Betsi Cadwaladr University Health Board special measures (level 5): progress report April to June 2025

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

Seven progress reports have been published since the escalation to special measures, reflecting on the progress made and the challenges that remain. The special measures framework for BCUHB sets out the improvements required. This report reviews progress against these requirements.

The organisation has made many changes over the last two years. Year one saw improvements in corporate governance and board leadership, while year two has seen a real focus on quality and safety, with the board responding to many legacy issues in an open and transparent manner.

The health board has set out ambitious plans for the year ahead – it has submitted a balanced three-year plan for the first time ever and was able to deliver an outturn deficit of £7.6m for 2024 to 2025, which was an improvement on the agreed target control total. Unfortunately, the plan could not be approved by Welsh Ministers because it did not meet the wider requirements of the NHS Wales Planning Framework 2025 to 2026, mainly those related to performance expectations.

This year, the focus is on reducing the number of long waits and the overall size of the waiting list – bringing it back to pre-pandemic levels – and tackling outpatient appointments in the most challenged specialities, as well as taking 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.

There are areas where the health board is leading the way in Wales including:

• the health board has launched the first IV access service in Wales at Ysbyty Glan Clwyd
• the community audiology van is the first of its kind in Wales
• Ysbyty Gwynedd has become the first NHS robotic training centre in Wales to train other surgeons in robotic knee surgery
• surgeons in Abergele Hospital are trialling augmented reality technology for total knee replacement surgery
• doctors-in-training have ranked Ysbyty Gwynedd’s emergency department as the best place to train in Wales for a second year running
• there are 344 active research studies – a 9% year-on-year increase; the first in-human trial launched at North Wales Clinical Research Facility in 2024
• the Living Well Service won the 2025 UK-wide Advancing Healthcare Awards; judges noted the team successfully transformed a long-COVID-19 service into a needs-led community model, addressing complex mental health and physical challenges
• in May 2025, a trial for the treatment of acute myeloid leukaemia started at Ysbyty Glan Clwyd
• the health board is piloting a service for people to access urgent medicines using the Pharmaself REMEDY machine at Dolgellau and Barmouth Community Hospital

The health board has made substantive appointments to its senior and executive team including the Chief Operating Officer, the Director of Environment and Estates, the Director of Performance and Commissioning, and the Executive Director of Finance. The new Executive Medical Director will start in September 2025.

The health board has strengthened its leadership capacity, embedding core values and behaviours and building systems that support continuous improvement and organisational learning. These efforts are closely tied to the wider cultural transformation, underpinned by a clear commitment to listening and responding to feedback from staff, partners, and communities across North Wales.

A cultural change and leadership programme is being implemented, including the recruitment and development of culture change leaders and the establishment of a people managers forum.

The Foundations for the Future major change programme is entering the design phase. This will reshape the organisation by aligning structures, people, systems, processes, culture, and strategy. It will tackle the core operational challenges, building a cohesive, agile, and sustainable organisation.

Work has continued this year to strengthen governance across the organisation with performance concerns escalated through the committee governance structures. The performance, finance, and information governance committee plays a key role in overseeing the board-approved integrated performance and accountability framework.

Over the last year, community conversations have continued with a more structured partnerships, engagement and communications strategy in place as noted on BCUHB's website. Key themes from patient experience metrics are routinely reported to the board to inform service improvements.

Extensive work has been undertaken across the organisation to embed quality at the core of all activities. Central to this, is the development of the Quality Management System (QMS), which was tested with early implementer services ahead of wider organisational rollout. 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 focused 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 in July 2024 and the integrated concerns hub which was operational from September 2024. More than 82% of complaints are closed within 30 days – the target is 75% – and the average time to complete a complaint is 20 days (compared to 59 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.

In April 2025, the health board entered a guilty plea in relation to a prosecution brought by the Health and Safety Executive for failure to prevent and manage inpatient falls following the deaths of three elderly patients who sustained falls in 2022 and 2023.

The Public Services Ombudsman for Wales issued a public interest report in April 2025 in relation to care commissioned by the health board from an NHS provider in England. Five Regulation 28 notices have been issued to the health board this year.

The NHS Wales people’s experience survey started in April 2025. By the end of May, the health board had received 11,879 responses; of these, 70% rated their overall experience as “very good” and 87% reported they were always treated with dignity and respect.

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

Improvement plans are actively progressing across 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 decision to pause all elective and emergency open Abdominal Aortic Aneurysm (AAA) repairs was taken in November 2024 following several adverse events, which resulted in a high mortality rate for the service; the board agreed to formally commission all emergency and elective open AAA repairs from the University Hospital North Midlands (UHNM) from 12 November 2024; UHNM has offered honorary contracts for vascular surgeons wishing to attend and participate in AAA procedures
• mental health – the Ablett site is in urgent need of redevelopment; the health board is aware of this and is working to develop plans to ensure the site is suitable for the needs of the local population; to support this, the Welsh Government has agreed a revised cost envelope for the project; the board is making good progress against the recommendations in the review of mental health reviews undertaken by the Royal College of Psychiatrists; mental health leadership has been enhanced through the appointment of a substantive director for the division
• increased focus on community and primary care services, such as neurodevelopment and dental services
• a dermatology clinical lead has been appointed and a tele-dermoscopy service has been launched; straight-to-test protocols have been implemented for suspected skin cancer referrals
• the train and treat initiative has commenced for ophthalmology to reduce hospital waiting times for patients requiring eye care, while providing training and development for optometrists to deliver a higher number of procedures in a community or high street optometry setting
• an oncology clinical lead has been appointed; homecare capacity is being maximised and extended hours on day units
• additional locums have been secured to support medical gaps in urology in the short term

Operational performance remains an area of considerable 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.

