Betsi Cadwaladr University Health Board special measures: year 1 progress report

On 27 February 2023, 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 in relation to serious concerns and raised the escalation level of the Betsi Cadwaladr University Health Board (BCUHB) to special measures. This decision was taken due to serious concerns about board effectiveness, organisational culture, service quality and reconfiguration, governance, patient safety, operational delivery, leadership and financial management.

This is the fourth progress report since the health board was placed in special measures. The first three reports set out the progress made during each quarter of the current special measures arrangements.

This report looks at the special measures journey over the past 12 months, highlighting lessons learned, improvements and challenges identified.

At the time of the minister’s decision in February 2023, special measures was the highest level of escalation in the NHS Escalation and Intervention Arrangements (2014). The revised NHS Wales Oversight and Escalation Framework (2024) was published earlier this year and supersedes this guidance. However, special measures (level 5) remains the highest level of escalation for NHS Wales organisations.

The special measures framework for Betsi Cadwaladr University Health Board sets out eight areas for improvement, covering the areas of concern which resulted in the escalation to special measures.

There has been considerable special measures oversight over the past 12 months including:

• a bi-monthly special measures improvement forum with the board, chaired by the Minister for Health and Social Services with the Deputy Minister for Mental Health and Well-Being in attendance; this allows Welsh Ministers to hold the board to account for delivering the appropriate actions in response to the special measures escalation
• monthly meetings between the Minister for Health and Social Services and the health board chair; these meetings are used to assess progress against the chair’s objectives, including delivery against the health board’s agreed special measures response plan
• quarterly meetings chaired by the Deputy Minister for Mental Health and Well-Being to seek assurance about mental health
• a quarterly special measures assurance board chaired by the NHS Wales Chief Executive to review progress against the priorities in each of the 90-day cycles
• 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
• the Minister for Health and Social Services, Deputy Minister for Health and Well-Being and the First Minister have made a number of visits to health board sites over the past 12 months

A small number of independent advisors were contracted to provide support related to finance, board governance, planning, quality and safety, engagement and communications, and mental health. A series of reviews have been undertaken which includes:

• independent review of concerns raised around BCUHB affiliated to patient safety
• independent safety review of BCUHB mental health and learning disabilities inpatient services 
• independent review of interim appointments to executive posts at BCUHB 
• assessment of key areas of workforce agenda (‘HR experts review’)
• independent review of the office of the Board Secretary
• vascular services assurance assessment review 
• independent review of executive team portfolios 
• independent assessment of integrated planning approach and processes
• procurement and contract management (health board led)
• Royal College of Psychiatrists review of mental health reviews
• Royal College of Surgeons of England review of urology surgical services
• listening to citizens, patients, staff and partners
• review of vascular pathways between August 2022 and August 2023 (underway)
• follow-up review of mental health inpatient quality and safety (underway)
• follow-up review of board effectiveness

The health board has developed its own management responses to many of these reviews across a series of themes. The published reports and associated management responses are available on the health board’s website.

The thematic approach being taken by the health board allows it to cover the breadth of issues and to address the real root causes. Seven themes have been identified:

• data, intelligence and insight
• culture
• risk management
• patient, family and carer involvement
• operating model
• organisational governance and compliance
• integrated planning

The health board has established executive-led delivery groups to assure connectivity across each theme. The health board will need to demonstrate evidence of progress against every recommendation in each review.

Governance, board effectiveness and audit

Over the past 12 months, there has been a focus on rebuilding and stabilising the board. The board has previously had a considerable number of interim appointments, but it now has a permanent chair, chief executive and vice chair, and the required number of independent members will be in place from March 2024. This will give the organisation the stability and focus it needs to improve.

Following the review of the office of the Board Secretary, the work associated with board governance has progressed. This includes:

• terms of reference for all the committees have been refreshed and all committees will be operational from March 2024; special measures is embedded within all the committees and independent members play a crucial role in ensuring the requirements of special measures are delivered
• a new board induction programme has been developed and all new independent members will be inducted via this process
• a board development programme is in place, which includes a focus on clinical services, site visits, key areas such as winter resilience planning and financial grip and control
• a risk management framework was agreed by the board at its meeting in September 2023, supported by the board assurance framework with implementation underway reporting to the audit committee

Audit Wales has recently published its follow-up review of board effectiveness at Betsi Cadwaladr University Health Board. It describes the challenges over the last 12 months, notes some of the improvements made and sets out the work that still needs to be done. It highlights that:

following a period of significant disruption and churn during 2023, the board is now in a more stable position. There is a new substantive chief executive in post, the dysfunctionality within the board described in our previous report is no longer evident and working relationships amongst senior leaders are more positive in overall terms.

