Before becoming Cabinet Minister for Health and Care, Mabon ap Gwynfor MS signalled that reforming the governance of NHS Wales would be an early priority. He commissioned and published a report, which argued for clearer accountability and stronger arrangements for oversight and performance management, including a more independent NHS Executive.
This article explains what governance means in practice, outlines the main oversight arrangements already in place, and highlights issues Members may wish to consider when scrutinising any programme of reform.
What is governance in the NHS?
In simple terms, governance is about who is responsible for decisions, how performance is monitored, how organisations are held accountable, and how ministers ensure the system is delivering results.
In NHS Wales, governance operates across several levels:
- Welsh Government (strategic direction, funding, oversight)
- NHS Wales Performance and Improvement (formerly the NHS Wales Executive) and national bodies (coordination and assurance)
- Health boards and trusts (delivery and local accountability)
Governance frameworks are intended to ensure that organisations deliver safe and effective care, use public money appropriately, and improve performance over time.
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The Welsh NHS Confederation’s explainer series provides accessible introductions to these topics, including: |
What do recent developments suggest about governance reform?
Recent developments suggest that any programme of governance reform is likely to focus less on structural reorganisation and more on how NHS Wales is overseen in practice.
In October 2024, the previous Welsh Government appointed an external Ministerial Advisory Group to review the effectiveness of current arrangements for improving performance and productivity in NHS Wales. Its report, published in April 2025, made 29 recommendations and concluded that improvement would depend in part on clearer objectives, stronger accountability, sharper performance management and better use of data.
Taken together with the Cabinet Minister’s previous emphasis on NHS governance, these developments point towards reforms aimed at clarifying who is responsible for delivery, strengthening scrutiny of performance, improving board leadership and making risks and progress more visible. They also suggest a stronger focus on whether existing national and local oversight arrangements are providing timely challenge and support.
That does not in itself indicate a settled programme of change. But it does provide a clearer sense of the direction of travel: more explicit expectations, closer monitoring, stronger accountability, and greater transparency about performance, risk and improvement.
What is the oversight and escalation framework?
The previous Welsh Government used an Oversight and Escalation Framework to review performance and assess risk across NHS Wales organisations.
The framework sets out how concerns are identified, the level of intervention that may follow, and the circumstances in which organisations may be de-escalated. It applies across health boards, trusts and special health authorities and is intended to provide a consistent structure for oversight, assurance and intervention.
There are five levels of escalation in the framework:
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Level 1 – Routine arrangements NHS organisations are responsible for maintaining appropriate governance arrangements and ensuring these are effective and provide quality and safe care. |
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Level 2 – Area of concern Welsh Government will meet with the NHS organisation to explore the nature and extent of the concern. The NHS organisation is expected to respond to those concerns. |
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Level 3 – Enhanced monitoring This applies when serious concerns have been identified. NHS organisations are expected to put effective processes in place to address issues of concern, while Welsh Government coordinates activity, observes, challenges and reviews progress. |
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Level 4 – Targeted intervention Welsh Government, other NHS bodies or external review bodies work with organisations where serious concerns have been identified. Support may include time-limited mentoring, advice from experienced individuals with clinical or governance expertise, and review work. |
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Level 5 – Special measures In exceptional circumstances, Welsh Government may find very serious concerns about an NHS organisation. Welsh Ministers may intervene under the NHS (Wales) Act 2006, including by providing targeted support or suspending or removing powers and duties from board members. These formal powers are intended as a last resort when other intervention is unlikely to succeed. |
What is the current escalation status of NHS organisations?
The previous Welsh Government published regular updates on the escalation status of NHS organisations in Wales. The most recent update, published on 9 April 2026, showed that every health board in Wales was under some form of intervention.
Table 1: Escalation status of Health Boards, Trusts and Special Health Authorities in Wales as at 9 April 2026
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Organisation |
Status |
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Aneurin Bevan University Health Board |
Level 4 for finance, strategy and planning, and performance and outcomes related to urgent and emergency care. |
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Betsi Cadwaladr University Health Board |
Level 5 (since February 2023). |
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Cardiff and Vale University Health Board |
Level 4. |
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Cwm Taf Morgannwg University Health Board |
Level 3 for performance and outcomes related to planned care. Level 4 for performance and outcomes related to urgent and emergency care. |
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Hywel Dda University Health Board |
Level 3 for performance and outcomes related to planned care. Level 4 for finance, strategy and planning, performance and outcomes related to urgent and emergency care, fragile services (including ophthalmology) and healthcare associated infections. |
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Powys Teaching Health Board |
Level 4 for finance, strategy and planning. |
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Swansea Bay University Health Board |
Level 3 for performance and outcomes related to planned care and children and adolescent mental health services. Level 4 for finance, strategy and planning, performance and outcomes related to cancer, healthcare associated infections, urgent and emergency care, and maternity and neonatal services. |
Among trusts and special health authorities, Public Health Wales NHS Trust, Velindre University NHS Trust, Welsh Ambulance Services NHS Trust and Health Education and Improvement Wales were all at Level 1. Digital Health and Care Wales was the exception, remaining at Level 4.
Betsi Cadwaladr University Health Board was placed into special measures (Level 5) in February 2023 in response to serious concerns about governance, leadership and performance. The Cabinet Minister has indicated publicly that the health board will be given a further period to demonstrate improvement, after which more fundamental organisational changes could be considered if progress is judged insufficient.
The previous Welsh Government published regular reports on the health board’s progress, alongside organisation-specific escalation frameworks for each health board and for Digital Health and Care Wales.
Public accountability meetings
Alongside these formal escalation arrangements, between October 2025 and March 2026, the then Cabinet Secretary for Health and Social Care, Jeremy Miles MS, held a series of public accountability meetings with health boards, trusts and special health authorities.
The meetings focused on in-year operational delivery, delivery against organisational plans, financial position and outlook, quality and safety, and risks to delivery.
Reflections on the meetings were subsequently published by the Cabinet Secretary.
What are the key considerations for scrutiny?
The emphasis on governance appears to reflect a view that some of the NHS’s current performance challenges may be linked, at least in part, to how the system is led, overseen and held to account. In that context, a key issue will be what governance reform is intended to achieve in practice.
- What specific governance problems is the Welsh Government seeking to address?
- How will governance changes improve outcomes for patients, such as waiting times or access to care? What indicators will demonstrate success?
- How quickly should improvements be visible?
- Will there be changes to how and when organisations are escalated?
- How will governance reforms strengthen leadership within health boards?
- Will new or improved data be published to support scrutiny?
- What happens if special measures and existing intervention arrangements do not deliver sufficient improvement?
It is too early to say exactly what the new government’s approach to NHS governance will involve. The key questions for scrutiny are therefore likely to become clearer once any proposals are set out in more detail.
Article by Rebekah James and Sarah Hatherley, Senedd Research, Welsh Parliament
