Cardiff and Vale University Health Board oversight and escalation framework: March 2026

Following an assessment against the NHS Wales oversight and escalation framework in June 2025, Cardiff and Vale University Health Board escalation level is level 4.

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 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 NHS Wales Performance and Improvement directed by Welsh Government. If appropriate, external support will be agreed with the organisation.

October 2022

Cardiff and Vale University Health Board was escalated to enhanced monitoring for finance, strategy and planning as the health board was unable to produce an approvable balanced 3 year plan in accordance with the direction given by Welsh Ministers and the NHS Planning Framework, which could be considered for approval under section 175(2A) of the NHS (Wales) Act 2006 (“the 2006 Act”).  

January 2024

The Minister for Health and Social Services confirmed the escalation status of Cardiff and Vale University Health Board would remain in level 3 enhanced monitoring for finance, strategy and planning.

March 2025

Cardiff and Vale University Health Board was escalated to level 4 (targeted intervention) for finance, strategy and planning due to a further deterioration of the financial deficit and the inability to achieve the set target control total for 2024 to 2025. 

July 2025

Cardiff and Vale University Health Board was escalated to level 4 due to increasing financial deficit, quality, planned care waiting times, cultural 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 five 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, and 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 Performance and Improvement

This framework sets out the expectations against each escalation domain. 

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 will be to level 1 (routine arrangements).

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 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 progress against the agreed improvement plan with sustained improvements against the de-escalation criteria over two successive quarters.
• 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:

• support a formal structure for reviewing and reporting progress
• signpost relevant best practice guidance and frameworks
• review and provide feedback on developed products
• enable shared approaches to key national issues across Welsh NHS organisations and promote shared learning
• direct NHS Performance & Improvement (NHS P&I) or make alternative arrangements to provide targeted support to areas of concern
• 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 an SRO for escalation and appropriate project leads. It is recommended that the SRO should be the Chief Executive Officer
• 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 level 4 plan in response to the areas of concern and commit sufficient resources to ensure that the plan deliverables are achieved
• provide regular progress reports and evidence against the escalation plan to Welsh Government

Welsh Government assessment of Cardiff and Vale University Health Board against the escalation domains in June 2025, raised concerns related to finance, quality, clinical services, leadership and governance. Having considered all the evidence, a decision was made 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 quality, cultural change, governance, and leadership.

Summary of high-level concerns as noted in June 2025

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

• the health board not forecasting achieving the targets set for the percentage of patients waiting over 52-weeks for a first outpatient appointment, over 104 weeks for referral to treatment and over 8 weeks for diagnostics.
• Planned care: the health board did not deliver the end of Q4 2024 to 2025 position or achieve target, Q1 2025 to 2026 plan has required further intervention to ensure delivery.
• Diagnostics: in April 2025, only 42.4% of pathways waiting for a specified diagnostics test waited less than 8 weeks, the worst performance of any health board. Only 17.6% were waiting less than 8 weeks for diagnostic endoscopy and 33.9% for NOUS, both being the worst performance across Wales.
• Urgent and emergency care: overall, the health board has performed well in this area but remains below the national targets.
• Adult mental health performance: for part 1A for adults remains challenged with the 80% target only being achieved once over the last 12 months and performance in April 2025 being at just 29.6%. Part 2 has shown little improvement over the last twelve months and remains below target.

A summary of high-level concerns related to quality includes:

• a high level of never events with 16 having occurred since January 2024 including six since January 2025
• the organisation does not currently have an established governance group to oversee the implementation of NatSSIPs2, which is a core requirement
• poor compliance with policies and procedures such as adoption of WHO checklist and IPC guidelines
• IPC infection rates: C.difficile and E. coli rates are variable, suggesting gaps in consistent infection prevention measures
• the health board complaint closure rate has been falling since August 2024
• an increasing mortality trend developing or mortality higher than Wales average for both hip fracture and stroke mortality

A summary of high-level concerns related to clinical services includes:

• a significant number of clinical service risks, and fragile or challenged services within the health board, including bone marrow and stem cells, critical care, paediatric critical care, gastroenterology, endoscopy and neuroscience.
• Stroke: the percentage of stroke patients given thrombolysis has been falling since May 2024. There is some evidence of improvement over the last two months as rates increased to almost 10% in February 2025.
• Identified as an outlier in NNAP and previously in the MBRRACE audits for maternity and neonatal services and are neonatal unit is in level 3 escalation with NJCC.
• In quarter 4 of 2024 to 2025 (March), 55.8% of neonatal shifts were staffed to British Association of Perinatal Medicine (BAPM) guidelines against a NNAP national average of 82.5%.
• HIW inspection reports and an invited Royal College of Psychiatry review of mental health services highlighted issues with risk assessment, care planning and investigation processes.

