Cwm Taf Morgannwg University Health Board escalation framework: August 2025

Following an assessment against the NHS Wales oversight and escalation framework in June 2025, Cwm Taf Morgannwg University Health Board escalation levels are as follows:

• level 4 for performance and outcomes related to urgent and emergency care
• level 3 for performance and outcomes related to planned care and cancer

Cwm Taf Morgannwg University Health Board is in 2 levels of escalation.

Level 4 (targeted intervention)

This 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 in order 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 directed by Welsh Government. If appropriate, external support will be agreed with the organisation.

Level 3 (enhanced monitoring)

This 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 issues and drive improvement itself. Welsh Government will co-ordinate activity to closely monitor, challenge and review progress.

November 2022

Planning and finance was escalated to enhanced monitoring as the health board had been unable to produce an approvable balanced 3 year plan.

Quality related to performance and long waiting times were escalated to targeted intervention following concerns around urgent and emergency care, planned care and cancer and CAMHS.

April 2024

Quality and governance domains were de-escalated from enhanced monitoring (level 3) to routine arrangements (level 1).

Maternity and neonatal services were de-escalated from enhanced monitoring (level 3) to routine arrangements (level 1).

November 2024

Performance and outcomes related to child and adolescent mental health services (CAMHS) measures was de-escalated to level 3 (enhanced monitoring).

March 2025

Performance and outcomes related to child and adolescent mental health services (CAMHS) measures was de-escalated to level 1 (routine arrangements).

Performance and outcomes related to planned care and cancer was de-escalated to level 3 (enhanced monitoring).

July 2025

Finance, strategy and planning was de-escalated to level 1 (routine arrangements).

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 Wales Performance and Improvement

Whilst the health board is in escalation:

• Normal performance management arrangements will continue through the Integrated quality, planning and delivery board (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 and 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 monthly integrated quality, planning and delivery meetings led by Welsh Government will be utilised to ensure effective ongoing oversight against the concerns related to performance and outcomes domain. This will incorporate the monthly oversight for UEC).

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 one 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:

• 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 NHS Performance and Improvement 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 an escalation intervention plan in response to the areas of concern and commit sufficient resources to ensure that the plan deliverables are achieved
• 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

Urgent and emergency care

The performance and outcomes level 4 intervention and focus for urgent and emergency 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
• ensure patients can access safe, timely and effective unscheduled care services
• deliver activity in line with agreed trajectories and implement any necessary changes where performance falls below trajectory
• demonstrate how the health board responds and handles concerns, complaints, incidents and patient experience feedback related to UEC (assessment of declared BCIs, including reasons why, actions taken, and lessons learnt)
• ensure delivery of the UEC enabling actions in the 2025 to 2028 planning guidance
• 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, 6 goals for emergency care and the national diagnostic and endoscopy programmes
• support the implementation and realisation of the GIRFT and the national programme reviews opportunities
• develop a prompt response to any Healthcare Inspectorate Wales (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:

• 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 improvement towards no more than 7% of patients waiting over 12 hours at each individual site and across the health board
• median time from arrival at an emergency department to assessment by a clinical decision maker should not exceed 60 minutes and maintained for 3 months
• 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)

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 will be required to action and demonstrate sustainable planned care and cancer services and must:

• develop a robust improvement plan in accordance with evidence-based practice and national requirements
• improve access to planned care and cancer services with reduced waiting times in line with the de-escalation criteria
• ensure delivery of the planned care and cancer enabling actions in the 2025 to 2028 planning guidance
• ensure compliance with all aspects of the cancer national optimum pathways and maintain cancer performance in line with the agreed standards and ensure that the backlog of patients waiting over 62 and 104 days is kept to a minimum agreed level
• demonstrate how the health board responds and handles concerns, complaints, incidents and patient experience feedback related to planned care
• ensure implementation of an outpatient’s transformation plan in line with the requirements of the planned care programme
• utilise 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
  • 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
• ensure effective responses to HIW unannounced inspections, Audit Wales and Royal College recommendations, developing and completing action plans that demonstrate sustainable evidence

The health board will be required to action and demonstrate effective communications and engagement and must ensure:

• meaningful engagement with patients related to service changes, waiting times policies and the provision of appropriate support that keep patients well whilst waiting
• patients are clear where they can and should access support
• 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:

• 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
• 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 agreed baseline)
• 68% 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
• 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