National Assembly for Wales

Y Pwyllgor Cyfrifon Cyhoeddus

Public Accounts Committee

04/12/2017

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Adam Price AM
Lee Waters AM
Mohammad Asghar (Oscar) AM
Neil Hamilton AM
Nick Ramsay AM
Rhianon Passmore AM

Y rhai eraill a oedd yn bresennol

Others in Attendance

Dave Thomas Swyddfa Archwilio Cymru
Wales Audit Office
Dr Andrew Goodall Llywodraeth Cymru; GIG Cymru
Welsh Government; NHS Wales
Frances Duffy Llywodraeth Cymru
Welsh Government
Huw Vaughan Thomas Archwilydd Cyffredinol Cymru, Swyddfa Archwilio Cymru
Auditor General for Wales, Wales Audit Office
Mike Usher Swyddfa Archwilio Cymru
Wales Audit Office

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Claire Griffiths Dirprwy Glerc
Deputy Clerk
Katie Wyatt Cynghorydd Cyfreithiol
Legal Adviser
Meriel Singleton Clerc
Clerk

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Dechreuodd rhan gyhoeddus y cyfarfod am 15:30.

The public part of the meeting began at 15:30.

2. Cyflwyniad, Ymddiheuriadau, Dirprwyon a Datgan Buddiannau
2. Introductions, Apologies, Substitutions and Declarations of Interest

Welcome, Members, to this afternoon's meeting of the Public Accounts Committee. Headsets are available for translation and sound amplification. Can Members please ensure phones are on silent? In the event of an emergency, follow directions from the ushers. We have received an apology from Vikki Howells, who is unable to be with us this afternoon. Do Members have any declarations of interest they want to make? No. 

3. Papurau i'w Nodi
3. Papers to Note

Okay. First of all, item 3. We've got some papers to note and the minutes from the meeting held on 27 November. Are we happy with that? Yes. Good. 

4. Arlwyo a Maeth Cleifion mewn Ysbytai: Sesiwn Dystiolaeth gyda Llywodraeth Cymru
4. Hospital Catering and Patient Nutrition: Evidence Session with the Welsh Government

Okay. Item 4, and hospital catering and patient nutrition, and we have our evidence session with the Welsh Government. This evidence session has been arranged to enable Members to scrutinise the Welsh Government on concerns that were raised following consideration of the last update during committee on 9 October. These included the overall lack of urgency apportioned to making progress implementing the committee recommendations, a lack of clarity on the timescale for completing work on the standardisation of nursing documentation and implementation of an electronic prescribing system, and also the vagueness of language used such as 'agreement in principle to development of an IT catering solution'.

So, can I thank our witnesses for being with us to clear up some of these areas? Would you like to give your name and position for the Record of Proceedings? 

I'm Andrew Goodall. I'm the director general for health and social services and the NHS Wales chief executive. 

I'm Frances Duffy and I'm director of primary care and innovation. 

And no strangers to this committee. We've got a number of questions. I'll kick off with the first one, Dr Goodall. The Welsh Government has previously indicated that there would be a three-year timetable for the development and roll-out of the standardised electronic nursing documentation by November 2019. Is this still the timetable that the project board and operational group are working to? 

Yes, at the moment, that remains the timetable. We've spent the last 12 months working through the choices around the documentation on the nursing side to ensure that we've got the ownership of the nurse directors and the professional groups. There's been a lot of engagement with a wide variety of colleagues beyond just the professional interests, and that would include reflections from organisations like community health councils, also union views from the Royal College of Nursing. The requirements for the e-documentation process has been signed off; that set out 29 specific high-level areas that need to be worked through in terms of us landing a very standardised system and process. And we have the requisite project board arrangements in place. We have wide involvement. We've also, obviously, as you'd expect, got Welsh Government engagement in that process, and there is a nominated nurse director in Wales who is the nurse director of the Welsh Ambulance Services NHS Trust, who is the ICT lead now amongst the nurse directors in Wales, and she has oversight of that mechanism as well. 

So, it is a three-year programme. Yes, all of the information has been gathered to create the baseline, and decisions have been made. I think critically what I would say is that we needed the nurse directors to give a judgment to us to proceed with the system and approach, which was, 'Was it to be an in-house development or were we looking to procure some product that was out in the market?' Their view was to recommend that we should go with in-house development. Again, to confirm, as part of that process, that's why we've now been able to recruit software developers, for example, for that project as well.  

I'm pleased to hear that the timetable is still being adhered to. Clearly, the committee did have a number of concerns about the—well, either it was a lack of urgency or a perceived lack of urgency. Do you understand why the committee had those concerns? 

I do understand the concerns and I tried to address some aspects of this just in my most recent correspondence, because it felt as though we had come down to the whole of NHS development in Wales falling on the shoulders of an individual in one of our support organisations in NHS Wales Informatics Service. And actually, there is a much more significant set of developments, which I've tried to set out in the correspondence, just to say: yes, of course, there is a process where we need to standardise the actual documents side, to choose how forms are going to prepared, to bring together some of our tools, but, actually, a range of the different systems that we have going in and being implemented across Wales at the moment, which are national choices, are all there to ensure that both nurses and other clinical staff are able to record their activities, and so make a record that is available to others. Whether that's in a GP environment and the way that GP systems are working—. Probably a good example of how we've changed our approach as well has been the commissioning of the community information system, which is a joint programme that's happening between local government and the NHS. Again, I can assure you, not least with all of the discussions about nurse documentation, that that absolutely sets out a standardised form and process. In fact, as we went out to the specification for that system, that took quite a lot of negotiation for us to get that right across Wales, because there were some differences, as one would expect, with the organisations and the way they've built these things up over the years. 

But I understand the concerns. Although there still remains an informaticist, who sits as a specialist within the NHS Wales Informatics Service, I can also confirm that we have allocated £1.2 million to support nurses who are allocated in roles that are outside of their clinical duties, who will actually be overseeing these for the individual health boards in Wales as well. So, I do think that we've actually stepped up our response on this system. 

I believe that it sounds very straightforward to achieve this on the one hand, but the one thing I would want to convey—and I tried to do that in my correspondence—was to describe that this is an enormous change programme for the NHS. Nobody has done this necessarily on a country-wide basis. If people were looking to standardise, even within a single organisation, it would be a very significant change. And it's not just about switching the IT on; it's to make sure that any transition occurs in a very safe manner and that everybody is trained up to deal with that. So, we may want to collapse our three existing pain management tools, which nurses use across Wales, down to one. But if you're experienced and expert in the use of one of those three, you need to be supported in the changes that need to be implemented, and the 29 requirements, I think, just shows the complexity of that. 

15:35

You've spurred the further interest of Members in that. First of all, Lee Waters, then Rhianon Passmore.

