Quarterly report: BCUHB special measures - stabilisation phase: cycle 1

Stabilisation phase - cycle 1: June - August 2023

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 on serious concerns, and raised the escalation level of the Betsi Cadwaladr University Health Board 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 second quarterly report that has been produced since the Health Board was placed in special measures. This report sets out the progress made during the last three months. The priorities for cycle 2 are published with the report: BCUHB special measures: September to November 2023 priorities

Background

‘Special measures’ is the highest level of escalation in the NHS Wales escalation and intervention framework. The special measures framework sets out eight domains for improvement, incorporating all the areas of concern that resulted in the special measures status.  

The complexity and scope of work in the domains is such that there will be four levels of the special measures intervention to support de-escalation. 

• Discovery 
• Stabilisation 
• Standardisation 
• Sustainability 

The first quarterly report sets out the progress made during the discovery phase. The health board is now in the stabilisation phase of special measures.

Purpose of this report

This report sets out the progress made against each of the eight domains during the first cycle of the stabilisation phase of special measures between June and August. The focus over this period has been responding to the serious issues that resulted in the health board’s escalation to special measures, developing and building the unitary Board, rebuilding trust and confidence and putting in place some firm foundations for the future. 

The Minister for Health and Social Services chairs a bi-monthly Special Measures Improvement Forum with the integrated board; the Deputy Minister for Mental Health and Well-Being is also in attendance. This allows Welsh Ministers to ensure that the health board is progressing with the appropriate actions in response to the special measures escalation. The Minister for Health and Social Services meets the interim Chair each month and will use these meetings to assess progress against his objectives. The Director General of Health and Social Services and NHS Wales Chief Executive chairs a quarterly Special Measures Assurance Board that reviews progress against the priorities within each 90-day cycle.

The Minister for Health and Social Services and the Deputy Minister for Mental Health and Wellbeing have visited the health board on a number of occasions, including the three acute sites and a number of other mental health and community settings. This has given them the opportunity to hear experiences of staff and patients, and to see the improvements being made. These include:

• The team in Ysbyty Gwynedd has introduced a nurse led telephone triage to the prostate pathway, which allows patients to go straight to test.  
• The Call 4 Concern Service at Ysbyty Gwynedd allows patients at the hospital and their families to call for immediate help and advice if they are worried that the health care team has not recognised their changing condition.   
• A new room for minor procedures is now operational in the East, allowing minor procedures to be conducted in the community and reduce planned care waiting times.
• An expanded specialised three-bedded unit that services the intense needs of patients after a surgical procedure has opened at Wrexham Maelor Hospital.  The Post Anaesthesia Care Unit (PACU) is for patients who need specialised care after having a planned or emergency operation. 
• A new treatment room is now available at Tywyn Hospital, providing an alternative way to access treatment and ease pressure on local services.  
• The use of AI software called the Galen platform is being piloted within the health board and the team is the first in the UK to use it clinically to assist in diagnosing breast cancer.  
• A new 8-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 of the post-pandemic era and has been designed using the lessons of the Covid pandemic.
• Results from a recent National Training Survey by the GMC shows over 90% of doctors in training are pleased with the quality of clinical supervision, experience and the teaching they receive at Ysbyty Gwynedd Emergency Department, which was also ranked best place to train in the UK by junior doctors in the same survey.
• Orthopaedic surgical teams at Ysbyty Gwynedd have now performed 100 robotically assisted knee replacement surgeries using innovative robotic technology. Ysbyty Gwynedd is the first NHS hospital in Wales to perform robotic knee replacements.
• The urology and operating theatre teams are now undertaking ‘hot’ emergency operations for kidney stones using cutting edge laser surgery. 
• The General Medical Council (GMC) has given approval for the new North Wales Medical School to recruit students for 2024. The University is actively recruiting students for its September 2024 intake. 

A review of cycle 1, including members of the Board, Independent Advisers and Welsh Government officials was held on 9 August. Whilst areas of progress have been made, it is still too early to consider the effectiveness and sustainability of these improvements. The following external reviews have concluded, and reports shared with the health board for consideration by the Board through its appropriate governance structures:

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

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

• Vascular Services Assurance Assessment. 
• Executive Team Portfolio Review.
• Independent Assessment of Integrated Planning Approach and Process.
• Procurement and Contract management (health board led).

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

Four priorities were set for this domain:

1. Ensure that board governance is effective, implement recommendations of the Office of the Board Secretary review, refresh committee terms of reference and embed Special Measures reporting, scrutiny and assurance in all committees. 
2. Commence plans for the recruitment of a permanent board including a permanent Chief Executive, interim Finance Director and Chief Operating Officer/ Executive Director of Operations.
3. Develop and start to implement a Board Development Programme.
4. Ensure a scheme of delegation is in place and clearly aligned to the operating model and organisational structures.

