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Stabilisation phase - cycle 3

To facilitate improvements whilst in special measures, a number of stages have been agreed. The discovery phase ended in May and the health board is now in the second phase of special measures which is stabilisation. This is made up of three cycles and the third cycle will commence on 1 December 2023. This paper sets out Welsh Government expectations for the third cycle within standardisation. 

Welsh Government will review progress made throughout the stabilisation phase of special measures and assess whether the organisation is ready to progress to the standardisation phase of special measures.  

The Special Measures Framework sets out the reasons Betsi Cadwaladr University Health Board was placed in special measures on 27 February 2023. These relate to serious concerns about board effectiveness, organisational culture, service quality and reconfiguration, governance, patient safety, operational delivery, leadership and financial management. 

The framework sets out in some detail the improvements expected between March and December 2023 alongside the five outcomes for the stabilisation phase of special measures.

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 frameworks now embedded within the organisation, supported by numerous corporate improvements. The health board is focused on building upon these to ensure they are embedded, resulting in sustainable improvements. 

The following external reviews have concluded, and reports are being drafted 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 assurance assessment of the inpatient mental health units
  • quality assurance and support
  • Board effectiveness follow up review undertaken by Audit Wales

It is really important that we start to see some of the outcomes and impact of the work undertaken in delivering real improvements and outcomes to patients and staff, that quality and safety process start to improve and waiting times in urgent and emergency care departments and for elective care start to improve.

Cycle 3 – Welsh Government expectations 

Governance, board effectiveness and audit

1.    Complete the recruitment of a permanent board, ensure that board inductions are undertaken and effective, and commence the board development programme.

2.    Develop and start to implement a clear action plan in response to the recommendations of the office of the board secretary review, including the agreement of a clear and transparent forward plan for committee business supported by standard operating procedures.

3.    Agree an effective scheme of delegation, that sets out the framework for delegation, decisions and accountability.

Clinical governance, patient experience and safety

4.    Ensure that effective procedure/process for learning from incidents, patient and staff feedback, inspections, internal audit and reviews, and begin to embed learning across the organisation.

5.    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.

6.    Develop 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.

Workforce and organisational development

7.    Develop and start to implement a clear action plan in response to recommendations from the review of interim appointments, executive team portfolio review and HR processes report – with an early focus on building sufficient capacity in the workforce team to deliver the plans. 

8.    Implement the learning and development framework.

9.    Continue to resolve outstanding respect and resolution cases including similar processes related to senior leadership. 

10.    Remove the systematic reliance on agency interims.

Compassionate leadership and culture

11.     Start to implement a programme of work focussed upon culture, compassionate leadership, values and behaviours and engagement with a practical focus on driving change. 

12.    Continue and embed the agreed approach to build trust and confidence within the organisation and with stakeholders, including the establishment of an effective mechanism for monitoring and improving staff engagement.

Clinical fragile services

13.    Commence implementation of a CAMHS and neurodevelopment action plan to improve performance.

14.    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.

Financial governance and management

15.    Continue to strengthen and stabilise the finance team with a focus on the senior finance team.

16.    Continue to deliver against the key priorities set out in the special measures finance plan.

17.    Continue to identify and deliver actions to make progress towards the target control total set out by Welsh Government. This includes strengthening delivery and accountability mechanisms for delivering savings of a cross-cutting nature within the organisation.

18.    Develop financial plan for 2024 to 2025.

19.    Implement agreed actions and findings from contracting and procurement review.

20.    Undertake a maturity assessment of financial governance grip and control in light of changes implemented through the special measures process with a view to considering if further independent review is required.

Planning and service transformation

21.    Submit a board-approved plan on time, supported by an effective workforce plan in place that will support the health board to deliver the plan in an agile and effective way. 

22.    Develop an approach to address the recommendations in the planning review, having commenced delivery of those most urgent.

23.    Have in place a comprehensive winter resilience plan which is delivered throughout the cycle. Ensure there are robust alternatives to emergency departments across the region. Take ongoing actions to ensure improvements across the three emergency departments with a clear focus on Ysbyty Glan Clwyd. 

24.    Commence a process with agreed timescales for the development of a clinical services plan.

25.    Ensure there are robust mechanisms in place to deliver the requirements of the orthopaedic business case, whilst ensuring existing sites operate against the agreed operating model and that productivity and activity levels are maintained.

Operational delivery

26.    Improve access and experience as measured by improvement in 52 week waits at first outpatient stage month on month, zero patients waiting over 156 weeks for treatment, zero 4-hour ambulance handovers and improved 4- and 12-hour emergency department waiting time performance.

27.    To adopt and implement many elements of the national programmes to ensure sustained and effective operational improvement. This will include as a minimum:

  • Embedding the principles which link the primary care and secondary care interface to reduce conveyance, admission, and drive LOS reductions.
  • Patient flow model work – launched – needs rollout across all 3 ED and aligned to pathways of care delay reductions.
  • Full embedding of SDEC/UPCC – alongside the work to support people in the community.
  • To review the capacity and demand in each service and start to embed a clinical operational delivery plan for all challenges specialities. 
  •  Implementation of health pathways, GIRFT recommendations and theatre productivity. 
  • Deliver enhanced community service provision to support older patients in the region .

Special measures monitoring

Welsh Government will use the following meetings to monitor performance against the special measures framework.

Integrated Quality, Planning and Delivery Meeting (IQPD) meetings

  • IQPD meetings are scheduled monthly (apart from when there is a JET meeting). They are chaired by the Deputy Chief Executive of NHS Wales or their nominated deputy.
  • They are used to assess performance against agreed trajectories, consider the overall quality and safety of services and to undertake deep dives on specific topics.
  • They will include a monthly check-in on special measures. Whilst this will predominately focus on operations and performance, other issues will be reviewed as appropriate.

Joint Executive Team (JET) meetings

  • The JET meetings take place twice a year, chaired by Chief Executive of NHS Wales.
  • They will be used to scrutinise quality, planning, delivery and performance including assess the overall performance of the organisation against national requirements, its IMTP/annual plan and any accountability conditions.

Other meetings 

  • Challenged services across the health board are subject to a monthly review meeting. Currently these focus on cancer, ophthalmology, planned care, vascular services and plastics.
  • They will be used to scrutinise quality, planning, delivery and performance including recovery plans, trajectories and serious incidents.

Special measures meetings

  • The Minister for Health and Social Services chairs a bi-monthly special measures improvement forum.  
  • The Deputy Minister for Mental Health and Wellbeing chairs a quarterly meeting with the health board to seek assurance on mental health.
  • The Chief Executive of NHS Wales chairs a quarterly special measures assurance board.

Meeting schedule

Joint executive team meeting - 05 December 2023

Integrated quality, planning and delivery meeting - 15 December 2023

Minister review meeting with the Chair - 18 December 2023

Cancer performance assurance meeting - 19 December 2023

Joint Ministerial Special Measures Improvement Forum - 17 January 2024

Monthly planned care touchpoint meeting - 18 January 2024

Integrated quality, planning and delivery meeting - 19 January 2024

Minister review meeting with the Chair - 24 January 2024

Cancer performance assurance meeting - 25 January 2024

Special Measures Assurance Board - 07 February 2023

Integrated quality, planning and delivery meeting - 19 February 2023

Minister review meeting with the Chair - 21 February 2023

Vascular touchpoint meetings - monthly

Plastics touchpoint meetings - monthly 

Ophthalmology assurance meetings - monthly