Publication - Advice and guidance

NHS healthcare standards: Board performance escalation framework

Published: 10 Jun 2021

NHS boards performance escalation framework announced on Thursday 9 June.

10 Jun 2021
NHS healthcare standards: Board performance escalation framework

NHS board performance escalation framework

  Description Response
Stage 1 Steady state “on-plan” and normal reporting Surveillance through published statistics and scheduled engagement of Annual Reviews/Mid-Year Reviews
Stage 2 Some variation from plan; possible delivery risk if no action Local Recovery Plan – advice and support tailored if necessary.  Increased surveillance and monitoring Scottish Government.  SG Directors aware
Stage 3 Significant variation from plan; risks materialising; tailored support required  Formal Recovery Plan agreed with Scottish Government.  Milestones and responsibilities clear.  External expert support.  Relevant SG Directors engaged with CEO and top team.  DG aware
Stage 4 Significant risks to delivery, quality, financial performance or safety; senior level external support required Transformation team reporting to Director General and CEO NHS Scotland
Stage 5 Organisational structure / configuration unable to deliver effective care Ministerial powers of Intervention

Stage 1 and stage 2

The designation of a Board as Stage 1 or Stage 2 is a policy specific process. This is managed by Scottish Government policy leads directly with individual Boards, as indicated by the reference in Stage 2 of the Framework to local recovery plans. A Board may be at Stage 1 (‘steady state’) in relation to one aspect of its operations and at Stage 2 in another. The decision for one policy area to place a Board at Stage 2 by requesting a local recovery plan does not place the whole Board at Stage 2.

Stage 3 and stage 4

The decision to move a Board to Stage 3 is made by the Health and Social Care Management Board (HSCMB) which may be prompted by awareness of a known weakness or the identification of an increasing level of risk in relation to a particular Board.

In relation to Stage 4, the decision sits with the DG Health and Social Care, where consideration of the Board’s position within the Escalation Framework would normally be prompted by a Board failing to deliver on the recovery actions agreed at Stage 3 or the identification of significant weaknesses considered to pose an acute risk to financial sustainability, reputation, governance, quality of care or patient safety. 

Stage 5

The decision to escalate a board to the highest stage in the Framework is taken by the Cabinet Secretary for Health and Sport with advice from the HSCMB. Escalation to Stage 5 involves the exercise of Ministers’ powers of intervention under the National Health Service (Scotland) Act 1978.

Current positions of NHS Boards

There are currently six health boards in Scotland who have been escalated to Stage 3 or above within the  Framework. This is the stage at which boards are considered to require a higher level of support and oversight from Scottish Government and other senior external support.

The six boards: 

  • NHS Ayrshire and Arran
  • NHS Borders
  • NHS Highland
  • NHS Lothian
  • NHS Tayside
  • NHS Greater Glasgow and Clyde

Six boards - current stages


NHS board

Current stage

Primary factors influencing escalation

NHS Ayrshire & Arran


Financial management and position

NHS Borders



Financial management and position

NHS Greater Glasgow & Clyde


QEUH & RHC (Infection control and related issues)

NHS Highland



Financial management and position

Governance, leadership and culture

Mental health performance

NHS Lothian


Mental health performance


NHS Tayside


Mental Health Performance