NHS Scotland: support and intervention framework

The NHS Scotland support and intervention framework is one of the key elements of our evidence-based approach to monitoring performance and managing risk across the NHS in Scotland.

The framework is overseen by the National Planning and Performance Oversight Group, a sub-group of the Government’s Health and Social Care Management Board. The framework applies to NHS territorial boards only. Arrangements for national NHS boards are covered by separate arrangements.

The framework provides five stages of a ‘ladder of escalation’ that provides a model for support and intervention by the Scottish Government. These stages are summarised in the table below:


Stage description

Support and intervention(s)

Stage 1 - steady state

NHS boards are delivering in line with agreed plans. Normal reporting arrangements in place.

The annual delivery plans, produced by all boards, form the basis against which performance is assessed throughout the year.

Surveillance through official statistics published by Public Health Scotland and scheduled engagement of NHS board annual reviews/mid-year reviews

Stage 2 - enhanced monitoring

Some variation from agreed plan (s), possible delivery risk if no remedial action is taken

A NHS board-led support package or recovery programme agreed and implemented. Increased surveillance and monitoring by Scottish Government. Scottish Government Directors aware.

Stage 3 - enhanced monitoring and support

Significant variation from plan, risks materialising, Scottish Government commissioned tailored support package is required 

Formal approach incorporating significantly enhanced support and scrutiny and likely to include a level of external support. Relevant Scottish Government Directors engaged with NHS Board Chief Executive Officer and top team. Director General Health and Social Care aware.

Stage 4 - senior external support and monitoring

Significant risks to delivery and tailored support is not producing the required improvements. Senior level external support required.

Senior level external support reporting to an Assurance Board chaired by Scottish Government. Assurance Board reports direct to the Chief Operating Officer for NHS Scotland and Director General Health and Social Care.

Onus remains on the NHS board to deliver the required improvements.

Stage 5 - statutory intervention

The level of risk and organisational dysfunction is so significant that the NHS Board requires direct intervention using statutory powers of direction.

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. Stage 1 is when boards are steady state and on track with their annual delivery plans. Stage 2 is an informal support stage, where SG is providing support and guidance, but not intervening in the board. This stage is intended to avoid reaching the threshold for stage 3 or higher. These designations are managed by Scottish Government policy leads directly with individual boards. A board may be at stage 1 (‘steady state’) in relation to one aspect of its operations and at stage 2 in another.

Stage 3 and stage 4

Stages 3 and 4 are formal escalations. This is when requirements for specified action by the board along with enhanced monitoring arrangements are put in place. No statutory powers are being exercised and, as such, the board Chief Executive is expected, in their capacity as Accountable Officer, to co-operate and provide leadership; to ensure the effectiveness and delivery of the Recovery Programme.

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 NHS 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 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. Escalation to stage 5 should not be viewed as part of the normal progression of a board on the framework; it should only be used in exceptional circumstances

Current positions of NHS boards

Of the 14 territorial health boards in Scotland, there are currently six territorial health boards 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 territorial NHS boards currently escalated to at least stage 3 are: 

  • NHS Ayrshire and Arran
  • NHS Borders
  • NHS Forth Valley
  • NHS Highland
  • NHS Orkney
  • NHS Tayside

Current stages and primary factors for the six territorial NHS Boards formally escalated

Territorial NHS board

Current stage 

Primary factors influencing escalation

NHS Ayrshire and Arran


Financial management and position

NHS Borders


Financial management and position

NHS Forth Valley


Governance, leadership and culture 

NHS Highland


Financial management and position

NHS Highland


Mental health performance

NHS Orkney 3 Financial management and position

NHS Tayside


Mental health performance

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