Digital Health and Care Wales oversight and escalation framework: May 2026

Following assessment in April 2026, DHCW was escalated to Level 4, reflecting serious and systemic concerns requiring coordinated Welsh Government intervention.

Level 4 is the second highest level of escalation within the NHS oversight and escalation framework. It is applied when organisations have serious problems and where there are concerns that they cannot make the necessary improvements without external support. The Welsh Government will take and co-ordinate action and direct intervention to support an organisation to strengthen its capability and capacity to drive improvement. It consists of a set of interventions designed to remedy the problems within a reasonable timeframe. The interventions will normally be undertaken by NHS Wales Performance and Improvement (NHSWP&I) directed by Welsh Government. If appropriate, external support will be agreed with the organisation.

October 2024

Level 1 with strengthened oversight, with a letter indicating the DHCW Board need to take action to improve deliverability and confidence in DHCW system partners.

March 2025

DHCW escalated to level 3 with enhanced monitoring of performance and outcomes related to the delivery of major programmes.

December 2025

Remained in level 3 with enhanced monitoring of performance and outcomes related to the delivery of major programmes.

April 2026

Escalated to level 4 for the whole organisation due to increasing concerns related to performance, programme delivery, governance, stakeholder and leadership challenges.

The NHS Wales oversight and escalation framework sets out the process by which the Welsh Government maintains oversight of NHS bodies and gains assurance across the system. It describes the escalation, de-escalation and intervention process, the 5 levels of escalation and the domains against which each health board will be assessed.

During escalation, interventions will be:

• collaborative: aligned with national structures
• collective: shared approaches and learning
• impact-focused: evidence of delivery and outcomes
• transparent: with openness and mutual accountability

This framework sets out the expectations against each escalation domain. 

De-escalation:

• occurs 1 level at a time
• requires sustained progress over 2 consecutive quarters
• is based on delivery against agreed plans and criteria

To be considered for de-escalation, an organisation must demonstrate progress against agreed improvement plans and the de-escalation criteria over two successive quarters.

There are two approaches to de-escalation:

1. Welsh Government will coordinate activity to closely monitor, challenge and review progress made by the NHS organisation. If the NHS organisation can provide evidence of sufficient and timely improvement, then the Welsh Government and external review bodies will share knowledge to enable them each to consider whether de-escalation of the intervention arrangements placed on the NHS organisation is appropriate. For de-escalation to occur, the NHS body may not have achieved all of the de-escalation criteria, but they will need to demonstrate progress against the agreed improvement plan with sustained improvements against the de-escalation criteria over two successive quarters.
2. De-escalation for those areas with quantifiable outcomes and targets such as performance and outcomes will take place once the de-escalation criteria have been met and sustained for the agreed period. If the NHS organisation meets the de-escalation criteria for a specific domain or sub-domain then they will be de-escalated to the next level on the escalation scale. This de-escalation will be automatically triggered outside of the normal escalation cycle and will be confirmed in writing to the organisation. 

The roles and responsibilities of Welsh Government are to:

• provide structured oversight and challenge 
• direct NHS P&I and intervention support 
• promote best practice and shared learning 
• work with DHCW to support key system enablers (for example, national architecture, financial sustainability)

The roles and responsibilities of the organisation are to:

• appoint Senior Responsible Owner (SRO) 
• ensure strong Board oversight and governance 
• deliver a credible Level 4 improvement plan 
• provide regular evidence-based progress reporting.

Welsh Government assessment of Digital Health and Care Wales against the escalation domains in June and November 2025, raised concerns related to the effective delivery of major programme and the associated governance/leadership arrangements. Having considered all the evidence, a decision was made in April 2026 to escalate the organisation to level 4. In doing so it was recognised there are many areas within the organisation that are working effectively, but that across the organisation that assessment and support is required for programme delivery, governance, leadership and culture.

Summary of high-level concerns: noted in April 2026

A more detailed breakdown with examples can be found in Annex 1.

