Quarterly report: BCUHB special measures - stabilisation phase - cycle 2

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 (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 third progress report since the health board was placed in special measures. The first two reports set out the progress made over the first six months of special measures arrangements and this report sets out the progress made during the last three months. The priorities for cycle 3 are published xxxxxx

Background

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

Purpose of this report

This report sets out the progress made against each of the eight areas during the most recent cycle of special measures, between September and November 2023. 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. 

Special measures oversight

The Minister for Health and Social Services chairs a bi-monthly special measures improvement forum with the integrated Board, which the Deputy Minister for Mental Health and Well-Being also attends. This allows Welsh Ministers to ensure 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 uses these meetings to assess progress against the chair’s objectives. The Deputy Minister for Mental Health and Well-Being chairs a quarterly meeting about mental health with the health board.

The Director General of Health and Social Services and NHS Wales Chief Executive, chairs a quarterly special measures assurance board to review progress against the priorities in each 90-day cycle.

There are a number of health board and Welsh Government meetings in place to track progress, including, but not limited to, monthly cancer and eye-care meetings, a monthly Integrated Quality and Delivery Board, a Joint Executive Team meeting twice a year, finance, quality, planned and unscheduled care touchpoints on a regular basis.

The Minister for Health and Social Services has visited a number of sites in the health board during the period of this report, including the Royal Alexandra Hospital, Abergele Hospital, Dolgellau and Barmouth Hospital, a primary care medical centre and a pharmacy in Rhyl. The First Minister met with the chair and chief executive in North Wales in September.

There continues to be a focus on delivering quality care including:

• People with bowel cancer in North Wales are benefitting from faster recovery following surgery, thanks to the introduction of state-of-the-art robotic technology. Following the successful rollout within gynaecology, general surgeons from across the health board are using the Versius surgical robotic system at Ysbyty Gwynedd for eligible bowel cancer patients.   
• 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.
• A new click and deliver service has been launched to provide access to naloxone, medication that can temporarily reverse the effects of an opioid overdose. 
• Following positive results in a pilot study at Wrexham Maelor Hospital, a new rapid placental growth factor test (PLFG) for pregnant women with suspected pre-eclampsia has been rolled out across the health board. The new test helps to improve diagnosis, prevent maternal complications, reduce still births and prevent pre-term deliveries.
• Renal staff at Ysbyty Gwynedd are trialling a new service, offering renal dialysis at night. Ysbyty Gwynedd is the only hospital in Wales to offer people their dialysis through the night so they can get on with their day-to-day lives.
• A new free digital app to help create more dementia-friendly environments and support people is now live after being developed and tested in North Wales. The health board worked with the University of Worcester to create the app, which will replace the current paper-based assessment tool used to assess how dementia-friendly care environments are.   
• Since launching the 111 Press 2 service in January, 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%.

A review of cycle two was undertaken at the special measures assurance board in November.  It is notable that good progress continues to be made on enabling actions. 

The innovative approach being taken by the Board to increase its visibility and strengthen engagement with communities across North Wales was demonstrated when the Annual General Meeting was held in a community centre in Llandudno. The focus for the AGM was on developments in same-day arthroplasty, mental health crisis services and initiatives in the community such as the Red Bag scheme (helping care home residents with the transfer of health information between hospital and care home).  A community engagement event was also held in Flintshire on 22 November. 

The health board has made some good progress on enabling actions since its escalation to special measures, as demonstrated by the planning, performance and risk management frameworks considered by the Board in its September meeting, supported by numerous corporate improvements. The health board is focused on building upon these to ensure they are embedded, resulting in sustainable improvements. 

However, the improvements related to operational performance and quality and safety are not being made as quickly and effectively as possible. Whilst there are some improvements in these areas as highlighted below, 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.

The following external reviews have concluded during this cycle, and reports are being prepared or have been shared with the health board for consideration by the Board through its 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)
• listening to citizens, patients, staff and partners

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

• A review of vascular pathways between August 2022 and August 2023.
• Follow up external assurance assessment of the inpatient mental health units.
• Board effectiveness follow up review undertaken by Audit Wales.

