Betsi Cadwaladr University Health Board special measures (level 5): year 3 progress report

On 27 February 2026, Betsi Cadwaladr University Health Board had been in special measures (level 5) for 3 years. The escalation decision, taken in 2023, was in response to significant concerns about governance, leadership, and performance. 

Over the past 12 months, the board has consolidated governance and leadership reforms and progressed its quality and safety systems. However, there are significant and persistent challenges in delivering safe, timely, and effective care, particularly in relation to cancer, planned care, and urgent and emergency care. 

In November 2025, the Welsh Government introduced a range of further measures to support the health board to improve patient care and experiences as part of the level 5, special measures intervention. This includes new senior-level capacity and expertise inside the health board, with additional support from NHS Performance and Improvement. The team of experts includes an improvement advisor, supported by experienced operational leads, who are working alongside the health board’s chief executive and board to drive rapid improvements. 

While significant challenges remain, it is important to recognise the scale of the work undertaken by the organisation:

• Betsi Cadwaladr University Health Board is the largest health board in Wales serving around 697,000 people and employing approximately 21,600 people
• the health board coordinates the work of 96 GP practices, and NHS services provided by 78 dental and orthodontic practices, 70 optometry practices and opticians and 144 pharmacies across north Wales
• every month, an average of 313,000 appointments are attended at general practices in north Wales, they refer around 34,300 people into hospitals or to other NHS services, and issue 10,800 fit notes each month 
• each month, NHS dentists see an average of 13,800 patients; 19,400 NHS-funded eye tests and clinical treatments are provided by optometrists, and 11,000 people access a wide range of pharmacy services
• each month, there are approximately 20,000 attendances to emergency departments and around 66,860 outpatient appointment attended

Improvements made since February 2023

Improved waiting times

There has been a 66% reduction in the number of pathways waiting more than two years for treatment. Of particular note, is the 84% reduction in two-year waits in orthopaedic treatment; a 57% reduction in general surgery and 65% reduction for ENT. This has been driven by targeted theatre productivity; protected lists for high‑volume procedures; and effective use of insourcing and outsourcing, where clinically appropriate.

The number of child and adolescent mental health assessments completed within 28 days of referral has improved from 57.8% in February 2023 to 90% in December 2025. Compliance against the 80% standard has been maintained for the last 18 months. 

The number of child and adolescent mental health therapeutic interventions started within 28 days following an assessment improved from 26.8% in February 2023 to 70% in December 2025.  However, this is still below the 80% standard. 

Strengthened governance

The health board’s Quality, Safety and Experience committee, targeted workforce actions, and clearer escalation routes have contributed to better compliance with key access standards for adults and young people. The challenge now is to sustain gains and reduce variation between localities and services.

The latest Audit Wales Structured Assessment has highlighted strengthened corporate systems of assurance, clearer risk and performance frameworks, and more cohesive board scrutiny via the Quality, Safety and Experience committee and the Performance, Finance and Information Governance committee.

Hergest Unit

A Healthcare Inspectorate Wales (HIW) unannounced inspection in September 2025 identified improvements in leadership visibility, safety protocols, infection control and patient experience. Staff were observed treating patients with dignity and respect. Required actions from this inspection relate to mandatory training compliance, therapeutic activity timetables and ward safety. 

Pharmacist independent prescribing

The health board has delivered the highest number of pharmacist independent prescribing consultations in Wales. This expands same‑day access for minor conditions and medicines optimisation, reducing pressure on GPs and emergency departments.

Investment in NHS dental capacity

More than £6.5 million in new NHS dental contracts have been secured, increasing access to routine and urgent dental care. 

Introduction of innovative clinical services and technologies

The opening of the North Wales Medical School strengthens the local clinical pipeline; a new pharmacy programme at Bangor University will boost local skills, a first‑of‑its‑kind community audiology van brings diagnostics closer to home, and augmented‑reality assisted knee surgery trials are supporting precision and efficiency in orthopaedic care. 

Emergency department recognition

The emergency department at Ysbyty Gwynedd has been recognised as the best place to train in Wales for 2 years running, in 2023 and 2024, reflecting improvements in clinical supervision, culture and educational governance, and supporting workforce retention in a pressured specialty.

Unqualified audit opinions

The annual accounts have received unqualified ‘true and fair’ opinions from Audit Wales for the last 2 years, showing stronger financial control and learning from historical accounting issues. 

Enhanced renal technology and patient monitoring

Renal services at Ysbyty Gwynedd and Ysbyty Alltwen have deployed body‑composition and fluid‑status assessment equipment, improving precision in care and long‑term outcomes. 

Ultrasound‑guided carpal tunnel service

Wrexham Maelor Hospital provides Wales’ first ultrasound‑guided carpal tunnel release service, enabling efficient day‑case treatment with faster recovery and improved patient experience, while reducing pressure on traditional theatres.

