Quarterly progress report: Betsi Cadwaladr University Health Board special measures, discovery phase

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.

The chair, vice chair and independent members of the Board agreed to step down, and a number of direct appointments were immediately made to ensure board stability.

This is the first quarterly report that has been produced since the health board was placed in special measures and this sets out the progress made during the last three months and sets the priorities for the next 90 days.

‘Special measures’ is the highest level of escalation in the NHS Wales escalation and intervention framework. A special measures framework has been agreed with the health board which sets out eight domains for improvement.

These domains incorporate all the areas of concern that resulted in the special measures status. Each of these will receive directed intervention, support and de-escalation planning.

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 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, which are:

• discovery
• stabilisation 
• standardisation
• sustainability

This report sets out the progress made against each of the eight domains during the discovery stage of special measures between March and May 2023.

The first three months has focused upon understanding in greater detail the issues that underpin the rationale for special measures and developing solutions.

Quality and safety

The health board has two Services Requiring Significant Improvement (SRSI) as designated by Healthcare Inspectorate Wales (HIW):

• Emergency Department at Ysbyty Glan Clwyd
• Vascular Services

Independent advisors

Following the escalation to special measures, the minister took immediate action to appoint a number of Independent Advisors (IAs) to support the Board. Details of these are at Annex 1.

Two operational support posts have been appointed to work directly with the health board, one of whom is co-ordinating a small team to focus on orthopaedics, and the other to support the health board with operational controls commencing with eliminating over four-hour ambulance handovers.

All appointments have been direct appointments either through the NHS Wales Executive or through an NHS organisation where the individual already had an employment contract. The contracts are initially for six months and vary between four and eight days a month.

The independent advisors meet with officials from Welsh Government and the health board.

Governance, board effectiveness and audit

Appointments have been made to the Chair of the health board and six Independent Members (IM) are in post. Details of these can be found on the Betsi Cadwaladr University Health Board website.

Confirmation of nominations expected for the trade union IM in the next 90-day cycle. The main board has met twice. There have been a number of workshops around planning and special measures. Committees took place during May 2023.

Five IAs have been appointed to work across the special measures domains, including board effectiveness and developing the organisational response to the Audit Wales review of board effectiveness. Discussions are in place for further appointments to support mental health, planning and stakeholder management. Changes have been made in the Office of the Board Secretary. 

Carol Shillabeer was appointed as interim Chief Executive on 2 May and will lead the organisation, on secondment from Powys Teaching Health Board. The process for recruiting a permanent Chief Executive started in March 2023 and is ongoing.

Clinical governance, patient experience and safety

An interim assessment in relation to concerns around Betsi Cadwaladr University Health Board affiliated patient safety which were previously made under protected disclosure has commenced. Rapid reviews are taking place in response to issues raised by HM Coroner and the Public Services Ombudsman. A programme of new reporting and learning processes has been agreed and is being implemented across the organisation.

Workforce and organisational development

Terms of reference for a rapid review of executive team portfolios developed and this will commence during the next 90-day cycle. An establishment review is underway, led by the interim director of Finance. A scoping programme to assess the effectiveness and implementation of the new operating model is underway. Workshops with local medical committees and local staff-side partnerships are being arranged. A clinical leadership conference of senior medical leaders was held in April 2023. A review of wellbeing, engagement and workforce policies underway, to be completed within the next 90-day cycle.

Clinical services

An independent mental health inpatient safety assessment took place in April to provide assurance and actions with regard to the mental health estate and action planning. 

The Royal College of Psychiatrists has commenced a review of previous mental health reviews to determine the extent to which the previous recommendations have been embedded and completed.

There has been ongoing oversight on vascular services. An independent assessment against the vascular plan will be undertaken by the Wales National Clinical Network.

A harm review is being undertaken on long waiting patients on the dermatology/plastics pathway and standard operating procedures for this in-reach service are being developed.

Compassionate leadership and culture

A preliminary review of cultural leadership is being led by Health Education and Improvement Wales (HEIW) alongside the health board workforce and organisational development team to assess the current situation and agree the next steps.

Financial governance and management

The domains and content of the Financial Governance and Management section of the Special Measures Framework have been agreed, and forms part of a Special Measures Finance Action Plan.

The content of the framework will focus prospectively on:

• 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
• implementing priorities associated with the financial control environment

The health board has developed a financial control action plan in response to the findings of the Ernst and Young report and an Audit Wales report. Delivery of this will form part of the special measures framework.

Additional focus areas have been identified which require further review which will be developed and implemented including a review of contract management.

Planning and service transformation

Draft annual plan submitted, areas of opportunity highlighted and revised plan for submission before the end of June. A Board workshop was held to understand the challenges and options.

A review of the planning function will be undertaken. Terms of reference for this work are under development.

Operational delivery

The Welsh Government has commissioned direct support, which is embedded within the health board and NHS Wales Executive for urgent and emergency care and orthopaedic delivery. A number of workshops held on both the orthopaedic and longer-term regional treatment centre business cases.
 

• Support for the Office of the Board Secretary.
• Rapid review of the Office of the Board Secretary.
• Review of interim appointments.
• Scoping work to understand further patient safety issues.
• Review of mental health reviews.
• Mental health inpatient safety assessment.
• A programme of work to develop a sustainable orthopaedics service.
• A programme of work to eliminate four-hour handover waits.
• Vascular service assurance assessment.