And that:

from a difficult position in February, the board and committee arrangements have steadily improved although there is much more to do which includes re-establishing a full set of committees below the board and improving the quality of assurances provided in board and committee papers.

The health board has confirmed that plans are in place to recruit to the remaining substantive posts to bring the board up to full capacity.

There is a clear understanding of the challenges and some of the building blocks to become an effective organisation are now in place.

Clinical governance, patient experience and safety

The new approach being taken by the board to increase its visibility and strengthen engagement with the public across north Wales was demonstrated when it held its annual general meeting in a community centre in Llandudno. A series of public conversation roadshows have taken place to allow local people to drop in and give their views about local health services. People were able to talk to frontline staff to learn about their day-to-day work and meet board members to talk about the health board’s future plans.

There has been a good focus on partnership working across local authorities, with the third sector, universities and engagement with the Regional Partnership Board and Public Services Board has been improved. This is demonstrated through the work on the North Wales Medical School and the Royal Alexandra Hospital in Rhyl.

The January board meeting included a citizens’ experience report (p 28) for the first time. It included the key themes from those interactions and conversations, to enable the health board to learn from them and act on any emerging issues.

A rapid review of clinical engagement has been completed and shared with the board as part of the special measures intervention. The newly formed People and Culture Committee will lead this work stream.

Workforce and organisational development

Work still needs to be done to ensure there is a permanent executive team in place. A director of corporate governance has been recruited and is due to start on 1 April 2024. A review of executive portfolios has taken place, and the health board is recruiting to fulfil some key posts.

The board considered the recommendations from the review of interim appointments to executive posts in a development session in September 2023 and shared its management response at its Renumeration and Terms of Service Committee in November 2023. Controls around the use of senior interim appointments have been strengthened. In December 2022 there were 41 senior interims in post, by January 2024 this had reduced to one, resulting in savings of £2.35m since December 2022.

Audit Wales has noted there is “evidence of better governance of establishment control and proper impact assessment for all requests to extend the tenure of senior interim roles”.

Compassionate leadership and culture

Betsi Cadwaladr University Health Board has had a succession of chief executives over recent years, which has contributed to uncertainty for staff and the development of different cultural and organisational behaviours across and within clinical specialties and sites.

The board has undertaken work to understand the extent, breadth and depth of the cultural challenges and a clinical engagement rapid review report was completed in September 2023. A listening to patients, families and communities report has also been completed. Both reports will be considered by the newly established People and Culture Committee.

The health board has worked with Health and Education Improvement Wales (HEIW), Academi Wales, local universities, and other NHS Wales organisations to launch a leadership development programme for existing staff, with bespoke training programmes for staff at different levels across the health board:

• executive development programme: a bespoke programme for health board executive directors emphasising strategic systems leadership and working as an effective team/board
• advanced senior leadership programme: a bespoke programme for those in tier 3 and 4, integrated health community directors and their direct reports
• transition to senior leadership: aimed at those transitioning from operational to senior management roles such as clinical leads, head of departments, matrons, heads of nursing, clinical site managers
• mid-level leadership and management programme: aimed at established operational mid-level managers who are looking at leading teams through change and uncertainty
• foundations of leadership and management programme: a mandatory programme for all staff who are new to a management role
• aspiring people managers

The board approved a proposal to launch and actively shape the organisation’s strategic intent around culture, leadership and engagement at its meeting in September 2023. This work is being supported by Michael West and Henry Engelhardt in a series of board workshops and leadership conferences are planned with 250 senior leaders.

Work is underway to complete a values and behaviours framework and a supporting cultural change plan.

