Escalation and Intervention

The Welsh Government accept that the current framework for identifying and tackling major issues with services in NHS Wales needs to be revised. In this post Tracey Rosell explores the acknowledged problems.

A full version of this blog is published on the Senedd Research website.

The joint NHS Wales Escalation and Intervention Arrangements (the E&I Arrangements) were launched in 2014. These require the ‘Tripartite Partnership’ of Welsh Government, Audit Wales, and Healthcare Inspectorate Wales to share knowledge and discuss the overall position of each Health Board and NHS Trust. The Director General of NHS Wales then makes recommendations to the Minister for Health and Social Services on the escalation levels of the various Health Boards and NHS Trusts.

The aims of the E&I Arrangements are to support NHS Wales:

• to address concerns about service delivery, quality, and safety of care, and organisational effectiveness,
• by ensuring that potentially serious issues are identified as early as possible and addressed effectively, and
• to address and deliver the required improvement, so the NHS body returns to routine arrangements as quickly as possible.

When are E&I Arrangements needed?

There are four escalation levels which apply to NHS Wales organisations: routine arrangements (operating as normal), enhanced monitoring, targeted intervention, and special measures. The latter addresses the most serious failures. Escalation typically occurs when there is evidence of concerns, and that independently the Health Board is not demonstrating sufficient and timely improvement. Conversely, with evidence of improvement, Health Boards can be moved to a lower escalation level.

Are the E&I Arrangements fit for purpose?

The E&I Arrangements do not set out a detailed blueprint for support, but can include challenge, monitoring, reviewing, mentoring, and/or bringing in expertise. In special measures, there is the ability for direct intervention, and possibly suspension of powers and duties. These formal powers are seen as a last resort.

There may be practical support. For example, targeted intervention in Betsi Cadwaladr is supported by a financial package totalling £297m up to the end of 2023/24. The financial implications render this a subject for the scrutiny of the Senedd’s Public Accounts and Public Administration Committee (PAPAC). It started an inquiry in March 2022 regarding E&I Arrangements, to explore whether they are fit for purpose and have achieved their objectives.

The Committee’s scrutiny will include examining the current position of Betsi Cadwaladr University Health Board (UHB). In November 2020, the UHB ended over 5 years of being in special measures, but concerns continue to be about its leadership, engagement, mental health services, strategy, and planning.

Even after a substantial period of being in special measures, the E&I Arrangements do not appear to be fully delivering the necessary solutions. This is despite a key principle behind E&I Arrangements aims to achieve timely and effective improvement.

The Welsh Government have commented that the E&I Arrangements have changed and evolved through working with Health Boards. However, it acknowledges that the framework as drafted is not clear about what factors trigger a change in escalation level. Staying at a heightened level of escalation can lead to inadequate services becoming accepted as the norm. Consequently, the Welsh Government acknowledges the current framework needs to be revised and refreshed, including a more timely delivery of improvements.

Tracey Rosell is an ESRC Doctoral Student at Cardiff University. Her PhD research is funded by the Wales Doctoral Training Programme (DTP). Her research is helping to understand leadership in extreme contexts in organisations, particularly within healthcare. The full article summarised in this blog was written during an internship with the Senedd Research team funded by the ESRC Wales DTP.