The health board was given an additional £40.3m in 2024 to 2025 to tackle the longest waits for planned care and diagnostics. This enabled the health board to reduce its Referral To Treatment (RTT) pathways waiting more than 104 weeks by 44% at the end of March compared to December 2024. This was the lowest number reported since July 2021.

There has also been a 65.7% reduction in the number of RTT pathways waiting over three years; and a 67.9% reduction in the number of pathways waiting over 14 weeks for a specific therapy.

In quarter one of 2025 tp 2026, the health board received an additional £5m to make further reductions in its waiting lists.

However, Betsi Cadwaladr University Health Board currently has two-thirds of the longest waits in Wales and must urgently make improvements to its planned care performance. It has committed to eradicating all 104-week waits by the end of December 2025.

The health board has historically reported strong cancer performance, but over the past 18 months this has not been maintained, with performance falling to 51% against the suspected cancer performance measure of 75% in January 2025. There has been a slight recovery over recent months, with 53.5% performance reported in April, but this remains the lowest in Wales. This must improve urgently.

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.

Performance for urgent and emergency care remains considerably below expected levels and has not seen the required level of improvement. The health board’s performance against the four-hour emergency department waiting time fell to 57.2% in March 2025 – its second lowest on record. This has improved to 59.8% in May 2025, but it remains the poorest performing health board in Wales. There has also been a significant increase in the number of people who spent longer than 12 hours in its emergency departments.

There have been some small signs of improvement in urgent and emergency care performance – ahead of the development of the national handover-45 taskforce, the health board has seen a 14.4% reduction in the number of ambulance handover delays over one hour across its sites over the last 12 months. In April 2025, the minor injuries unit in Dolgellau re-opened following the recruitment and training of staff.

Performance against the various measures for adult mental health remains relatively stable. In March 2025, 72.7% of assessments were completed within 28 days, against the 80% target. The health board has achieved the national target for the percentage of adults who receive a mental health intervention within 28 days following assessment in nine out of the past 12 months, achieving 84.1% against the 80% target in March 2025.

Performance against the various mental health measures for under-18s has also improved, with 96% of assessments completed within 28 days in March 2025. The percentage of interventions started within 28 days has increased to 43.4% in March 2025, performance remains below the target of 80% and must improve.

The health board has a three-year child and adolescent mental health services (CAMHS) improvement plan in place, with a focus on early help and crisis response models.

The health board’s Well North Wales programme received national recognition in the June 2025 edition of the Journal of Public Health, for its work in co-producing health and wellbeing services with communities in high-need areas and cited as an exemplar of best practice in delivering whole-systems, place-based approaches to public health.

The health board has seen the largest number of NHS dental contract terminations of any Welsh health board, with 16 since April 2022. In October 2024, it undertook a deep dive into primary care dental services, which looked at key areas including performance, service delivery and the service structure. The report and recommendations will form the basis of future strategies and improvement plans.

The procurement process for dental services concluded on 24 March 2025. Approximately £6m of contracts have been awarded, which will help to stabilise access to NHS dentistry and specialist dental services across north Wales. This includes a new dental practice in Connah’s Quay, which is anticipated to open in September 2025.

Access to primary care remains another area of challenge. The health board currently 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 alternatives to the emergency department; progressing the strategic approach to a mixed model of primary care; implementation of the new GMS contract assurance framework; and improved board visibility of primary care performance data.

The health board presented its annual accounts for 2024 to 2025 here noted on BCUHB's website at an extraordinary board meeting on 26 June 2025, along with the Auditor General’s report noted here on BCUHB's website about the accounts, which recognised notable improvements in governance arrangements during the year. The accounts received a qualified regulatory opinion as the health board did not achieve its first financial duty to break even over the period 2022 to 2023 to 2024 to 2025.

The health board was able to deliver an outturn deficit of £7.6m for 2024 to 2025, which was an improvement on the target control total of £8.6m. This also represented a £16.8m reduction compared to the £24.3m outturn deficit delivered in 2023 to 2024 and a £12.2m improvement compared to its planned deficit position.

The Executive Director of Finance was appointed in February 2025 and action has been taken to further strengthen and stabilise the finance team, with additional resources identified and redirected to support key areas to address through the special measures framework and strengthening capacity for key deliverables, technical accounting, ongoing monitoring and performance reporting.

In March 2025, the board approved a financially-balanced Integrated Medium Term Plan (IMTP) for 2025 to 2028 here noted on BCUHB's website, setting the direction and organisational ambition for the year ahead including a planned break-even financial position for 2025 to 2026. This is a significant step forward and the first time the health board has been able to submit a financially-balanced IMTP.

The health board has made improvements to its integrated strategy and planning approach, including the development 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 for Penley and Tywyn community hospitals as noted here on BCUHB's website. Over the coming months, the health board will carry out wide-ranging engagement with stakeholders, with recommendations to be presented at the December board meeting.

There has been steady and measurable improvement made across key areas including leadership, governance, clinical quality, and financial management over the past two years.

Significant challenges remain – especially in planned and urgent and emergency care, which will require additional focus during the coming months. The priority is to improve operational grip and control, agree and implement a new operating model, improve performance and build the necessary foundations for sustainable, system-wide improvement.