Five priorities were set for this domain:

1. Consider the recommendations of the office of the board secretary review. Develop and start to implement a clear action plan to enable and support effective governance processes across the organisation.  Agree a clear and transparent forward plan for committee business supported by standard operating procedures that are accessible to all.
2. Mentor and support the Board to ensure it can both constructively challenge and support the organisation in line with the requirements of special measures.
3. Continue the recruitment of a permanent board.
4. Commission and start the delivery of a board development programme. 
5. Agree an effective scheme of delegation, that sets out the framework for delegation, decisions and accountability.

The Board considered the recommendations from the office of the board secretary review in a development session in September and shared its management response at its Audit Committee in November. 

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 play a crucial role in ensuring that the requirements of special measures are delivered.

Work has continued to develop and support the Board. Mike Parry was appointed as the new Associate Board Member, in his capacity as Chair of the Stakeholder Reference Group for BCUHB until 30 June 2024. Gareth Williams has been appointed as vice-chair and Urtha Felda and Dr Caroline Turner have been appointed as independent members until November 2027. Details of the independent members can be found at health-board-members. 

Interviews for a permanent chair took place in November and a pre-appointment Health and Social Care Committee hearing has been scheduled for 24 January 2024.

On 14 November 2023, the health board announced that Carol Shillabeer had been appointed as the permanent Chief Executive.  A new post of Director of Corporate Governance is now in the active recruitment phase. This role will advise the Chair, Chief Executive and the wider Board on all matters relating to Corporate Governance. 

Work on the board development programme has continued and this will be rolled out in cycle 3. The Board now incorporates visits and discussions with clinical and service teams as part of its development. During this reporting cycle, this included:

• Planned care, with a focus on action that will reduce waiting times and improve outcomes and experience for citizens. This included a visit to Llandudno Hospital to see the potential planned care hub.
• Urgent and emergency care department at Ysbyty Gwynedd where members of the Board followed the emergency pathway through the SDEC (same day emergency care) unit, medical assessment unit, and to the discharge unit. Whilst there, the Board heard about the emphasis on staff support which has earned the department the recognition from the GMC survey as the best place to train in the UK.

The health board have undertaken a significant amount of work on a revised SORD and SFIs. These were endorsed by the Audit Committee on the 16 of November and submitted to the Board with a recommendation to approve and adopt on 30 November. 

Three priorities were set for this domain:

1. Develop, agree and start to implement an effective procedure/process for learning from incidents, patient and staff feedback, inspections, internal audit and reviews, and begin to embed learning across the organisation.
2. Consider the recommendations of the review of patient safety concerns, working with the NHS Executive to develop the required clinical governance processes, develop and start to implement a clear action plan in response to these recommendations.
3. Develop and embed an approach and robust procedure to support the implementation of the Duty of Quality utilising the Health and Care Quality Standards to drive continual improvement to meet the needs of the population.

The number of issues raised by HM Coroner and the Public Services Ombudsman remain high and this is very concerning.  A programme of new reporting and learning processes have now been developed and a new standard operating procedure is in place. This has direct oversight from the medical director, with a clear escalation process.

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

A quality roundtable was held with the health board, Welsh Government, independent advisors and the NHS Executive in November to agree key areas of focus.

Three priorities were set for this domain:

1. Consider the recommendations from the review of interim appointments, executive team portfolio review and HR processes report. Develop and start to implement a clear action plan in response to these recommendations – with an early focus on building sufficient capacity in the workforce team to deliver the plans. 
2. Implement the learning and development framework.
3. Continue to resolve outstanding respect and resolution cases including similar processes related to senior leadership. 

The Board considered the recommendations from the review of interim appointments in a development session in September and shared its management response at its Renumeration and Terms of Service Committee in November.

