rating their overall experience in August 2024 as 6.90 out of 10 being excellent.

Examples of improvements made following the feedback include:

• vending machine installed in Ysbyty Gwynedd emergency department following feedback about access to food
• waiting times announcements placed on loop at Wrexham Maelor Hospital
• improved patient information in the waiting area at Ysbyty Glan Clwyd

In August 2024, Healthcare Inspectorate Wales (HIW) announced it has de-escalated the emergency department at Ysbyty Glan Clwyd from a service requiring significant improvement, following an unannounced inspection at the department earlier this year. Inspectors acknowledged improvements had been made since previous inspections, but highlighted that further changes were still needed, and people were waiting too long to be treated.

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 August 2024, the number of RTT orthopaedic patient pathways waiting more than 104 weeks has reduced by 49.4%, the number of pathways with total waits more than 104 weeks has reduced by 1.2% and there has been a 7.0% 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.

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.

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

The health board continues to work closely with colleagues across the health and social care system, the Welsh Government, 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.

Work around culture and developing compassionate leadership is progressing across the health board. Progress is being monitored by the health board’s people and culture committee. Consultation and engagement related to the health board’s values and behaviours framework has been undertaken with a final version to be shared with the board at its meeting in November 2024. The health board has introduced a leadership development framework.

On 3 October, the First Minister and Cabinet Secretary for Health and Social Care officially opened the North Wales Medical School at Bangor University. The first direct intake of students took place in September, with 80 students starting their studies in medicine. Student numbers will gradually increase until they reach optimum capacity from 2029 (140 students per annum).  

A senior and executive director recruitment programme is underway. The following senior appointments have been made:

• Director of Corporate Governance - April 2024. 
• Executive Director of Allied Health Professionals and Health Science - August 2024
• Interim Executive Director of Public Health – August 2024
• Director of Commissioning and Performance - October 2024

The recruitment processes for the following positions are expected to conclude in October 2024:

• Director of Estates and Environment
• Executive Director of Workforce and Organisational Development
• Chief Operating Officer

The health board has reported progress against the special measures reviews as follows:

• independent safety review of mental health and learning disabilities inpatient services and follow-up review - 94% of actions complete, with five outstanding actions due to be completed by the end of March 2025
• review of contract and procurement management - 96% of actions complete, with two outstanding actions due for completion
• independent review of interim appointments to executive posts - 71% of actions complete; the two outstanding actions will be part of the new staff journey programme of work
• review of the Office of the Board Secretary - 97% of actions complete; the two remaining actions are part of a review of the structure of the office of the Board Secretary
• independent review of the Vascular Quality Panel: Part 1 and 2 - all actions are progressing with no reported risks to delivery
• independent review of concerns raised around patient safety - 79% of actions complete; there are 10 actions outstanding and progressing, linked to implementation of the quality management system
• independent review of integrated planning - 70% of actions complete; all remaining actions are in progress with no significant risks to delivery identified
• Royal College of Psychiatrists review of mental health reviews - 15% of actions complete, with 58% of all the actions underway.
• Royal College of Surgeons of England review of urology surgical services - progress underway against the 24 recommendations identified.

The published reports and associated management responses are available on the health board’s website.

A review of contract and procurement management was commissioned by the health board and undertaken by NHS Wales Shared Services Partnership (NWSSP) Internal Audit Service. 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.

In 2023 to 2024, Betsi Cadwaladr University Health Board delivered an outturn deficit of £24.3m, which was a £4.3m shortfall against the target control total of £20m. The health board made progress in-year against its original plan, but it was one of three which did not deliver on the target control total set by the Welsh Government.

For 2024 to 2025, it was unable to submit a financially balanced Integrated Medium Term Plan (IMTP) and submitted an annual plan with a planned deficit of £19.8m. The forecast position relies on the organisation delivering £48m of saving schemes.

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. Improvements and deliverables include:

• head of financial governance role created within the finance department to support sustainable improvements in financial governance
• financial governance environment has been enhanced through additional oversight by specialist groups, the executive team, and committees of the board
• a fully-refreshed budget holder handbook has been developed, and forms part of a rolling training programme for all budget holders
• the health board is working with NHS Wales Shared Services on the procurement and governance training programme; more than 200 staff have attended training sessions over the last six months
• a new "file note" system has been introduced across the health board to capture any breaches in procurement requirements
• the value and sustainability framework assigns an executive lead to each savings category, supported by teams providing clinical, operational, and finance expertise
• significant progress has been made in-year towards delivering the savings requirements set out in the organisations plan both in terms of actions, financial value, and supporting enablers

The health board was unable to submit a balanced 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.

The health board has committed to initiating and progressing development of its clinical services strategy and clinical plan in 2024 to 2025.

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. Seventy per cent of the actions have been completed and the health board reports that all remaining action are in progress with no significant risks to delivery been identified.

A new integrated planning process was endorsed by the board in September 2024, which is fully aligned to the 'Integrated planning framework'. The new process was due to launch across the organisation in October 2024.

Fragility, quality and inconsistency of service delivery were real concerns across a number of services when the health board was placed in special measures. There were particular concerns relating to mental health, vascular services and urgent and emergency care. Many of these challenges still remain, despite progress being made in some areas. Work undertaken since February 2023, highlights the fragile nature of many services across the health board.

Child and Adolescent Mental Health Services (CAMHS)

CAMHS and neurodevelopment improvement plans have been developed and agreed by the health board’s executive team. The focus is on developing a sustainable model.

All areas are now delivering some extended hours; services in the west operate every day; the service in the centre operates Monday to Friday and at present the service in the east is operational two days a week. This will increase following recruitment.

Royal College of Psychiatrists review of mental health reviews

At its public board meeting in July 2024, the health board approved a plan setting out actions and timescales in response to the findings from the Royal College of Psychiatrists’ review of mental health reviews.

In September 2024, the health board confirmed it has appointed a mental health special adviser for a period of 12 months. They will be the independent chair of an expert advisory group established with family and user representatives, and Llais. This new group is an important aspect of the health board’s governance and oversight arrangements for its response to the Royal College’s review.  

The health board’s Quality, Safety and Experience (QSE) committee will be the main oversight mechanism and regular chair’s assurance reports will be utilised to support the expert advisory group and QSE committee. The first progress report was due to be presented to the QSE committee at its meeting in October 2024. The health board will provide six-monthly progress reports to the board, commencing in January 2025.

A progress report on the improvements being undertaken in vascular services in north Wales was considered by the board at its meeting in July 2024. The paper concluded that progress is now being made and that several sources of external assessment support that conclusion. There is, however, further work to continue to make improvements to outcomes and experience as well as sustainability.

The increased stability of the service enables the health board and specifically this service to focus more upon proactive, continued future development. Strategic changes in this speciality will continue across the UK and internationally, the health board will consider these further over the coming months.

The special measures framework provides clarity in our expectations in terms of the priorities and milestones the health board must achieve. 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.