A summary of high-level concerns related to performance and outcomes includes:

• repeated failure to deliver major programmes to plan
• limited benefits realisation despite sustained investment
• delivery confidence weakened by repeated resets and reprofiling
• misalignment between milestones and operational readiness
• national delivery delays impacting health board planning
• leadership capacity absorbed by recovery activity

A summary of the high-level concerns related to governance, leadership, workforce and culture includes:

• insufficient delivery grip and realism in leadership behaviours
• late identification and escalation of risk
• focus on milestone delivery over system outcomes
• weak system engagement and co-ownership with health boards
• reduced system confidence in delivery reliability
• capacity and capability not aligned to portfolio scale and complexity
• over-reliance on key individuals
• unsustainable workforce model (temporary and external roles)
• limited flexibility to respond to emerging priorities
• growth not matched by delivery maturity
• erosion of confidence across health boards and partners
• reduced credibility of national digital commitments
• increased external scrutiny and reputational risk
• risk of disengagement from future national programmes

A summary of high-level concerns related to finance, strategy and planning includes:

• continued investment without commensurate delivery
• weak alignment between funding and delivery confidence
• limited portfolio-level financial grip
• insufficient use of stop or reset mechanisms
• lack of long-term financial sustainability clarity

Intervention support

DHCW has initiated improvement activity, including:

• programme recovery and reset
• strengthening delivery and assurance functions
• review of financial and benefits realisation arrangements 
• Welsh Government has commissioned NHS Performance and Improvement Intensive, Support, Recovery and Turnaround (ISRT) to assess:
  • adequacy of current actions
  • underlying root causes
  • required scale and pace of improvement

This intervention will be made up of 2 phases.

Phase 1: The Evaluative Phase

Welsh Government, with the support of NHS P&I and in alignment with the leadership of the organisation will arrange an independent review against the areas of escalation concern and its proposed actions to understand and advise all parties on:

• the underlying causes of the areas of escalation and challenge with a specific focus on programme management, governance, organisational culture and leadership.
• a view on the validity and likely efficacy of the established improvement plans.
• an outline of the approach to a phase 2 intervention programme. 

Phase 1 will take around 8 to 12 weeks, undertaken by independent and suitably skilled individuals with senior operational and executive experience background to support understanding of the underlying cultural dynamics within the organisation. 

Phase 2: The Delivery Phase

Terms of reference for the delivery phase will be agreed following the outputs of Phase 1. 

Monitoring and assessment

During the period of level 4 intervention, monitoring and reporting arrangements will include:

• an Escalation Board chaired by NHS Wales Chief Executive and Director General Heath, Care and Prevention
• Ministerial oversight in line with framework 
• monthly performance and delivery reviews

Leadership and Governance 

In order for the health board to be de-escalated to the next level of intervention, they must demonstrate:

• effective board oversight and governance maturity 
• early, transparent risk escalation 
• demonstrable delivery confidence and decision-making grip 
• improved stakeholder confidence and system engagement 
• strengthened workforce capacity and reduced key-person dependency

The organisation must evidence the criteria through: 