Clinical services

The special measures framework highlighted a number of clinical services, which were fragile because of poor quality and poor patient experience; staffing levels; and sub-optimal outcomes and performance. The health board is working to improve these services to ensure they can deliver in line with clinical standards and this focus will continue as we move into the next phase of special measures.

Vascular services

In June 2023, Healthcare Inspectorate Wales (HIW) published its follow-up report about vascular services at the health board following an unannounced inspection. As a result, the service was de-escalated from a ‘service requiring significant improvement’.

An independent assessment against the vascular plan has been undertaken by the by the NHS Executive Vascular Clinical Network. This was subsequently considered by the health board’s Quality, Safety and Experience Committee and the board and a management response has been completed. The assessment concluded that the ‘service has improved from the previous reviews and in the opinion of the reviewers now provides a much safer service’ and that ‘the vascular surgeons work more collaboratively, with patient management being MDT (multi-disciplinary team) driven’.

The Welsh Government has commissioned a vascular case note assessment, which has reviewed 40 patient pathways accessing treatment between August 2022 and August 2023. The final report is expected in March 2024.

Improvements continue to be noted in the vascular service, building upon the recent reviews undertaken. There have been a number of engagement events with families following the publication of the Vascular Quality Panel findings. The vascular improvement plan is comprehensive and is reviewed and updated on a regular basis.

Orthopaedics

In February 2023, waiting times for orthopaedics across Betsi Cadwaladr University Health Board were considerable, with 2,472 orthopaedic patient pathways waiting over 104 weeks.

An improvement plan was put in place and key aspects of this tested through the orthopaedic ‘perfect month’ in Wrexham in June 2023. The improvements noted were spread across the other sites and a decision taken to maximise activity at Abergele Hospital. This site has led the way in implementing clinical best practice and now provides an increasing number of same-day orthopaedic procedures.

Waiting times for orthopaedic pathways have improved, with 1,172 patient pathways waiting over 104 weeks in December 2023, a 52.5% improvement since February 2023, the lowest level since April 2021.

Considerable work has been undertaken to develop the future model for orthopaedics and a business case to create an orthopaedic hub in Llandudno was approved by the board at its meeting in September 2023 and subsequently approved by the Minister for Health and Social Services on 23 November 2023. Work has started on the new hub, with a completion date of December 2024.

Mental health

The leadership and management of the mental health service (including children and adolescent services) remains fragile, but there have been a number of more positive HIW inspections over the last 12 months, suggesting a stabilising service.

The board considered the recommendations from the independent safety review of BCUHB mental health and learning disabilities inpatient services in a development session in September 2023 and shared its management response at its Quality, Safety and Experience Committee in October 2023. A further external assessment took place in January 2024 to assess the extent to which the recommendations have been embedded. This report is expected in March 2024.

The Child and Adolescent Mental Health Services (CAMHS) and neurodevelopment improvement plans have been developed and agreed by the executive team. The process has involved a round table planning event supported by the NHS national leads.

The Royal College of Psychiatrists has completed a review of previous mental health reviews to determine the extent to which the recommendations from these reviews have been embedded and completed. This report is expected in March 2024.

Performance against the various mental health measures for adults has improved, with 85.3% of adults having had an assessment within 28 days in December 2023 compared to 73.8% in February 2023 and 87.6% of adults having had an intervention within 28 days compared to 84.6% in February 2023. For people under the age of 18, performance against parts 1a and 1b of the mental health measure remains below target, but improvements have been seen when compared to February 2023.

The health board entered a guilty plea in response to a Health and Safety Executive prosecution related to the death of a patient on a mental health inpatient ward (North Wales health board fined after failings resulted in woman’s death | HSE Media Centre). It received a sizeable fine. It is essential the health board ensures the learning from this prosecution is embedded across its sites.

Work on the improvement plans for other fragile clinical services is ongoing, although final versions have not yet been shared with the Welsh Government. We are concerned that the health board is not responding as quickly as it could to some of the issues these services are facing. Of particular concern is the dermatology service, which has come under considerable pressure since the summer because of an increasing number of staff vacancies and the challenge of recruiting, especially in the west of the health board area. Difficulties recruiting substantive staff mean there is a reliance on interim and locum staff.