Thank you. Can I just clear up my understanding of your position on the issue? It's clear from your letter and your testimony how complex this is, and how there are competing priorities, and clearly this is not something that you feel is able to be done quickly by the system. You said in your most recent letter to us that when the original recommendations were made, a system was seen as a solution to support the outcome, but you say that progress has been made without needing a national system in place. In your letter to us in September, you did say that the internal stakeholders had agreed, in principle, to support an all-Wales system. So, can you just clarify whether or not you think an all-Wales system is still desirable—we'll still discuss whether or not it's achievable and by when—or not?

Chair, I can respond to that. That's about the catering system rather than the nurse documentation system, which I was just outlining. So, I can clearly go in to answer the questions on the catering system, but I was just reflecting my overview—

The trouble is that the two have become interwined, haven't they?

No, they are two very distinct processes. The catering system is a technical area, and I will respond to where we are on that, and why we've had different agreements on where it stands in the priorities. The nurse documentation system that came out of the nutrition and catering approach is a different mechanism in place. It's more about standardising the documents and then going out to the market on our purchasing and procurement approach on that, and it isn't the catering system, just for clarity. 

You rightly answered the question I asked you, and we were going to go on to the catering area later, unless you specifically wanted to go into that. It's probably easier to keep it separate, I would think, at this point. Rhianon Passmore.

I'm sorry if there was any confusion on the two being brought together.

Thank you, Chair. So, with regard to the clear deadlines, and with regard to the clear progress that you seem to be making in terms of appointments and funding, my question really is, within that timescale, are you on track?

Yes, we are on track at the moment. We expect to deliver it within the three years. I think all of the progress we wanted to make about the choice of whether it was going to be an external procurement or an in-house system, and the clarity on the requirements, that's all happened in line with the timetable. The ownership is there that I would wish from the nurse directors, and I think that has worked very well under the leadership of the nurse director in the Welsh ambulance services trust. So, if I was to highlight concerns at the moment, I wouldn't be highlighting a concern currently on the timetable. I think it's reasonably straightforward and we are on track. 

I'll bring you back in, in a little while, Lee, on those questions about catering. But, Adam Price. 

Right, okay. Staying at the high meta level for the moment, and the overall nursing digitalisation, or what's your preferred phrase for this whole area? Nursing documentation digitalisation?

Yes, nurse documentation digitalisation. 

Okay. You described, I think, the sort of multifaceted, multi-stakeholder nature of what you're trying to do. Could you just say a little bit about the management structure for this very ambitious, leviathan-like project you've got—the project board, an operational group as well? Could you say a little bit about that, and particularly—you've talked a little bit about the composition—how frequently do they meet and how do they interact with the rest of the service and the variety of stakeholders?

15:40

So, project board arrangements in place—reporting lines for that through to the informatics board. There's a professional link back to the nurse directors, which is discharged by one of the nurse directors actually operating in the chair. I think we do need to keep that professional context in place. There's also a need to make sure that it links and liaises through the more technical information support. So, our planning and delivery meeting, which is where our informatics experts gather; they have a role to play in this at this stage—but, you know, a range of individuals involved. There are stages that we go through where we need to change the nature of some of the individuals. So, the senior responsible officer will stay the same, which is the nurse director that I've outlined, but there'll be moments when—for example, when we're moving into the procurement perspective, we need to change some of the representation around the table to do that. When we are signing off the technical specifications, we need to just make sure that there's perhaps different involvement there, and, when we're going through the implementation phase, which takes us into 2019, that may require a different feel from some of the more front-line both nurse professionals and informatics staff as well. But—

According to the respective phases. 

Yes. Is there a bit of a trade-off between having the membership sufficiently tightly focused, which would take you down a smaller group, to having it sufficiently engaged, which takes you in the opposite direction? You have to kind of make an assessment.

I think it's a tight group in the sense that we've not suddenly ended up with hundreds of people around the table with interest. We have adopted a workshop approach, so that as and when we need to break out to sign things off—for example, there's a technical workshop that's happening in mid December that's intended to make sure that the programme board does its job to oversee the timetable to call the decision making, but what it does is it reaches out to relevant colleagues, which are there. There is a professional discussion that's just happened through the respective nurse directors, which we arranged aside from the project management arrangements. So, I think we've left it with sufficient people around the table, but tight enough, I think, in terms of the numbers and the constitution. 

And is the project board sufficiently empowered so that it's a decision-making body? There's no line of accountability—basically, it comes to the project board and they can decide.

They can decide on the terms of reference within the nurse documentation, to sign off the requirements and to give that professional view. Obviously, we have some oversight of the funding mechanisms that are in place and how they need to be discharged. That's why it reports into the informatics board, which is the forum whereby we draw in all the relevant areas of information together, and I obviously have some oversight just with my NHS Wales chief executive role.

Coming briefly, Chair, on to the question of funding then, it seems to me that we live in an age when professional and political reputations often founder on IT projects. Do you have sufficient capacity within—? You described the ambitious and multi-dimensional nature of what you're trying to do. Do you have the resources that you require in order to achieve the objectives that have been set?

There are clearly limits within resources. There is a revenue budget that is available to fund NHS Wales Informatics Service as our national information service. There are budgets that are out with health boards and trusts where around 600 ICT staff are employed to discharge these areas, and there are judgments we need to make about whether we expand it or not. There are limitations with the available capital moneys that we have on an annual basis. We have to call and prioritise these. Obviously, ICT has to make its own judgment about how much it can access through those national capital funds. These aren't wholly just for ICT investments; they will pay for hospital bills or equipment replacement or new ambulances on the road. So, we have to provide a variety of calls.

We have seen some expansion for future budgets in terms of additional money being made available for ICT, which is quite important. I think we've thought about our way of allocating some of the funds, so, when we have looked to invest in the extra nurse support on this particular programme, we've used our efficiency through technology fund as one route for that, which is a bit of a different flexibility. But we are certainly constrained, to some extent, with the speed of implementation that we can achieve across Wales, given that there is a very significant array of IT systems. When I set out my original correspondence, it wasn't a comprehensive list of absolutely everything going on in the ICT world about national systems, but it was to give a flavour of some of the choices we need to make. We are commissioning an emergency department system, we are commissioning a national pathology system in Wales, radiology, a patient management system, and, ultimately, we have to make some choices on how that money works. I think it's sufficient for this three-year project, however. I do think we've now organised that in a much better way, not least for some of the feedback from this particular committee. 