The reliance on interims is reducing. As of 1 October 2023, there were 7 interims on agency contracts, 4 interims on Bank contracts and 2 interims on secondment. This is a significant reduction from February 2023 where there were 32 interims on agency contracts, 6 interims on bank contracts and 1 interim on secondment.

The executive team portfolio review has now been completed and an update on progress against these recommendations will be provided to the November Board. The implementation of the recommendations from these reviews will require considerable focus and action in cycle 3 to ensure that the organisation is structured correctly to deliver. 

A comprehensive leadership development programme has been agreed and includes:

• 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, IHC 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.

Three priorities were set for this domain:

1. Agree and start to implement a programme of work focussed upon culture, compassionate leadership, values and behaviours with a practical focus on driving change. 
2. Implement a programme to stabilise and support the executive team and empower the senior leadership team.
3. Continue and embed the agreed approach to build trust and confidence within the organisation and with stakeholders, including priority community groups.

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.  A behaviours framework will be presented to a future Board meeting for approval.

The initial focus will include understanding the current pervasive culture, consideration of the independent reviews, and development of a comprehensive leadership development programme and approach. The concept of the Leadership Alumni will also be further developed into a clear offer that supports and enables leaders and leadership in practice. The newly established People Committee will undertake a key oversight role of this work.  

The Board has engaged with Michael West, a well-regarded expert on Compassionate Leadership, who led a learning and development session with the Board on 1 December 2023 and will lead a wider Leadership Conference on 14 December 2023. 

Three priorities were set for this domain:

1. Agree a mental health strategy, agree and commence implementation a CAMHS and neurodevelopment action plan to improve performance.
2. Review, revise and implement clear improvement plans including but not limited to vascular (including enabling phase 2 of the vascular review), urology, ophthalmology, oncology, orthodontics, dermatology and plastics.
3. Agree the clinical leadership arrangements for services across the organisation and commence implementation of the clinical engagement proposal.

Further work has been undertaken on the mental health strategy and the CAMHS and neurodevelopment action plan throughout this cycle and this has involved a round table planning event supported by the NHS national leads.

Performance against the various mental health measures for adults continues to improve, with 84% of adults having an assessment within 28 days in September compared to 73.8% in February and nearly 83% having an intervention within 28 days.  Whilst performance for under 18s against parts 1a and 1b of the mental health measure is below target, improvements have been seen when compared to February.

The Board considered the recommendations from the independent mental health inpatient safety assessment in a development session in September and shared its management response at its Quality, Safety and Experience Committee in November.  A further external assessment is planned for January 2024 to assess the extent to which the recommendations have been embedded. 

The review of mental health reviews being undertaken by the Royal College of Psychiatrists is progressing at pace.

An independent assessment against the vascular plan has been undertaken by the by the NHS Executive Vascular Clinical Network. This will be considered by the Quality, Safety and Experience Committee in a closed session in November before a management response is issued.  It concluded that ‘BCUHB vascular service has improved from the previous reviews and in the opinion of the reviewers now provides a much safer service. The vascular surgeons work more collaboratively, with patient management being multi-disciplinary team (MDT) driven.’

Welsh Government has commissioned a vascular case note assessment, this commenced in November and will review a number of patient pathways accessing treatment between August 2022 and August 2023. 

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

Work on the improvement plans for the other fragile services is ongoing, although the final versions have not yet been shared with Welsh Government and there is a real concern that the health board is not responding as quickly as it could to some of the issues these services are facing.

The dermatology service has come under considerable pressure since the summer with an increasing number of vacancies and a reliance on interim and locum staff. This will impact upon both the dermatology and skin cancer performance in the coming months.  An immediate recovery solution has been put in place to ensure the impact on urgent cancer patients is minimised. The Welsh Government has given the health board an additional £200,000 to establish a tele-dermoscopy model which will support faster triaging of patients.

