Betsi Cadwaladr University Health Board special measures (level 5): year 2 progress report

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.

The last 2 years have been challenging for the organisation and a period of significant change as it responded to a wide range of issues, including:

• industrial action
• attempts to improve performance and operational grip and control
• ongoing challenges from the current financial environment

The financial context in which the health board, and virtually all other public bodies in Wales, operate continues to be challenging. While the health board still has an underlying financial deficit, which it must address, it has made good progress in relation to financial controls and management since the escalation to special measures.

The special measures framework for Betsi Cadwaladr University Health Board sets out the improvements required, including the areas of concern which resulted in the escalation to special measures. This report looks at the special measures journey, highlighting lessons learned, improvements and challenges identified.

Prior to the escalation to special measures, the health board struggled with ineffective leadership and governance, as highlighted by multiple reviews. The Audit Wales report on board effectiveness (2023) emphasised “dysfunctional board dynamics” and called for immediate remedial action.

A new leadership team, including a chair and 3 independent board members were appointed on a temporary basis in February 2023, while recruitment of a permanent board took place. There is now a full complement of permanent independent board members, including a chair and vice chair in place. An interim chief executive was appointed in May 2023 and was confirmed as permanent in February 2024 following an open recruitment process.

Recruitment has been ongoing to complete the executive director team, and a number of appointments have been made including the:

• Executive Director of Allied Health Professionals and Health Science
• Executive Director of Public Health
• Executive Director of Finance

Appointments have also been made for the:

• Director of Performance and Commissioning
• Director of Environment and Estates
• Director of Corporate Governance
• Chief Operating Officer

The health board incorporated learning from other health boards and launched a refreshed induction programme for independent members in September 2023. In July 2024 it agreed a board development programme, an important step in improving governance practices.

The board has also approved several key documents to ensure compliance and good governance including the integrated performance framework, the risk management framework and the integrated planning framework. More recently, the revised board assurance framework was approved by the board in January 2025.

Governance capacity has been strengthened through structured development sessions. Board meetings are now quorate, with attendance rates exceeding 89% for 2023 to 2024, supporting effective decision making processes.

Work has begun on the organisation’s long term succession and development plan, with the health board’s leadership framework supporting this work. An executive portfolio review has been completed, with initial recommendations implemented and vacant posts are in the process of being filled. A large focus has been placed on reducing the number of interim and agency staff.

The "foundations for the future" major change programme is underway, having completed the discovery phase and is currently in the design phase. This will be a major transformation for the organisation bringing together structures, people, systems, processes, culture and strategy, to address the core issues in how the organisation currently operates.

Prior to the escalation to special measures, corporate governance systems within the health board “lacked coherence”, with significant challenges in compliance with the corporate governance code. Decision making processes were hindered by inadequate information flow, further exacerbating governance inefficiencies. In response, the health board’s special measures action plan established a robust governance framework to address these gaps.

By June 2023, all committee structures had been reinstated, supported by clear terms of reference and enhanced cross-membership between committees to improve oversight. Chairs and vice chairs of all committees were appointed, and work plans for each committee were developed and refined by the end of July 2023. Work plans were formally endorsed at the September 2023 board meeting.

Findings from independent reviews commissioned as part of special measures have been received and discussed by each relevant committee. The majority of actions are now complete.

The 2022 Audit Wales structured assessment identified critical deficiencies, including weak working relationships and inadequate scrutiny of risk and financial management. These issues were pivotal to the decision to place the health board in special measures.

In response to the structured assessment, the health board’s audit committee developed a work plan to address gaps in oversight and compliance. The 2024 Audit Wales structured assessment reported progress in improving corporate governance and other areas, including financial management. Some of the findings from the report included:

Overall, we found that since last year’s structured assessment and our follow up work on board effectiveness, there have been positive developments in some of the health board’s key corporate governance arrangements and progress in recruiting to some business critical senior roles.

However, there remains much to do especially in respect of establishing a stable, cohesive and high performing executive team, developing a longer-term strategy and supporting clinical services plan, and ensuring the health board’s organisational structure and operating model is fit for purpose.

