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Areas of concern

  • Governance, board effectiveness and audit.
  • Workforce and organisational development.
  • Financial governance and management.
  • Compassionate leadership and culture.
  • Clinical governance, patient experience and safety.
  • Operational delivery.
  • Planning and service transformation.
  • Vulnerable clinical services including vascular, mental health, urology and other clinical areas.

Guiding principles

  1. Patients first; everyone using services should expect to receive consistently high standards of care and treatment.
  2. Staff empowerment; ensuring that they have the right working conditions and resources to support their own wellbeing and deliver the best care and services possible and sharing of best practice.
  3. A quality and safety ethos that drives everything.
  4. Delivers services that improve the health of the population and works to reduce heath inequalities in collaboration with partners based on trust, respect, and learning.
  5. Has strong, compassionate leadership supported by robust and effective governance systems.
  6. Provides safe, high quality urgent and emergency and planned care services.


  • Terms of reference.
  • Quarterly reports; including reflections and achievements.
  • Agreed terms of reference and reports.
  • Regular reporting to Board.

Terms of reference

  • Learning and building upon previous interventions and support.
  • Oversight of improvement plans: establish arrangements to seek active and robust assurance that recommendations of special measures improvement plans and those from other reviews are being implemented; set milestones and track progress against them. 
  • Agreed terms of reference for each and every intervention and assurance review.
  • Clinical reviews: agree a process to undertake a review into patient safety concerns and other appropriate clinical reviews; any emerging actions or learning to be acted upon.
  • Public and patient engagement: ensure effective public and patient involvement and engagement in all aspects of the improvements needed and to rebuild public trust and confidence.
  • Escalation of any clinical or governance issues or concerns, should they emerge.
  • Advice to ministers on any further action required to support improvement through quarterly reports and monthly meetings.

Values and behaviours

  • Patient focused: decisions, recommendations and actions will be driven primarily by safety, quality and patient experience considerations.
  • Valuing people: a well led, highly motivated and appropriately engaged workforce is a fundamental requirement for the delivery of safe, high quality, patient centred services.
  • Open and transparent: subject to the constraints of patient confidentiality and data protection, work will be conducted and decisions will be made in an open and transparent manner.
  • Inclusive: engage with staff, patients and stakeholders involving them actively in the oversight and improvement process.
  • Collaborative: within an environment of robust scrutiny and challenge, to work collaboratively with Betsi Cadwaladr University Health Board to optimise the improvement process and avoid unnecessary bureaucracy, duplication of effort and resource.

Learning from other interventions

Learning from previous interventions highlights the benefits of investing time at the outset of any intervention process to establish and jointly agree solid foundations. This includes:

  1. Adopting a ‘whole systems’ approach (that is one which considers service failings in the context of organisational leadership, governance, culture, capacity and resource).
  2. Being clear about the underlying causes of the problem and tackling those rather than the symptoms which resulted in the intervention.
  3. Clearly defining the standards to be met and the mechanism by which the change which is necessary to meet those standards will be brought about.
  4. Providing the qualities, capabilities and capacity to deliver the equation of change.
  5. Establishing clear timescales, progress measures and milestones.
  6. Developing an explicit strategy for escalation and de-escalation.
  7. Setting out clear lines of governance and accountability.

Independent advisors

  • Support the board to make decisions based upon sound governance principles and an assessment of the impact of decisions on safety and quality.
  • Provide appropriate challenge in examining the current health board systems.
  • Provide advice, subject to their own individual skills, backgrounds and experience.
  • Support and mentor board members in the form of active listening, provide encouragement and offer feedback.
  • Advise on alternative mechanisms that could be applied from a strategic or operational basis.
  • Provide support to help improve operational performance and deliver the agreed transformational change needed.
  • Provide specialist HR, governance and leadership support.

