Betsi Cadwaladr University Health Board special measures (level 5): progress report July to September 2025.

On 27 February 2023, the escalation level of Betsi Cadwaladr University Health Board was raised to special measures (level 5). This was in response to significant concerns about governance, leadership, and performance.

This is the eighth progress report to be published since the escalation to special measures. These reports set out the progress made by the health board and the outstanding challenges. The special measures framework for Betsi Cadwaladr University Health Board sets out the improvements required.

The organisation continues to build on the changes and improvements it has made since the escalation to special measures in respect of corporate governance, executive, clinical and board leadership, improving quality and safety, enhanced financial grip and control and renewed patient and stakeholder engagement.

However, the expected improvements in operational delivery are not yet being realised. The special measures improvement plan set a clear expectation that the overall size of the waiting list and the number of long patient waits for planned care would be substantially reduced, bringing them back to pre-pandemic levels. It is also expected that the health board will tackle the large number of outstanding outpatient appointments in the most challenged specialities and take action to improve waiting times for urgent and emergency care services. This is a priority for the health board as it has by far the largest proportion, and the longest waits, in Wales.

The health board is leading the way in many areas across Wales including:

• Renal patients at Ysbyty Gwynedd and Ysbyty Alltwen will benefit from new specialist machines to help clinical teams measure and assess patients’ fluid levels and body composition with greater precision, improving comfort, safety, and long-term health outcomes.
• The ultrasound-guided carpal tunnel release service at Wrexham Maelor Hospital is the first service of its kind in Wales. It offers faster recovery, lower costs, and better patient outcomes without the need for a traditional operating theatre.
• The North Wales Cancer Treatment Centre at Ysbyty Glan Clwyd has been re-designated as a centre of excellence for brain tumour research, treatment, and care by the Tessa Jowell Brain Cancer Mission.
• A new radiology system has significantly improved scheduling and clinical reporting for medical images such as x-rays, CT scans, MRI scans, and ultrasounds.
• 3 health board teams have been shortlisted for the NHS Wales Awards, including the Welsh language team for their work to promote bilingual services on hospital wards.
• Ysbyty Gwynedd’s theatres open day welcomed more than 70 attendees for a behind-the-scenes experience, showcasing the work of the hospital’s surgical teams and the cutting-edge technology that supports patient care.
• The Welsh Government has invested £9.49 million in 2 new linear accelerators at the North Wales Cancer Treatment Centre at Ysbyty Glan Clwyd. These will deliver more precise and efficient radiotherapy, targeting cancer cells accurately and reducing harm to surrounding tissue.
• Following £4.4 million Welsh Government investment, Colwyn Bay Hospital and Ysbyty Glan Clwyd will see older x-ray machines replaced with new digital radiology systems. Wrexham Maelor and Ysbyty Gwynedd will receive new fluoroscopy systems and see their mammography equipment replaced.

There have been some recent changes to the board. Sir Paul Lambert has been appointed as the independent member to lead on finance and will also chair the health board’s audit committee. Peter Lewis has taken on the role of chair of the stakeholder reference group and represents the group as an associate member on the board.

The recruitment of substantive executive director roles continues. Interviews for the executive director of people and organisational development take place in October 2025. Dr Clara Day joined the health board as executive medical director at the end of September 2025. Only one interim executive director appointment remains.

A board development session was held in August 2025, two-and-a-half years after the new board was established. This was an opportunity to reflect on progress made around governance, culture, financial management and quality. The board focused on the one-health-board approach and agreed the longer-term strategic intent is to promote early intervention and community-based health and well-being, alongside the sustainable development of services to serve the needs of local communities.

The Foundations for the Future major change programme, which is currently underway, is designed to align structures, people, systems, processes, culture, and strategy. It aims to respond to the operational challenges, and build a cohesive, agile, and sustainable organisation.

The Board is focused on listening to patients, staff and citizens. Feedback remains consistent, there is an emphasis on the impact of long waiting times and variation in access across the health board; challenges in navigating and communicating with the system; the importance of compassion and dignity; and the need to address the specific challenges faced by women, young people, people with dementia, and other vulnerable groups.