We found that there is now a full cadre of substantive independent members on the board and that board and committee meetings are conducted appropriately and transparently. However, ongoing instability within the executive team, gaps in wider senior leadership structures, and ongoing challenges with the operating model are compromising the health board’s ability to tackle the significant challenges it faces.

We found that while the health board is making reasonable progress in strengthening its systems of assurance, there is more to do in relation to the board assurance framework and ensuring systems of assurance are fully owned and utilised to drive improvements across the organisation.

Board self-assessments, which were carried out in 2022, found gaps in board effectiveness, with insufficient attention to strategic risks and inadequate mechanisms for board evaluation. In 2023, the new board implemented a structured self-assessment process as part of its board development programme. Key themes were prioritised, such as:

• strategy alignment
• risk oversight
• collective performance

Recommendations from these assessments have been actioned through targeted training and revised governance practices.

In September 2023, the board considered its approach to culture, leadership and engagement and made 9 key commitments. These commitments have been progressing and include the development and implementation of a leadership development framework. Three leadership conferences have been held over the last 18 months, as well as the establishment of targeted leadership development programmes for staff at all levels.

Prior to the escalation to special measures, patient and community engagement was inconsistent and lacked a structured approach, limiting public input into board decision making processes. A series of community conversations was launched in 2023, engaging more than 5,000 people in discussions about healthcare services in north Wales. This approach ensures more inclusive engagement with a wide range of communities and is complemented by key themes from patient experience analysis routinely reported to the board to inform service improvements.

A public engagement framework was approved in June 2023, ensuring systematic and inclusive engagement with diverse communities. Patient experience metrics are routinely reported to the board, with themes informing service improvements.

Work to actively involve patients, carers and citizens is ongoing to create a 2 way dialogue between the health board and the local population. This is being led by board members as part of a revised approach to engagement.

The chair and chief executive hold regular briefing sessions with elected members and attend county council meetings and committees across the region in order to support openness and transparency in terms of progress, challenges and opportunities, and to encourage dialogue on the issues that matter most to people.

The 2021 staff survey highlighted low engagement scores, with 48% of respondents feeling undervalued. By contrast, the 2023 survey showed a 12% improvement in staff engagement scores, with notable increases in leadership visibility and wellbeing support. Initiatives such as the "living well, working well" handbook and menopause support programmes have helped to enhance staff wellbeing. The overall staff engagement score is now 72%, close to the all-Wales average of 73%.

The new board identified the importance of the leadership, capability and culture domain, prioritising interventions in this area and leading by example. Whilst this is one of the areas that will take some time to turn around, important work on the leadership development framework and organisational values and behaviours has been prioritised and progress is being made as highlighted by the approval of the values and behaviours framework by the board in November 2024.

In 2023, the health board was dealing with serious legacy issues, including:

• failures to act promptly with the complaints process
• insufficient or ineffective strategic planning and support being undertaken
• the timeliness of health board investigations
• the continued reliance on paper patient records

The health board did not have effective procedures and processes in place to learn from incidents, patient and staff feedback, inspections, internal audit and reviews or to embed learning across the organisation and the number of issues raised by HM Coroner and the Public Services Ombudsman was high. Two services were classed as services requiring significant improvement by Healthcare Inspectorate Wales.

The Welsh Government commissioned a review of patient safety concerns in 2023, and instructed the health board to work with the NHS Executive to develop the required clinical governance processes and implement a clear action plan in response to this review. The board considered the recommendations from this review in a development session in September and shared its management response at its Quality, Safety and Experience Committee in November 2023.

In November 2023, the chief executive commissioned a review of all outstanding cases awaiting inquest. In total, 262 cases were reviewed, and significant learning was identified about how the health board approaches its investigations aligned to the coroner’s observations. This review was completed by spring 2024 and resulted in a new approach to managing and learning from concerns.

The health board has developed a new integrated concerns policy for incidents, complaints and mortality reviews, which was approved by the board in July 2024 and began implementation from September 2024. The new policy introduces a daily virtual concerns hub, where teams meet to share learning, insights and information about investigations, together with new resources to support staff engaged in the investigations process. This brings together all resources needed to help staff work through the steps outlined in the policy.