Key stakeholders

  • Patients and staff.
  • Betsi Cadwaladr University Health Board.
  • Minister for Health and Social Services.
  • Welsh Government. 
  • NHS Wales Executive.
  • Independent advisers.
  • Llais.
  • Healthcare Inspectorate Wales.
  • Audit Wales.
  • Health and Safety Executive.
  • Improvement Cymru.
  • Local authorities.
  • Regional and public service boards.
  • Members of the Senedd.
  • Members of Parliament.
  • Unions.
  • Health Education and Improvement Wales / Deanery. 
  • Royal colleges. 
  • The Nursing and Midwifery Council, General Medical Council and The Health and Care Professions Council.
  • Third sector.
  • HM Coroner.
  • Local health boards. 
  • NHS Wales Trusts.
  • Digital Health and Care Wales.

Working with regulators

  • Inspection work and independent reviews will take place during the period of special measures.
  • Important that within the ethical and constitutional bounds of the relevant regulatory frameworks there is a two-way flow of information.  
  • Regulators will be provided with the opportunity to comment upon and where appropriate contribute to the formal progress reports prior to finalisation.

Performance monitoring and assessment

  • Performance incorporates quality, safety, governance and sustainability.
  • Agreeing milestones, targets and measures.
  • Optimising reporting processes.
  • Monitoring and evaluation process.
  • Assessment criteria.
  • Escalation and de-escalation process.
  • Reporting methodology.

Intervention terms of reference

  • Explains rationale.
  • Sets out aims and objectives.
  • Solution focused.
  • Clear lines of responsibility and accountability.
  • Agreed timescales.
  • Immediate feedback.
  • Final report.

Engagement and communication strategy

  • Statement of principles.
  • Clarity of responsibilities.
  • Engagement methods and tools (targeted to audience).
  • Regular stakeholder briefings: staff engagement and internal communications.
  • Public communication – building trust and confidence.
  • Political briefings (who does what and when).
  • Media handling (who does what and when).
  • Social media and web presence.

Clinical review strategy

  • Scope and terms of reference.
  • Data handling and information sharing.
  • Patient and family engagement and communication.
  • Staff engagement and feedback.
  • Learning from evidence and best practice.
  • Resourcing.
  • Review methodology.
  • Reporting format and process (emerging issues).
  • Putting things right, redress and civil litigation.
  • Referral policy (professional bodies, coroners, and so on).

Working together

  • Opportunity to engage in designing special measures process.
  • Independent advisors to support and advise.
  • Monthly oversight meetings.
  • Quarterly special measures review meeting.
  • Scheduled monthly meetings with chair and CEO.
  • Quarterly reports.
  • No surprises.

Five outcomes

  • A well-functioning Board.
  • A clear, deliverable plan for 2023 to 2024.
  • Stronger leadership and engagement.
  • Improving access, outcomes and experience for citizens.
  • A learning and self-improving organisation.

Compassionate leadership and culture

  • Cultural diagnostics.
  • Leadership development.
  • Leadership capability and capacity.

Financial governance and management

  • Financial governance.
  • Resource allocation and utilisation. 
  • The financial control environment.
  • Maturity of the finance function.
  • Review of interims and tender waivers.

Planning and service transformation

  • Ensure there is integrated planning capacity and capability within Betsi Cadwaladr University Health Board both in terms of Integrated Medium Term Plan (IMTP) strategic and operational planning.
  • Assessment of the organisation’s approach to developing their IMTP and the associated decision-making mechanisms.
  • Ensure sufficient planning capacity and capability for strategic planning.
  • IMTP development process including the triangulation of plans to operational, workforce and financial inputs.
  • IMTP development stakeholder engagement and input.
  • IMTP development decision making process and governance.

Governance, board effectiveness and audit

  • Accountability and governance review.
  • Audit Wales and Kings Fund actions.
  • Office of Board Secretary, board committees and governance process.
  • Digital maturity assessment.
  • Ensure appropriate governance is in place, particularly with regards to providing appropriate scrutiny of risk, performance, leadership style and practice.

Clinical governance, patient experience and safety

  • Clinical leadership.
  • Clinical services: vascular, urology, mental health and dermatology.
  • Clinical behaviours and practice.
  • Regional delivery models.
  • Clinical network arrangements.
  • Clinical job planning.
  • Quality management systems and duty of candour assessment.
  • Review into patient safety concerns.
  • Oversight of the putting things right process.
  • Review how patient experience is utilised.
  • Ysbyty Glan Clwyd urgent and emergency care.
  • Review of clinical governance.