15:45

Your counterpart in England has made a very, very big pitch that actually, at a very broad level, digitalisation is one of the key solutions to the challenges and pressures that the NHS faces in England. How do we compare in terms of digital innovation? Are we playing catch-up or are we actually ahead of the game? Can we point to areas, broadly speaking, where we're actually coming up with new, innovative uses of digital here in Wales that are actually being then taken up elsewhere in the UK and more broadly? And how much—? In as much as it is possible to measure it, how much are we spending, not just on digital, but on innovation overall within the NHS, compared to the other NHSs across the UK? 

Chair, if I start and I'll bring Frances in perhaps for some broader reflections. I certainly feel that there's an aspect of trying to learn from what other systems have tried to do. The tradition of the NHS, not least when we had many different organisations—we've obviously collapsed things down now to seven health boards and three trusts—was that sites would be developing their own site systems, organisations would be developing their own individual trust systems, when we had those previous structures in Wales. What we've been trying to do over the last decade, I think, is to make some sense of those as legacy systems and try to convert these into a much more standardised all-Wales approach. So, one of our advantages, I think, has been to try to bring together specifications at systems where, recognising that patients move around themselves, we are able to track the information with the patient in a much better way. And I do think that, some of our opportunities of what we've done in Wales, you will find other systems that haven't achieved a country-wide approach to the implementation of some of these systems. IT is often a very tricky area. So, the fact that we do have a national pathology system in place—laboratory information management system—and that has been implemented and is available, that we have a Welsh clinical portal where we have referral information available that people can access records of different members of staff, is probably more unique to Wales when you compare it with some of the other alternative systems at this stage. 

The community information system would be the first time that, as a country, we have developed the social care record and the NHS record together across both local government and the NHS, and we already have nine local authorities implementing that. We have the first joint implementation by Powys. That's actually taken place. So, I do think that in the context of, 'Are we making a difference or not or making progress?', there's a judgment to make whether you leave it with organisations or do it nationally, but I do think that national emphasis has happened. 

Frances, you may be able to comment on perhaps some experiences elsewhere. 

Yes. Obviously, I keep in contact with colleagues in NHS Digital in Northern Ireland and in Scotland as well. So, when we've looked at the whole systems there are some things that you might see perhaps in some parts of England or in Scotland where we think, 'That would be good; they've made some progress.' But, by and large, most people are very, to some extent, envious of our ability to be able to do things on an all-Wales basis. So, we have made some substantial progress. I think, as Andrew has highlighted, the Welsh community care information system in particular is something that our colleagues throughout the UK are very interested in—how far we have taken that. But there are—. Obviously, there are some things where we feel we could do more and others where we feel we are in front: the imaging service and the two national GP systems as well. So, there's quite a number where we feel we've made good progress.  

Thank you. Just a very simple question—you've mentioned the nurse director, with regard to the electronic nurse documentation roll-out, and obviously the legacy systems that we're trying to standardise and the steps that you've already referred to. At a local level is there an equivalent of the nurse director who is purely responsible or partially responsible for this roll-out?

So, even with oversight from Welsh Government through the chief nursing officer and then the senior responsible officer being the nurse director of the Welsh Ambulance Service NHS Trust, yes, every nurse director will have an interest in the way in which the standardisation of the documents happens in their own area. What we have put in place, though, is an individual nurse of a senior level to stand out from their normal clinical duties and they are funded to take on the responsibility for the local implementation. So, I think that is important, because, clearly, care and treatment do need to be provided. We were probably missing that kind of infrastructure in place previously and we're pleased that we've been able to help with that from a Welsh Government perspective at the moment, but none of it would remove the local nurse director's interest in terms of the health board responsibility to oversee the progress there as well.

Although this is a technical implementation of the system, it's about outcomes for patients and about how we pursue care and treatment, and we mustn't lose sight of that. The danger is that an organisation feels it's an 'on' or 'off' switch. That's why I emphasise that this is about change of practice—of the way nurses are actually performing their duties at the ward level or in their individual clinics or indeed in the community environment.  

15:50

So, bearing in mind the importance of that cultural change and operational work practice change, is there, at health board level or trust level, somebody who is purely responsible for this roll-out, or is it amalgamated into a sort of general role, bearing in mind the importance of it and what is needed in terms of that three-year timescale? 

At the moment, there will be an individual holding and co-ordinating it while we're going through the development of the requirements. As we move into the procurement perspective, as organisations move to the implementation phase, I would expect there to be clear local programme arrangements in place, and, albeit that it's a technical issue, I'd be very surprised if that wasn't professionally led by the organisations. So, one would expect that that will be the nurse directors who are leading that on a local basis, but they will need the expertise around the table.

Just to add to that, we have seen then, with the WCCIS integrated system, we put in additional money to provide that local implementation support. So, at the moment, very much, the nursing record is about making sure we've got the right requirements, that we understand what we're trying to achieve, make sure we have that procurement. But, obviously, as Andrew had said earlier, as we move through the development of the project then you look at your project team and who are at the right level, what's the right level of support. At that point, you would ensure then that there were properly trained people that would do the implementation throughout the health boards.

And that would be led from a Welsh Government perspective, wouldn't it? 

We would be overseeing the national roll-out and implementation as we've done with the roll-out of our national pathology systems, as we've done with our patient management systems as well. So, we would be adopting the same approach on the nurse documentation.

I take your point on this—we shouldn't confuse ends with means, and this is about patient care, it isn't about digital for its own sake. But we discussed with the Permanent Secretary our concern that the responsibility for driving digital through the Welsh Government and its agencies is disjointed—because you have responsibility for NWIS, it's the biggest spender in digital, but that's not really joined up coherently with the drive for digital across the Welsh Government as a whole, is it?

Again, I would say the last 12 months have changed that. You're absolutely right: we have a responsibility to spend the available money within our system to work through a wide range of projects and individual systems that have been implemented but we need to take account of doing that in the broader public service context. I actually don't think, a decade ago, we would necessarily have made the decision about the community information system. That was through liaison with local government that we actually chose to do something quite different that made sure it was about organising services around the citizen and around the patient as they moved around.

We have changed some of the representation around the informatics board as well, which I chair. So, Caren, who's the chief digital officer, who I know has been here giving evidence previously, now sits and is a member of that committee, so it allows us a broader context on where we're going with public services. Also, we have agreed through the Cabinet Secretary about the role of Julie James with her digital overview and having an ability to oversee the system. So, actually, we have examples of how Ministers are working together in that respect as well.

I think, from my perspective, I need to make sure, if you like, the executive implementation of issues—that we make sure that that happens and there's the level of detail there. But I do think we're moving into a different environment, with Ministers having clear expectations of the way the public services work together on these issues. Some of the data centres, for example, are shared data centres, which provide support not just to GP systems but to the broader NHS and local government data that is held in Wales.

