Y Pwyllgor Cyfrifon Cyhoeddus - Y Bumed Senedd
Public Accounts Committee - Fifth Senedd16/04/2018
Aelodau'r Pwyllgor a oedd yn bresennol
Committee Members in Attendance
|Adam Price AM|
|Lee Waters AM|
|Mohammad Asghar AM|
|Neil Hamilton AM|
|Nick Ramsay AM||Cadeirydd y Pwyllgor|
|Rhianon Passmore AM|
|Vikki Howells AM|
Y rhai eraill a oedd yn bresennol
Others in Attendance
|Andrew Griffiths||Gwasanaeth Gwybodeg GIG Cymru|
|NHS Wales Informatics Service|
|Huw Vaughan Thomas||Archwilydd Cyffredinol Cymru|
|Auditor General for Wales|
|Mark Jeffs||Swyddfa Archwilio Cymru|
|Wales Audit Office|
|Steve Ham||Ymddiriedolaeth GIG Felindre|
|Velindre NHS Trust|
Swyddogion y Senedd a oedd yn bresennol
Senedd Officials in Attendance
|Claire Griffiths||Dirprwy Glerc|
|Meriel Singleton||Ail Glerc|
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 y cyfarfod am 14:00.
The meeting began at 14:00.
Can I welcome Members back from the Easter recess to this afternoon's meeting of the Public Accounts Committee? Headsets are available for translation and sound amplification. Please ensure that electronic devices are on silent. In an emergency, follow the ushers. We've received no apologies today. Do Members have any declarations of interest they'd like to make at the start of the meeting? Okay.
Item 2, and we have some papers to note—first of all, the minutes from the meeting held on 19 March. Happy to approve those? Okay.
Secondly, the challenges of digitalisation—the Welsh Government have written with additional information regarding the relationship between the Welsh and UK Governments in respect of the procurement of digital services. In line with the earlier agreement, I've forwarded a copy of this letter to Russ George, the Chair of the Economy, Infrastructure and Skills Committee. Are Members happy to note that response? Lee.
There are a couple of issues that arise for me. The purpose of the letter, you'll remember, was to query why Welsh public services were sticking to large, long-lead-in-time procurement contracts and not going with the more agile approach that the NHS in England, in particular, or the digital sector in UK Government have gone for. I think the letter answers some of the questions, but not to my huge satisfaction. So, for example, it says on the first page that:
'Larger digital requirements go through the Digital Outcomes and Specialists framework',
which is known as DOS. As I understand it, the whole point of this DOS framework is that it allows organisations to second in experts. So, if they want a particular piece of work on user research or cloud technology, for example, they can pull in an expert from this DOS framework to work within and build capacity within an organisation. It's not clear from this letter whether or not the Welsh Government or the Welsh public sector are doing that, and the letter is very narrowly on the Welsh Government's own activities, rather than the broader picture, which is part of the problem we picked up in the first place with the Welsh Government. So, I think that (a) that's a problem, (b) the fact they're not using DOS—or it's not clear from the letter if they're using DOS in the way I was intending we ask. And then, thirdly, they talk about how they are—the letter is essentially saying they're doing it all fine and they're using this new Government digital services framework, but, actually, when you look at the table on the final page, the amount being procured through the G-Cloud framework, which is far more agile and nimble, which is more attractive to small and medium-sized enterprises, it's £602,000, whereas, under the traditional frameworks, they're still procuring not far off of £5 million. So, only about 10 per cent, roughly, of their overall procurement is going through this G-Cloud. So, the—
A pretty small proportion, isn't it?
The tenor of the letter is, 'All is well, we're doing as you wanted,' but, actually, on the detail, it's not very convincing and this speaks to my wider concern that we are getting a pattern of responses from the Welsh Government that suggests they don't really get this. So, I'd be grateful if you could push back a little, I think.
You'd like us to go back to them and—
I think I'd like further details on how they're using the digital outcomes and specialists framework, and, in particular, the breakdown of the G-Cloud spending, but the broader point is how this applies to the Welsh public sector more generally, rather than just Cathays Park.
Did you want to come in?
I just wonder—. You've had a couple of exchanges of correspondence with them, and I wonder whether the best way to actually address the difference, really, between getting a response that is very narrow on the Welsh Government and one on the Welsh public sector's greater use of ICT is actually to have an evidence session with them. Because I fear that you will simply correspond, you'll get another response, and it'd be easier, I think, to arrange an evidence session.
I think the economy committee is—I forget now what exactly the work programme looks like, but I think the economy committee is planning to do something as well, so maybe it's a matter for the clerks to liaise to see the best way to handle it.
Yes, we can do that. We've a pretty packed schedule, but if there's time—
If we could write in the first instance, just to get some clarification on the points I mentioned, but I think that's a good idea, to do a broader piece of work.
We've got Andrew Slade anyway on 4 June, so that'll be an opportunity for us to follow up. So, we'll get the letter off in the meantime, and we can follow up on all those issues. Okay. Thanks, Lee.
Moving on, and following the evidence session with the Welsh Local Government Association on 26 February, they've sent additional information on the preventative care fund and anomalies in spend between local authorities and the pupil deprivation grant. Do Members have any comments on that? All happy to note the response from the WLGA? Yes, happy. Good.
Following the evidence session with the Fostering Network on 12 February, they too have sent additional information on best practice examples of measuring the impact of fostering and the fostering well-being programme, which is being delivered across the Cwm Taf regional board. Colin Turner has extended an invitation for us to attend any of the master classes, and, if you're interested, we can make arrangements for that.
Moving on, following the evidence session with the Welsh Government on 5 March, Andrew Slade has again sent additional information. I also wrote to him before the recess welcoming the review of the National Procurement Service and Value Wales that is currently being undertaken. I advised that, given this review is ongoing and due to report its findings later this year, it would be premature for the committee to draw conclusions at this stage, but I advised of the committee's views on the terms of reference, as we discussed in the committee meeting of 19 March. Lee.