• 28 February 2023, targeted intervention meeting, repurposed as special measures intervention meeting.
• 15 March 2023, meeting Minister for Health and Social Services and chair of Betsi Cadwaladr University.
• 22 March 2023, integrated quality, planning and delivery meeting and special measures touchpoint.
• 29 March 2023, mental health review meeting, Deputy Minister for Mental Health.
• 3 April 2023, ministerial special measures forum, chair and deputy CEO, Betsi Cadwaladr University.
• 3 April 2023, meeting with Minister for Rural Affairs and North Wales, and Trefnydd.
• 21 April 2023, integrated quality, planning and delivery meeting and special measures touch point.
• 3 May 2023, ministerial special measures improvement forum, chair and interim CEO.
• 4 May 2023, workshop, Welsh Government / Independent Advisors / Betsi Cadwaladr University Health Board.
• 5 May 2023, assurance summit, Ysbyty Glan Clwyd Emergency Department.
• 22 May 2023, meeting Minister for Health and Social Services and chair of Betsi Cadwaladr University.
• 26 May 2023, special measures assurance board.
• Fortnightly meetings, Vascular.
• Three-weekly meetings, Plastics.
• Monthly meetings, Cancer.

The Board and the Welsh Government have agreed the following priorities for the next 90-day period:

Governance, board effectiveness and audit

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 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.
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.

Clinical governance, patient experience and safety

5. Ensure that there is an effective procedure/process for learning from incidents, and that preparations for inquests and Health and Safety Executive (HSE) hearings are clear and effective.
6. Agree, support and enable the review of patient safety care. 
7. Work with NHS Wales Executive as they undertake a review of clinical governance. 
8. Review mechanisms for clinical engagement, drawing up recommendations for improvement.

Workforce and organisational development

9. Support and enable a review of executive director portfolios. 
10. Resolve outstanding respect and resolution cases including similar processes related to senior leadership. 
11. Support and enable a review of interim appointments; implement recommendations.

Clinical services

12. Implement the recommendations from the mental health inpatient safety assessment.
13. Agree mental health strategy, agree and commence implementation a Child and Adolescent Mental Health Services (CAMHS) and neurodevelopment action plan to improve performance and improve CAHMS performance.
14. 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. 

Compassionate leadership and culture

15. Working with Health Education and Improvement Wales (HEIW), consider options, agree and commence a programme for executive team and senior leadership development.
16. 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.

Financial governance and management

17. Stabilise the finance team and address capacity concerns.
18. Implement the financial governance action plan in response to the findings of the Ernst and Young report and other concerns.
19. Commence delivery of an agreed efficiency savings plan and improvements to the financial plan that minimises the financial deficit in 2023 to 2024.
20. Commence an assessment of the potential financial opportunities for 2024 to 2025 and 2025 to 2026 and develop the contribution of value-based healthcare.
21. Implementing priorities associated with the financial control environment such as contract management.

Planning and service transformation

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

Operational delivery

24. Improve access and experience as measured by elimination of 52 week waits at first outpatient stage, zero 156 week referral to treatment waits, zero four-hour ambulance handovers and increased 4 and 12 hour emergency department waiting times performance.
25. Recommence the planned care programme with clear executive oversight.
26. Develop a plan for improving access to orthopaedic care and reducing waiting times for patients.
27. Develop a plan for data/digital which delivers easily accessible data for frontline staff including dashboards for patient safety, quality and experience.

Alan Brace OBE has been both a finance director and a chief executive officer in a number of health bodies in Wales. In 2016, he was appointed as the director of finance of the Health and Social Services Group in Welsh Government, the post he held before retirement in 2021. In September 2018, he was made an honorary professor in Swansea University School of Management.

Susan Aitkenhead has extensive clinical, operational, governance and strategic experience in delivering healthcare across a variety of settings and sectors. She has held both provider and commissioning executive and non-executive board roles within the UK and overseas. Susan has also worked in a variety of national policy roles such as at the Department of Health in England providing advice and support to ministers and officials across central government departments, at NHS England and NHS Improvement, where she was deputy Chief Nursing Officer (CNO), and in professional regulation at the UK Nursing and Midwifery Council. More recently, Susan independently chaired a multi-professional Vascular Quality Review Panel which was set up in response to findings from a previously undertaken Royal College of Surgeons’ invited service review at Betsi Cadwaladr University Health Board. 

Dr Graham Shortland OBE, Bachelor of Medicine, Diploma of Child Health, Fellow of the Royal College of Paediatrics and Child Health was the executive medical director and board member at Cardiff and Vale University Health Board between June 2010 to April 2019 and was responsible for significant strategic developments and services improvements during that time. Subsequent to his retirement from the medical director post, Graham has advised NHS Employers as part of the Senior Negotiating Team for England, Wales and Northern Ireland that successfully negotiated the new specialist, associate specialist, and specialty doctor contract with the British Medical Association. He has conducted a review as external expert, with a senior paediatric colleague for a children’s hospice to advise on future strategy and conducted and chaired, a review for a large NHS Wales university health board into its process of mortality reviews during COVID. 

David Jenkins was appointed General Secretary of the Wales Trades Union Congress in 1983, a position he held for twenty-one years, during which time he also served on a number of public bodies including the Welsh Arts Council, the Monopolies and Mergers Commission, the Employment Appeal Tribunal, the Welsh Industrial Development Advisory Board and the National Disability Council. David retired from his position as General Secretary in 2004 and was appointed by Welsh Government as chair of Health Professions Wales from 2004 to 2006 and as chair of the National Leadership and Innovation Agency for Healthcare in Wales from 2006 to 2009.  

Geraint Evans is a former executive director of Workforce and Organisation Development at Aneurin Bevan University Health Board. Geraint has extensive experience of leading strategic change and workforce transformation at board level in the NHS, local government and the private sector.