Terms of reference

The Cabinet Secretary for Health and Social Care has established an external ministerial advisory group on NHS performance and productivity (‘the group’) to consider and provide an independent view on the existing arrangements and mechanisms in place that ensure and support improving NHS performance and productivity across NHS Wales.

The group will operate independently from NHS Wales and, through its membership, will provide the Cabinet Secretary for Health and Social Care with:

• external assurance on the effectiveness of current arrangements which aim to improve performance and productivity in NHS Wales
• observations on how current arrangements could be strengthened to further improve performance and productivity.  

The nature of this work will focus on the oversight and assurance mechanisms in place across the system in the first instance, not the delivery arrangements of individual NHS bodies.

The ministerial advisory group does not have executive powers, it is advisory only.

The group will consider and form:

• a reflection of the current performance delivery position in NHS Wales, relative to other parts of the UK
• an assessment of the processes in place at a system level to drive improvements in efficiency and productivity in NHS Wales
• an independent view on priorities for improving performance and related targets
• an assessment of how the NHS in Wales is responding to the delivery of productivity and efficiency measures and system variability in performance
• an assessment of the current levers for change and of suggested improvements on increased productivity and performance from Welsh Government officials

The group will be expected to draw on their knowledge and experience of approaches they have delivered elsewhere, and appropriate comparative evidence bases of other systems in order to provide views on how performance and productivity in Wales could be improved in the areas specified below.

The group will work with lead Welsh Government officials who will provide the necessary information from a Welsh performance context to inform the group’s assessment.

Once the assessment has concluded, a written report will be produced for the Cabinet Secretary for Health and Social Care. The draft report will be written by the Welsh Government officials who are providing the secretariat function for the group and will be produced within 6 months of the first meeting.

The group will ensure that the report:

• gives consideration to the current performance position and relevant context for NHS Wales delivery arrangements
• gives consideration to the existing oversight and accountability arrangements currently in operation
• gives consideration to the work programme of the Value and Sustainability Board, and other national support mechanisms such as the planned care programme, as relevant to support the efficiency and productivity agenda
• contains recommendations which are deliverable within the current structure and operating framework of NHS Wales
• is cognisant of the current financial constraints on public finances and financial challenges facing NHS Wales
• recognises the duty of quality and candour in Wales and reflect achieving improvements in performance and productivity against the imperative of securing positive patient outcomes, patient safety, improved quality of care and financial balance
• contains recommendations on areas where the UK nations could work together to improve productivity and performance

To ensure the report is based upon a detailed understanding of the existing performance, mechanisms and structures, the group is encouraged to take a view from the Director General of Health, Social Care and Early Years or NHS Chief Executive on the draft report prior to completion.

The Cabinet Secretary for Health and Social Care will consider the report and decide how to respond to recommendations.

The report will summarise the group’s assessment of how the performance of NHS Wales, compares with other comparable systems and how based on their experience and appropriate external evidence base comparators further improvements could be made in the following areas:

• planned care – to consider how NHS Wales can deliver shorter waiting times for treatment across all specialities aligned to the national targets which have been set out in the national planned care transformation programme
• how successful the NHS in Wales has been in treating those who have waited the longest and those who are the most urgent alongside supporting adherence to GiRFT and Royal College standards
• cancer performance – with a specific focus on improving waiting times for first contact, time to diagnosis and decision to treat, improving patient outcomes and securing equity of outcomes across Wales
• how has diagnostic performance impacted on the wider performance metrics, and what further action is required to improve access to diagnostic testing across the system
• reflecting on the National Six Goals for urgent and emergency care programme report on the progress in securing improvements against the national emergency care performance targets
• recognising the wider integrated care position, how Wales is performing on patient flow metrics, particularly in relation to pathways of care delays and their wider impact on system resilience, including how Wales could deliver improvements in reducing the number of pathways of care delays
• how NHS Wales is putting mechanisms in place through the NHS Executive and other central mechanisms to deliver improvements on a once for Wales basis and address variation in health board performance and delivery

Performance of the NHS Wales needs to be considered in the context of the following:

• NHS Wales recovery from the pandemic
• levels of performance variation
• the overall levels of population health, demographics and service demand
• the wider financial challenge to public services and NHS across the UK

It is envisaged that lead officials will provide the group with the initial assessment and evidence base of the current performance in Wales against the key areas outlined above to inform the groups consideration.

In producing this report the group should consider:

• how the performance and productivity of the NHS in Wales could be improved
• the potential scope for the introduction of further additional measures to improve a combination of performance and productivity across the system, based on experience and evidence of proven solutions in other comparable systems
• how existing mechanisms could be strengthened
• if any changes to financing arrangements could be used to deliver improvements, whilst recognising the relationship between the existing allocation mechanisms in Wales and the operating model with population health boards
• how digital architecture could be used more effectively to support improvements in performance
• how governance and accountability arrangements can be strengthened to improve performance and productivity

Members will be appointed by Welsh Ministers through an open competition following a public appointments process. The Cabinet Secretary for Health and Social Care can also make direct appointments to the group. All members are required to adhere to the terms issued to them by Welsh Ministers on appointment, this includes declaring any private interests which may be perceived to conflict with the role and responsibilities of the group including any business interests and positions of authority outside of the role.