• improvement in delivery governance maturity, demonstrated through a bi‑annual self‑assessment aligned to the national digital governance maturity matrix, with clear evidence of actions closed and sustained
• clear governance and assurance systems are in place with issues escalated appropriately through clear structures and processes with effective board oversight and a clear framework that drives improvement
• demonstrate portfolio‑level governance and assurance arrangements are fully embedded, including: 
  • public and ministerial risk is actively managed, with fewer high‑profile delivery issues requiring reactive intervention
  • routine use of delivery confidence, dependency and benefit assurance as primary decision inputs.
  • clear thresholds for pause, reset or stop agreed and demonstrably used
• demonstrate that effective oversight and scrutiny of current service provision and delivery of key national priority programmes is consistently being provided by the board and the appropriate committee
• demonstrate robust risk management arrangements for identifying, recording, managing risks across the organisation with risks being escalated early and transparently, with reduced incidence of “late discovery” risk at point of impact
• demonstrable evidence that Board and DDaT Leadership Board oversight is effective, including: 
  • regular, evidence‑based challenge of delivery confidence
  • decisions taken where confidence is low (including reprioritisation or de‑scoping).
• senior leadership behaviours reinforce realism, early escalation and system impact, supported by improved confidence signals from health boards and national forums
• improved confidence from oversight and assurance bodies such as Audit Wales and DDaT governance.
• demonstrate performance concerns are being managed through routine governance mechanisms rather than escalation‑driven scrutiny
• improved health board confidence, demonstrated through: 
  • stakeholder feedback and reduced concerns
  • less reliance on Welsh Government brokerage to secure adoption or commitment
• co‑design and shared accountability approaches are embedded, including: 
  • early health board involvement in scope, sequencing and dependency decisions
  • clear articulation of local readiness, cost and workforce impacts before national commitments are made.
• reduced volatility in national delivery commitments, with fewer late changes to sequencing, scope or expectations
• robust programme and portfolio delivery capacity and capability has improved and is aligned to portfolio risk and complexity, including: 
  • explicit capacity modelling at portfolio level
  • clear prioritisation decisions where capacity is constrained
  • reduced frequency of recovery resets and reprofiling caused by dependency or capability gaps
  • improved confidence ratings from independent assurance or internal challenge
• reduction in single‑point dependency risks, demonstrated by: 
  • strengthened deputy and succession arrangements for critical roles
  • reduced reliance on a small number of individuals to hold delivery, safety or assurance functions.
• more sustainable workforce model, with reduced dependency on short‑term or externally funded roles for core delivery and assurance functions

Performance and Outcomes 

In order for the health board to be de-escalated to the next level of intervention, they must demonstrate:

• sustained delivery of priority programmes over 2 quarters 
• milestones aligned to operational readiness 
• evidence of benefits realised at scale 
• reduced reliance on recovery-led delivery

The organisation must evidence the criteria through: 

• sustained delivery of agreed milestones across priority national programmes (for example, NHS Wales App, LIMS, RISP, WICIS), where: 
  • milestones are independently assured as deliverable and outcome‑linked, not solely activity‑based
  • delivery performance is maintained across two successive quarters without reliance on re‑baselining or repeated reprofiling
• milestone delivery aligns with readiness for live service use, demonstrated by: 
  • reduced post‑milestone clinical safety, technical stability and operational readiness issues
  • health board sign‑off confirming readiness at agreed deployment points
• measurable benefits realisation at scale, with at least: 
  • one major national programme demonstrating validated clinical, operational or productivity benefit, beyond pilot or partial rollout
• clear evidence that delivery capacity is no longer concentrated disproportionately on recovery of underperforming programmes, freeing leadership focus for proactive portfolio management

Finance, Strategy and Planning

In order for the health board to be de-escalated to the next level of intervention, they must demonstrate:

• strong financial governance and portfolio oversight 
• alignment between funding and delivery confidence 
• effective use of stop or reset controls 
• clear long-term financial sustainability model 
• credible  3 year plan

The organisation must evidence the criteria through: 

• robust financial governance and a financial control environment in place with risks minimised
• stronger portfolio‑level financial grip, including: 
  • clear alignment between investment, delivery confidence and likelihood of benefit realisation
  • visibility of trade‑offs between programmes where affordability or confidence is constrained
• demonstrable use of pause, reset or stop mechanisms to control cost exposure on low‑confidence trajectories
• continued investment in national programmes is conditional on assured delivery readiness, supported by documented decisions
• clear articulation of a medium‑ to long‑term financial sustainability model for national digital services, including: 
  • ongoing platform costs
  • downstream health board cost, workforce and support impacts
• strategy and planning improvements with an agreed annual self-assessment, underpinned by the planning maturity matrix
• submit a credible 3 year plan in line with the current planning framework.

