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What are the planning and escalation frameworks in the NHS in Wales?

The next in the Welsh NHS Confederation's explainer series focuses on how planning and escalation works in the NHS in Wales.

28 January 2025

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Similar to other in other UK nations, the NHS in Wales is obligated to plan and deliver services now and for the future. Every local health board (LHB), NHS trust, special health authority and national hosted body in Wales produces a plan to define the strategic priorities and planned activities they will take on to support, develop and improve health and care services, as well as address population needs and improve health outcomes.

Duties on NHS organisations

The National Health Service (Wales) Act 2006, as amended by the NHS Finance (Wales) Act 2014, sets out requirements for NHS planning in Wales. Under the legislative framework, LHBs and NHS trusts have two statutory duties:

To prepare a plan for its population and for the delivery of services to that population, and
To financially break even over a rolling three-year period.

To satisfy these duties, the boards of LHBs and trusts must submit a three-year Integrated Medium Term Plan (IMTP) for the consideration and approval of Welsh Ministers. The NHS Planning Framework sets out the statutory directions from Welsh Ministers to the NHS, including priorities and expectations. The Planning Framework is issued by Welsh Ministers each year in the Autumn, with plans submitted the following Spring.

What are IMTPs and how do they work?

IMTPs set out how organisations will use their resources over a three-year period to deliver high quality healthcare services, which address population needs and improve health outcomes. IMTPs are approved by NHS boards before being submitted to Welsh Government for assessment by officials and a range of NHS Wales Executive partners. The statutory plans submitted by LHBs and trusts are then considered for formal Ministerial approval.

LHBs and trusts are required to produce Integrated Medium-Term Plans (IMTPs) annually. Special health authorities (SHAs) and other national bodies, including NHS Wales Shared Services Partnership and the NHS Wales National Joint Commissioning Committee, are not formally covered by the Acts. These NHS bodies do however comply with the spirit and requirements set out in the NHS Planning Framework and develop and publish IMTPs.

Where organisations are not able to submit a financially balanced, three-year IMTP, or where plans are not approved, a detailed annual plan should be developed. Being unable to submit a three-year IMTP is a breach of the statutory planning duty and may therefore have implications under the NHS Wales Oversight and Escalation Framework (see below).

What is the NHS planning framework?

Published annually, the NHS Wales planning framework provides specific guidance for NHS bodies in the development of IMTPs, including Ministerial priority areas and additional expectations from national programmes and specific policy requirements.

The context for the planning framework is set within the Well-being of Future Generations (Wales) Act 2014, A Healthier Wales and National Clinical Framework ambitions around prevention, quality, reducing health inequalities and, more recently, the cost-of-living crisis.

The priority areas are based on existing policy and decided by the Minister/Cabinet Secretary in post. The latest strategic priorities areas have been issued by the Cabinet Secretary for Health and Social Care in the NHS Wales Planning Framework 2025-28. The Cabinet Secretary set out his strategic priorities alongside the delivery expectations for each priority.

These are:

Timely access to care
Population health and prevention
Building community capacity
Mental health access
Women’s health

Published alongside these strategic priorities and delivery expectations are evidence based enabling actions. These enabling actions underpin the priorities to successfully achieve the core service and desired changes. These include value projects, digital innovations, workforce development, financial sustainability, and improved ways of working. These actions will build confidence in the plans and ensure realistic delivery.

What is the NHS Performance Framework?

The NHS Wales Performance Framework describes how NHS organisations in Wales will be measured and how they report performance. It sets out performance measures that reflect the Ministerial priority areas of focus and primary support functions, as outlined in the NHS Wales planning framework. In addition to the performance framework, in June 2024 he Deputy Chief Executive of NHS Wales issued Key Performance Indicators (KPIs) to support clear incremental improvements.

What is the role of these NHS frameworks in supporting the Welsh Government’s wider policy goals?

When preparing IMTPs, NHS organisations must consider Wales’s wider legislative landscape, which has a strong emphasis on collaboration and integration.

NHS organisations’ IMTPs must follow both the obligations and the outlook of relevant legislation, paying close interest to several legislations. While not an exhaustive list, this includes:

The Well-being of Future Generations (Wales) Act 2016
Social Services and Well-being (Wales) Act 2014
Equality Act 2010 and the Socio-economic Duty
Nursing Levels (Wales) Act 2016
Regulation and Inspection of Social Care (Wales) Act 2016
Social Partnership and Public Procurement (Wales) Act 2023
The Health and Social Care (Quality and Engagement) (Wales) Act 2020
Public Health (Wales) Act 2017
Welsh Language Standards
Anti-Racism Wales Action Plan.

In addition to the legislative frameworks, NHS bodies must also reflect on A Healthier Wales and demonstrate their influence on the foundation economy and the climate change agenda. These present a context for how NHS organisations should work collaboratively, with a relentless pursuit of delivering the best quality NHS care consistently across Wales.