Yes, I think Mr Slade, again, is not quite addressing the points that we wanted addressed in the fullest terms. So, he quotes a figure, again saying all is well, of the number—. So, this question of the McClelland methodology, of how many public procurement specialists you need per £10 million of spend—. And, in his letter, he says that if you take the McClelland, I think it is, measurement, which would suggest you need 300—and the Welsh Government are at that, by saying they have 326 fully qualified public sector procurement specialists, but that includes 58 at student level. We've seen, from the previous programme, that the problem with the student programme is they don't stick around, they leave as soon as they can. So, I'm not sure that is a fair depiction of where the public sector is truly at, because, if you take that 58 out of his figure, he's some way below the 300 McClelland measurement. He then goes on to say, using the UK Government—which would suggest a different figure, that they meet both—. Sorry, they're on course. But I don't think they are, and I think including the student level in that figure changes the picture, and I don't think that's very straightforward of him.
The second point is on Kevin Morgan's work, which is the penultimate point of his letter, again about skills. He answers it by quoting community benefits, which has got nothing to do with skills. So, on two points, I don't think Mr Slade is being straightforward with the committee and directly answering the questions that we put to him, which isn't a very good start in his new role. But I'm dissatisfied on both those points with his response.
I'm due to make a statement on this to Plenary on 2 May, I think it is, so that might be an opportunity for us to follow through some of this, but also in the—this is the letter that I wrote on 23 March, and I pointed out in that letter that there is clearly a wider capability challenge for the review process to consider. But I take your point. The response that's come back, really, is, I suppose, woolly in some ways, but it's not exactly answering the questions we posed.
Well, he directly doesn't answer the specific question on the Kevin Morgan point, and I think he's using statistics to throw us off the scent on the first point.
Taking the student—
Sorry, Chair. Taking the student figures out, it's 326, is it?
No, I think it's 326 with the students, isn't it?
No, I think it's 384 with the students, and 326—
Oh, apologies. You're right.
So, I think it probably comes more down to whether you use the—which methodology you use. So, in that sense, they're just above the 300 figure, but then if you take the different model, then—
You're right, I misread that. But even with that—
But, regardless of numbers, they need the appropriate skills. The evidence you got from various people who came suggested, basically, we were short of the skills and the mindset to properly deliver procurement.
As I said, I'm going to be making a statement on this, so I can highlight some of these points, and I think they certainly need to be a bit clearer on the way that they're going to address the capacity issues.
Well, in that case, I think, even the 300 figure, it really is the—you can take 10, 15 or 20, can't you, and that's the very, very base level, and, as Huw says, then if you also add in other factors about the quality and the level of seniority and experience, then you're really at the bare minimum level there.
I think this second point, addressing Kevin Morgan's suggestion—I think this response is just misleading, because he's talking about community benefits and we asked about skills.
It does seem to be a recurring issue, doesn't it, with some of the letters we are getting back? I did ask about the wider issues, so I suppose the danger is that there's a distraction going on there, isn't it? I think that's the point you're making, Lee.
I'm making two points. I'm making the substantive point, but I'm also making the point about senior Welsh Government officials not answering in the spirit in which they should be answering. So, I think we should push back.
Do you want to do a follow-up in the meantime?
I would suggest so. I'm not sure what other Members think.
Yes, I think so.
Just to clarify exactly what we did ask.
I think it is odd, the response about Kevin Morgan's paper. It's a totally different issue, and it's critiquing the paper more generally, and we weren't asking about that at all, so it's strange to say the least.
We can make that point.
I think we should.
And use that word.
I was being polite.
That's why I thought it was a good word.
Okay, item 3 and returning to the scrutiny of the Natural Resources Wales annual accounts for 2015-16. NRW were due to provide an update in addressing our recommendations following the scrutiny of the annual reports. They've advised that the Wales Audit Office have commenced an audit of their action plan, and NRW have asked for a deferment in providing an update until this work is complete, which they envisage will be before the summer recess. I'm content to agree to this, but, auditor general, did you have any comments that you wish to make?
I certainly will be carrying out an audit of how they're dealing with the action plan. There'll also be issues possibly coming from the current audit of the accounts, so I think it is desirable to delay the evidence session.
Okay, item 4, and the audit of Cardiff and the Vale university health board's contractual relationship with RKC Associates. Cardiff and the Vale university health board have provided an update on the action plan following the public interest report published by the auditor general last year. Members will wish to note that, of the 26 identified actions, four remain outstanding. CVUHB have advised that work is ongoing to implement the final action points. I asked for a further update in September. You may also want to note that the two contracts referred to NHS Counter Fraud Service Wales are nearing conclusion, and I'll be provided with an outcome when those are available. Do you wish to comment on—?
I'm just simply saying that Cardiff and the Vale have actually addressed quite seriously the issues in the public interest report. They report quite regularly to their board and the audit committee on the action plan, and have also engaged quite positively with my own staff. So, I think you can be confident that what you have here is the realistic assessment.
Good. Happy to note that? Lee.
Can I just add something? I think it's a good response, but I remain concerned with the issue we discussed at the time, which is proportionality—that they don't go overboard in response to their failings and try and impede the normal procurement work that goes on. My specific concern is around the issue of senior leaders, because they say in their new procedures senior leaders will be included and encouraged to raise concerns, and specifically, in the third paragraph from the bottom,
'This provides that the CEO and Vice-Chair can be contacted should a staff member feel they cannot raise a concern with their manager.'
But in the evidence we took, from what I recall, the concerning behaviour was by the chief executive himself, the previous chief executive. So, I'm not entirely clear on what they're going to be doing to address concerns at that level, because the session we had with the chair at the time certainly did raise issues about her failure to properly scrutinise and hold the chief executive to account. But I don't see anything about that in particular that's come out of their lessons learnt. I'm not sure if the auditor has a view on that.