In response to the feedback, the board has introduced:

• New models of care in response to complaints about long surgical and radiotherapy waits. This includes hand and nerve surgery in minor operating rooms; ultrasound-guided carpal tunnel release and a new IV access service. More than 300 procedures have been delivered outside theatres; the carpal tunnel release cost has reduced from around £2,100 to £760 per case and IV waits have fallen from weeks to the same-day.
• A proactive “while you wait” text messaging service, a virtual chat function, and a new “self-care while you prepare” hub to support people while they are on a waiting list. This has helped reduce missed appointments.
• Two specialist bereavement nurses have been appointed to ensure families have access to compassionate, structured support at the most difficult times. This is in response to concerns about end-of-life care and dignity.

Work continues to embed quality into all health board activities. Central to this is the development of the health board’s quality management system (QMS), which was tested earlier this year. The QMS is built around four key pillars, quality planning, quality improvement, quality control, and quality assurance, which are being integrated into core frameworks and processes.

The health board has made improvements to its management of governance in relation to learning from events reports. Robust systems are now in place for tracking and oversight of learning from events reports, resulting in improved claims and redress processes. These improvements strengthen governance, transparency and accountability across the organisation.

There has been a continued focus on improving processes and systems in response to complaints. This is supported by the integrated concerns policy for incidents, complaints and mortality reviews, which was approved by the board in July 2024 and the integrated concerns hub which was operational from September 2024.More than 79% of complaints are closed within 30 days and, the health board has consistently achieved the 75% closure rate for complaints within 30 days since November 2024. The average time to provide a complaint response is 19 working days, an improvement compared to 59 working days in April 2024. The remaining complaints are complex and often multi-faceted or multi agency-related complaints which take longer to investigate and resolve.

The health board has undertaken a thematic review focused on never events, bringing together professionals from all disciplines to collectively examine the underlying factors and identify meaningful improvements. This has supported a comprehensive analysis of practices and resulted in actions to improve patient safety.

The NHS Wales people’s experience survey was launched in April 2025. By the end of September 2025, the health board had received 36,548 responses; of these, 68% rated their overall experience as “very good” and 86% reported they were always treated with dignity and respect, and 90% of respondents reporting they were ‘always’ able to communicate in their preferred language.

In June 2025, Healthcare Inspectorate Wales (HIW) published a report following an unannounced inspection of Ysbyty Gwynedd’s maternity services. Another report following the unannounced inspection of Ysbyty Gwynedd’s emergency department was published in July 2025. HIW has confirmed the health board took the appropriate actions to address the immediate issues raised.

Fragility, quality and consistency of service delivery continue to be of real concern across a number of services, including vascular, urology, orthodontics, ophthalmology and dermatology. Good progress has been made in some, including plastics and oncology.

Improvement plans are in place for each of the identified fragile service areas, supported by a regular review cycle to ensure timely and effective action. 

Board committees have maintained oversight and provided support including:

• Vascular: The board agreed to formally commission all emergency and elective open abdominal aortic aneurysms (AAA) repairs from the University Hospital North Midlands (UHNM) from November 2024. UHNM has offered honorary contracts for vascular surgeons wishing to participate in AAA procedures. Work is underway to develop and transform local pathways of care. In April 2025, HEIW notified the health board it will not be placing foundation year one (FY1) doctors in the vascular surgery department in Ysbyty Glan Clwyd from August 2025. This follows concerns about working, culture and supervision arrangements in the department. A detailed improvement programme is being implemented to strengthen the quality of support and training. A satisfaction questionnaire has been sent to the outgoing FY1s to understand their experiences in the vascular department and identify any further areas for improvement.
• Mental health: A business case is being developed to replace the Ablett Unit, in line with the revised cost envelope agreed with the Welsh Government. It will be submitted in early 2026. The leadership and management of mental health services in North Wales has been strengthened over the last two years through the appointment of a substantive director of mental health and learning disabilities, a medical director for mental health and learning disabilities, an executive director with responsibility for mental health and a consultant nurse for dementia.
• Ophthalmology: Progress is being made to improve waiting times for cataract surgery but the total number of people who are overdue for their clinical follow-up date for eye care conditions continues to increase, as does the risk of harm in this group. The health board has started a programme of reviewing follow-up lists to identify those people at greatest need and has introduced new glaucoma and medical retina pathways through primary care providers. See-on-symptom (SOS) and patient-initiated follow-ups (PIFU) are also being introduced. There has been improved pathway work with community optometrists and successful ongoing implementation of cataract referral refinement to enable effective streaming to high volume, low complexity pathways.
• Urology: A contract is now in place for North Wales patients to receive cystectomies at Arrowe Park Hospital, bringing services back closer to home, providing greater stability and improved patient experience.
• Oncology services have strengthened through additional recruitment of two permanent medical oncologists and one fixed-term clinical oncologist, and ongoing international recruitment of specialty doctors. Service innovation includes the transition of some treatments from intravenous to subcutaneous delivery which releases capacity and improves patient experience. September also saw the opening of the new Maggie’s Centre at Ysbyty Glan Clwyd, the first centre of its kind in North Wales.
• Orthodontic services remain under significant pressure due to recruitment challenges. As part of mitigation, diversification of the workforce is underway with dental nurses being trained as orthodontic therapists and increasing options for Dentists with Special Interests.

Betsi Cadwaladr University Health Board remains an outlier in Wales in terms of planned care and emergency care. While there has been some progress, greater focus and action is needed to ensure people in north Wales receive timely access to services.

The health board has received £15.7 million to support improvements in planned care in 2025-26. This includes funding to support reductions in total waits, outpatient waiting times, cataract and diagnostic waits. There have been some signs of progress in reducing the longest waits, which saw a reduction of 44% between December 2024 and March 2025, but that rate of improvement has not been maintained. At the end of July 2025, there were 5,399 pathways waiting more than 104 weeks across 15 specialties.

Betsi Cadwaladr University Health Board has the longest planned care waits in Wales and must urgently make improvements to its planned care performance.

To accelerate improvements, the health board is using its additional waiting times resources to commission external capacity in outpatients, cataracts, dermatology, urology, neurodevelopment and diagnostics. These services are maintaining continuity of care while sustainable models are developed. The health board has also mobilised a major change programme to make sustainable, systematic improvements across the organisation, applying the organisational design principles to simplify, streamline and standardise best practice. A new approach for pre-operative assessment is in the pilot stage and will soon be extended across the organisation. This will streamline processes, enhance patient experience and enable improved theatre efficiency and productivity.

The health board has historically reported strong cancer performance, but over the past 18 months this has not been maintained, the latest figures show 55% performance against the 62-day suspected cancer pathway target.It is taking a range of actions to improve cancer performance, including additional endoscopy capacity, a dermatology insourcing contract, waiting list initiatives and recruitment to key roles to improve the capacity and resilience of challenged tumour sites. The health board must take urgent action to improve cancer performance.

Emergency department performance at hospital sites in North Wales remains a significant challenge. We have been clear about our expectations for improvement.

The health board’s performance against the four-hour emergency department waiting time target fell to 57.6% in August 2025, this was 7.7 percentage points worse than performance in August 2024 and 3,985 people waited more than 12 hours in the emergency department, 835 (27%) more than in August 2024.

In August 2025, Ysbyty Glan Clwyd reported the worst four-hour emergency department waiting time performance of any Welsh emergency department, with just 34.2% of people admitted or discharged within four hours. It also reported its third highest recorded number of 12-hour emergency department waits that month.

The board’s September meeting included a deep dive into urgent and emergency care, concluding the current position is in crisis. It highlighted the need to find immediate solutions to end long ambulance patient handover delays, corridor care, clogged emergency departments and delays in discharging patients.

A “short-term plan" to halve the number of people in its hospitals who are experiencing delayed discharges and are waiting to be signed off and return home is being developed. In the longer-term, the goal is to create a single operating model for emergency departments across the region, replacing the current three-site model with each doing things differently.

