Tackling serious problems in the Welsh NHS: what are the arrangements for improvement?

Published 12/04/2022   |   Reading Time minutes

Four out of the seven local Health Boards in Wales are currently subject to escalation and intervention arrangements. This means the Welsh Government has had to take greater control in response to concerns about performance or specific issues. Many of the issues predate the pandemic, but some will have been compounded by the pressures of the last two years. The NHS Wales Escalation and Intervention (E&I) Framework is there to support improvement in the quality and safety of services, ensure NHS organisations have appropriate governance in place, and to help increase public confidence in their local health services where problems or failings have been identified.

This article outlines the current NHS Wales Escalation and Intervention Arrangements.

NHS Wales Escalation and Intervention Arrangements

In March 2014, the joint NHS Wales Escalation and Intervention Arrangements (the E&I Arrangements) were launched. Under these, the ‘Tripartite Partnership’ of Welsh Government, Audit Wales and Healthcare Inspectorate Wales (HIW) meet twice yearly (and more often if serious concerns arise) to share knowledge and discuss the overall position of each health board, who provide health services to their local population, and NHS trusts who manage all-Wales or specialist services.

Based on those discussions the Director General of NHS Wales then makes recommendations to the Minister for Health and Social Services on the escalation levels of the various health boards and NHS Trusts.

The aim of this joint work is to support NHS Wales:

  • to address concerns about service delivery, quality, and safety of care, and organisational effectiveness,
  • by ensuring that potentially serious issues are identified as early as possible and addressed effectively, and
  • to address and deliver the required improvement, so the NHS body returns to routine arrangements as quickly as possible.

These arrangements relate to organisational level issues, and are not designed to tackle individual complaints, which are dealt with through the existing NHS complaints procedure Putting Things Right .

What are the escalation levels?

There are four escalation levels which apply to NHS Wales organisations:

  1. Routine arrangements: this effectively means business as usual
  2. Enhanced monitoring: a pro-active response led by the NHS body to put effective processing in place to drive improvement. It is closely monitored, challenged, and reviewed by Welsh Government and external review bodies
  3. Targeted intervention: co-ordinated and/or unilateral action to strengthen the capacity and capability of the NHS body to drive improvements
  4. Special Measures: measures identified when the current arrangements need significant change. Welsh Ministers may intervene as set out in the NHS (Wales) Act 2006

The interactive map below shows the most recently published escalation status for NHS Wales bodies, which as of 11 February 2022.

Escalation status for health boards in Wales


Source: Welsh Government written evidence to Public Accounts and Public Administration Committee.

Explainer text: the infographic shows the escalation status of Welsh health boards: Aneurin Bevan, routine; Betsi Cadwaladr, targeted intervention; Cardiff and the Vale, routine; Cwm Taf Morgannwg, special measures for maternity and targeted intervention for quality and governance; Hywel Dda, enhanced monitoring for financial control; Powys, routine; Swansea Bay, enhanced monitoring.

When and why is Escalation and Intervention needed?

Escalation typically occurs when there is evidence to indicate sufficient and timely improvement is not happening. Escalation can encompass a whole organisation but may also target an individual service such as maternity services, or a specific area of concern such as financial performance or waiting times for treatment.

Health boards in Wales have been escalated for a wide range of concerns. For example, the previous Health Minister Vaughan Gething put former Cwm Taf Morgannwg UHB maternity services into special measures after the Royal College of Midwives and Royal College of Obstetricians and Gynaecologists jointly published a report identifying serious failings.

There are also examples where Health Boards have been able to demonstrate improvement and have therefore been moved to a lower level in the E and I Arrangements. For example, in August 2019, Cardiff and the Vale UHB was de-escalated to routine arrangements, following improvements in service and financial performance.

In November 2020, Betsi Cadwaladr was de-escalated from Special Measures to Targeted Intervention, although the Targeted Intervention Framework (TIF) for the UHB still contains a challenging range of areas for improvement. The Senedd’s Public Accounts and Public Administration Committee (PAPAC) started an inquiry in March 2022 regarding E&I Arrangements, considering evidence submitted by the Welsh Government, and the UHB, to explore the current position of Betsi Cadwaladr – which had been in Special Measures for over five years - and the broader question of:

  • whether the E&I Arrangements are fit for purpose, and
  • have achieved their objectives.

The Chair of Betsi Cadwaladr UHB believed that,

the Targeted Intervention Framework has afforded the board the opportunity to set a clear trajectory for improvement, which can be evidenced and assessed, both by us and by that Tripartite.

The Wales Centre for Public Policy have published research on supporting Improvements in Health Boards (2019), which highlighted the value of peer challenge, clear objectives and leadership, but also the need to empower the whole system, including middle management and medical staff.

However, The Welsh Government acknowledge in their evidence to PAPAC that “the framework as drafted is not clear about what factors would trigger a change in an organisation’s status”, that there’s been a tendency to widen the issues included, and:

…having organisations in Special Measures for a prolonged period of time is not desirable. The longer an organisation stays in a heightened level of escalation the more it becomes the ‘norm’.

Welsh Government indicate they’ve been working with Audit Wales, HIW, and health boards to review the current arrangement and acknowledge that the framework needs to be revised and refreshed over the coming year. Clearly there’s an acceptance that there’s room for improvement in existing arrangements. Will this also lead to improvements in how quickly and effectively major concerns in healthcare delivery are dealt with?

Article by Tracey Rosell, Senedd Research, Welsh Parliament