Workforce and organisational development

  • Culture, values and behaviours.
  • Stronger Together review and refresh.
  • Review executive structure and portfolios.
  • Support and stabilise HR Team.
  • Arrangements for handling the Ernst and Young review.
  • Respond to grievances and related issues.
  • Staff well-being and support.
  • CEO recruitment.
  • Staff engagement and communications.
  • Staff side relations.
  • Workforce planning and integration.

Operational delivery

  • Improved planned care performance.
  • Improved adult mental health, CAMHS and neurodevelopment delivery.
  • Regional treatment centres.
  • Consistency in urgent and emergency care over the next six months.
  • Evidence of actions implemented from identified within the speciality reviews.
  • Clear plans to reduce backlog and increase efficiency.
  • Strategies for orthopaedics, general surgery and ophthalmology including business plans for orthopaedics.

Clinical services

  • Strategic vision developed, strong and credible strategy and action plan for vulnerable services such as Mental Health, Vascular, and Urology.
  • These services to integrate with corporate functions.
  • Outstanding issues and recommendations completed and embedded as business as usual.
  • Corporate governance and effective oversight and scrutiny.
  • Learning is routinely identified, shared and driving improvements in care.
  • Visible executive, board and medical leadership.
  • Evidence of positive shifts in culture.
  • Improving performance in line with requirements and expected standards.

Strategic vision

Clinical Plan and Annual Plan developed, agreed and communicated to the public. Early actions delivered providing confidence that sustainable longer term continuous improvement is achievable.

Confidence and trust in the organisation improves.

Integrated performance and quality

Ensuring Betsi Cadwaladr University Health Board is a data-driven organisation that ensures data is understood and utilised in decision making at all levels. Demonstrating a strong link between ensuring quality and performance improvement. Quality and safety is embedded in everything the organisation does.

Culture change

There is evidence of positive shifts in culture in key areas such as multidisciplinary working and addressing the blame culture.

Structures and delivery

Ensuring all parts of the organisation are clear on accountability and expectations at all levels to ensure successful delivery. Empowering effective decision making and a constant focus on performance improvement.

Effective and functioning board

All independent members inducted, committees up and running operating to an agreed schedule with clear decision making points supported by a well-managed on-boarding system. Effective oversight and scrutiny of current service provision consistently being provided by the Board and the appropriate committee.


Ensure that all recommendations from the royal colleges, Health Inspectorate Wales and other reviews are discharged and either verified or delivered or scheduled for delivery within the health board's longer-term improvement plan.

Learning and improving

Effective investigations being conducted on a 'business as usual' basis. All learning is routinely being identified and shared and there is evidence that this is driving improvements in care. A culture of listening, learning and improving is embedded throughout the organisation based on early and rapid triangulation and resolution of issues from a variety of sources, including patient, user and staff feedback.

Stronger leadership and engagement

Ongoing development of leadership and management skills at all levels/professions to strengthen management maturity. The organisation is focussed on all aspects of strategic workforce planning and maximising the skills of its current staff. Continuation of embedding/demonstrating lived values and behaviours throughout the organisation. Demonstrate a greater emphasis on engagement.

Programme management

Effective programme management structure is in place, which defines objectives of the improvement work, has plans which show how the work is delivered and what barriers could impact on delivery of outcomes; structures has effective, open and transparent reporting, with effective Board oversight. 

Clinical leadership

Clinical leadership is visible and effective; there is leadership development support in place and the consultant body as a whole is actively engaged in driving forward service improvement.

Strengthened clinical services

Such as vascular, mental health, urology, oncology and ophthalmology are supported by strong clinical leadership, an effective integrated improvement plan, project management structure and effective transformation support.

Improved access, outcomes and experience

Demonstrated by patient feedback, ambulance handovers, urgent and emergency care waiting times and access to planned care and mental health services.