You took evidence from the new chief executive as well as the chair, and basically they were reporting that there'd been a reluctance by staff to report under the previous chief executive and management structure. So, I think that they're taking this seriously. I think if you've got particular instances or particular concerns, you can write and seek further clarification, but the fact that they are taking, if you like, the equivalent of a whistleblower status seriously I think is good news.
It is, absolutely, but the question remains in my mind at least: what happens when it's the CEO who's exhibiting behaviour that's causing concerns? And that doesn't really address that, because what it's saying here is that you can report to the CEO. I guess you could report to the chair, but, last time, it was the chair who was not really on top of it. I'm not sure what the answer to that is, but that was the problem last time, and for all the stable doors that have closed after the horse has bolted, they don't really address that issue, which was the problem last time.
No, but within the health board there are clearly procedures, and it would be the chair. I hear what you say about the chair, but equally there are procedures that allow wider whistleblowing within the public service, so I trust people would use those.
That's all for the good but it doesn't quite address my specific concern.
I can't give you a specific answer.
I don't know if others share my view, and those who were here who took evidence—
You're concerned about who would they actually go to, then, if the chair wasn't willing or was not in a position to act, and then they're directed to the chief exec. You're going to end up without anyone you can really see.
Because that was the issue last time, and they've created all sorts of procedures for everybody else, which is grea and a good thing, and I applaud it, but it still doesn't quite address the issue that was the weakness last time. So, I was just wondering if it's worth us writing back and asking specifically in that instance at a senior level.
Yes, we can do that.
Okay. Item 5, the responses to the committee's report on the scrutiny of the accounts for 2017. As I said, Jo McCarthy's going to—. Jo, did you want to summarise the responses we've had?
Thank you. Subject a number of exceptions, all bodies actually accepted the committee's recommendations. They've provided information in response to the committee's request, or they've agreed to do so when that information becomes available. The exceptions relate to the Welsh Government and the National Library of Wales. Both organisations have provided a range of information to the committee in respect of the recommendations. However, it's not clear from this information what, if any, action they plan to take in light of some of the committee's recommendations.
Looking specifically at those exceptions, taking first the recommendations to Welsh Government, the first two of the committee's recommendations relate to the reporting of financial performance. Members noted as part of their scrutiny of the 2016-17 accounts that the Welsh Government accounts actually set out information about administrative performance but didn't set out information about its performance in relation to its targets, or its objectives, such as those set out in the programme for government.
So, the committee made a series of recommendations. It suggested that Welsh Government should consider how best to report its performance, should make clear which elements of the Treasury's guidance it sought to comply with, and then, having considered that, it should then issue further guidance to its sponsored bodies.
In its response, the Welsh Government has noted that future performance reporting will include a cross-reference to its new well-being of future generations report. It aims to publish the first of those this coming summer, and that, in preparing its accounts, it notes that it complies with the requirement of the financial reporting manual, subject to exceptions that they deem not to be material. However, no mention is made in the response of whether Welsh Government aims to publish this new report at the same time that it publishes the accounts, nor does it provide any information about the content of the report—so whether, in preparing the report, Welsh Government will seek to comply with Treasury guidance on performance reporting.And finally, the response doesn't note whether further guidance will be issued by Welsh Government to its sponsored bodies.
Finally, in respect of Welsh Government, it's also unclear from the response whether it aims to take any action in response to the committee's recommendations about different approaches to reserves policies for its sponsored bodies. This is particularly relevant given the greater flexibility afforded to it from 2018-19 by the new Wales reserve.
Turning, then, to the National Library of Wales, the committee made three recommendations, two of which related to the library's planning processes. The committee recommended that the library should not assume that current levels of public funding would continue and that the planning process should address a range of scenarios, including any reductions in the resources available to it. While the national library has provided a range of information, it notes that it continues to monitor its risk and considers that there is limited scope for future efficiency gains to protect its front-line services. It also notes that it will soon reach a point where fundamental changes will have to be made if is to remain financially viable if its funding is at or at lower than the current level. The response also notes that cuts will probably result in a closure of some of the core functions and that it would require financial support to implement compulsory redundancies. It also notes that one of its greatest challenges has been the inability of Welsh Government to provide any medium-term budgets. However, the national library's remit letter for 2018-19 has recently been issued. This reports that its revenue allocations for 2018-19 and 2019-20 will remain at the same level as they were for 2017-18, while it will receive additional capital allocations over the next three years.
The third and final recommendation to the library related to the pension fund. Members recommended that the national library review the pension scheme as a matter of urgency and provide assurance that it can provide a scheme that is sustainable in the longer term. In its response, the national library notes that the board of trustees is disappointed with this recommendation. It summarises the actions and considerations of the board, some of which were subsequent to the preparation of the 2016 accounts. However, not in all cases have changes been made. The library notes that some of the changes that it considered would not achieve savings, or may actually result in an increase in cost. However, it notes that over recent years it has improved the funding position, moving just from about 60 per cent funded to being nearly fully funded as at 31 March 2016, which was the date of the last actuarial valuation.
Thanks, Jo. Did you have a comment on this?
No, I entirely agree with those comments. Particularly, I have to say, I'm disappointed by the Welsh Government—the tenor of the Welsh Government's response—in that the thrust of the recommendations from the committee both this year and last has been about making the annual report and accounts understandable and cross-referencing to the performance of the Welsh Government on various funding streams so that you know, if the money's being spent on education, what's being achieved out of that. What they're saying, essentially, is there's a network of reports, which, if you read them all together, will give you that response. It doesn't give us the kind of clarity that we've been trying to urge on the various audited bodies.
Any questions? Lee.
The national library's response is typically defiant. I just wonder if the auditor has any reflections on that.
I thought that the response in terms of pension was reasonable. It did set out the changes they had considered and also changes they might consider, which I think is useful. But they also make, I think, the legitimate point that their planning has changed with the fact that they now have indicative budgets, and that is something that we've been urging as a committee on a number of fronts, in that it helps audited bodies to actually have some degree of certainty for their second and third years. I make similar comments about the broader nature of the national library's response but, certainly on those two points, I think they have reasonable arguments.