Sure, it's a complex picture no doubt, but it's just the drive and pace internally that I'm questioning. Frances Duffy mentioned several times the WCCIS, a system that you tell us is a national social care and community system. Now, as I understand it, it's been two and a half years since that was announced. You've mentioned it's implemented in Powys, which, as I understand, has got 40 staff. There's still no date when it's going to be used at any single Welsh hospital and you're citing that as the achievement that is to give us some peace of mind that progress is moving to pace. I'm not quite convinced.

We've focused on rolling it out in local authorities in the first instance, mainly because, in the order of priorities, there were systems that required to be replaced, and we've built that into the programme at this stage. So, the ability to make sure that those local authorities were able to discharge, starting with Ceredigion and Bridgend—so, nine of the local authorities out of the 22 have already been through their implementation. We needed, on the health side, to make sure, actually, going back to the nurse documentation, that there was a standardised approach to the way in which the information could be collected for community health data. Although there are examples of community-based systems, for many in the community setting, they've not really had the ability to access ICT in the same way, so this is fixing a problem that's been there for many years. And Powys was more of a test centre because it was manageable, I think, in terms of the learning that needed to come through, and there was a reciprocal relationship there already with Powys on the local authority side. So, I think we deliberately started with those arrangements in that organisation. There is a timetable for roll-out, which extends into the other health board areas. Obviously, it's a community-based system, so it will be about the way in which we make that available for the community staff. Alongside it, we will also need to make sure we're investing in some of the available ICT technology. I'm afraid I haven't got the timetable to hand for today—you may have, Frances—but I'd be very happy to give a note, which just gives you the confidence and assurance about what that looks like over the next two or three years on the community information system.

15:55

Yes, but, roughly, it's taken two and a half years to get it to Powys. What's roughly the timetable for getting it everywhere else?

It was two and a half years to go through a national procurement process; to get agreement, sign up, from 22 local authorities plus seven health boards in Wales; to have a European Official Journal of the European Union process in place, given the materiality of the information; to have a specification developed; and then to develop a standardised set of forms in a community setting that has had little access to information and data. So, I know two and a half years will sound a long time, but simply the procurement process and the specification involved with these issues, it will take time to roll out the nurse documentation process.

We've become used to things taking time, with respect. Every IT system we come across takes time. The hospital catering one, which we'll come back to, has taken something like six or seven years to get to the point where we think it should get to. So, you've cited several times now the WCCIS as the exemplar. I understand there's been a recent internal gateway review into that. Can you tell us how that's going?

Yes. I've not had the feedback of the gateway review yet. The gateway review reflects on the progress that's been made, but is more about looking forward to say, 'What are the areas that we need to highlight?' I think there will be some distinctions between the local government reflections on the implementation as opposed to the NHS side, which is kind of new territory. So, I think people feel pretty confident about what they've done. That's why we've now got over a third of the organisations in place on the local government side. I think the health side will still want to demonstrate that we can get to the outcomes and benefits concerned at the moment.

So, you say you don't have the information about what the review showed. Does Frances Duffy know what—?

No. The gateway review had been for the WCCIS project board, the leadership group, so they will have received the gateway, and then they will update us through the national informatics board.

Okay, because my information is showing it in amber and red status.

I would say that that should be expected on a gateway review. A gateway review is absolutely about unlocking the next steps and the things that people need to do—not least in the short term—to get projects there, and many gateway reviews that take place actually will reflect in that way, in my experience. The reason that we ask for them is to be very robust about the next set of choices that we need to make.

Lee, I'll bring you back in again very shortly, so you'll have a second bite of the cherry, but I want to bring Mohammad Asghar in, and then Neil Hamilton.

Thank you very much, Chair. Afternoon, Andrew and Frances. My question to you directly is: has there been an evaluation of the electronic nurse record introduced to Betsi Cadwaladr university health board's children's wards? What benefits have the staff seen from this new pilot scheme, and what is your thinking about if improvement is made on that level on these areas and this can be rolled over to other parts of Wales, and what is the timescale? All questions in one.

There were two areas where we highlighted wanting to learn from nurses in ward areas and piloting local developments. The Betsi Cadwaladr one was an interesting area because it was done through a commercial relationship with a local company that was brought in as part of that commissioning arrangement. What it meant was that the nurses themselves felt they very much owned the output and the outcome. The danger of that kind of approach is although it creates consistency, when you try to lift up one ward and then share it with another ward, maybe they have different reflections.

Actually, I had the opportunity to see this in practice up in Betsi Cadwaladr around a year or so ago, and I was impressed by the way in which the nurses had approached it, just to try to make some sense of their roles. I would say that there were some difficulties in using this as a replacement to the nurse documentation, because you're automating, you're replacing duties and skills, but the reflection would be that over time it did free up nursing time in terms of the understanding of the way in which the system went.

I think the roll-out of the system that was in ABMU probably felt the trickier of the two. I think it probably took longer for the nurses to feel that it was genuinely helping rather than assisting. Ultimately, ICT is meant to actually free up time for nurses to focus on their core care and treatment responsibilities, and there was an emerging view from that one that it seemed to be more of an add-on, in terms of their experience, rather than genuinely replacing. But these two ward areas aside and the way in which we've approached those particular pieces of software and development, the whole point of developing the broader systems that we've referred to and accessing them, whether it's test results or reporting, is always to make sure that we're freeing up the actual care time on the ward, or in the individual department or in the community.

On the Betsi Cadwaladr one, we'll just need to make a decision on the best way of carrying on. One of the downsides of going for a national procurement is when you add up 10 organisations and 100 different hospital sites and talk about a procurement system, you end up with very big national programmes going out to European adverts. And what I quite liked about the north Wales proposal was the ability to get alongside local innovation and local development, and it seems that we should develop national systems when they're right, but I think we should have some flexibility to develop innovation at a more local level when it's appropriate, too.

16:00

Just to add to that, the success of the Betsi one, as Andrew said about the engagement of the nursing staff in designing the system, was they could see then at the end of it that it did make substantial savings; I think at least an hour a shift they felt they could do. So, all of that learning and thinking then has informed the main roll-out of the major programme, and a key benefit from that has been that nursing in other areas can see the benefits that happened in Betsi. So, therefore, there is something to go at, and they will then see—. You know, that will encourage them then to participate in the development. 

Very quick; you've almost answered what I was going to ask. In terms of stakeholder buy-in and that initial getting stuck into a new system—a national standardised system—you've mentioned the Betsi roll-out, but have you cracked that engagement issue in terms of having that buy-in of whether or not it's actually going to be an add-on that's going to be more onerous, or it's going to be beneficial in terms of time and capacity for the workforce? 

I think at the professional level, all of the nurse directors want this to happen, think it will make a difference and believe in the specification that's been developed, and have clearly signed up to the requirements. The workshops that I referred to that have been necessary to work through some of the technical details, they continue to extend out to involve front-line staff, representatives of staff, unions, local areas, technical people in a different way. 