The group will be comprised of a chair and a small number of members with expertise in securing improvements in the performance and productivity of the NHS at a national, system-wide level. Welsh Ministers will want to ensure that group members bring a diverse range of lived and professional experiences.

The chair is accountable to the Cabinet Secretary for Health and Social Care for their personal performance. The members are accountable to the chair of the group for their personal performance.

The group will be supported by Welsh Government. Welsh Government will provide support and information on the existing current arrangements in place for NHS performance and productivity in Wales.

The group will be automatically disestablished after 8 months unless otherwise specified by the Cabinet Secretary for Health and Social Care.

The group will demonstrate high standards of corporate and personal conduct and will be asked to subscribe to the 'Code of conduct for board members of public bodies'.

The chair will:

• facilitate constructive debate to aid decision making
• ensure that conflicts of interest and disputes are recorded and shared with Welsh Government
• bring to the cabinet secretary and the Director General – Health, Social Care and Early Years Group attention any significant and urgent matters that the Group has been made aware of or is due to discuss
• report to the cabinet secretary on the work of the group
• adhere to the requirements set out in their terms of reference

Members of the group are responsible for:

• bringing their experience and knowledge to matters within the group's remit
• being open to ideas and work to reach compromises if required
• provide suitable evidence and comparative information from other systems to support recommendations
• attending meetings regularly and contributing to work in support of the group
• standing down from any business where they may have a perceived conflict of interest
• adhere to the requirements set out in their terms of reference

Meetings will be held virtually by default in line with Welsh Government guidelines.

At the beginning of each meeting relevant Welsh Government officials will be available to present information on a specified area (from the list of issues above) to aid the group’s discussion. The schedule for each meeting will be agreed at the initial meeting.

Information requests from group members will be submitted to the Welsh Government Escalation and Intervention Team.

The Welsh Government Escalation and Intervention Team will arrange for Welsh Government or NHS Wales colleagues to attend meetings as requested by the group based on the relevant topic area to ensure the right intelligence and expertise is provided to the group.

The secretariat function for the group and the writing of the report will be supported by Welsh Government.

No deputies will be accepted in place of members.

No minimum number of members is required for a meeting to be quorate.

There will not be a published output from each meeting; the group will report back to the cabinet secretary via monthly meetings and the final report.

The chair will meet with the cabinet secretary monthly. At these meetings, the chair will update the cabinet secretary on the progress of their work and provide a view on any interim or immediate action which the group consider the cabinet secretary could consider taking to improve performance and productivity in the short-term.