The thing that struck me is that your team have encouraged us to play with this notion of scenario planning so that they could look ahead, and they're saying in response that their current four-year planning process has been supported by the Wales Audit Office. So, what's the Wales Audit Office's view? Should they be scenario planning, or is this sufficient?
Compared to where they were, we have seen a significant shift in the library. Our concern was that, initially, the planning was very much bound by a one-year horizon. With the fact that they now have better certainty for a second and third year, we'd expect them to revisit their planning.
Right, so you're not satisfied with that?
No, I'm saying that I'm satisfied. At the point at which they prepared their plans, I'm satisfied. They now have the ability to be a bit more flexible in terms of scenario planning.
Right, and they need to keep doing that. Okay, thank you.
So, I suggest we write to back to the national library with our concerns, and the Welsh Government as well.
There are so many things the Welsh Government—. In terms of the library, I think the auditor is generally content. I guess the only point we could make, if we wanted to write, is just to remind them to keep up the good work in terms of their scenario planning on an annual basis.
Yes, I mean, I think the library should be—we should welcome the fact that it's a very, very full response and that they clearly have addressed some of the constructive suggestions that have been made. So, indeed, we should encourage them to continue to do so.
Chair, I was just going to add, in terms of that journey travailed, that there has been a lot of water under the bridge. But, obviously, the fact that we're still going to be keeping our eye on the ball, so if we could have the carrot and the stick, I think that would be useful.
Yes, that's my intention.
Okay, moving on. Our witnesses are with us. Welcome. This is the first evidence session for our inquiry into the informatics service. Representatives from health boards are attending committee next week and the Welsh Government are scheduled to come on 14 May. We've also written to a number of stakeholders inviting their views on the findings of the auditor general's report, reflections on wider practice elsewhere across the UK and any general comments on the implementation of information technology systems. So, welcome. Would you like to give your names and positions for our Record of Proceedings?
Good afternoon. I'm Steve Ham. I'm the chief executive of Velindre and the lead chief exec for informatics in Wales, and also the joint senior responsible owner on the digital strategy informing health and care.
I'm Andrew Griffiths, I'm the director of NHS Wales Informatics Service and the chief information officer for NHS Wales and also the programme director for the digital strategy.
Great. Thanks for being with us. A number of questions for you—if I kick off with the first one. Overall, the auditor general’s report found significant weaknesses across a wide range of areas. Are current arrangements fit for the purpose of delivering effective informatics systems?
Yes, I think we welcome the report. I think it did highlight a number of areas where we've been able to strengthen arrangements. I think what we've now got in place is a range of initiatives to address what was highlighted in the audit office report and I'm confident that we can take that forward positively.
Can I just add that I think the report does recognise some of the improvements we had in train at the time? I think Dr Goodall's letter to the auditor general actually sets out some of the other actions that have been taken as well in the interim, which we're all focused on delivering in terms of improving some of the issues that were raised in the report.
It seems that some of the problems that were identified had been known about for some time but not addressed. So, can we have confidence that, this time around, those problems will be addressed and it won't simply disappear into the long grass?
Again, I'd say that the issues that are being raised within the report have been addressed historically in different projects. I think what we've got to recognise is what's being done is highly complex. It is about change and the culture of the NHS as well. So, I think there's been a continual process of lessons learnt over the period, but this has helped as a helpful checkpoint, if you like, which enables us to now address those more systematically.
Your written submission refers to several recent improvements and developments in planning. It seems to me that we've been waiting a very long time for the electronic patient record. The roll-out has been remarkably slow. What do you think are the key reasons for that?
I think you've got to look at the overall approach to the electronic health records and recognise that what we're doing in Wales is doing something across the whole of the country and all of the systems. So, we haven't concentrated just, for example, on secondary care—we've looked to establish a record that covers both primary care, secondary care, community and social care. So, what we're endeavouring to do is quite a big task—for a whole nation, we're looking to create an electronic record for each citizen that spans all of the organisational sectors. I think that's a key point of differentiation between some other initiatives in this area. I think in order to establish that, then, clearly, we've had to engage with all the organisations across Wales and tackle some really complex issues. Some of those issues, although they sound very simple, actually take a long time to address. So, I think some of those have been about identifying the correct patient. So, whilst, again, that seems a simple thing to do, actually making sure that when you are putting all this information together, against my record, then I want to make sure that it is the right Andrew Griffiths that you're attributing that information to.
So, there are a lot of systems in place, with a massive patient index linking all the different IT systems that are already in place to make sure that we are bringing the right information safely together. I think identifying the staff is another big issue, so making sure that we know who's accessing the patients' records has been key as well. So, lots of these infrastructure projects take a long time to actually be put in place and make sure that we've got right, but having those in place means that we are able to make quicker progress going forward. So, we're taking an approach, really, of making sure that the clinicians who need access to this information can safely view it, that there is an audit tool in place so that any access to any of the IT systems that are in place in the NHS in Wales are logged, so that people can know that only authorised people have viewed that record. And all of those processes and systems take a long time to actually be put in place.
So, I think we've gone through a period, really, of doing a lot of the infrastructure and the basic work, if I can put it that way, to establish a platform that means that we can deliver more and more content within that record over the coming days. But I think it is key to recognise, in community, primary care, the fact that clinicians in Wales now can see the primary care record in secondary care and other settings, what's been established with the move to electronic referrals, and the prioritisation of referrals, and that a range of other things have been major achievements and things that we can really build upon.
I think there's something about the scale of what we're trying to achieve as well, in terms of the scale of the NHS. We've taken a country-wide approach to this to have one set of solutions. We talk about 'once for Wales' in the report, which I'm sure we'll come to at some stage this afternoon. It's been an important step, and I think we're taking an approach that puts us in a leading position across the world in terms of what we're trying to achieve. So, rather than taking individual organisation approaches, we're looking for something that joins up all the organisations in Wales, so that as our staff and patients move, their data and information follows them consistently and accurately.