The discharge lounge at Ysbyty Glan Clwyd has been improved to become a discharge hub to accommodate people for up to 24 hours, helping to manage the flow of patients through the hospital and reducing unnecessary delays for people who are ready to go home. The hospital’s medical day unit has been moved to a larger ward, helping to reduce hospital admissions and relieve pressure on the emergency department. 

In each of the last four years, £3 million in six goals funding has been provided to the health board to improve urgent and emergency care. This has been used to deliver urgent and emergency care improvements, including:

• same day emergency care services which are seeing more than 1,500 patients a month with more than 80% being discharged without needing a hospital stay
• introduction of a system escalation hub to improve the focus on early hospital discharge

It will receive a further £2.7 million this year to deliver its local improvement plan aligned to national priorities including:

• effective community-based falls response services
• a robust single point of access for all urgent and emergency care patients to support more people in the community
• actions described in the optimal hospital flow framework to ensure people are discharged home when clinically ready, with the right support and without delay

Performance against the adult mental health measures remains stable. In June 2025, 81.7% of assessments were completed within 28 days and 79.6% of interventions started within 28 days of assessment, against the 80% target.

Performance against the mental health measures for under-18s has improved, with 98.6% of assessments completed within 28 days in June 2025. The percentage of interventions started within 28 days of assessment has increased to 50.7% in June 2025, this is below the target of 80% and must improve.

There has been an increase in the number of people open to adult learning disabilities services with a valid annual health check. These have increased from 281 in January 2025 to 324 in July 2025. The health board continues to work towards improving this position. 

The child and adolescent mental health services (CAMHS) enhanced crisis model reports improved outcomes for children and young people, with a 30% reduction in paediatric hospital admissions and 70% reduction in section 136 presentations with improved liaison out of hours in 2024 to 2025 compared to the previous two years and a 31% reduction in unscheduled admissions to paediatric wards in acute hospitals.

Neurodiversity continues to pose significant service challenges, with high demand outpacing capacity. However, the health board has eliminated waits of more than four years for children and has received further Welsh Government funding of £2.8 million to eliminate three-year waits for children’s neurodevelopmental assessments by March 2026.

The health board directly manages 12 general practices and has a large number of single-handed practices. A priority for this year is the development of the primary care same-day offer to provide more equitable access to primary care as an alternative to people seeking care at emergency departments. The health board must also progress the strategic approach to a mixed model of primary care; implement the new GMS contract assurance framework and improve board visibility of primary care performance data.

The health board reported a year-to-date deficit of £13.6 million at the end of August 2025, which includes £2.8 million in undelivered savings and £1.8 million for employers’ National Insurance contributions.

The health board has made improvements to its integrated strategy and planning approach, including the commencement of its 10-year strategy and clinical services plan and the creation of a clinical services planning framework.

In May 2025, the board approved the process and timeline for a formal service review and options appraisal to develop long-term, sustainable service models following the temporary closure of inpatient beds at Penley and Tywyn community hospitals. It has undertaken targeted engagement with patients, staff, community representatives, and local stakeholders to inform decisions about future service models for these sites. Feedback has highlighted the importance of local access, community-based provision, and clear communication about change.

At its meeting in September, the board approved phase one of the plan for the transformation of the Royal Alexandra Hospital for submission to the Welsh Government. A new planning application was submitted to Denbighshire Council on 26 September 2025 and full planning permission is forecast for November 2025. If all approvals are granted, building would commence in the first quarter of 2026 to 2027. A programme of refurbishment and improvement works to the existing main Grade II listed Royal Alexandra Hospital building are planned to go ahead separate to these new building proposals as part of the second phase of the scheme.

This report reflects the considerable improvements made across the health board including leadership, governance, clinical quality, and financial management since the escalation to special measures. Foundations for the Future will ensure the health board moves to implement a new operating model which will improve performance and build the necessary foundations for sustainable, system-wide improvement.

However, significant and urgent improvement is still required to ensure the people of North Wales have timely access to planned care and emergency care services.