What is the NHS Wales Oversight and Escalation Framework?

The NHS Wales Oversight and Escalation Framework sets out the Welsh Government's process for maintaining oversight and gaining assurance across NHS Wales organisations, and the approach to escalation and intervention where there are matters of concern that need to be addressed. It delivers the parameters of how the Welsh Government Health, Social Care and Early Years Group will work with the NHS in Wales.

A clear focus of the Oversight and Escalation Framework is how NHS organisations are delivering against their IMTPs and the NHS Wales Planning Framework, and both frameworks closely align.

The NHS Wales Executive supports the Welsh Government in its oversight interfaces, highlighting areas of concern through its functional model and key principle of quality assurance, providing leadership, direction and a supportive learning environment.

What is the oversight process?

The triangulation of quality, planning (including finance and workforce) and delivery (quality and performance) form the themes by which NHS organisations are assessed on their progress and against their IMTP. The focus of assessment is on the quality of service and patient experience.

The Welsh Government leads the oversight of NHS Wales organisations with support from the NHS Wales Executive as follows.

Test IMPT flow diagram infographic by Welsh Confed

Assessment against the framework uses quantitative data, such as the published performance framework metrics, and qualitative information. Key independent sources include Audit Wales, Llais and Healthcare Inspectorate Wales. This includes information from the National Quality Management System (NQMS), patient safety reviews, clinical audit, and assessment against quality statements and NICE Standards. It also considers information from conversations on quality improvement, value in health, digital, national programmes and clinical networks to strengthen organisations in a rounded assessment of their position and progress. The framework promotes a ‘no surprises’ method and supports early identification of emerging issues and concerns, so that they can be addressed before they have a material impact or performance declines further.

What is the NHS Wales escalation and intervention process?

The oversight and escalation framework sets out how performance is evaluated, and risk is examined across the NHS. In line with the joint escalation and intervention arrangements, the Welsh Government, Health Inspectorate Wales and Audit Wales meet every six months (and additionally between these times if serious concerns arise) to share knowledge and identify issues early on in order that these can be resolved effectively. This meeting is known as the tripartite meeting.

They discuss the position of each health board, NHS trust and special health authority in respect of:

Governance
leadership, capability and culture
performance and outcomes
finance, strategy and planning
quality of care
fragile services
other issues as appropriate

Information and evidence from these meetings is considered further and the Welsh Government makes recommendations to the Cabinet Secretary for Health and Social Care on future escalation levels.

Escalation levels

NHS organisations are responsible for maintaining appropriate governance arrangements. They need to make sure these are effective and provide quality and safe care.
Welsh Government will meet with the NHS organisation to explore the nature and extent of the concern. The NHS organisation is expected to respond to these concerns.
NHS organisations to put effective processes in place to address issues of concern. Welsh Government will co-ordinate activity, observe, challenge and review progress.
Welsh Government, other NHS or external review bodies will work with organisations where serious concerns have been identified. Support could include time limited work such as:
- mentoring
- advice from experienced individuals with the necessary clinical or governance skills
- review work.
In exceptional circumstances, Welsh Government may find very serious concerns about an NHS organisation. Welsh Ministers may intervene as set out in the NHS (Wales) Act 2006. This could include providing targeted support, suspending, or removing powers and duties from individual or all members of the NHS organisation’s board.
These formal powers are a last resort when other intervention is unlikely to succeed.

How does de-escalation take place?

To be considered for de-escalation, an NHS organisation must show that the de-escalation and sustainability criteria have been constantly met. The overarching aim is to support NHS organisations subject to intervention arrangements to achieve the required improvement and address any issue(s) efficiently so that they may commence the de-escalation process once improvements are noted and continuous.

Where appropriate, the Welsh Government will organise activity to closely monitor, challenge and review progress made by the NHS organisation. If the NHS organisation can deliver evidence of adequate and timely improvement, then the Welsh Government and external review bodies consider whether de-escalation is suitable. De-escalation will be to the next level on the intervention scale, with decreased oversight and reporting at each stage of de-escalation.

Summary

In summary, local health boards and NHS trusts develop IMTPs annually, which set out how organisations will use their resources over a three-year period to deliver high quality healthcare services, set within the context of organisations’ longer-term clinical strategies. Board approved plans are submitted for assessment by Welsh Government officials and a range of NHS Wales Executive partners before being considered for formal, Ministerial approval.

Published annually, the NHS Wales planning framework provides specific guidance for NHS bodies in the development of IMTPs. Meanwhile, the NHS Wales Performance Framework describes how NHS organisations in Wales will be measured and how they report performance. The NHS Wales Oversight and Escalation Framework sets out the Welsh Government's process for maintaining oversight and gaining assurance across NHS Wales organisations, and the approach to escalation and intervention where there are matters of concern that need to be addressed.