Do you think, just before I bring Rhianon in, there's a danger—? Clearly, the NHS has got a lot on its plate at the moment, and it's got to respond to the parliamentary review of health and social care. Is there a danger, over the months and years, that this will get lost amongst all the other things that the NHS has to do, and so, really, it's not been done yet, and it becomes increasingly difficult over the next few years to see it happening to the extent we'd like it to?
I mean, I think that the parliamentary review is a really good opportunity to push forward on the digital agenda. I think if you look at lots of the recommendations within the parliamentary review, it is about creating a system for Wales—a seamless system, a joined-up system—and you can only really integrate care and deliver that seamless care if the information is available about that patient's care wherever they turn up. And what we've got are the building blocks in place that will allow that to happen digitally. So, I think the challenge for the NHS is how we manage to do that organisational change and take advantage of the digital technology that is now available, and increasingly will become available, what our patients expect, increasingly, as well. So, the challenge for us is how we integrate that, but I think what we'll find is that the digital agenda is really key to many of the points that have been made in the parliamentary review. So, I think it's an exciting time.
It's integral to that because it's—
Yes, it's integral to it, and I think it's an exciting time for those developments.
Good. Rhianon Passmore.
Thank you. You've already touched on the driver within the parliamentary review, so in regard to—. You've mentioned the building blocks so that we can understand the vast scale of the initiatives that have taken place already, systemically and process-wise. Whereabouts are we in terms of the capstone at the end of this journey, so that we can actually encapsulate how long, in real terms, outside of deadlines and outside of the challenges that you haven't yet articulated that you face on this agenda—. Realistically—to pick up on the Chair's overarching point—how much longer have we got on that journey? Is there a finish?
Yes, I think it would be nice to answer that by saying 'two years' or something, but I think the reality is that it's a continual process. Now, I get the point you're making, though, that we want to get to that point where you no longer need, for example, the medical record when you turn up in secondary care. So, we've already seen in primary care that general practitioners work without paper notes; they work entirely digitally. What we're seeing in secondary care is an increased usage of the digital record. So, as an example of that, two years ago there were about 9,000 clinical users of the Welsh clinical portal. Now, there are 14,000 users of the clinical portal. As more content is added into that system, then clinicians are increasingly turning to that first before going to their notes. So, we are starting to see out-patient clinics being run without calling for the medical records. I think, over the next 12 months, we'll see that accelerate greatly, and I think, over three years, I'd be very disappointed if we weren't seeing a situation where the first point of contact for all clinicians within secondary care as well was the digital record. I think we'll start to see, over the next 12 to 18 months, an acceleration in that because people need—. There's a bit of chicken and egg here. In order to make it worth while looking at the clinical records, you need the content to be there. Historically, the content has been on paper. Now, increasingly, the content is electronic and so we are seeing clinicians moving to viewing the electronic first.
So, just finally, then, on that point—strategically, that's realistically how long you think it's going to take for this 'agenda for change'. So, what needs to happen to increase, strategically, from that direct GP level, that change of behaviour, and how much faster can it be if we decide to turn thumbscrews on this.
Yes, I think that we can do it quicker. I think that what has come to the fore, through this report and through other reports that have been done, is the absolute requirement, which we all know, for clinical engagement. We need the clinicians to be leading this, and to be understanding the benefits of the digital agenda and taking it forward. So, we've established a range of things to try and engage with the clinicians better, and to use them as champions for the change. I think, as well, as people start to use the system more they become their own champions and start to talk about how they can do things differently. So, I think the main challenge for us is: how do we start to say—if I can put it that way—'Well, they've computerised the record. Now, how do we make the real digital change happen?', which is how do people start working differently as a result of the digital technology? So, if I can give just one example of where we're seeing that happen: where referrals are being prioritised digitally, electronically, then we're seeing that people are then able to change their working practice. So, in one cardiac clinic, they're now reviewing those referrals electronically, and as a result of that, they're able to take different decisions than they were previously, when they were doing it on paper, because they have access to the GP record, so they can see what current medication the patient is currently on. And I think 10 per cent of the new referrals have been returned to the GPs with advice because they're able to give that advice because they know about a patient previously when they only had the paper referral. Then, 20 per cent of those referrals are now being seen by a nurse-led clinic because they know, again, enough about the condition to direct them into that position. So, I think, as people start to see that happening, they see the benefits, they will increasingly take up the opportunities that digital provides.
Steve, did you want to come in on that?
I'll just add to that. I think the other two things that come to mind that we're not picking up: the work that we're looking at, in terms of prioritisation, to be actually focused on making sure what we want to deliver and when, in a way that we haven't before, as highlighted by the audit report. We've been developing our planning capability and function over the last 18 months. We've got our first take on a prioritised plan, which has been to the national informatics management board this year, which will give us a better focus, I suppose, on those points we want to achieve and when. That currently is a one-year plan. By October, or the winter, we will have a three-year plan for the integrated medium-term plan, which will be a joined-up plan across all the service—all 10 organisations, or 11 organisations, with Health Education and Improvement Wales—and NWIS and Government in terms of determining what our priorities are over the next three years. So, I think that would help us to have that end point that you were mentioning in terms of where we want to get to.
I don't think we need convincing about the benefits of greater digital use in the NHS. I think the question is whether or not NWIS has got the capacity and the capability to deliver that. You said, Mr Ham, that there had been improvements, but the audit office report says that, despite the improvements, there are still some key weaknesses. So, I'd like to know what specifically you're doing to address that, because as I understood your opening statements, you essentially think you're on the right track, but it's very complicated, which we know, and you're doing the right thing because you're trying to do it all at once. But the evidence does suggest that maybe that approach is not the best approach because, given the difficulty the English NHS had in this field, do you think that carrying on, trying to do it all in one big chunk is the right thing to do? You mentioned the building blocks, but from the auditor's report, it's saying that this was a vision first developed in 2003, some time ago now:
'the building blocks…are expected to be rolled out over the next five years',
by which time the world will have moved on quite a lot. So, 20 years after the vision we'll still only have the building blocks. So, I'm really not filled with confidence that you get the scale of the criticism that this report represents.