Quality and Safety

In order for the health board to be de-escalated to the next level of intervention, they must demonstrate:

• evidence of robust quality governance and improvement

The organisation must evidence the criteria through:

• quality and safety, quality governance and quality improvement with an agreed bi-annual self-assessment

High-level concerns related to performance and outcomes include: 

Repeated failure to deliver major national programmes to agreed milestones, with delivery slippage becoming normalised despite recovery actions and executive assurances (for example, continued delays across the NHS Wales App, LIMS, RISP and WICIS). 

Sustained under‑realisation of intended clinical, operational and productivity benefits, with success often evidenced through activity or partial deployment rather than outcomes (for example, the NHS Wales App and diagnostics programmes showing limited evidence of benefits realised at scale despite sustained investment). 

Revised timelines, programme resets and additional support have not restored delivery confidence, pace or quality, undermining the credibility of forward plans and performance reporting (for example, repeated reprofiling of milestones across national diagnostics and WICIS without materially different outcomes). 

Achievement of milestones has not consistently aligned with readiness for live service use, as evidenced by post‑milestone issues (for example, ongoing clinical safety, technical stability and operational support concerns following key releases within LIMS, RISP and other national platforms). 

Delays and uncertainty in national digital delivery are constraining health board planning, operational readiness and local transformation activity (for example, uncertainty around NHS Wales App sequencing limiting local adoption planning and benefits realisation). 

Persistent underperformance across multiple programmes absorbing disproportionate senior leadership attention and delivery capacity and reducing the ability to focus on higher‑confidence initiatives (for example, extended senior recovery focus on NHS Wales App, diagnostics and WICIS limiting progress on other national priorities).

High-level concerns related to governance, leadership and culture include:

Senior leadership has not consistently modelled a strong delivery culture grounded in realism, early escalation and decisive action (for example, optimism bias and late challenge emerging around recovery confidence in major programmes such as the NHS Wales App and diagnostics).

Cultural factors appear to inhibit early, open reporting of delivery risk, dependencies and confidence, resulting in issues surfacing at the point of impact rather than through proactive management (for example, delivery and readiness concerns escalating late across programmes such as WICIS and RISP).

Leadership focus has tended to prioritise organisational milestone delivery over end‑to‑end system outcomes, including health board readiness and operational impact (for example, programme milestones being achieved without assured local capacity, readiness or benefit realisation for deployments such as the NHS Wales App).

Engagement with health boards has not consistently reflected co‑design or shared accountability, reinforcing transactional rather than collaborative system working (for example, variable health board commitment and continued reliance on Welsh Government brokerage to secure adoption of national programmes).

Leadership behaviours and structures have not consistently reinforced shared responsibility for cross‑cutting outcomes, limiting system trust and confidence (for example, low and variable confidence across health boards and national governance forums in DHCW’s ability to deliver complex, interdependent programmes reliably).

Insufficient delivery capacity and capability across a high‑risk national portfolio. The scale, complexity and concurrency of national programmes exceed available workforce capacity and capability, limiting delivery pace and the ability to recover underperforming work (for example, Programmes including EPS rollout, LIMS, RISP and WICIS required repeated re‑forecasting and remediation, reflecting challenges in managing dependencies, suppliers and all‑Wales readiness).

Fragility arising from over‑reliance on critical individuals. Key programmes and assurance functions depend on a small number of individuals, creating single points of failure and increasing delivery and escalation risk (for example discussions repeatedly highlighted reliance on specific programme, clinical safety and architecture leads, with progress slowing when these individuals were unavailable or diverted to urgent priorities).

Sustainability risks from workforce model and specialist skill constraints. Heavy reliance on temporary, contract and externally funded roles, combined with stretched specialist skills, undermines organisational resilience and knowledge retention (for example, delivery across DPIF‑funded programmes has been supported by short‑term roles, with ongoing concern about sustaining capability once external funding ends and managing handover risk).

