31 March 2022

Dear Mark and Jo,

Betsi Cadwaladr University Health Board

Thank you for attending the Committee meeting, along with your colleagues, on 9 March.

Whilst we appreciate your engagement with our questions during the session, we had concerns about some of the responses you provided and wish to seek clarity on certain points.

Service transformation and change

§    Overall, there appeared to be no firm action plan for securing the improvements required within the Health Board (‘the Board’), no sense of the scale of the problems or urgency to address these. There was no clarity provided on what the priority areas are for the Board and the evidence lacked sufficient detail including no set timescales, particularly in respect of the transformation of vascular and mental health services. We were disappointed by the lack of ownership and responsibility taken by the executive of the problems at the Board. There were many references to what staff across the organisation are doing, rather than what senior management are doing to set strategic direction and take responsibility.

§    We noted that the board is in a period of de-escalation with a targeted intervention framework currently in place. We asked for an explanation of how effective that framework had been in terms of recognising the concerns, in agreeing a strategy for the future, and also supporting improvements. The framework appears wide-ranging and ambitious.  However, the evidence we heard implies that much of the focus has been on self-assessment and we are concerned about the potential dangers of this being over optimistic and not focussing sufficiently on clear priorities, detail, addressing weaknesses , and transparency around the extent of the issues.

§    During the meeting, you were asked about the challenges posed by the geographic area covered by the Health Board and for your view on whether this had contributed to any of the failures identified in the Health Board over the last decade. We would appreciate if you could provide a conclusive and clear view on whether you believe the Health Board’s geographical size has contributed to these failures.

§    It would also be helpful to understand how your new operating framework can address these issues, particularly as it was not approved during the Health Board’s public board meeting on 10 March. I note the Chair’s concerns from this meeting that the new operating framework may not be sufficiently understood or accepted by senior managers and executives within the organisation. This is of significant concern, as the issue of managers not implementing and delivering change within the Health Board has previously been raised by the Committee and remains an area of interest. Please provide us with details of what work is being undertaken to improve engagement with managers at all levels of the board to ensure operating frameworks are fully understood and managers are supported in delivering timely, tangible, visible  sustainable change and improvement.

Mental health services

§    Please provide a detailed response about how you intend to address issues in this area with timescales for implementation. I ask that you provide us with details of your objectives and priorities, how you are measuring performance against these, including any benchmarking activity to compare the board’s performance with similar health boards.

§    In particular, the Committee would appreciate details about the timescales and steps taken to address:

§    Lower level ligatures; and

§    the mixing of cohorts in mental health care. The Executive Director of Public Health’s evidence that this process  would be phased out from 21 January 2022 is noted, as is the fact this deadline has not been met. 

§    We heard in the evidence that these practices would be stopped within “months” and achievement against this target is expected to be provided to the Committee by 1 September 2022. This is not sufficient and we remain concerned about the pace of change in respect of mental health services. Many of these areas of concern remain unaddressed despite recommendations and conclusions made in various reports over the past decade including the Holden, Ockenden, HASCAS and Public Accounts Committee reports.. We are also concerned about the ongoing presence of executives and managers at the Health Board who were implicated in the conclusions of these reports and about their ability to deliver the internal change required.

§    We also note the comments recently made by the First Minister that “the improvement in mental health services in North Wales has not been as fast as it needs to be” and that “there are clearly further actions that need to be taken to make sure that, in all aspects of mental health services, people in North Wales get the service they deserve". This  assumption seems to be supported by your own Targeted Intervention Framework self-assessment, which shows mental health only at Level 1 in November 2021.

§    During evidence we asked for clarity about what issues are yet to be addressed and why. The answers  did not provide us with the assurances we need that improvements are being delivered. For example, we heard about the work being done on ward accreditation and although some wards have reached a silver level there are still wards that are on white where no progress has been made. Please could you provide us with details of accreditation approach and what it means in practice including how it is implemented, what it measures and how  staff are being supported in attaining each level of accreditation. Please could you explain why the two wards that remain on white have not made any progress.

§    The Chairman told the Committee that there was a “concern about the fitness” of the Hergest facilities’ ability to provide “modern, clinical services in a safe fashion”. The Chairman also noted that the Health Board would “dearly love to be able to submit a business case in terms of the Hergest”, but that this was complicated by a “shortage of capital nationally”. The Committee wants further details about the efforts to create a safe environment in the Hergest unit and what fiscal options have been considered to address these problems, such as seeking to convert revenue funding to capital funding.

Vascular services

§    The Committee were concerned about this issue and would welcome your response to the Royal College of Surgeons of England’s report on vascular surgery at the Health Board and the steps you are taking to respond specifically to the recommendations made therein, along with timescales for implementation. The Chairman stated that he would expect the Health Board to be able to demonstrate significant improvement, in keeping with the Minister's expectation, within three months. He also noted that monthly updates on progress against the issues highlighted in the report were to be provided to the Minister for Health and Social Services, the most recent of which was sent on 7 March. I would appreciate if this update, and future updates, could also be shared with the Committee.

Financial Management

§    Your comments on financial sustainability were noted by the Committee, however it was felt that insufficient detail was provided in respect of maintaining fiscal balance after the 2023-24 fiscal year, when additional Welsh Government funding for the Health Board  ends. Your Director of Finance noted that ”we have opportunities that are between £70 million and £110 million, but to actually deliver those is going to be difficult and will require a change in practice both from an operational and a clinical perspective. We don't anticipate it in the life of the current IMTP”. The Committee wishes to know more about your long-term financial planning, with an indication as to how financial balance can be achieved without this additional funding.

§    The Chief Executive told the Committee that there were was an opportunity to “unlock the transformational savings that we feel do exist in North Wales”. Can you provide further details about what these transformational savings and service changes may be, with an indication of timelines for when these can be achieved.

§    Your Director of Finance acknowledged that the development of a regional treatment centre would have a huge impact and was a critical project for the Health Board. What services will this deliver and what is the timescale for delivery?

During the private consideration of the evidence received, Members agreed to revisit the above issues with you in the Autumn 2022 term, following their consideration of your responses to the above points. As such, I would be grateful if you could respond by 30 April 2022.

I am copying this letter to the Minister for Health and Social Services.

Regards,

Mark Isherwood MS
Committee Chair