I still feel that the culture of using ICT systems and ingraining it into day-to-day activities will still remain the main issue. It's why we've looked to invest funding. It is more important to find the funding sometimes about the change management process than it actually is about the system in itself, and I think that's where we've got a lot of learning in Wales over recent years, and we are looking to put that right. But I do think that there is good contact and engagement, and I do think there is now ownership and, as I said earlier, we are on track for the timetable that we set out.

Given that NWIS has had to be involved in the development of an electronic solution, to what extent have the chief nursing officer and nurse directors been involved in seeking a more standardised approach to nursing documentation? 

I think their professional leadership has been essential in bringing it together. As much as this is about landing the IT system, we've needed people to make judgment calls. We've not fully reconciled all of these areas. There are a range of tools and methodologies in place that mean that there will be variable practice across Wales at the moment. So, there will be a core set of three pain management tools, for example, that will need to be changed and revised into one. I think the scale of the challenge has been a concern, I think, from the nurse directors over time, but I do feel that the opportunities for this and the way in which some of our other systems have now worked to ingrain an ICT approach better has probably given them some reassurance as well. 

The particular thing that's changed, though, is the tradition would have been for organisations to just battle for their own local systems. I do feel now we'll always start with the default being, 'Can we have the national approach?' and then arguing why it shouldn't be a local system.  

So, the nursing leadership has acted together as a team to try to resolve these potential conflicts, you say. 

Yes, they have, and that's why we'd asked for them to do two things: one is sign off the actual requirements for the system, and then actually determine whether they felt it was going to be best served by in-house development or by the external procurement, and they've discharged that expectation and role. I know that they are happy as well to have some additional local resource, so at least they've got some ability to co-ordinate better, even if it doesn't remove their local responsibility as nurse director. 

Back to Lee Waters, if you've not exhausted your line of questions. 

I'll return to the question I prematurely asked at the beginning, if I might, and so on to the hospital catering system, and whether or not you are convinced, because the tone of your letter is sceptical about whether or not a national system is desirable and achievable, and the right use of money.

16:05

I tried to be open in my response because I just wanted to help your own reflections about your worries on this system. Where we have ended up with issues is that I wanted to have clarity from the informatics perspective about whether people felt that a system through a national lens could make a difference or not and whether it could add any value, and that's where we had an agreement in principle.

What was clear to me, however, from the case that was being put forward—and this is in respect of the limited budget and funds that are available for us to choose all of these variety of systems—it was never going to be able to pull its way up the list beyond us implementing the national radiology system or implementing GP systems. So, my concern is that although I had the agreement in principle secured—it took me a couple of goes around the business case—I've obviously said in here that I don't think that the case was strong enough, good enough, to get above all of those other national systems at this stage.

However, the second point that was a worry is a real risk to the business case because there has been genuine progress over the last six years on the catering area and some of the original issues that were outlined back in 2011. For example, in areas like wastage, we've materially improved those wastage figures, so, the opportunity to make a revenue saving for the future has minimised.

If I give you a direct example: Velindre NHS Trust, which I know is one of our smaller organisations, but if they were looking to sign up to a national system, they've only got £5,000 worth of wastage, anyway, because of the nature of their service. Their system would be much more expensive than any potential savings, even if they were perfect. So, I try to be realistic, recognising there has been a shift over the years.

The third worry I had was as I explored whether we could use one of the existing systems and, in particular, that of Cwm Taf, as an organisation that had clearly addressed some of these areas: could we just lift it up and use it for the whole of Wales? Unfortunately, the advice was that by going to a national system, we would have to comply with all the usual procurement criteria to go out, recognising the material spend that would happen on this. This is a system that's going to cost somewhere between £2 million and £3 million pounds. And what I didn't want to do was destabilise the organisations that actually had made progress in terms of it and insist that they were going to have to comply with a national system.

Therefore, through shared services that have a responsibility for some of our operational services oversight in Wales, there will be a national framework contract in place, there will be a national specification, and organisations can therefore draw down from that and comply. They can prove their own local case to make sure the system can be used, and we can wrap all of that up in one procurement process on their behalf.

There are a couple of issues raised there. You said that you feared it would never really be able to punch its weight, if you like, in terms of the other priorities. You say in your letter,

'Our emphasis and priority will inevitably always be on national clinical systems'.

So, this is not considered really up there with the big boys in that muscular world, is it?

When we're matching it within limited funding, which is, would we not do a radiology system? Would we not replace our GP systems? Would we not roll out a patient-management system for Wales? Would we not do our pathology system? It doesn't punch its weight on that, no. It's a discrete system.

My concern is, we started off this inquiry over a year ago on the quality of food people were served in hospitals, and we got diverted into IT. I'm not really interested in IT; I'm interested in how to improve the quality of hospital food. But one of the points on that is that the patient experience was not getting the proper attention within the NHS that the clinical debates were having. And here we have, again, an example of why a system that has been identified as one that would improve the patient experience is not being seen as comparably attractive within that internal ranking. So, it's just compounding the problem we started off identifying in the beginning.

It does, but there are a range of choices that we need to make. We had, for example, £10 million-worth of extra capital that was allocated to us this year. We went through a prioritisation process on it. We focused on continuing the roll-out of existing systems and to increase the pace of their implementation so that we'd get consistency across the whole of Wales. And in that £10 million, it was not possible to get the catering system to rise above that.

But I do feel that there remains something in this to go at, even in an environment that has reduced, for example, the wastage areas, and that's why I at least want to complete the process, which is that there will be a system to be available. It would also mean for the future that as a system that is in use, for example, in Cwm Taf, and the time at which they need to replace it contractually, would then be able to revert to that standardised template and approach in place as well.

So, you're saying, organically over time, it could move to a standardised approach.

It could move to a standardised approach, but I would worry that the organisations that have made the greatest progress on this in the short term would we affected, simply by the principle of saying it must only be delivered through a national system in this particular example.

I understand that, and I must say, I welcome the new ambitious targets on food waste. I think that's excellent.

And to reassure you on the wastage target, we had dropped down to 6 per cent—we'd gone up five. We've only got four organisations in Wales now over the 5 per cent target, so we may need to recalibrate that as well. But we already have two organisations that are down to 2 per cent on their wastage, which I think is a really good sign of progress.

16:10

My concern remains around pace and drive and the expertise that was touched on earlier. Do you feel that you have the specialist skills in place below the senior leadership level to be able to drive this agenda forward? Because there's a litany of examples of delay and poor implementation.

If we embrace the context of how all organisations are working, and also the national information service, aside from clinical members of staff, we have around 1,200 ICT staff. Around 600 of those are located in health boards and trusts and around 600 are actually in the NHS Wales Informatics Service, our national organisation. 