Implementation of a new radiology system

The new radiology system has significantly improved scheduling and clinical reporting for medical images such as x-rays, CT scans, MRI scans, and ultrasound scans

The board has strengthened oversight through refreshed membership, clearer risk and performance frameworks, and increased transparency in reporting. A substantive board is in place, changes this year include the appointment of Sir Paul Lambert as the independent member to lead on finance, and Peter Lewis as chair of the stakeholder reference group.

There have been substantive appointments to the executive team, including the chief operating officer, executive medical director and director of workforce and organisational development. Of the 12 executive director and director roles on the board, 9 were appointed since February 2023.

The Audit Wales Structured Assessment 2024 recognised positive developments in corporate governance and progress in appointing to business‑critical roles, while highlighting the need to bed‑in a stable, cohesive executive team and to finalise a longer‑term strategy and clinical services plan. Welsh Government oversight remains in place including special measures forums, all‑age mental health assurance meetings, and monthly meetings between the Cabinet Secretary for Health and Social Care and the health board’s chair.

The board is focused on changing the organisation’s culture. This will take time, but it is tackling legacy issues more transparently. A consolidated lessons‑learned response to historic accounting matters was published in July 2025.

Workforce stabilisation is central to improvement efforts, with reductions in key vacancies and improved training compliance. Implementation of the Speaking up Safely Framework is starting to strengthen psychological safety, and leadership walkabouts have improved visibility and followed the principles of compassionate leadership. However, workforce morale is mixed, with pressure on frontline teams impacting retention. Workforce planning needs greater alignment with service redesign and performance expectations.

The Foundations for the Future major change programme, which is planned for 2026 to 2027, is designed to align structures, people, systems, processes, culture, and strategy. It aims to respond to operational challenges and build a cohesive, agile and sustainable organisation.

The board is focused on listening to patients, staff and citizens. Feedback remains consistent and 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 September 2025, the health board became the first in Wales to implement the new Radiology Informatics System Procurement (RISP), progress has been made on Laboratory Information Management System (LIMS), maternity digital systems, and the Welsh Intensive Care Information System (WICIS). However, digital transformation continues to be an area of significant risk and the governance required to deliver these programmes is fragile.

Data quality, particularly in performance reporting, needs continued focus. In November 2025, the Chief Statistician for Wales, temporarily suspended reporting of referral to treatment (RTT) waiting list statistics for the health board. This followed concerns about the accuracy and integrity of the RTT data submitted by the health board for several months.

A review into the health board’s data collection, quality assurance and governance processes was undertaken, examining governance, technical processes, coding issues and assurance mechanisms within the heath board and across the national system. The review team found that omission of a specific clinician identifier from the health board’s month-end reporting led to under-reporting in official statistics between April and September 2025. This has now been rectified and RTT reporting recommenced in January 2026.

While variation persists, the health board now has a quality management system (QMS) in place with clearer governance, improved divisional structures and more systematic clinical oversight. 

The QMS is built around 4 pillars:

• quality planning
• quality improvement
• quality control
• quality assurance

These 4 pillars are being integrated into core frameworks and processes. 

Patient safety has been strengthened through reductions in overdue incidents, accelerated learning processes, improved serious incident handling and enhanced duty of candour compliance. Mortality review processes are more robust, helping identify trends and areas for priority action.

There are signs of improvement in some clinical services including maternity, diabetes, and renal care, albeit with continued fragility. Sustained improvement in outcomes will require continued investment, strengthened workforce models, and more consistent clinical leadership.

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 80% of complaints were closed within 30 days in November 2025, 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 18 working days, a big improvement compared to 59 working days in April 2024. 

The health board has made improvements to its management of governance in relation to learning from events reports. Systems are in place to track and oversee learning from these reports, resulting in improved claims and redress processes.

In January 2026, Healthcare Inspectorate Wales (HIW) published its report following an unannounced inspection of the Hergest unit at Ysbyty Gwynedd. It highlighted strong teamwork across the Aneurin, Cynan and Taliesin wards, with patients and families describing staff as approachable, attentive and supportive. The inspection recognised the quality of compassionate care being delivered in challenging circumstances, alongside the strength of safeguarding arrangements, infection prevention and control measures, and the clear commitment to patient safety. The presence of bilingual staff, enabling people to communicate in Welsh or English, was highlighted as an important strength and reflects the health board’s commitment to person-centred care.

The report highlighted challenges in providing meaningful, structured therapeutic activities to support recovery, record-keeping, physical environment, workforce pressures, including staff vacancies, reliance on temporary staff and raised staff concerns around wellbeing, resources and senior leadership visibility.

