Hywel Dda University Health Board Escalation Framework: September 2025

Following an assessment against the NHS Wales oversight and escalation framework in July 2025, Hywel Dda Bay University Health Board escalation levels are as follows:

• level 4 for finance, strategy and planning, performance and outcomes related to urgent and emergency care, quality of care related to HCAIs and fragile services
• level 3 for performance and outcomes related to planned care, cancer and leadership and governance

Level 4 (targeted intervention) 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 the health board 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 the NHS Wales Performance and Intervention (NHS P&I) directed by Welsh Government. If appropriate, external support will be agreed with the organisation.

Level 3 (enhanced monitoring) occurs when Welsh Government has identified serious concerns related to the NHS organisation. Monitoring will be more frequent than that carried out under routine arrangements and may also take a wider variety of forms, including regular interactions and meetings in addition to written progress updates and submission of evidence, including updated action plans and qualitative and quantitative data. The NHS organisation will need to demonstrate that it is taking a proactive response to the escalation and will need to put in place effective processes to address the issue(s) and drive improvement itself. Welsh Government will co-ordinate activity to closely monitor, challenge and review progress. 

September 2022 

The health board was escalated to targeted intervention from enhanced monitoring for finance and planning. Quality and performance remained in enhanced monitoring following concerns around urgent and emergency care, planned care including cancer, neurodevelopment and child and adolescent mental health services.

January 2024

The health board was escalated to level 4 (targeted Intervention). The escalation of the whole organisation into level 4 reflected escalating concerns across all the domains within the oversight and escalation framework.

March 2025

The health board was de-escalated to level 3 for performance and outcomes relating to planned care and CAMHS and for leadership and governance.

July 2025 

The health board was de-escalated to level 3 for cancer and to level 1 for CAMHS.

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: we will seek to minimise duplication by working collaboratively with other national committees, groups and programmes
• collective: we will maximise shared knowledge by sharing common approaches, tools, guidance
• impact focussed: we will examine and seek assurance and evidence how organisations are obtaining assurance over delivery and impact of actions
• be undertaken with openness. transparency, and mutual trust and respect between the health board, Welsh Government, and the NHS P&I

Whilst the health board is in escalation:

• normal performance management arrangements will continue through the Integrated Quality, Planning and Delivery (IQPD) and Joint Executive Team (JET) meetings
• quarterly escalation meetings will be chaired by the Director General of the Health, Social Care and Early Years Group Chief Executive NHS Wales: these will cover both the level 4 and 3 progress, but with a greater scrutiny on level 4 actions and impact. The May and November meetings will be part of the JET meeting
• finance, strategy and planning level 4 touchpoint meetings will be agreed with the Finance, Planning and Delivery team within NHS P&I: these will examine progress made against the action log, review evidence and agree outputs for inclusion at the Welsh Government led escalation meetings
• the monthly IQPD meetings led by Welsh Government will be utilised to ensure effective ongoing oversight against the concerns related to performance and outcomes domain

This framework sets out the expectations for de-escalation against each area and domain of escalation. Where possible, these de-escalation criteria are consistent with other health organisations in escalation.

De-escalation will be no more than 1 level at a time with reduced oversight and intervention at each stage of de-escalation. De-escalation from level 3 (enhanced monitoring) will typically be to level 1 (routine arrangements).

To be considered for de-escalation, an organisation must demonstrate that progress towards the de-escalation criteria is being made.

There are 2 approaches to de-escalation:

• The 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 sustained improvements with a credible improvement plan to maintain improvements.
• 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 of time. 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:

• support a formal structure for reviewing and reporting progress
• signpost relevant best practice guidance and frameworks
• act as a critical friend and sounding board on existing practices and new developments
• review and provide feedback on action plans
• undertake and share relevant analysis and deep dives of national data
• enable shared approaches to key national issues across Welsh organisations and promote shared learning.
• direct the NHS P&I to provide targeted support to areas of concern to help the health board to improve their progress against programme objectives
• work with the health board on critical enablers relating to regional planning, clinical services redesign, infrastructure (digital and buildings)

The roles and responsibilities of the health board are to:

• appoint SROs for all areas of escalation
• ensure Board ownership and oversight with a clear governance structure, ensure that the Board is appraised of the escalation plan and evidence regular progress updates to the Board on progress against de-escalation criteria
• produce a realistic and achievable level 3 and level 4 plan in response to the areas of concern and in line with the agreed de-escalation criteria
• provide progress reports and evidence against the escalation plan to Welsh Government
• give assurance that there are formal review mechanisms in place within the health board to monitor and deliver the required improvements

Finance

The health board will be required to action and:

• Demonstrate financial governance and financial control environment mechanisms that are robust, and sufficient assurance is received on their effectiveness by undertaking a review of the financial management arrangements in place against an appropriate best practice frameworks and developing and implementing an action plan to address any gaps in approach
• Articulate clearly the drivers of the current deficit to inform a triangulated approach to identify and deliver actions that will improve efficiency, sustainably reduce costs, and maximise the sustainable use of resources.
• Evidence clear policies and processes supporting the identification, delivery and monitoring of all savings schemes and opportunities. This should include having a clear and robust opportunities framework and pipeline that contains realistic opportunities to support and manage the short-term challenges being faced, as well as driving the larger-scale transformational changes that will support long-term sustainability.
• Evidence an integrated planning approach and strategy to deliver as a minimum the 2024 to 2025 outturn position set for the health board, with a clear roadmap and key milestones for delivery of a breakeven plan over the medium term. This should include clear and realistic planning assumptions, which triangulates with the organisation’s longer-term strategic objectives around service delivery, workforce, infrastructure, etc.
• Challenge and stress-test the health board’s plan submission for 2025 to 2026 and identifying opportunities for improvement.
• Deliver an improving financial trajectory in line with the organisation’s Board approved plans, including significant progress towards in-year financial balance over the next 3 years.

The health board will be required to action and demonstrate financial governance and a control environment through:

• the financial governance framework at the health board that is robust in both design and implementation, including a self-assessment against best practice frameworks
• the financial committee structure; clearly articulated and addresses key risks
• financial reports and supplementary presentations that include the analysis and narrative explanation required to enable management and the board to discharge their duties
• financial controls at the health board that are robust in both design and implementation, including a self-assessment against model frameworks, review implementation of the Standing Financial Instructions, internal audit reviews, or other control reviews
• the finance function that has the necessary capacity and capability to support the needs of the wider organisation
• holding budget holders and managers to account for delivering their financial plans
• delivery of its action plan to improve the financial governance and financial control environment

The health board will be required to action and demonstrate understanding of the existing deficit and key drivers and must:

• demonstrate there is a clear understanding of the cost drivers and investment decisions responsible for the growth in deficit across the organisation, including an explicit breakdown by key service area and cost driver
• review prior year investments to assess whether the planned benefits have been delivered
• implement a robust process for challenging underlying deficits reported at local divisional levels
• understand that the drivers and investment decisions responsible for the growth in workforce are well understood and are reviewed for ongoing value; and are monitored through the integrated performance report
• ensure integrated performance reports clearly identify and monitor metrics against key activity cost drivers

As a result of the above, there are triangulated approaches to identify and deliver actions to improve efficiency and maximise the use of resources

The health board will be required to action and demonstrate development and realisation of opportunities and must:

• have a clear process and approach across the organisation to support the identification, delivery and monitoring of all savings schemes
• develop a comprehensive opportunities framework with a constant pipeline of opportunities and establish clear roles and responsibilities for developing opportunities into saving schemes and subsequent delivery of these saving schemes
• translate national opportunities identified through the Value and Sustainability Board into local savings
• have clear policies and processes in place to enable budget holders and managers to realise and deliver identified savings schemes
• demonstrate how the health board uses Value based health care principles across the organisation through specified services and pathways

The health board will be required to action and demonstrate a clear financial plan and strategy through:

• an integrated and triangulated plan, with clear and realistic planning assumptions to deliver a recurrent breakeven position over the medium-term, with a clear roadmap and key milestones for delivery
• a clear engagement plan to communicate the necessity for financial improvement across the organisation

The health board will be required to action and demonstrate delivery of a plan through:

• a clear improvement in the planned financial trajectory for 2025 to 2026 (significant progress towards delivery of the target control total), including further progress around identification and delivery of recurring opportunities

De-escalation criteria

In order for the health board to be de-escalated to the next level of intervention, they must meet the criteria set out below:

• demonstrate that there are robust financial governance and robust financial control environment in place with risks minimised
• make substantial progress in delivering the level 4 action plan, including actions to improve the organisation’s understanding of the existing deficit and key drivers and development and realisation of opportunities
• demonstrate a substantial financial improvement trajectory to deliver as a minimum the outturn position of 2024 to 2025 and progress towards 3 year trajectory to in-year financial balance

The strategy and planning intervention and focus whilst in level 4 escalation covers the following areas.