When I was describing earlier some of the choices of system that we've made on the implementation side, actually, we have gone at scale for a range of systems and implemented them consistently across Wales, and achieved benefits. So, although you, I know, are concerned about some of the time delays on it, we have been able to demonstrate, actually, significant changes. So, for example, on the last GP implementation, we introduced a mechanism for texting out from GP practices across the whole of Wales, just as part of a standardised approach. And we can demonstrate that 40 per cent of lost appointments have been improved on the premise of actually introducing this technology and working it through.

So, I think there is a scale and complexity about the range of systems that we've had. The delays are because we're not just simply landing an implementation in one organisation on one site; we are rolling out across seven health board areas and, actually, we are accessing services in probably around 100 different hospital sites across Wales, and that is the complexity of what we're trying to do here.

I don't need convincing on the complexity, nor, indeed, the value of innovation. My question remains: is there sufficient pace and leadership and pressure within the system? And I look forward to seeing the auditor's report on NWIS, which I'm told is imminent. 

Just very finally, if I could ask you about the workforce planning and this issue of skills and do we have the right skills. You rightly acknowledged there the difficulty of retaining staff, and I guess my reflection on this is that, given the delays that we've seen—and there was another delay that my attention was drawn to the other day, which was that the pathology system is three years late, and we had a seven-year delay on the catering system—if you were a go-getting young tech type in Admiral or some start-up, would you really be thinking of joining the NHS and NWIS as a way of fulfilling your professional desires? Do we really have the culture to drive this forward, and is the leadership there that puts the weight to this process and the drive behind it?

We are in a competitive arena for people who can choose where they want to apply their ICT skills. It feels as though we're in a better place than a few years ago in terms of that, no doubt because ICT skills are coming through much more strongly through the education setting at this stage. Out of 600 staff in NWIS, there are 35 active vacancies at the moment, which is a better position than we've been in in the past, which is a good thing. But I do think it's important to try to ensure that we can demonstrate innovation and different speed.

Frances may want to comment on general processes. There are some aspects about the business case process that we go through, which are Treasury regulations and rules about how large material capital projects need to be taken forward. There may be some reflection that we need to make about whether that is agile enough, particularly for the area of ICT, which moves on at such a pace that I think we need a much quicker mechanism, and I do think there's a broader discussion, not least for how we discharge that in Welsh Government, but maybe more broadly.

On the question of how do we make it attractive to people to come into ICT as a profession, I think we have to show flexibility on our employment models. I think we can have an advantage with our relationships with the university sector in Wales to make sure that we're plugging in our needs and specifications alongside those that are coming through. There are opportunities to increase apprenticeship approaches, to look at graduate entry in a bit of a different way, and actually there is a skill base of experience for people who would've come through different routes. So, it could be people leaving the military, for example, that we may be able to plug into in different ways. So, I think we need to think differently about some of the employment opportunities that we have, and again, that's not always been in the space of the NHS, traditionally, over the years, but it is part of the NWIS workforce plan at the moment.

But ultimately, surely you need leadership and a can-do culture so that people feel that they can affect change. And everything you've told us today is all about the complexities of this and the various processes that you have to go through. So, I come back to the question: is NWIS best placed within the NHS to really create that digital drive that's needed to bring change?

I think we'll need to look at the NWIS governance review and reflect on the best nature for pushing on some aspects. I don't think all of this sits with NWIS as an organisation; half of the ICT spend in Wales is actually on staffing within the health boards and trusts themselves, and there's something about getting on—. I do think we are trying to link more with local innovation and companies with an interest in ICT and creating relationships there. But I do think that, for our large procurements of our large systems, there is something, probably, about, as I said, the capital process—that it will, inevitably, add time on to some of our processes, because it's about the value for money and the responsibility for public funds. It would be nice to think that there's a different way of generating that that means that we could be more innovative going forward. 

16:15

Just to add on that, on the workforce, I think there has been a fear that we were reactive to pressing needs, but over the last year or so we have been working with NWIS to put forward a much more engaging forward plan for their staff. I was very pleased to see that they're beginning to give us some information and data about the age profile of the staff. We're getting more younger people coming in. The gender balance, as well, is good, particularly for an IT firm. So, it's good to see that. There's the work that they've been doing with the universities, looking at helping to influence different courses so that we've got something that will help us bring ICT expertise into the health sector. We've been working with the rest of the NHS looking at digital skills, particularly around analytical capacity. So, there's a fair piece of work that's going on to try and improve and to make it a more attractive offer. Often, when you've got an area of specialism like this, you do have an issue around some of your finances and salary levels, but with a turnover rate of just about 10 per cent for NWIS it's not extraordinarily high for that kind of industry. So, there's a lot that they're doing to retain and attract staff.

There's something about knowing that you can make a difference as well. So, for those staff who have been involved in our Welsh clinical portal and its development, and the software development around it, when you start to see some of the figures that come through—having more electronic referrals into the system, seeing that, in Cardiff and Vale, they've managed to reduce their cardiology waiting list probably by about 70 per cent on the premise of using the technology to speed things up in the system and remove delays—there is something about people actually understanding the impact that they will have on patients and the system more broadly, and that in itself is exciting for some of those involved in these developments. 

Just regarding the catering here, Andrew, I know there's a lot of waste and cost and expense to the hospital and the NHS regarding kosher and halal and vegetarian and non-vegetarian. Would you consider giving patients' families the choice, the option, to bring food from home so that they can eat what they require in the hospital? It woud probably save quite a lot of money.

From a professional perspective, that would be quite difficult. Inevitably, we know, people will turn up and be alongside their family arrangements. But we obviously have to make sure, in terms of people accessing nutrition and generally, that there's a safety aspect about what people are eating in there. It doesn't preclude people turning up and being with their loved ones and their families at various times, but from a system perspective, I don't think we would want to go down that route. If there was any occurrence that had occurred around an individual family, to be able to track it back within the system becomes quite important. So, I wouldn't envisage that that could happen.

I do think that families have a really important role to play as part of nutrition and catering and whatever we do to improve our menus, and what we've rolled out on an all-Wales basis, and to really focus on this. Actually, you'll see across Wales now examples where visiting times that were previously stopped when the food was coming around—you know, we're trying to make sure that they happen at the same time, because actually, families ar able to help in that kind of environment. They're not to replace the duties of the staff who are there, but actually that's part of giving support anyway at this time. So, we've tried to be much more open and reflective about these types of areas. But I honestly, from a system perspective, can't see us reverting to that kind of approach. 

I understand. You're perfectly right and I agree with you, but on the other hand, some patients, from personal experience, do not like hospital food. That's it. You could be co-ordinating with the families what sort of food—or some sort of system of connectivity with the family members—

There are some people who will never like hospital food. We did discuss that in the inquiry. 