1. The NHS Wales Oversight and Escalation Framework sets out Welsh Government’s Ministers’ mechanism and approach for gaining assurance from NHS Wales organisations. The framework was published in January 2024 and sets out the Welsh Government's approach for gaining assurance from NHS Wales organisations; and the approach to escalation and intervention where there are matters of concern that need to be addressed.
2. The National Health Service (Wales) Act 2006 and National Health Service Finance (Wales) Act 2014 provide the legal context for this framework which sets out the rationale for Welsh Ministers seeking assurance and the Welsh Ministers’ powers of intervention.
3. Wales legislative landscape has a strong emphasis on collaboration, co-production and integration. The Well-being of Future Generations (Wales) Act 2015, the Social Services and Well-being (Wales) Act 2014 and the Public Health (Wales) Act 2017 provide the legislative backdrop for health and social care in Wales. Together, these three pieces of legislation place a firm emphasis on reducing health inequalities through long-term prevention and the delivery of sustainable, outcome focused services. Other specific pieces of legislation are the Nurse Staffing Levels (Wales) Act 2016, Welsh Language Measure 2011 and the Equality Act 2010.
4. The Wellbeing of Future Generations (Wales) Act underpins the programme for government and a healthier Wales, and shapes how we work and what we do to deliver the values and commitments of the Welsh Government.
5. A Healthier Wales (AHW) sets out a long-term vision for health and social care in Wales. It proposes a whole-system approach to health and social care which is equitable, and where services are designed around individuals and groups based on their unique needs and what matters to them, as well as quality and safety outcomes. One of the core values described in AHW is “Putting quality and safety above all else – providing high-value evidence-based care for our patients at all times.”
6. The NHS Wales Value and Sustainability Board has been established to drive a systematic approach to strengthen cross system working, to deliver actions for financial improvement and the delivery of more sustainable health care on a consistent basis.
7. The annual NHS Wales planning framework sets out the ministerial priorities and key deliverables which provide a focus in the oversight process and closely align to the assessment of organisations as part of this framework.
8. There is a statutory duty for health boards and trusts to develop a 3-year, financially balanced and board approved Integrated Medium Term Plans (IMTP). These must set out how ministerial priorities are to be achieved within the resources available to organisations. Monitoring of the plan delivery takes place via existing performance management arrangements. Failure to submit a financially balanced IMTP is a breach of the statutory duty and will therefore have consequences under the escalation and intervention framework.
9. Monitoring the deliverables of the Welsh Government framework and policies along with organisational outputs from each framework are all important aspects of the escalation and intervention process including:
   • quality and safety framework 
   • duties of quality and candour 
   • performance framework
10. The National Quality Management System (NQMS) brings together data from a number of sources, including patient safety incidents, for triangulation and to inform a range of activities in relation to learning and quality and governance assurance.
11. The duty of quality in the Health and Social Care (Quality and Engagement) (Wales) Act 2020 (“the 2020 Act”) has two aims – to improve the quality of services, and to improve outcomes for people in Wales. It places a duty on the Welsh Ministers to exercise their functions with a view to securing improvement in the quality of health services. The duty of quality seeks to ensure we strengthen our quality management systems with appropriate focus on quality planning, quality control, quality improvement and quality assurance. It defines quality as ‘continuously, reliably, and sustainably meeting the needs of the population that we serve.’ Together, the domains of quality and quality enablers create the health and care quality standards 2023.
12. The organisational position against the priorities and measures set out in planning and performance frameworks will be reviewed and incorporate:
    • annual objectives agreed with the chairs of NHS Wales organisations; the frequency of review meetings with the chairs will be determined by their escalation status
    • accountable officer letters issued by the Chief Executive of NHS Wales which outlines the responsibility for financial management and performance
    • Welsh Government response to an organisational plan inclusive of accountability conditions.

13. The following diagram sets out the arrangements for the oversight of NHS Wales organisations:

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14. Assessment against the framework will utilise a variety of information including quantitative data, such as the published performance framework metrics and qualitative information. Information from the NQMS, patient safety reviews, clinical audit, and assessment against quality statements and NICE Standards will feature prominently. Information derived from conversations on quality improvement, value in health, digital, national programmes and clinical networks will also feature to support organisations in a rounded assessment of their position and progress.
15. Information from relevant independent third parties, inclusive of Llais, Audit Wales and Healthcare Inspectorate Wales has a key role in informing Welsh Government assessments.

16. Oversight meetings are set out as follows:
    Joint Executive Team (JET) meetings:

    • JET meetings take place twice a year, chaired by the Chief Executive of NHS Wales
    • they meetings scrutinise quality, planning, delivery, and performance of the organisation against national requirements, its plan, and any accountability conditions

    
    Escalation meetings:

    • all organisations in an escalated status will have a formal escalation meeting chaired by Welsh Government
    • these meetings monitor progress against specified and agreed de-escalation criteria

    
    NHS Wales Performance Board:

    • the NHS Wales Performance Board meets monthly and is chaired by the Chief Executive of NHS Wales; all health board and Welsh Ambulance Service Trust (WAST) chief executives attend
    • the NHS Wales Performance Board assess performance against the agreed performance trajectories

    
    Integrated Quality, Planning & Delivery (IQPD) meetings

    • monthly meetings chaired by the Deputy Chief Executive of NHS Wales or their nominated deputy
    • IQPDs assess performance against agreed trajectories, consider the overall quality and safety of services and to undertake deep dives on specific topics; health boards should proactively raise areas of concern

    Service specific meetings:

    • additional monthly meetings will be held with organisations to focus solely upon services which are challenged across Wales such as cancer, ophthalmology, and planned care
    • these meetings scrutinise quality, planning, delivery and performance, including recovery plans, trajectories, and serious incidents

17. The diagram below sets out the governance of the relationships and interface meetings:

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18. The Welsh Government will use its monthly Quality and Delivery Board to meet with NHS Wales Executive colleagues and other key parties to discuss all organisations and issues of concern.
19. The establishment of the NHS Wales Executive in April 2023. Was intended to consolidate national activity and bring a consistent approach to planning, priority setting based on outcomes, performance management and accountability. The NHS Executive’s role is to support the delivery of improvement and quality, and provide a vehicle to support both Welsh Government and the NHS to enable improvement. They are not an accountable body nor do they hold organisations to account. They should be supporting the operational delivery of national policies and providing WG with intelligence and assurance on delivery.
20. The establishment of the NHS Wales Joint Commissiong Committee (NWJCC). The NWJCC is a Joint Committee of the seven health boards acting collectively on their behalf. However, individual health boards are ultimately accountable to their population and other stakeholders for the provision of the services commissioned by the NWJCC for the residents in their area.