Welsh NHS trapped in ‘doom loop’, former minister and health board chief warn

Mark Mansfield

NHS Wales is trapped in a “doom loop” that leaves health leaders producing reports rather than improving care, a former Welsh Government Minister and an ex-health board chief have warned.

Lee Waters and former Hywel Dda chief executive Steve Moore are calling for fewer targets, clearer routes out of government intervention and practical support to cut waiting lists.

“Every board is escalated, everyone is reporting, and too little time is left for the hard work of improvement,” Mr Moore said.

“You can’t fix everything at once. The answer is to fix the things that matter most first: waiting lists, fewer targets, and practical support to help services change.”

Their paper, From Escalation to Improvement, also warns against breaking up Betsi Cadwaladr University Health Board and argues that money alone will not resolve the health service’s problems.

It was written with Tim Daley and Victoria Ford of Swansea-based consultancy Perago. The paper declares that Perago and Mr Moore’s advisory business provide the kind of external improvement support it recommends.

The Welsh Government said: “The new Accountability and Support Framework was introduced precisely to address the issues raised in the paper. It shifts the focus from process and reporting towards improvement, support and measurable outcomes, whilst maintaining appropriate accountability for performance and public resources.”

The authors’ analysis of all seven Welsh health boards between 2015 and August 2026 found that every board had been subject to some level of escalation since September 2023.

Escalation ranges from additional monitoring to special measures. The authors argue that a process intended to flag exceptional concerns has become routine, absorbing the time and attention of staff responsible for improving services.

They want national performance measures reduced from 53 to fewer than ten, with a single reporting channel and published, measurable conditions for leaving intervention.

The paper acknowledges that the Welsh Government’s Accountability and Support Framework, announced on September 29, offers an opportunity for change, but says success will depend on its implementation.

Waiting lists should be the first priority, with a national programme led by health board chief executives and medical directors aiming to make Wales the fastest-improving UK nation on planned treatment waits.

Teams involving clinicians, theatre and booking staff, managers, analysts and patients would identify successful approaches, test them locally and spread improvements across Wales.

The report describes an unnamed Welsh hospital where theatre utilisation improved by around 20% after staff worked together to address delays.

Those gains disappeared within months after the lead manager was moved to other work.

Victoria Ford, Perago’s managing director and group chief executive, said: “Big change starts small, with the people who do the work. But it only lasts if boards make improvement their main business, give teams, including clinicians, time to lead it and scrutinise whether it’s working.”

Sustained recovery

The authors identify Cwm Taf Morgannwg’s maternity and neonatal services as the clearest example of sustained recovery, moving from special measures in 2019 to routine arrangements in 2024 with independent oversight and published conditions.

They contrast this with Betsi Cadwaladr, which has remained under intervention at varying levels since June 2015. It left special measures in November 2020 before returning in February 2023.

Breaking up the north Wales board might be “politically attractive”, the paper says, but is “probably the worst option for tackling the underlying causes” of its difficulties.

Instead, the authors want Betsi to become the first test of a different approach to escalation, with realistic timescales and support to strengthen leadership and improvement capacity.

The paper cites a combined £199 million health board deficit in 2025–26, despite a 4.5% real-terms increase in revenue funding the previous year, as evidence that improvement must address how services are organised.

“This proposal is deliberately practical,” Mr Waters said. “Its first steps don’t need legislation, a new funding settlement or another reorganisation.”

The authors say urgent and emergency care requires a longer-term programme of investment in social care, rehabilitation and community services, rather than simply adding hospital beds and ambulances.

Confidence

Mr Waters warned that failing to improve NHS performance would have consequences for patients’ confidence in the service.

“Unless we get a grip on this quickly more and more people are going to migrate to the private sector,” he said.

“The numbers are still small, but they point to a slow unravelling of the social contract behind the NHS.”