A summary of high-level concerns arising from both internal and external service reviews of HSDU, theatres, cardiology, adult mental health and wet AMD includes:

• unprofessional behaviour, including swearing, bullying, harassment, and coercive behaviour
• issues related to psychological and physical safety
• lack of effective management and leadership
• poor teamwork and lack of trust
• inconsistently applied HR policies, and systemic poor behaviours tolerated
• concerns about fairness in promotions and work-life balance
• lack of a reporting culture, absence of standardised pathways and inconsistent practice
• failure to report, escalate or learn from errors, near misses, and incidents
• concerns about ability to speak up
• persistent safety risks with issues with assessing and addressing risk
• poor documentation, record keeping and adherence to policies
• operational inefficiencies and lack of strategic planning
• poor estate conditions affecting service delivery and staff morale
• lack of robust governance frameworks

A summary of high-level concerns related to governance and leadership includes:

• concerns about the ability to deliver organisational redesign and change
• workforce surveys highlight cultural and well-being concerns
• safeguarding and staff conduct raised in a number of internal and external forums
• five risks scoring 25, and 62 scoring 20 on the health board’s corporate risk register

A summary of high-level concerns related to prevention and population health includes:

• general medical services sustainability is recorded on the health board’s risk register as a risk level 20 to 25.
• the health board has not been able to implement the ear wax management primary and community care pathway and not been able to progress in increasing the number of first point of contact advanced audiology practitioners
• the health board was identified as an alarm outlier in the National Paediatric Diabetes Audit 2023-24 for adjusted mean HbA1c (30.5%)
• vaccination and immunisation uptake in the health board has historically been amongst the lowest in Wales, especially in regard to childhood vaccinations

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

• the health board forecasting a year-end deficit of £58.2 million, above the control total of £9.1 million, and more than double the outturn deficit of 2024 to 2025 of £27.1 million
• the health board was unable to submit a financially balanced IMTP or supportable and acceptable annual plan.
• self- assessment against the planning maturity matrix was level 1
• significant vacancies within strategic planning function
• management and condition of health board estate

Intervention support

The health board has recognised these internal issues and has itself started a series of its own interventions and have programmes in many areas in response to their internal concerns over the last year; this includes:

• mental health transformation 
• shaping our future quality excellence
• shaping our future generations 
• organisational re-design and the future operating model
• community by design
• clinical services plan
• population health plan
• people and culture plan
• digital and estates plan 

The health board is tendering for expertise to aid them in identifying financial options and choices to enable the articulation of a credible financial plan for 2026 to 2027 and beyond.

These programmes are underway and at different stages of development and delivery and include elements of external independent provider support. The Welsh Government intervention needs to make an assessment about whether these programmes are sufficient in clarity, scale, pace and whether they will target the underlying and possibly cross-cutting root causes.

This intervention will be made up of two phases.

Phase 1: The evaluative phase

Welsh Government, with the support of NHS P&I and in alignment with the leadership of the health board 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 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 and senior medical leadership background to support understanding of the underlying clinical cultural dynamics within the organisation. 

Phase 2: The delivery phase

An agreed 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 meeting chaired by the NHS Wales Chief Executive and a small number of the health board and Welsh Government Executive Team members
• oversight between the Chair and the Cabinet Secretary in line with the Oversight and Escalation Framework
• monthly NHS P&I operational performance and delivery meetings to support operational improvements across a range of areas

Leadership and governance 

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 (via submitted documentation) leadership and governance progress through an agreed bi-annual self-assessment, underpinned by the governance maturity matrix
• evidence that 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 that effective oversight and scrutiny of current service provision is consistently being provided by the board and the appropriate committee
• evidence that risk management arrangements are in place for identifying, recording, managing risks across the organisation
• implement and evaluate that leadership programmes are in place to support the ongoing development of leadership and management skills at all levels
• report improved staff engagement in NHS Wales surveys
• evidence that plans are in place to develop and maintain a sustainable workforce demonstrated by improved staff retention, staff well-being, a reduction in the number of vacancies and the number of interim and agency staff