An immediate recovery solution was put in place to minimise the impact on urgent cancer patients. However, this is dependent on additional waiting times initiatives and is not sustainable. The service requires transformation. The Welsh Government has provided the health board with an additional £200,000 to establish a tele-dermoscopy model which will support faster triaging of patients.

Financial governance and management

The health board has agreed a special measures finance action plan and a financial control environment action plan with the Welsh Government and the NHS Executive. This is reviewed and challenged to support progress and assurance on the delivery of the plan and key milestones. Investigations in respect of a small number of suspended staff are ongoing.

Action has been taken to stabilise the finance team, with additional resources identified and redirected to support key deliverables, technical accounting, ongoing monitoring and performance reporting. Benchmarking work on the finance function of the health board has been completed and will inform the future finance operating model. Actions are in place to strengthen the capacity of the senior finance leadership team. A programme of refreshed procurement training with a range of activities is being rolled out within the health board.

Progress is being made on the identification and delivery of a savings plan, with a material increase in savings forecast delivery with confidence, as at the end of December 2023.

Internal audit has undertaken a review of procurement and contract management. The report, which identified 24 actions, has been reviewed and endorsed by the health board’s Audit Committee and there is a management response to each recommendation. Focus has been placed on three key areas:

• control environment: revision of standing orders, scheme of delegation and standing financial instructions completed and endorsed through executive, Audit Committee and board
• training, publication, and awareness of the processes for procurement and contracts: NHS Wales Shared Services Partnership (NWSSP) was engaged to produce and deliver training packages to all officers engaged in procurement, with sessions completed with front-line staff and executive members
• reporting of performance to those charged with governance: a detailed compliance report has been produced for the Audit Committee to evidence the impact of the enhanced control environment

Planning and service transformation

The health board has made progress on enabling actions since its escalation to special measures, as demonstrated by the integrated planning framework, integrated performance framework and the risk management framework that were all agreed by the board at its September 2023 meeting.

A learning organisation framework has been developed and agreed by the executive team. A comprehensive review of current Putting Things Right (PTR) processes has been completed including incidents, claims, inquests, complaints and subsequent learning. The health board is in the process of developing a quality management system, building on the experiences of exemplar organisations, with a first version expected in May 2024.

A strengthened approach by the executive team is being adopted in relation to performance, in line with the board-approved integrated performance framework.

Operational delivery

There has been a reduction in the number of long waiting times for patients, at both the outpatient and treatment stage since February 2023. The number of pathways waiting over 52 weeks for a first outpatient appointment has fallen by 8.9% between February 2023 and December 2023. The number of pathways with total waits over 104 weeks has reduced by 23.8% and there has been a 27% reduction in the number of pathways waiting over eight weeks for their diagnostic tests over the same period.

The health board is working closely with colleagues across the health and social care system, Welsh Government, the Welsh Ambulance Services Trust and the NHS Executive to alleviate urgent care pressures and improve the experience of patients. However, performance for urgent and emergency care remains a significant challenge.

Service improvements

There are many examples of service improvements and innovation, which the health board has introduced over the last 12 months including:

• Wrexham Maelor Hospital is the first in Wales to use a new procedure, a cutting-edge laser, to remove bladder tumours or suspicious areas; the procedure uses a Trans Urethral Laser Ablation (TULA), an examination of the bladder using a camera on a thin flexible tube that uses a laser for bladder treatment; this will improve people’s outcomes and experience
• the health board has completed the expansion of Wrexham Maelor Hospital’s Emergency Department, which has created more consulting and treatment rooms for patients who need urgent care
• the discharge lounge at Ysbyty Glan Clwyd has been enhanced and now provides a discharge hub to accommodate people for up to 24 hours, helping manage the flow of patients through the hospital and reducing unnecessary delays for those who are ready to go home
• results from a recent national training survey by the General Medical Council (GMC) shows more than 90% of doctors in training are pleased with the quality of clinical supervision, experience and the teaching they receive at Ysbyty Gwynedd’s emergency department; it was also ranked best place to train in the UK by junior doctors in the same survey
• the health board is the first in the UK to use artificial intelligence software, known as the Galen platform, to assist in diagnosing breast cancer
• a new eight-bed respiratory support unit has opened in Ysbyty Glan Clwyd, supporting patients with respiratory issues requiring regular higher observations, but who are not sick enough to need high dependency care; this is the first bespoke design and purpose-built respiratory support unit in Wales in the post-pandemic era and has been designed using the lessons from the pandemic
• the health board has established a North Wales Dental Academy to address recruitment, retention and upskilling dental professionals
• a new stroke rehabilitation centre opened in Llandudno General Hospital to ensure patients have the best chance of a good recovery after having a stroke; this is the second of three new specialist community inpatient rehabilitation centres to open in North Wales for patients who no longer need specialist stroke treatment at an acute hospital, but still require stroke rehabilitation that cannot be delivered at home; the first was in Ysbyty Eryri in Gwynedd
• a “straight to test” pilot approach has been introduced so patients have an mpMRI test sooner after being referred for diagnostics on suspicion of cancer; people are seen more quickly, undergoing an MRI scan around 18 days after a GP referral
• since launching the 111 press 2 service last year, the health board has taken more than 8,000 calls from people who require urgent mental health support; feedback has shown 99.3% of callers reported a reduction in their distress scores after contact with dedicated wellbeing practitioners; referrals to local primary mental health support services have reduced by 8%