Limited headroom for recovery, surge activity or reprioritisation. The current workforce profile provides little flexibility to respond to emerging issues or ministerial priorities without displacing other committed work (for example, enhanced monitoring and escalation activity absorbed senior and specialist capacity, reducing the organisation’s ability to proactively support recovery in other at‑risk programmes).

Organisational growth not yet matched by delivery maturity. Significant growth in scope, staffing and funding has not yet resulted in a commensurate improvement in delivery maturity or outcome. (for example, the shift from a detailed 2025 to 2o26 milestone‑heavy remit to a more outcome‑focused 2026 to 2027 remit reflected recognition that increased activity had not improved delivery confidence).

Erosion of confidence among health boards and system partners. Repeated delays, resets and changes to delivery timelines have reduced confidence in DHCW’s ability to deliver national programmes predictably, affecting local engagement and commitment (for example ongoing slippage and re‑profiling in programmes such as the NHS Wales App and EPS rollout have contributed to increased caution from health boards around planning, adoption and dependency commitments).

Reduced credibility of national digital delivery commitments. Persistent under‑delivery across major programmes risks undermining confidence in national digital ambitions and future commitments across the NHS and Welsh Government (for example, continued challenges in programmes like LIMS, RISP and Digital Maternity have weakened confidence that nationally announced milestones can be delivered to plan).

Increased scrutiny and challenge from oversight bodies. Performance, assurance and delivery issues heighten the risk of further adverse scrutiny, with reputational implications for both DHCW and Welsh Government (for example, sustained escalation, enhanced monitoring and engagement with Audit Wales and Public Accountability Meetings have increased visibility of delivery concerns and system confidence issues).

Risk of disengagement from future national transformation. Perceived delivery risk may make health boards more cautious or resistant to participation in future national initiatives, undermining system‑wide digital transformation (for example, delivery experience on complex national programmes has increased scepticism about future all‑Wales rollouts, particularly where local cost, workforce or change impacts are unclear).

Impact on ministerial, public and broader reputational confidence. Ongoing visibility of difficulties in high‑profile programmes risks shaping wider perceptions of DHCW capability, regardless of progress elsewhere, and may attract public or media attention. (for example, high‑profile programmes linked to frontline services, combined with increased FOI requests and public commentary on digital delivery, risk amplifying reputational damage in the absence of decisive system‑level intervention). 

High level concerns related to finance, strategy and planning includes:

Escalating cost exposure in under‑performing national programmes. Significant investment has continued in major national digital programmes without commensurate progress toward delivery, increasing the risk of poor value for money and sunk‑cost lock‑in (for example, high levels of historic and ongoing investment, including DPIF‑funded activity, have not consistently translated into demonstrable outcomes in some priority programmes).

Weak alignment between financial spend and delivery confidence. Continued funding has not always been clearly linked to independently assured delivery readiness or likelihood of benefits realisation, limiting confidence that expenditure is proportionate (for example, repeated re‑profiling and additional funding requests have occurred despite persistent delivery risks and low confidence trajectories).

Limited financial grip and decision‑making at portfolio level. Financial oversight is stronger at individual programme level than across the national portfolio, constraining the ability to rebalance investment toward higher‑confidence or higher‑impact outcomes (for example, portfolio‑level affordability and prioritisation trade‑offs are not consistently visible, reducing assurance that spend reflects strategic risk and benefit).

Insufficient use of pause, reset or stop mechanisms to control cost. Governance arrangements have not consistently enabled timely financial intervention when delivery confidence deteriorates, resulting in continued expenditure on low‑confidence trajectories (for example, investment has often continued during periods of enhanced monitoring or recovery, rather than being actively constrained or reset).

Medium‑ to long‑term affordability risks for the system remain unclear. The cumulative cost of maintaining, supporting and evolving multiple national digital systems is not articulated within a coherent long‑term financial sustainability model, including downstream impacts on health boards (for example, national solutions risk creating unfunded local implementation, workforce and support pressures alongside ongoing central system costs).