Work has continued to develop and support the unitary Board. Details of the Independent Members can be found at health-board-members. A board induction programme has been developed and will be used for all new appointments. Work has started on the design of a board development programme. Whilst some changes have been made to the scheme of delegation, further work needs to be undertaken to ensure that this is responsive to the needs of the organisation.

Carol Shillabeer was appointed as interim Chief Executive on 2 May and will lead the organisation, on secondment from Powys teaching Health Board, until the end of March 2024.  Russell Caldicott has joined the health board as the interim Executive Director of Finance, and Adele Gittoes has taken up the post of interim Executive Director of Operations on secondment from the NHS Executive.  

These appointments along with the newly appointed Independent Members will strengthen the accountability, governance and operational controls across the Board. These recent interim appointments have been made as the health board needed to take urgent action to ensure that the right people are in place in this early phase of special measures. These appointments are part of a process and the long-term plan to ensure that the right people are in place. The process for recruiting a permanent Chief Executive is underway.  

A campaign to recruit a Vice-Chair and two permanent Independent Members is now underway and a further campaign to recruit a permanent Chair and further Independent Members will commence in October.  Arrangements for appointing the Independent Member – Trade Union are also progressing.

Further support for mental health, planning and stakeholder management is now in place to help the Board until the end of March 2024.

A detailed review of the Office of the Board Secretary has been completed. There is significant redesign work required to ensure that this function works effectively, and these changes will commence in cycle 2. In the meantime, there have been some changes to the team with staff returning from secondments. 

Terms of reference for the committees have been refreshed, but further work is required in this area in light of the completed review. Special measures is now embedded within all the committees and Independent Members will play a crucial role in ensuring that the requirements of special measures are delivered.

A small number of core board committees have been running throughout this cycle. Further committees will commence towards the end of the year, following the appointment of the Vice-Chair and further Independent Members.

Four priorities were set for this domain:

1. Ensure that there is an effective procedure/process for learning from incidents and preparations for inquests and HSE are clear and effective.
2. Agree, support and enable the Review of Patient Safety Care.
3. Work with NHS Executive as they undertake a review of clinical governance. 
4. Review mechanisms for clinical engagement, drawing up recommendations for improvement.

Rapid reviews continue to take place in response to issues raised by HM Coroner and the Public Services Ombudsman. A programme of new reporting and learning processes is now being rolled out across the organisation. HM Coroner has raised a number of issues relating to the health board during this period. In response to this, a new standard operating procedure is being developed. This will have direct oversight from the Medical Director, with a clear escalation process.

Welsh Government commissioned an assessment in relation to concerns around affiliated patient safety in the health board. This work has concluded, and the health board is taking the recommendations and next steps through their agreed governance structure. This will then form the basis of a clinical governance intervention to be undertaken by the NHS Executive in cycle 2.

The way in which the health board engages with the clinical community has been reviewed. A clinical engagement proposal was received at the end of cycle 1, and the implementation of this will be undertaken in future months.

Three priorities were set for this domain:

1. Support and enable a review of Executive Director portfolios.
2. Resolve outstanding respect and resolution cases including similar processes related to senior leadership.
3. Support and enable the review of interim appointments – implement recommendations.

The Executive team portfolio review has now been completed. The recommendations from this review alongside the outcomes of the operating model stocktake will require considerable focus and action in cycle 2 to ensure that the organisation is structured correctly to deliver. 

A review of wellbeing, engagement and workforce policies has been completed and shared with the health board for consideration through its board committees and structures, and to commence the appropriate changes in the next 90-day cycle. 

The review of interim appointments has been completed. There are significant recommendations around how this process is managed in future. This includes the scheme of delegation for agreeing appointments. The response will be considered by the Remuneration and Terms of Service Committee.

Three priorities were set for this domain:

1. Implement the recommendations from the Mental Health Inpatient Safety Assessment.
2. Agree a mental health strategy, agree and commence implementation a CAMHS and neurodevelopment action plan to improve performance and improve CAHMS performance.
3. Review, revise and implement clear improvement plans including but not necessarily limited to vascular (including enabling the vascular review), urology, ophthalmology, oncology, dermatology and plastics.

The independent mental health inpatient safety assessment that took place in April made recommendations that need to be implemented. The focus for the health board has been upon implementing these recommendations. A follow up assessment will take place in cycle 3. 

The CAMHS and neurodevelopment improvement plans require further development to meet current challenges and will be completed in cycle 2. The process has involved a round table planning event supported by the NHS national leads support.

There has been ongoing oversight on vascular services. In June 2023 Healthcare Inspectorate Wales published their report on vascular services following an unannounced inspection and also de-escalated the service from 'a service requiring significant improvement' -  BCUHB-SRSI-de-escalation. An independent assessment against the vascular plan is also being undertaken by the Wales National Clinical Network.

For other clinical services, including ophthalmology, oncology and dermatology, improvement plans are being developed, and all are supported by improvement groups.