The health board will be required to action and demonstrate delivery of milestones within the approved plan and must:

• show evidence of improved integrated planning across the organisation to develop an approvable IMTP, providing a route map towards the health board’s longer-term ambition
• deliver a credible annual plan as a stepping stone towards a full and financially balanced IMTP
• make good progress in delivering the ministerial targets, delivery expectations and enabling actions (as set out in the NHS Wales Planning framework 2025 to 2028), accountability criteria and the level 4 requirements

The health board will be required to demonstrate how the delivery of a clinical strategy and plan is supporting:

• future planning and investment decisions
• decision making across the organisation

The health board will be required to demonstrate how regional planning is supporting the health board to:

• ensure the delivery of key objectives through the Joint Committee with Swansea Bay University Health Board, demonstrating improved regional collaboration where required to ensure continued safety, quality and ongoing viability and sustainability of regional services, including orthopaedics and ophthalmology

De-escalation criteria

In order for the health board to be de-escalated to the next level of intervention, they must meet the criteria set out below:

• submit an acceptable annual plan in line with the current planning framework
• evidence an integrated planning across the organisation which supports the development of a coherent and deliverable annual plan
• evidence a clear roadmap and implementation of the health board’s clinical services plan
• increase Welsh Government’s confidence in delivery based on an assessment against an agreed planning maturity matrix evidence progress made with regional planning in relation to orthopaedics, ophthalmology, stroke services, urology, and upper gastrointestinal services in 2025 to 2026 as demonstrated by joint plans, improved working, and increased activity delivered through regional working

The fragile services intervention and focus whilst in level 4 will alter over time in response to workforce and estate challenges. The current focus will be on the 9 clinical areas identified in the health board’s clinical services plan:

• Critical care
• Dermatology
• Elective orthopaedics
• Ophthalmology
• Urology
• Emergency general surgery
• Stroke
• Endoscopy
• Radiology

De-escalation criteria

In order for the health board to be de-escalated to the next level of intervention, they must meet the criteria set out below:

• evidence that the health board has the appropriate mechanism to understand the drivers behind a fragile service through the triangulation of key data points, including staffing levels, staff and patient feedback, concerns, incidents, stakeholder feedback (such as, HIW, Audit Wales, HMC, Royal Colleges, Llais), mortality reviews, duty of quality, candour, infection protection control, performance, clinical and medical leadership
• demonstrate that fragile services are supported by strong clinical leadership, have an effective integrated improvement plan, project management structure and effective transformation support
• show progress is being made towards key performance metrics
• evidence that all recommendations from the Royal Colleges, HIW and other reviews specific to Hywel Dda UHB are discharged and either verified or delivered or scheduled for delivery within the health board's longer-term improvement plan
• evidence that the Board is sighted on fragile services and has a robust response and action plan for each area
• 65% R1 ophthalmology patient pathways to be waiting within or no longer than 25% of their target date for an outpatient appointment and maintained for 3 months

Urgent and emergency care 

The performance and outcomes level 4 intervention and focus for urgent and emergency care (UEC) covers the following areas: 

The health board will be required to action and demonstrate sustainable services and must:

• ensure that recovery and improvement plans are in place and that agreed priorities are being implemented, in accordance with evidence-based practice and national requirements
• improve unscheduled care performance to ensure that patients access safe, timely and effective unscheduled care services, reducing waiting times, delays and improving quality
• deliver activity in line with agreed trajectories and implement any necessary changes where performance falls below trajectory
• deliver the UEC enabling actions in the 2025 to 2028 planning guidance
• demonstrate how the health board responds and handles concerns, complaints, incidents and patient experience feedback related to UEC as part of the quarterly escalation meetings
• assess declared BCIs, including reasons why, actions taken, and lessons learnt
• ensure that patients are clear where they can and should access support, signposting away from emergency services

The health board will be required to action and demonstrate working with national programmes and respond to external reviews and must: 