In June 2025, 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 has taken 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
• dermatology

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

In November 2024, the health board paused the direct provision of planned and emergency open abdominal aortic aneurism (AAA) vascular surgery in north Wales following several clinical risks. Arrangements were put in place for people to be treated at the Royal Stoke University Hospital until the end of March 2026. The longer-term service model for AAA procedures is now being considered. 

In April 2025, Health Education and Improvement Wales (HEIW) notified the health board it will not be placing foundation year one (F1) 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.

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 have been strengthened over the last two years through the appointment of a director and medical director for mental health and learning disabilities, executive director with responsibility for mental health and a consultant nurse for dementia. 

Progress has been made against the findings of a review undertaken by the Royal College of Psychiatrists. A detailed progress report was presented to the board in January, alongside a summary report from the chair of the expert advisory group.

Urology

North Wales patients receive cystectomies at Arrowe Park Hospital, which provides greater stability and improved patient experience.

Oncology services

Two permanent medical oncologists and one fixed-term clinical oncologist have been recruited, strengthening the service. There is ongoing international recruitment for specialty doctors. Service innovation includes the transition of some treatments from intravenous to subcutaneous delivery releasing capacity and improving patient experience.

Stroke services

Performance against UK SSNAP standards remains below expectation. Actions for improvement are focused on timely admission to stroke units, thrombolysis pathways and therapy access. The health board’s Quality, Safety and Experience committee receives targeted stroke updates and tracks compliance across all three acute sites.

Performance is the area of greatest challenge. Despite targeted initiatives and pockets of improvement, the scale and consistency required for de‑escalation have not yet been achieved. 

Sustained investment and insourcing in CT, endoscopy, echocardiography, and ophthalmology have reduced waiting lists and strengthened pathway resilience. These improvements, while not yet sufficient to shift system‑wide performance, provide building blocks for recovery.

Urgent and emergency care 

Urgent and emergency care performance remains fragile, with ambulance patient handover delays and flow constraints impacting performance. Work under the Six Goals for Urgent and Emergency Care programme has strengthened system co-ordination, but sustained improvement requires structural pathway change. 

In January 2026, the health board reported further deterioration in performance against the four-hour emergency department waiting time target, recording the health board’s lowest ever performance. The organisation also continues to report the highest number of 12 hour emergency department breaches in Wales.

A major change programme for urgent and emergency care is in place; a rapid review of emergency departments was undertaken in January 2026 and the adoption of urgent and emergency care operational principles have clarified triggers for escalation, patient flow controls, and measurement of safety in emergency care pathways.

The Welsh Government provided the health board with almost £100,000 in December 2025 to fund falls management training and lifting equipment for 40 care homes across north Wales. Funding has also been allocated to support flow champions and delivery of the optimal hospital patient flow framework.

Interventions include:

• implementation of the North Wales Community Falls Response Service, to ensure equity of outcomes across the region
• integration of minor injuries units, urgent treatment centres and urgent primary care centres into the same day urgent care model in the community to support more people to access care and treatment closer to home and reduce demand on the three emergency departments
• development of a fully implemented enhanced care service provision (step up and down model) to support improved patient discharge processes and a shorter length of stay for inpatients

Cancer

The health board has historically reported strong cancer performance but over the past two years this has not been maintained. Pathway consistency and waiting times for access to diagnostics are the main areas of concern. Cancer performance has varied across tumour sites and overall performance against the 62 day target has fallen throughout the year, the latest figures for December 2025 show performance at 51.2%, the lowest performance ever reported against the suspected cancer pathway (SCP) target.

The health board 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.

Planned care

There has been improvement in reducing waiting times for first outpatient appointments over the past 12 months. With support from the Welsh Government, the health board has expanded the number of clinics provided during evenings and weekends across several specialities. 

Since September 2025, more than 45,000 additional weekend appointments have been offered, with 36,578 more people seen. A dedicated support service helping people to stay well and prepare for treatment while they wait has been introduced.

The following improvements in planned care were reported at the end of December 2025:

• The number of pathways waiting more than two years for a first outpatient appointment has fallen by 95% compared to December 2024 and the number waiting more than one year has reduced by 68% over the same period.
• Just over 6,400 fewer pathways are waiting more than two years for treatment, a 64% reduction compared to December 2024 with the biggest reductions being seen in dermatology (99.6% reduction) and ophthalmology (83.2% reduction).

Despite these improvements, people are still waiting too long to be seen and treated. The health board must continue to reduce waiting times. 

The expansion of pharmacist independent prescribing and availability of new dental contracts has improved access in areas of highest need. Frailty pathway work and intermediate care developments demonstrate positive movement in moving more care closer to home and easing pressure on acute hospital services.

Primary care contracting arrangements have strengthened considerably, providing clearer mechanisms for assurance, quality management, and service stability. 

North Wales has seen the largest number of NHS dental contract terminations compared to other health boards in Wales. There have been 17 terminations since April 2022, (since the start of contract reform).  A further five practices have confirmed that they will terminate their contracts by the end of March 2026. 