Two priorities were set for this domain:

1. Working with Health Education and Improvement Wales, consider options, agree and commence a programme for Executive Team and senior leadership development.
2. Develop an approach to build trust and confidence within the organisation and with stakeholders including the development of a structured approach to renewing engagement with priority community groups.

A review of cultural leadership has been undertaken as part of the HR experts review. The health board will need to review these recommendations and agree the next steps. The learning organisation discovery work will be completed this month and the draft framework will be shared with stakeholders.

Work on engagement with priority community groups has commenced with some external support.

Five priorities were set for this domain:

1. Stabilise the finance team and address capacity concerns.
2. Implement the financial governance action plan in response to the findings of the E&Y report and other concerns.  
3. Commence delivery of an agreed efficiency savings plan and improvements to the financial plan that minimises the financial deficit in 2023 to 2024.
4. Commence an assessment of the potential financial opportunities for 2024 to 2025 and 2025 to 2026 and develop the contribution of value-based healthcare.
5. Implementing priorities associated with the financial control environment e.g., contract management.

A new interim Director of Finance, and two other appointments, have been made to strengthen the senior finance team. There is still a considerable amount of work to be done to strengthen capacity, capability and improve morale.

The health board has agreed a special measures finance action plan with Welsh Government and the NHS Executive. The health board has developed a financial control environment action plan in response to the findings of the EY report and the Audit Wales report on its annual accounts for 2021 to 2022. This is embedded within the special measures finance action plan.

The action plan is focused upon stabilising the finance team and developing capacity, implementing the financial governance / control action plan, commencing delivery of an agreed savings plan and improvements to the financial plan that minimises the financial deficit in 2023 to 2024, assessing opportunities for future financial years and developing value-based healthcare, and implementing priorities associated with the financial control environment.

At its meeting on the 24 August 2023, the board approved the annual accounts for 2022 to 2023. The financial challenges and projected financial deficit are significant and will require the board to make some difficult decisions in the coming months. 

The health board has commenced a review of procurement and contract management.

Two priorities were set for this domain: 

1. Produce a clear and deliverable annual plan for the organisation for the current year, that delivers improvements in ministerial priority areas.
2. Transformation and improvement support to become focused upon key risk areas and to be embedded in the frontline teams to assist in change programmes.

A Board workshop was held to understand the challenges and options facing the organisation and help shape and support the plan. The annual plan was then approved by the board on 22 June and submitted to the Welsh Government. The submitted plan, in line with the other six health boards, was a deficit plan. This means that the health board has not provided a plan in accordance with the direction given by the Welsh ministers and the NHS Planning Framework, which the Minister for Health and Social Services could consider for approval under section 175(2A) of the NHS (Wales) Act 2006 ('the 2006 Act').

An independent planning review is underway; fieldwork was undertaken during August 2023.

Four priorities were set for this domain:

1. Improve access and experience as measured by elimination of 52 week waits at first outpatient stage, zero 156-week Referral to Treatment (RTT) waits, zero 4 hour ambulance handovers and increased 4 and 12 hour performance.
2. Recommence the planned care programme with clear executive oversight.
3. Develop a plan for improving access to orthopaedic care and reducing waiting times for patients.
4. Develop a plan for data/digital which delivers easily accessible data for frontline staff including dashboards for patient safety, quality and experience.

There has been a reduction in the number of long waiting patients at both the outpatient and treatment stage. The number of people waiting over 52 weeks for an outpatient appointment has fallen by 35% from January 2023, and the numbers with total waits over 104 weeks has reduced by 27%. The focus on eliminating 4-hour handover, whilst not yet achieved, is resulting in improvements each month. There were 566 handover delays in excess of 4 hours in July 2023, in August this fell to 465, this is considerably better than the 1042 noted in March 2023.

Additional operational support has been commissioned for urgent and emergency care and orthopaedic delivery. Good progress has been made on the orthopaedic business case.  

A Planned Care Programme Board has been established, and it met for the first time in August. It was chaired by the Chief Executive, and it will focus upon the delivery of ministerial targets. Work is ongoing on the development of the required dashboards. The clinical coding and intelligence plan is progressing and will be used to support GIRFT (Getting it Right First Time) priority areas as the first stage.

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

Joint Ministerial Special Measures Improvement Forum - 13 September 2023

Cancer performance assurance meeting - 19 September 2023

Monthly planned care touchpoint meeting - 22 September 2023

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

Quarterly Ministerial Meeting - mental health (Deputy Minister for Mental Health and Wellbeing) - 10 October 2023

Cancer performance assurance meeting - 16 October 2023

Joint Executive Team meeting (JET) - 26 October 2023

Monthly planned care touchpoint meeting - to be arranged

Special Measures Assurance Board - 10 November 2023

Joint Ministerial Special Measures Improvement Forum - 20 November 2023

Cancer performance assurance meeting - 24 November 2023

Monthly Planned Care touchpoint meeting -  to be arranged

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

Vascular touchpoint meetings - bi-weekly

Plastics touchpoint meetings - monthly

Ophthalmology assurance meetings - to be arranged