I think we do recognise the criticism that the report highlights. What we also recognise is that this isn't a one-off thing, so we're not doing these things slowly and gradually. As we're going through, we are refreshing the things that we've already done. So, it is a continual process on lots of those building blocks, which are coming together, and providing that electronic record in all of the pieces of work we do. So, although I accept the point that you're making, that it can appear as one mammoth thing, in fact there are lots of different projects that are being taken forward and each of those projects have got their own governance around them. Also, as we embark on any new project, we look at what's the best approach now, given the change in technology. So if we look over that period already, then we have changed our approach technically to lots of what we're delivering. So, we started off when the technology was different, but now, as we are developing new systems or procuring new systems, then clearly we're asking for different requirements, different underlying technology, and making sure we're continually modernising that.
So I don't think we're going to get to a point where you're simply saying that we've done the vision from a long time ago, but it was the vision of that time, and it's static at that point. It will have moved on dramatically in terms of technology and capabilities as a result of that ongoing review, reviewing everything that we've done, making sure that we're learning the lessons as we go along as well. But I fully accept that this is a major endeavour, as you've acknowledged, and it's hard work doing this stuff. It's hard to make sure that we are pulling all those pieces together and integration is a key challenge for us, how we make sure that's happening, both technically and on the ground, and culturally and in change terms as well. So it is a big challenge, but I think we are learning those lessons and making sure that we are developing a programme that is fit for today, not for yesterday.
You mentioned, I think, Steve, the opportunity for us to become a world leader—always great to hear that—but I'm just interested: who are the world leaders? Where around the world can we look and find a health system that has actually achieved the level of ambition in terms of digitalisation that we would like to see here?
You might want to pick that one up. I've certainly been looking for that. We're out in the front of some of this area. I think finding someone to give you the ambition, set the ambition, is quite challenging. There are others who are actually on the same path as us, but I think where we are—and Andrew will give you some examples—we're actually alongside a lot of people in trying to put together this whole-system approach to actually digitising what we do. I think the opportunity in the strategy that was launched two years ago was to broaden that, and actually look at patients and citizens, and I think, certainly from the conversations we've been having, we're fairly unique in how we're looking at that as a system. Individual organisations around the world are doing it. We're looking at it from the system, and I think what we're trying to do is get the balance right between the organisation, the citizen, the patient and how the whole system comes together for them. But I'm sure, Andrew, you'll pick up some detail.
I think there are lots of places around the world that are doing well in lots of areas of this. I think what appears to me is that there are very few countries that are taking a holistic approach across all of their sectors. I think Estonia is a good example of where they're doing it. I think there are some other regions in Spain and other places that, again, pull together an electronic record within the secondary care setting. But trying to find somewhere that has linked both their primary and secondary care, and community and social care, actually there are very few, if any, that have done that.
We've also seen some good practice in the United States, where particular areas have come together. Utah was an example we saw at the Welsh NHS Confederation conference a couple of months ago, where they have implemented a system across their secondary care setting. But again, as you'll understand, their system is different; some of their drivers are different. So, I think that our approach, to some extent, is unique in trying to get that one patient record, that seamless system, that works for the patient and not for the organisation.
I don't want to get too anecdotal about this, but I've had recent experience with a couple of hospital operations, and the standard of care that I received was excellent. The digital experience was appallingly poor. It was like walking back in time 30, 40 years ago. So, I would get a slip of paper through the post that would offer a slot, et cetera, then I would have to phone a number that was only available for three hours a day, and often I couldn't get through, et cetera. What's the problem there, then? Is it the digital change aspect? What's going on? That experience is bizarre in this day and age, isn't it?
I accept that. I think the focus of the revised strategy two years ago was around the patient's experience of the NHS and how we can digitalise that and make that better. I think it is challenging because it is such a big system, the NHS. What we're seeking to do in that whole area is try to make sure that we are joining those dots. So, for example, the referral system, making that electronic; making sure that in secondary care, they're able to prioritise that; make the appointment. The next joining up here is then with the patient themselves. So, some of that goes down to, again, how we securely know who you are, that we've got your e-mail address and your mobile number so that we're able to communicate with you differently.
So, at the moment—and I accept the limitations of this—the My Health Online product is the main product that links with patients. The functionality there is limited at the moment, and we've got a programme in place to look at how we now widen that experience. For the people already registered, how do we collect their e-mail addresses and then start to engage with them digitally and accelerate that process? So, there is work in train to do that, but I do accept that that is a key weakness.
Just finally, Chair. This goes to Lee Waters' point, really, and what you said in the earlier answer, which is about the holistic approach: hugely ambitious, cross sectoral. And you mentioned Estonia as possibly the only other example, maybe, on a national scale. There, of course, digital is almost like the defining animating principle of the entire Government, isn't it? In fact, the nation has adopted it, and it's known around the world on that basis.
What's the relationship between what you're trying to do in the NHS and the Government's broader digital strategy and the work of the chief digital officer? Is there sufficient commitment in terms of the resource and the investment that you needed? Because this is seen as, actually, digitalisation in every sector is the primary national objective.
I think they're intertwined, aren't they? One can't function without the other. If we don't have the Government's approach to digitalisation, we can't implement some of the things that are in our plans. So, they do sit hand in hand, and certainly the chief digital officer sits on NIMB and attends to make sure we have that joined up, so there's clarity about what we're doing and the interaction with the wider strategy. So, it will be absolutely intertwined.