In its recent report, Audit Wales has been very clear that considerable work still needs to be undertaken:

… some fundamental challenges still remain in the context of an organisation that is in special measures. Substantive appointments to the board need to be completed as quickly as possible to bring the board up to full capacity. Work must continue to build a united and effective executive team, to resolve the on-going personnel issues in the Finance Department, and to strengthen corporate governance leadership arrangements within the organisation. These activities need to be supported by continued progress with a board development programme that builds a cohesive and unified board that supports a positive organisational culture by setting the right 'tone from the top'.

The Welsh Government, through its oversight and assurance function, is clear that the improvements related to outcomes, performance, clinical fragile services and quality and safety need to be accelerated. While there are some improvements in these areas, they are not enough and are not always sustainable.

Of particular concern are the cases highlighted by both HM Coroners and the Public Services Ombudsman, 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.

North Wales coroners have issued 25 Prevention of Future Deaths (Regulation 28) reports to the health board since January 2023, and many of them highlight consistent themes, which the health board must address. These are:

• quality of treatment plans and continuity of care impacted by lack of an integrated electronic health record
• timeliness of responses by the Welsh Ambulance Service impacted by delays in the health and social care system
• quality of investigations and effectiveness of actions

The health board has established an investigations and learning programme, and the medical director is the nominated senior responsible owner. The programme has direct oversight from the chief executive and the wider executive team and reports directly to the Quality, Safety and Experience Committee with a clear escalation process in place to review, and where required, improve:

• the quality of each investigation
• the quality of action planning resulting from investigation including the tracking of implementation
• evidence of learning outcomes being reported / shared / implemented widely

The board has considered the recommendations from the assessment in relation to concerns raised around affiliated patient safety in the health board in a development session in September 2023 and shared its management response at its Quality, Safety and Experience Committee in November 2023.

The health board does not have a robust quality management system in place and this needs to be accelerated at pace.

Whilst there have been improvements in corporate governance, this must now be reflected across quality governance and operational delivery. These two areas must be the focus for improvements over the next 12 months.

The Welsh Government expects the following areas to be progressed:

• a quality management system
• improved board awareness and consideration of the quality and safety of services
• effective functioning of the board committees
• improved data on clinical pathway delivery, clinical outcomes and patient experience used to identify service failures and drive through quality improvements
• quality planning for clinical services
• demand and capacity planning
• delivery of action plans
• improved quality of incident investigation
• a focus on consultant job planning
• clinical engagement and leadership of improvement
• improved clinical culture
• reduced waiting times across those services, where the standards are not being achieved

Betsi Cadwaladr University Health Board has stabilised and started to put in place the building blocks to become a sustainable organisation over the course of the last 12 months under the current special measures arrangements.

The reviews which have been undertaken have highlighted areas of fragility and have pinpointed where further improvements are needed. These will require continued focus by the health board. The steps and processes put in place by the chair, the independent members, the chief executive and executive directors are having an impact and it will require effective team working and leadership to build upon these in the coming 12 months.

The last 12 months have been challenging, and it will take considerable time to fully rebuild the health board. However, progress has been made.