The implementation of this new approach has improved the timeliness and quality of investigations for complaints and preparation for inquests. It will also ensure the prompt identification, recording and review of incidents and complaints, while also ensuring patients, families and staff are empowered to play a meaningful role in the investigation process.

The health board has also developed a learning repository, which is a knowledge management system that enables healthcare professionals to access, share, and learn from data and insights related to patient safety incidents. The system integrates data from various sources and supports collaborative learning.

During 2023 and 2024, the board worked with the Institute for Healthcare Improvement to develop its approach to quality management. The health board’s quality management system was approved by the board in May 2024 and implementation is underway. A specific emphasis is being placed on quality planning as a core feature for development of specialty plans for fragile services.

During 2022 to 2023, 29.4% of complaints were closed within 30 days, compared to the all-Wales target of 75%. In March 2023, there were 290 overdue complaints, demonstrating a significant backlog and a missed opportunity to respond to the public in a timely and candid manner, and to learn and improve in real time.​ Complaints resolution has shown steady improvement. In October 2024, the health board achieved the 75% target, which has been maintained.

The health board entered a guilty plea in response to a Health and Safety Executive (HSE) prosecution related to the death of an individual on a mental health inpatient ward. It received a sizeable fine.

The HSE has summoned the health board to appear before Llandudno Magistrates’ Court in relation inpatient falls.

In 2024, the Public Services Ombudsman for Wales issued 3 public interest reports.

The number of regulation 28 notices issued to Betsi Cadwaladr University Health Board since January 2023 currently stands at 33. Of these, 6 relate to deaths that occurred after the escalation to special measures. In 2024, the health board received 10 notices, a significant reduction from the 22 in 2023. There has been 1 notice issued so far in 2025.

Inspections undertaken by Healthcare Inspectorate Wales (HIW) have highlighted positive improvements. In February 2022, HIW designated vascular services in north Wales as a “service requiring significant improvement”, it was de-escalated following a review of progress published in June 2023.

In August 2024, following an unannounced inspection at Ysbyty Glan Clwyd emergency department, HIW was satisfied necessary improvements had been delivered against the most significant areas of concern raised in its 2022 inspection report and de-escalated the department from a “service requiring significant improvement”.

An adverse event in November 2024, combined with an alert from the Vascular Society led to the health board taking the decision to temporarily pause direct provision of planned and emergency open abdominal aortic aneurism (AAA) vascular surgery in north Wales. Clinical arrangements have been put in place for people to be treated at Royal Stoke University Hospital until the end of March 2025. Consideration is now being given to the longer-term service model for AAA procedures.

The leadership and management of mental health services in north Wales has been strengthened over the last 2 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. Recruitment for a director of nursing for mental health and learning disabilities is underway.

In May 2023, the Welsh Government commissioned the Royal College of Psychiatrists to provide an external assessment to review the extent to which recommendations from 4 previous reports on mental health services in the health board have been implemented and embedded.

The college found there was good evidence for implementation in relation to 37 out of a total of 84 (44%) recommendations in the 4 external reports. There was some evidence for implementation in relation to nearly half (41) of the recommendations and little or no evidence for 6 (7%) recommendations.

The review was presented to the board in May 2024 and a detailed response plan setting out actions and timescales in response to the review’s findings was approved by the board in July 2024, following engagement with families who had experience of the service.

An expert advisory group has been established to review, check and challenge evidence of progress in relation to these recommendations, which is chaired by a special advisor appointed by the board. The board is receiving six monthly progress assurance reports, the first of which was presented at its meeting in January 2025.

There have been a number of more positive HIW inspections at mental health settings over the past 2 years, which have recognised improvements made since previous inspections.

In August 2024, the health board launched its 3 year plan for 2024 to 2027, which incorporated the agreed special measures priorities.

The 2024 Audit Wales Structured Assessment found:

The health board is planning to develop sustainable long-term organisational and clinical plans. To support this work, it will need to strengthen its approach to planning and ensure plans are achievable.