Quality and safety 

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 (via submitted documentation) of quality and safety, quality governance and quality improvement progress through an agreed bi-annual self-assessment.
• Maintain the number of cumulative C.difficile cases, hospital onset E.coli BSI and MRSA BSI cases to be in line with all-Wales average over two successive quarters.
• 65% of complaints to be closed within 30-working days (by date received) over 2 successive quarters. 
• Austained reduction in never events (by incident date) to be demonstrated over 2 successive quarters.
• The health board reports improvement over two quarters in the raising concerns sub-score on NHS staff survey.
• An analysis and deep dive when the rate of hospital mortality within 30 days following emergency admission for hip fracture in patients aged over 64, and rate of hospital mortality within 30 days after emergency admission for stroke deviate from the all-Wales average.

Clinical services

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 (via submitted documentation) progress against each clinical service through an agreed bi-annual self-assessment
• demonstrate progress over 2 quarters against the 5 outcome measures for each service of concern:
  • quality and IPC
  • workforce
  • outcomes
  • patient, family and staff feedback
  • operational KPIs

Performance and outcomes

In order to be de-escalated to the next level of intervention for planned care and cancer, the health board must demonstrate progress over two quarters against: 

• 60% performance maintained against the SCP target
• 100% of open outpatient pathways to be waiting less than 52 weeks
• 100% of open pathways to be waiting less than 104 weeks
• 80% of open pathways to be waiting less than 52 weeks
• 15% reduction in the number of patients delayed by 100% for their follow up appointment in three consecutive months (based on the July 2025 baseline) 
• 65% R1 ophthalmology patient pathways to be waiting within or no longer than 25% of their target date for an outpatient appointment
• 80% of patients waiting for a diagnostic test to be waiting less than 8 weeks
• 80% of patients waiting for a diagnostic endoscopy to be waiting less than 8 weeks
• 80% of patients waiting for a NOUS and non-cardiac MRI to be waiting less than 8 weeks
• 85% of patients waiting for therapies to be waiting less than 14 weeks

In order to be de-escalated to the next level of intervention for urgent and emergency care, the health board must demonstrate: 

• continuous reduction of ambulance handovers over an hour of at least 11% in 3 consecutive 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
• a median time from arrival at an emergency department to assessment by a clinical decision maker should not exceed 60 minutes
• continuous reduction in delayed pathways of 5% (based on agreed baseline)

In order to be de-escalated to the next level of intervention for adult mental health, the health board must demonstrate progress over two quarters against: 

• 80% of LPMHSS mental health assessments undertaken within 28-days from the date of receipt of referral
• 65% of therapeutic interventions started within 28-days following an assessment by LPMHSS
• 80% of health board residents in receipt of secondary mental health services who have a valid care and treatment plan

Population health and prevention intervention

In order to be de-escalated to the next level of intervention for population health and prevention, the health board must demonstrate progress over 2 consecutive quarters for: 

• the percentage of children up to date with scheduled vaccinations by age 5 to be in line with the all-Wales average
• HPV vaccine uptake rate for children by the age of 15 to be in line with all-Wales average
• the percentage of adult smokers who make a quit attempt via smoking cessation services towards the target compliance over the 12-month period measure
• positive action taken to mitigate the General Medical Services sustainability risk register of 2025
• positive action taken in response to the alarm outlier in the National Paediatric Diabetes Audit 2023 to 2024 for adjusted mean HbA1c (30.5%)

Finance 

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 (via submitted documentation) progress against each financial areas through an agreed bi-annual self-assessment.
• Demonstrate that there is robust financial governance and a 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.
• Develop an annual plan with Board approval demonstrating a substantial financial improvement trajectory and delivering as a minimum the target control total.

Strategy and planning 

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 (via submitted documentation) strategy and planning improvements through an agreed bi-annual self-assessment, underpinned by the planning maturity matrix
• Submit a credible annual plan in line with the current planning framework
• Evidence of a clear roadmap and implementation of the health board’s clinical services strategy and plan