Five priorities were set for this domain:

1. Continue to stabilise the finance team and address capacity concerns.
2. Continue to implement the financial governance action plan in response to the findings of the E&Y report and other concerns. This includes completing and finalising the end of year accounts for 2022 to 2023 and strengthening the financial control environment.
3. Deliver an agreed efficiency savings plan that minimises the financial deficit in 2023 to 2024, understand the drivers behind the financial deficit.
4. Undertake an assessment of the financial outlook for 2024 to 2025 including key cost drivers and opportunities.
5. Undertake the review of procurement and contract management.

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 undertaken and completed which will inform the future finance operating model under future cycles.  Actions are in place to attempt to strengthen the capacity of the senior finance leadership team.

The health board has an agreed special measures finance action plan and a financial control environment action plan with 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. Detailed actions have been captured with Audit Wales on the agreed improvement areas following the 2022 to 2023 accounts process which are included within the special measures action plan to gain assurance on the actions to address those in advance of the 2023 to 2024 accounts process.  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 an increased level of savings plans and delivery, with a material increase in savings forecast delivery with confidence as at month 7.  As with all health boards the organisation is focussed on identifying actions to progress towards target control totals set by Welsh Government. The health board has initiated a review of all investments as part of this process.

The health board has received the draft output of the review of procurement and contract management undertaken by internal audit.  The recommendations will be reviewed by the Performance Finance and Information Governance Committee in December, along with consideration of the outputs and next steps and assurance mechanisms on required actions being considered through the special measures process and action plan.

Four priorities were set for this domain: 

1. Make sustainable progress in delivering the board-agreed annual plan, ensure there is an effective workforce plan in place that allows the health board to deliver the plan in an agile and effective way.  Focus transformation and improvement activity on the areas within special measures to ensure sustainable and effective change.
2. Embed urgent primary care centres as a core strategy for winter planning including immediate proposals for Ysbyty Glan Clwyd and take ongoing actions to ensure improvements across the three emergency care departments with a clear focus on Ysbyty Glan Clwyd.
3. Participate in the Integrated Planning Review and start the process for the 2024 to 2025 annual plan. Develop and commence a process with agreed timescales for the development of a clinical services plan.
4. Agree a future operational model for orthopaedic services.

The independent planning review has been undertaken and the final report is being completed. This will be considered by the Performance, Finance and Information Governance Committee. 

The Integrated Planning Framework was approved by the Board at its meeting in September. The implementation of this framework is now underway, and the active development of a 3-year Plan for 2024 to 2027 has now commenced with a clear timetable through cycle 3. The Board considered and reviewed the progress made in relation to the implementation of the current Annual Plan at its meeting on 30 November. This signals a strengthening of the mechanisms to provide transparency in relation to progress, identifying areas of challenge in delivery and demonstrating the impact of the annual plan priorities for the population.

The Board has also approved a number of frameworks that will act as the foundations of an effective organisation. The implementation of the planning, performance and risk management frameworks is now underway and a continued focus on these areas will continue through the next cycle.

The orthopaedic business case was approved by the Board at its meeting in September 2023. This was then approved by the Minister for Health and Social Services on 23 November 2023.

Two priorities were set for this domain:

1. Improve access and experience as measured by elimination of 52 week waits at first outpatient stage, zero patients waiting over 156 weeks for treatment, zero 4-hour ambulance handovers and improved 4 and 12-hour emergency department waiting time performance.
2. Design an integrated performance framework based upon clear and accurate data and visible dashboards for performance, 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 a first outpatient appointment has fallen by 16.6% between February and September and the numbers with total waits over 104 weeks has reduced by 21.7% in the same period.  

The focus on eliminating 4-hour handovers, whilst not yet achieved, is resulting in some improvements.  There were 621 handover delays in excess of 4 hours in October 2023, this is a 20% reduction compared to October 2022 and considerably better than the 1,042 noted in March 2023.

While the emergency department waiting time target improved in October 2023, when compared to October 2022, they remain a significant challenge.

A strengthened approach by the Executive is being adopted in relation to performance, in line with the Board-approved Integrated Performance Framework. Further work is required to fully implement the framework and therefore this will continue to be developed during cycle 3.