We clearly have to offer flexibility on these arrangements—respecting religious requirements, for example, or individual areas. In part, that's what we drove through the all-Wales menu framework. Again, it was the country taking responsibility to say that these were the menus that would be available, and having some consistency so people knew they could access that at a local level.

Thank you. We've already touched on this earlier in terms of provision of a new procurement process. Is there any concern—you have touched on this briefly—in regard to those hospitals or trusts that have adequate systems in place, catering and IT systems in place, that if we move over to a national system, this will make it very difficult for them? If so, what mechanisms have you got in play to support that transition?

16:20

It was genuinely my view and reflection. So, as I had the feedback from the various exercises that we've done, with people clarifying what the national system would look like, it was really clear from those organisations that had already got there that they were concerned that the procurement process would just mean that they ended up complying for the sake of it, when they were already demonstrating progress. That is partly why I've reverted to making sure, through the shared services, that we will do the specification. We'll have the national off-contract arrangements, so there will be a framework contract in place that people can draw down. But, I was worried that the organisations that had already got it in place would end up getting very distracted, rather than focusing on the patient care and outcomes that we were looking for and continuing to improve some of their underlying wastage rates.

But they could access it in the future, as I was explaining earlier.

Okay. So, in that regard, you feel confident that the transitional process will be adequate to not unbalance what's there.

Yes, I think so. Also, it will then be clearer that the organisations signing up will probably be those where there is a better case for them to do it. It will be because they do need to make some progress on wastage, and they will be able to identify the revenue savings.

So, in regard to a picture as to what is out there, what would you quantify for us here in this committee as to those that are delivering adequate systems—is it 60:40, 30:70 or more than that?

I think at the moment the number of organisations that have probably got systems in place that we feel are the basis for being compliant is two or three out of the seven organisation at the moment, so there is an opportunity there. There is a balance between the core systems that people are using and drawing off where they can—people going beyond that into database-led areas, people looking at some web development around patient-ordering mechanisms, and then there are still some manual mechanisms in place that absolutely would benefit from this type of implementation. To be honest, if six out of the seven organisations were already compliant with these areas, we probably just wouldn't be reverting to the national system in the same way. That's why I still feel that there is some scope here.

Most health bodies are reliant on paper-based systems still for their catering. How confident are you that they have access to reliable and timely information to manage their catering services?

I would separate it into two areas. So, at a technical level, they all have to produce information on a consistent basis across Wales as part of our annual returns and reporting. That happens through our operational service reviews, and that allows us to have a sense of the costs for catering. In broad terms, this often translates into some of the value-for-money audits that are done and some of the Wales Audit Office areas as well. So, that's more the annual process that's in place.

On a local basis, the fact that people have been able to demonstrate progress on the original standards and recommendations, and that they've been able to demonstrate their drop in wastage—. They are able to address these issues, but it's just easier for some organisations than others because they have access to some of the IT already. I wouldn't remove the fact that there is clearly a case still for some of the manual process in place with these organisations to be dealt with.

Everybody is able to manage within their budgets. They have financial systems that are available for them to help to review that—our procurement processes are actually done through a standardised system. So, there are other supported mechanisms in place, but, clearly, it would all be improved if we could just get everybody to have absolute compliance with the IT.

Just to go back to something you said earlier on, in relation to the other competing priorities that are greater than standardising your IT for catering services, there's a capital cost up front of bringing this in, and that obviously has to be financed for years to come. In comparison with the projected cost of financing this project, is there a greater-than-one return on the investment, or would you say that it's not really worth embarking upon a massive project of standardisation because it doesn't actually have a payback that is positive?

The reason I've retained the national framework approach is because I still think for some organisations there is some scope for them to do that. There are some organisations where they've got to such a low level of wastage already that the system would end up possibly costing more than they'd be able to recover, for example, so I think that would be a worry and a concern.

I do still feel that there are, certainly for one or two organisations, opportunities for them to create it. When we, however, reviewed the business case, two things happened. First, the capital investment cost had actually risen from what was a smaller discretionary amount that was more residual: £400,000. The current costs on this are predicted to be somewhere between £2 million and £3 million, and it becomes a more significant judgement to make about how we do it. But, actually, the savings in the system had changed because, when we originally tracked this back from 2011, obviously things had moved on quite a bit. Even on the 2015-16 figures, the wastage has reduced materially. We actually think our figures, when they come out for 2016-17, will also have demonstrated a further improvement again. But, for one or two organisations, there is clearly an opportunity and some scope still to go at this level of saving and make it an invest-to-save, but they'll now do so through going through the national specification and the national framework. 

16:25

Can I just follow that up? You said the costs are projected to go up from £400,000 to somewhere between £2 million and £3 million. Why is that? 

There was a change on some of the capital assumptions that were there about the up-front costs on this. There were clearly some revenue costs that need to be done on there, but we just asked the professionals involved in here, both from an information and from a catering perspective, to revisit it. The original business case was one that had emerged some years ago and I just wanted it to be really clear and be updated for the current environment and on the latest figures, and, certainly, when we had the 2015-16 figures made available on the annual data, we were able to throw them into the modelling as well.

And does that raise questions about NWIS's ability to plan?

No. I think that there's a change of environment in terms of—

—what they can procure. There's quite a choice about the different areas, but the capitalisation approach on how the spend would be approached was something that was different in the methodology as well. 

Right, and I understand the pragmatic judgment you're making and, from your point of view, I can understand that in terms of the relative priority and so on, but I guess that the other way of looking at that is maybe that reflects a scepticism from the health boards themselves, that they don't really think that the procurement systems or the leadership is up to scratch and they'd rather stick with what they've got than risk going through the whole gamut of barriers that are in place.

I think the professional perspective is that, if there was the discretion to have a system like this in terms of all of the choices that we make, they would welcome it. They may choose other priorities themselves in terms of some of the things that they want to go at. They want to make sure that, if they implement the system—to be clear is it a system that is being implemented at a cost, which is an extra budgetary pressure, or is it a system that's being implemented where it can actually support and make a saving. So, that's really the distinction that they want to make. 

So, can you give us some idea then: if you go for this more pragmatic having a framework and allowing people to opt into it as their own systems run their natural course, what do you expect to be the overall timeframe for achieving what we set out to achieve in the first place?

We've got a timetable in place for working through these issues. We've established that, within three years—and this will be heading for 2019-20 with the full implementation. Because of the materiality of the system, then it has to have a clear national specification. We are going through that process in the same way as with the nurse documentation discussion at the moment. We would be looking for the procurement process to kick in and then be making the decision on the final preferred supplier and that will be coming through 2018 into 2019, but, again, if it helps, Chair, I'm happy to give you just a note of the current timetable that's outlined for the next three years on this particular scheme and how it will be taken forward.