• work with and implement the recommendations from national programmes including but not limited to Strategic Programme of Primary Care, Six Goals for Emergency Care and the National Diagnostic and Endoscopy Programmes
• support the implementation and realisation of GiRFT and the national programme reviews opportunities.
• develop a prompt response to any HIW unannounced inspections, Audit Wales and Royal College recommendation, developing and completing action plans that demonstrate sustainable evidence

De-escalation criteria

In order for the health board to be de-escalated to the next level of intervention, they must meet the criteria set out below:

• continuous reduction of ambulance handovers over an hour of at least 11% in 3 consecutive months and maintained for 3 months (Based on agreed baseline)
• continuous monthly improvement towards achieving no more than 7% of patients waiting over 12 hours at each individual site and across the health board
• continuous improvement in the median time from arrival at an emergency department to assessment by a clinical decision maker to achieve a maximum of 60 minutes
• continuous reduction in delayed pathways of care (with a focus on those caused by assessment issues) of 5% for 3 consecutive months and then maintained (based on agreed baseline)

The enabling metrics for de-escalation are:

• a 3 month continuous reduction of at least 5% in each month, from the November 2023 baseline, in the number of people admitted as an emergency who remain in hospital over 21 days since admission
• a 3 month continuous reduction of at least 5% in each month in pathways of care assessments issues from the November 2023 baseline

Quality of care related to HCAIs 

The performance and outcomes level 4 intervention and focus for quality of care related to Healthcare Acquired Infections (HCAIs) covers the following areas: 

The health board will be required to demonstrate how they are delivering sustainable services through:

• stabilisation of the increased trajectory of cases of HCAI and evidence of continuous improvement accompanied by a strong QI approach and plan that has oversight and monitoring by the health board Quality, Safety and Experience Committee and Board

The health board will be required to demonstrate appropriate governance and leadership through:

• a clear improvement plan based on a root cause analysis to address the issue of hospital onset HCAIs
• having clear and effective response mechanisms in place to respond to outbreaks reporting directly to Board

De-escalation criteria

In order for the health board to be de-escalated to the next level of intervention, they must meet the criteria set out below:

• reduce the number of hospital onset C-Diff infections by 25% and maintain for 3 months (from a baseline of the average number of cases in quarter 3 (2023 to 2024) of 8 cases to no more than 6 per month)
• reduce the number of hospital onset Staph Aureus infections by 33% and maintain for 3 months (from a baseline of the average number of cases in quarter 3 (2023 to 2024) of 3 cases to no more than 2 per month)
• reduce the number of hospital onset E-Coli infections by 25% and maintain for 3 months (from a baseline of the average number of cases in quarter 3 (2023 to 2024) of 7 cases to no more than 5 per month)

Planned care and cancer

The performance and outcomes level 3 intervention and focus for planned care and cancer covers the following areas: 

The health board must demonstrate how they have sustainable planned care and cancer services through:

• a robust improvement plan in accordance with evidence-based practice and national requirements
• improved access to planned care and cancer services with reduced waiting times in line with the de-escalation criteria
• delivery of the planned care and cancer enabling actions in the 2025 to 2028 planning guidance
• compliance with all aspects of the cancer national optimum pathways and maintain cancer performance in line with the agreed standards and ensure the backlog of patients waiting over 62 and 104-days is kept to a minimum agreed level
• how the health board responds and handles concerns, complaints, incidents and patient experience feedback related to planned care and cancer at the quarterly escalation meetings
• implementation of an outpatient transformation plan in line with the requirements of the planned care programme
• utilisation of regional working arrangements to improve outcomes and improved access to services

The health board will be required to action and demonstrate working with national programmes and respond to external reviews and must: 

• work with and implement the recommendations from national programmes including but not limited to Planned Care Improvement, Cancer Recovery Programme and the National Diagnostic and Endoscopy Programmes
• support the implementation and realisation of the 3 Ps policy, GiRFT, theatre optimisation, the CIN optimisation programmes and related national improvement recommendations
• respond effectively to HIW unannounced inspections, Audit Wales and Royal College recommendations, developing and completing action plans that demonstrate sustainable evidence

The health board must demonstrate improved communications and engagement through:

• having effective and meaningful engagement with patients related to service changes, waiting times policies and the provision of appropriate support that keeps patients well whilst waiting
• ensuring patients are clear where they can and should access support
• ensuring the benefits of new pathways such as straight to test, primary care management, self-management and see on symptoms pathways are communicated effectively