While there are improvements in the health board’s approach to financial management and delivery of savings, significant challenges remain in terms of spending within budget. The health board was not able to meet its statutory financial duties for 2023 to 2024 despite significant financial assistance from the Welsh Government. The health board is predicting it will achieve its financial control target in 2024 to 2025, this will be challenging and is reliant on making one-off savings.

In December 2024, in recognition of pressures being experienced by all health boards, the Welsh Government allocated a further £11.15 million to the health board, with an expectation that the planned deficit is reduced to £8.6 million for 2024 to 2025. A further £7.3 million was also allocated to support improvements in planned care and diagnostics as part of the Welsh Government’s commitment to reduce the longest waiting times.

The health board has had considerable focus on strengthening financial governance and the financial control environment, including:

• additional oversight by specialist groups, the executive team, and board committees and improved reporting
• a revised scheme of reservation and delegation
• standing financial instructions endorsed
• appointment of a substantive, permanent executive director of finance
• head of financial governance role created to support sustainable improvements in financial governance, addressing issues identified in the Ernst Young report and leading to an unqualified opinion on the latest annual accounts
• a clear understanding of the underlying deficit position, incorporated into the 3 year plan
• implementation of the recommendations from the contract procurement management review, including rolling out procurement and governance training to more than 500 staff members
• enhanced controls to capture any breaches in procurement requirements

Operational performance is an area of challenge for the health board. Progress has been made in some areas, but more focus and action is needed to deliver timely access to care for people across north Wales.

Cancer performance remains below target and the health board must address the backlog in the number of people who are waiting more than 62 days to start definitive treatment. Performance against the 62 day target has been impacted by challenges in services such as urology and dermatology.

Planned care is receiving considerable support from the NHS Executive and Welsh Government. Following an initial prioritisation of the longest waits, the focus is now on reducing the number of people who have extended waiting times beyond 104 weeks (2 years) for treatment.

There has been a reduction in the number of long waiting times at both the outpatient and treatment stage since February 2023. Between February 2023 and December 2024, the number of planned orthopaedic pathways waiting more than 104 weeks has reduced by 62.7%, and the number of pathways with total waits of more than 104 weeks has reduced by 6.1%. However, there has been a 15% increase in the number of pathways waiting more than eight weeks for their diagnostic tests over the same period.

Performance against the various mental health measures for under 18 year olds has improved, with 91% of assessments completed within 28 days in December 2024 compared to 57.8% in February 2023. Performance has been above the 80% target in each month since July 2024. However, while there has been an improvement in performance in the percentage of interventions started within 28 days in December 2024 (48.5% compared to 26.8% in February 2023) performance remains below the target of 80% and must improve.

For adult mental health, performance for interventions completed within 28 days remains above target at 83.6% in December 2024, and there has been an improvement for assessments completed within 28 days at 84.8% in December 2024, which has remained above the 80% target in 10 of the last 12 months.

There have been small pockets of improvement in ambulance handovers at north Wales emergency departments at some points in the last year, but this remains a significant area of challenge. The health board is working with the Welsh Government, the national 6 goals for urgent and emergency care programme and the NHS Executive to improve operational delivery of urgent and emergency care services and the safety and experience of patients. However, performance for urgent and emergency care remains considerably below where we want and expect it to be.

The health board has reported the north Wales system has been more resilient this winter despite increased demand through winter viruses.

There is a continued use of data captured from patient interactions to inform quality improvement processes and the experience of patients, families and carers. All 3 of the emergency departments in north Wales are testing changes to incorporate patient feedback with the health board’s Patient Advice and Liaison Service (PALS), working closely with the communications team to promote feedback and how feedback is heard and actioned.

The all-Wales emergency department survey went live as an SMS feedback survey across all the health board’s emergency department sites in October 2024.

Betsi Cadwaladr University Health Board has stabilised and started to put in place the building blocks to become a sustainable organisation over the course of the last 2 years under the current level 5 (special measures) arrangements.

Progress has been made in relation to corporate governance, financial control and governance and over the last 12 months the quality management system has begun to demonstrate improved grip and control.

The focus the chair, independent members, chief executive and executive directors are bringing to these areas has made an impact but, as this report highlights, there are areas of continuing fragility, which are linked to operational performance and clinical services, where further improvements are urgently needed.