Urgent care for affected patients will be provided via NHS 111 Wales and the health board is expected to re-procure these contracts soon. Two tender exercises in 2024-25 resulted in the award of around £6.5m over multiple practices and locations, including the establishment of a new dental practice in Connah’s Quay at the end of February 2026. 

Frailty pathways and intermediate care developments represent a positive shift towards reducing hospital demand and strengthening community resilience.

Population health

The health board continues to prioritise prevention and the reduction of health inequalities through a system‑wide approach with local authorities and partners. 

The health board’s executive director of public health published the annual report in December 2025, setting out 4 ambitions for building a healthier, fairer North Wales:

• building strong foundations
• building fairer communities
• building health places
• building health across the system

Weight management services are being redesigned to a broader, lower‑intensity model to increase reach, reflecting high levels of overweight and obesity in the working‑age population, with targeted action to improve access for excluded groups. 

The breastfeeding service (Bronfwydo Mon Anglesey) has demonstrated tangible benefits, including reducing dropout rates for breastfeeding mothers through tailored support​. Community-based projects, such as My Life in Conwy West, provide health and lifestyle guidance informed by community needs and feedback. In 2024, the health board reported rates of exclusive breastfeeding at 10 days of 37.8%, in line with the all-Wales average of 38.7%. 

Smoking cessation performance remains strong, with 7% of the North Wales population supported by Help Me Quit services in 2024 to 2025, and 4.2% in the current financial year to date (quarters 1 and 2 of 2025 to 2026). This is supported by effective incentive schemes and a focus on high‑risk groups, including people living in deprived areas and pregnant women.

Vaccination uptake presents a mixed picture. While RSV uptake is above the Welsh average and winter vaccination delivery is co-ordinated across primary care and community pharmacy, HPV uptake remains below the national average and MMR coverage varies across localities. Targeted interventions with GP practices and schools are underway to address gaps. Staff vaccination uptake continues to be a challenge, with innovative approaches being implemented to improve coverage.

Further progress has been made to address wider determinants of health, including the development of a regional prevention and wellbeing framework, work towards a unified social prescribing model, and the establishment of an inclusive health offer focused on groups experiencing the greatest inequalities.

Financial governance has improved, reflecting strengthened internal controls, and enhanced audit processes. Achieving an unqualified ‘true and fair’ audit opinion for the health board annual accounts for two consecutive financial years signals a departure from historical weaknesses.

The latest Audit Wales Structured Assessment, which was published last year, recognises the improvements made under the chair’s leadership, including strengthened corporate systems of assurance, clearer risk, and performance frameworks and more cohesive board scrutiny through its committee structure. 

The submission of an integrated three-year plan for 2025 to 2028 was a milestone for the health board, reflecting a step forward and growing maturity in its planning process.  However, this plan was neither supportable nor approvable. The ongoing planning task is to align operational trajectories to realistic capacity and demand models and deliver validated monthly milestones, within available resources. The health board has commenced work on its clinical services plan.

The health board met its target control total in 2024 to 2025. The Welsh Government has provided significant recurrent, and non-recurrent funding support to the organisation with clear expectations on delivering financial balance alongside clear delivery commitments. Disappointingly, the board has been unable to deliver that plan and its financial position has deteriorated to a year-end forecast deficit of £17.4 million for 2025 to 2026. It is clear there is a need for reflection if the failure to deliver the plan relates to planning challenges or delivery challenges. 

Delivery of the health board’s savings plan remains challenging, particularly in relation to securing recurrent savings. While non-recurrent savings improved in-year resilience, long-term sustainability depends on more transformative service and workforce change across the health board. More work is required at pace for the board to ensure it has a strong foundation for developing and delivering its plans within available resources.

Greater organisational openness has been a notable feature of the past three years. The implementation of the duty of candour, publication of special measures updates, and clearer reporting about incidents and complaints have all contributed to a more transparent culture. Staff engagement has been widened through leadership walkabouts and improved communication channels, while cultural maturity still requires sustained focus. These changes mark a shift towards a more accountable and responsive organisation.

Although performance trajectories have proven difficult to improve in line with expectation, foundational work has taken place across planned care, diagnostics, maternity, urgent and emergency care, and primary and community care and lays the groundwork for longer-term improvements. Importantly, the board has developed a more mature understanding of risk, accountability, and assurance, enabling it to move from crisis response to longer-term strategic decision‑making.

The organisation continues to face considerable performance challenges, particularly in planned care, cancer and urgent and emergency care. The foundations for improvement are clearer, more transparent, and more consistently embedded across the health board. The health board must now urgently build on these foundations and deliver rapid and sustained improvement, delivering safe and timely access to high-quality planned, emergency and cancer care for people across north Wales.