I think one of the things that came out of the launch of the strategy two years ago was the establishment of the 'information for you' work stream, which has been really important, actually, to get us that focus to balance against the work that we're doing to support our professionals who are in place. We need to get that balance right. Having the two work streams sitting side by side has been really helpful. It's given us a focus around the 'information for you' aspect. I think the work at the parliamentary review, and the visioning that's going to come out of that in terms of where we want to get to—as the review sets out—will actually crystallise that because digital is at the heart of what the parliamentary review is expecting us to come up with as a response.
So, the work of our visioning—that interaction with you and your experience—is really fundamental in terms of where we get to. I think we're finding a new balance between the two, but we do actually need to make sure we get to the end points that you set out as well. So, there's a real prioritisation challenge for us—the work that we're doing on the planning and the prioritisation—which is why we've established a fourth work stream in the strategy launch that is around a planned future, because without that planning we will never know what the end point is, and then we won't actually get there. So, I think between the four work streams we've got a good balance of a way of actually prioritising. We've got mechanisms now in place to actually put that prioritisation into place, and I'm sure that in response to some of the auditor general's issues in the report, I think that will start really coming through over the next 12 months to make sure we're absolutely focused on that.
Okay, a couple of quick supplementaries, and I will bring Vikki in. First of all, Oscar.
Thank you. Listening to the gentleman, it's wonderful because last week I spent in hospital with my wife. The NHS have actually done a wonderful job with machine and man and woman there—doctor, clinician, nurses, you name it—a wonderful job. I'm listening to you now with additional skill to them. You know, this social media—. Not social media. You know, MIR and MRI and all these different gadgets they do for blood, urine and scanning everything. They're experienced doctors. We've got wonderful nurses and doctors there that actually saved the life of my wife, I can assure you. Hats off to them. But, the new skills for them with this new information technology, I think that will deter them from what they're doing.
Every patient has a little book and they write with their own pen—no machine, no gadgets—and every next doctor or consultant who come and see it, they don't look at a machine; they look at the papers. And skill sector training. The nurses changing every few hours, and the new staff will never be used to the patient. That's another thing. And what happened with the cyber attacks. We know it's happened in the past, not long ago—very recently—all the NHS was crippled. So, these certain areas have got to be looked at. There's a life at stake. One little error and one person—. The window of life is only four to six hours in certain cases—heart and stroke.
So, basically, my question to you is: you want to bring in this technology, you know, informatic technology with the doctor. Have you got real experience and training and expertise to make sure this information doesn't go somewhere else? Confidentiality—one doctor should have 1 per cent rather than the entire—. So, how can you protect the public of 60 million population, 3 million of which are Welsh people, from this?
I think, again, we recognise that a lot of what you said are the challenges of doing digital change.
Yes, absolutely. And I think that what we need to do is make sure that we're engaging with all those clinicians and taking them on that journey, so that they are getting the benefits from what they then do. And we need to make sure that the technology is easy for them to use, so that it's as easy as the pen and the paper. I think what we're seeing, though, is a bit of a step change, so that, for example, when somebody comes into hospital as an in-patient, then previously if that person hadn't been in hospital before or that particular hospital, there would be no paper notes for them to look at.
Now, with the digital technology in place, they can now view that patient detail, so they can see already what their current medication is. So, in actual fact, the digital is achieving better patient safety than the pen and paper. So, I think it's key to be setting out the fact that, actually, the digital record will make sure that there is more information available for the clinician in order that they can treat that patient better, not make it worse. But I take your point, and that's why some of these things are so difficult to make sure that we're doing them correctly.
I think as far as cyber security and confidentiality are concerned, then those are two big concerns for us—how we make sure the systems are secure. So, there are two levels of that. There's a technical level where we've got to make sure that our data centres are secure, that they are resilient in what they do. And secondly, the other aspect is the information security, so that we know that only authorised people are accessing the system. And then also, as I referenced earlier on, we have an audit tool that records every access that a person makes, so that we can also proactively make sure that only those people that should be looking at a particular record are looking at that record. But it is a big challenge for us, and we recognise lots of those things.
Okay, and Lee Waters.
On this first-principle question of: are you right to continue with a whole-system approach, or might it be better, in reflection of the enormous criticism you've had, both from the Wales Audit Office and from the parliamentary review—? Taken together, that's a profound criticism of your organisation and its approach. Given that, I'm not encouraged to reflect on whether a different approach based on iterative development about prototypes would be a better way forward rather than this big 'once for Wales' approach.
First of all, I'd say it isn't an NWIS approach, I think it's an NHS Wales approach and has been signed off as the NHS strategy. NWIS in that sense is a delivery arm to make sure that strategy moves forward. And, secondly, what I would say is that what we are actually doing is we are doing an iterative approach. If you look at something like the Welsh clinical portal, it started off as a development that was giving access to results within the hospital from the path lab locally and from the radiology department locally, and that was the extent of the functionality. We have continued to develop that, so there's been two releases of that software every year and every new release has a new development that comes within it. So, we are taking an iterative approach to that. You'll see that with things like the common ailments service, which again is an iterative approach to the development. And what we've found is, as we've had—we were gathering—more information, we were able to use it in different ways. Also, the discharge process—originally that wasn't within the product. We've developed discharge modules so that we can do electronic discharges. Again, that is using the information we already had. We held workshops with clinicians. It was an agile approach to the development; we started to work with both medical clinicians and with pharmacists to look at how could we improve the discharge process, and we've done that by using information from the primary care system and also results from the secondary care system.
But all these examples you've quoted were characterised by delays. A lot of your projects are delayed and, in the conversations I've been having with a whole range of people across the NHS, one thing that comes back time and again is that there's a lot of tolerance for delay in the system and the confidence in you as a delivery body—and this is captured in the report—the word that comes out time and again is frustration towards NWIS. It seems from your evidence and your tone that you essentially think that you're on course and doing the right thing despite all of these criticisms and frustrations.