So, by 2020, you expect everybody to be on the same system.

But it's frontloaded with the 18 months to 21 months that it takes simply to get through (a) the specification, and secondly the European procurement process on here.

We've kind of neatly come back to the very first question I asked about the timetable and about your confidence of sticking to that. Lee, sorry, I—.

So, just to be clear: you're saying it will be by 2022 that you—.

No. We'd be looking at the implementation 2019 to 2020. So, it should be—

Yes, but you then said it would take 24 months to go through the processes—or did I misunderstand that? 

No, no. I was saying that—to try and describe that time, if you're saying, 'Well, why is that taking so long?', just to try to clarify the technical aspects of its specification to pin it down to be clear on what's going out to the market, the European procurement process, then the market analysis—

Sure. So, by 2020, you'd expect everybody to be on the same system.

By choice to choose off the national framework and for those organisations that have not had access to be able to draw it down, yes.

I'm new to this area, I certainly don't have the expertise of Lee Waters, but I'm kind of interested in this line of questioning, which, if I can summarise in my own head—you know, to what extent in evaluating relative priority of different projects do you take a whole-systems approach, because, you know—. For example, if you identify that, actually, this particular IT project is essential in order to improve food and nutrition within the health service, and that is important because it links to patient experience—you know, basically the prognosis for people is worse if they go into a hospital environment that is terrible physically, badly designed, and they get poor food. So, if you change the refraction on your lens, then, actually, you could come to a very, very different analysis about what this small particular cog down here does for you. Do you have that—(a) does the question make sense to you, and do you have that kind of ability to see the bigger picture?

16:30

The question does make sense. And I would say that, over time, schemes and the roll-out of technology has probably happened on the basis of the available funds, and areas that were more pressing in their approach. So, there may be some very obvious things there, but, when your contractual arrangements on GP systems are simply coming to an end, you have to step into the territory to go at it. I think that NWIS and NHS Wales in general terms—and this would, I think, be some context for the Wales Audit Office review on informatics anyway—has to make some choices within all of that, and I think, probably over the years, has accumulated many different objectives.

What we've tried to do over the last 12 to 18 months is instill a different discipline, a methodology, around this. So, we have actually developed a prioritisation framework, and not only have we developed that, we were able to apply that to the allocation of capital for this last year for some of the judgments that we made. I have to say that, in that analysis that we did, which tried to be more holistic in the approach, to look at the outcomes, the catering system still wasn't featuring strongly within that particular context in terms of it being a support mechanism. But we have now got a methodology, we've signed it off in the informatics board, it's available, and we've already applied it this year to some of the capital allocation that's been made by the Cabinet Secretary. So, I think we feel like we're in a different place, but a lot of these were legacy systems over time, which we've just tried to co-ordinate and bring together nationally. And I think we are now starting to make some sense of them.

So, given that you're not putting all the emphasis on the kit, if you like, back to the question of quality of hospital food for the patient in the ward, I was pleased to see that, in your letter to us, the all-Wales menu framework group does now discuss feedback within their meetings. But one of our recommendations was having a board member who had direct responsibility for this and they regularly took reports to board. So, given that you can't give us the reassurance we're looking for in terms of the systems that the audit office thought that we should put in place, within what anybody would think was a reasonable timescale, can, at least, you give us some reassurance that there's going to be an emphasis from your leadership, throughout the system, that this kind of patient experience stuff matters and is going to have a spotlight shone on it?

Yes, I can give you that reassurance. Obviously, we confirmed in my letter as well about the allocation not just of executive leads and organisation in this area, but also around non-executive, so independent, members sitting around board areas. I do think, as a system, we need to find a way of moving some of our reflections about, if you like, our processes that are in place and really to look at the outcome side, and whether it's looking at the development of clinical outcomes, whether it's individual impact for patients, a collection of patient experience, in terms of the care as they arrive, and having that more easily available, to not just be sample-sized surveys, trying to collect everybody's experience through these routes, and certainly having feedback on information and people's take on the quality of the food that they have—that should be absolutely a feature of quality reports into boards and oversight. And I'm happy to reassure you that that should be part of my expectations for the system in Wales.

We're out of time, but, very briefly, Rhianon Passmore.

Very briefly, just basically following up, you mentioned that there are two or three boards that you think are adequate enough in terms of their systems not to move into a national system. So, if it is choice-based, autonomous, what is actually driving those that are not up to spec, that are not adequate, to move into the national system?

Well, if you're asking what's the drive for them to decide to sign up to the national system, there's three things that I would suggest. One is that they still have some opportunities to go at wastage, and they will be organisations still with a high level. So, although we've seen some significant improvement and some dropping down, one or two organisations absolutely could use this as part of that approach. Secondly, that they have a responsibility for value for money still within their schemes to sign up to. And, thirdly, they have a responsibility to do better for patients through those arrangements that they're putting in place.

I still don't understand why that would necessarily drive them into jumping into a national system.

Well, we will be overseeing wastage rates, for example, with the reset target, and we will be asking people to recalibrate around those kinds of arrangements. So, as part of our own governance, we won't be just sitting and observing, we'll be waiting and expecting. So, for me, it's a balancing issue. Ultimately, if they can demonstrate good patient outcomes and they can demonstrate improvement on wastage and it doesn't need to be driven through an IT system, then I think that's acceptable to have a balanced discussion with them. If they're not achieving either of the former, and they are declining the opportunity for a national system, that's a very different discussion with them.

I think, in addition to—

In addition to that, we do have the dietetic leadership group. So, there are groups of professionals within health boards themselves who will be overseeing and looking at the development of the systems, and they're constantly challenging on where health boards have progressed. So, they're looking at the standardisation of menus, wastage figures, et cetera. So, where health boards are not making progress, then there would be a further push from that.

16:35

Because there's a huge difference between wastage as the driver and whether or not somebody's nutritionally able to survive in a hospital environment.

I absolutely accept that distinction, and we need to.

Okay, that's it. Can I thank our witnesses, Dr Andrew Goodall and Frances Duffy, for being with us today? That's been really helpful. We'll provide you with a transcript of today's meeting for you to look over before it's finalised. Thanks for being with us today.

5. Cynnig o dan Reol Sefydlog 17.42 i Benderfynu Gwahardd y Cyhoedd o'r Cyfarfod
5. Motion under Standing Order 17.42 to Resolve to Exclude the Public from the Meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

I propose our old friend Standing Order 17.42, to meet in private for item 6, which is consideration of the evidence we just heard.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 16:36.

Motion agreed.

The public part of the meeting ended at 16:36.

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