De-escalation criteria

In order for the health board to be de-escalated, they must meet the criteria set out below:

• maintain a minimum of 63% compliance for 3 months against the suspected cancer target
• 100% of open outpatient pathways to be waiting less than 52 weeks and maintained for 3 months
• continuous improvement towards 75% of all open outpatient pathways waiting less than 26 weeks
• 100% of open pathways to be waiting less than 104 weeks and maintained for 3 months
• continuous improvement towards 80% of all open pathways waiting less than 36 weeks
• continuous monthly improvement towards achieving a 12% reduction in the number of patients delayed by 100% for their follow up appointment in 3 consecutive months and maintained for 3 months (based on the agreed baseline)
• 85% of patients waiting for a diagnostic test to be waiting less than 8 weeks and maintained for 3 months
• 85% of patients waiting for a diagnostic endoscopy to be waiting less than 8 weeks and maintained for 3 months
• 85% of patients waiting for a NOUS and non-cardiac MRI to be waiting less than 8 weeks and maintained for 3 months
• 90% of patients waiting for therapies to be waiting less than 14 weeks and maintained for 3 months

The governance and leadership level 3 intervention and focus covers the following areas, and the health board will be required to action and demonstrate.

The health board must develop improved governance to show:

• all parts of the organisation are clear on accountability and expectations at all levels to ensure successful delivery.
• effective decision making is in place that supports financial management, performance improvement, safe, timely and quality care
• revised standard operating processes are in place following the organisational restructure and have been successfully audited
• effective programme management, 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; effective, open and transparent reporting, with effective strategic board oversight.
• the health board is a data-driven organisation that ensures data is understood and utilised in decision making at all levels
• effective oversight and scrutiny of current service provision consistently being provided by the board and the appropriate committees
• succession and development plans are in place to ensure operational efficiency at all times

The health board must demonstrate and action improved leadership through:

• delivery and leadership that enables the organisation to implement national strategic programme objectives
• an improvement in sustainable service delivery with increased focus on the short and medium term.
• ongoing development of leadership and management skills at all levels and professions to strengthen management maturity
• being focussed on all aspects of strategic workforce planning and maximising the skills of its current staff.
• continued embedding and demonstrating lived values and behaviours throughout the organisation.
• visible and effective clinical leadership
• positive shifts in culture in key areas such as multidisciplinary working
• senior leaders setting the desired culture and tone for the organisation which promotes equality, inclusivity, openness and transparency
• a listening, learning, and improving culture being embedded throughout the organisation based on early and rapid triangulation and resolution of issues from a variety of sources, including patient outcomes, user and staff feedback

The health board must demonstrate how Board self-assessment supports:

• review of strategic risks and ensure that risk management is aligned with the health board’s risk appetite
• an appropriate governance framework is in place, particularly with regards to providing appropriate scrutiny of performance, leadership style and practice
• regular self-assessment against an agreed maturity matrix
• responsiveness to the outcome of self-assessments and external assessments and observations by setting objectives that will improve effectiveness

De-escalation criteria

In order for the health board to be de-escalated, they must meet the criteria set out below:

• revised standard operating processes in place following the organisational restructure assessed as effective by internal audit
• effective oversight and scrutiny of current service provision consistently being provided by the Board and the appropriate Committee(s) as demonstrated by Committee and Board papers, including evidence of Board considering the Duty of Quality to inform their decision making
• effective programme and performance management structure is in place, with effective Board oversight and a clear performance and delivery framework that drives improvement
• Board is sighted on key risks and areas of concern on a regular basis and is able to offer constructive scrutiny on performance and effective oversight and scrutiny
• clear governance and assurance systems in place with issues escalated appropriately through clear structures and processes
• full and substantive Executive Director Team, with a clear organisational structure in place with robust succession and development plans in place to ensure adequate capacity and capability in all areas of the organisation to deliver high quality, sustainable care
• effective leadership programmes are in place to support the ongoing development of leadership and management skills at all levels and professions to strengthen management maturity
• improving staff engagement in NHS Wales surveys
• self-assessment against the governance and leadership maturity matrix which evidences the agreed level.
• the Board acts on, and addresses appropriately, concerns raised through NHS regulators and Royal Colleges