No, I don't think that. I think what I'm trying to reflect is the fact that, as we've been going along, we have been trying to learn those lessons, we have taken the audit report and the parliamentary review into account in what we're doing, and we are trying to make sure that we're building all of those lessons in as we move forward. So, it would be wrong to say that we set out on an approach and we've kept on it regardless. What we've sought to do is to work agilely to make sure that we are building innovation into what we're doing. We have changed courses on the priorities of what developments we do next, seeking to get the most benefit out of what we're doing. So, I wouldn't say that, but what I would say is that it is to misunderstand the system to say that we're building one big system for Wales. It is a system that's made up of lots of different developments and integrating those different systems into something that then gives a view of that information for the patient.
Can I just add? There's a couple of things. We've also put in place some process and structures in the system over the last couple of years to bring that conversation closer together. So, we've now got a group called the informatics planning and delivery group, which has got the assistant directors of informatics from the health boards and trusts, alongside NWIS colleagues, sitting down and working through these issues and taking stock together about where we are and actually redirecting the view for the future. We've also established regular workshops with both clinical colleagues and the assistant directors and NWIS colleagues as well to actually sit down in a free-thinking space every four or five months to actually reflect on where we are and actually pick up where we're looking in the future. I think, lastly, the two reports—this and the parliamentary review—actually put that challenge up there about looking at where we're going and are we going in the right direction. Certainly, in Dr Goodall's letter, he sets out that there will be a review, which actually picks up those things. We've also started working with Eric Gregory from the parliamentary review team to look at a prioritisation process and initiate a start-stop-accelerate process during the coming year to actually make sure that we are validating together—not just NWIS, but together as a system—the sense of direction that we've got in place. So, I think there's a lot of things going on to improve that, but we take the point that there is an opportunity to actually look at where we're going, and I think the picture that will come out of the parliamentary review about what the services ought to look like in four or five years' time will be a really important stepping stone about what we do next and the prioritisation piece.
I think the issue for Members is that we have been waiting such a long length of time already, and, okay, we all accept we'd like it to be gotten right rather than done in haste, but you'll appreciate that, because of those time lags to date, there is concern about the speed in future. Vikki Howells.
Thank you, Chair. It seems to me that understanding the phrase 'once for Wales' is key, really, to the issue here. So, if you had to describe that in layman's terms, what would you say?
I think 'once for Wales' means that we are seeking to do this across the whole of the system, the health and care system, in Wales and we're seeking to make sure that, where we have initiatives, we are then making sure that that is then made available across the NHS. So, I think one of the difficulties can be—and we see it happening elsewhere, and, indeed, we've had it happen as well—is that you can get a very good system working in one particular department but then making sure that the whole of Wales benefits from that is a key part. So, what we're doing is making sure that, in any of the things that we are starting, we have the ability to make sure that then gets rolled out across the NHS in Wales so that the whole of the NHS can benefit rather than the sort of 'not invented here' syndrome that sometimes we see.
I think, for me, it's about making sure, both for our clinicians and patients and their families, that that data follows them consistently wherever they go, that they can look at it wherever in the system they appear—going back to the earlier point about GP information and your point about the data and how quickly that follows you accurately around the system and you can access it. Where we're going to is that, as a patient, you will also be able to access that so you can see what your record is as well. If we don't build on the 'once for Wales' there will be inconsistent standards. We will set standards. We've got the information standards board, which actually set the standards for the information, and we're now establishing the technical standards board as well, which will give us a really strong standards-based approach, which will give us a bit more flexibility on the 'once for Wales' delivery, which has all been about one system, and I think we're expanding that in response to some of the challenges we've had posed to us.
In terms of the technicalities there, then, there seems to be a bit of tension between whether it is a sort of whole-Wales approach or whether health boards are able to go off and design their own systems. Some of the evidence I'm looking at suggests there's disagreement within the NHS about what 'once for Wales' actually means. Surely that's at the heart of some of the problems and the fact that all of this is taking so much time. How would you account for these differences in opinion?
I'm not surprised that there are differences of opinion. There clearly will be. The NHS is a big organisation. There are lots of views on how you do different things. I think you're right: there are tensions between how you make progress locally and then make sure that's applicable across Wales. So, there are—. It would be wrong to say that there aren't tensions around that. But I think what we are seeking to do, through the definition, which we've had—. We've agreed now at the national informatics management board what the definition is. What we're seeking to do is make sure that we use that definition in order to speed up the progress that we're making and getting that agreement at the outset of any new projects that have started.
Certainly, from the answers that both of you have given so far, your view of 'once for Wales' seems to be based on flexibility and trialling different processes in different areas, but the Welsh Government's recent written response refers to creating
'a list of services and functions best suited to the approach, to be mandated.'
So, is there going to be mandatory working within this, and how will that sit with the health boards?
I think, again, that what we've got established are lots of systems that you might describe as being 'once for Wales'. So, there are national systems in place for identifying patients, the clinicians and all those—and the Welsh clinical portal and other products. What we are then seeking to do is make sure that—where there are different projects starting, where there are new developments happening, where there are new systems being bought, we want to make sure that those can then be used across Wales. They might start off as a project in one area, but then it would be wrong not to have the ability then to be able to utilise that across the rest of Wales.
Okay. And how would you respond to the Wales Audit Office report that said that health boards are developing workarounds or their own duplicate systems because they don't have confidence in NWIS, therefore 'once for Wales' rarely happens, as they would rather use systems they've been forced to develop because NWIS isn't ready in time?
Again, it's difficult without going into the actual specifics of some of those issues, but I think what we see happening there is that, where particular clinicians are trying to find a new way of working and not all those elements have been provided to them to do that, out of frustration, they will then create workarounds. So, what we are seeking to do is really find out what those problems are. So, there are various service boards for the projects, there are various workshops that have been held to try and make sure that we are picking up on those areas, because it is complex and difficult to know exactly what needs to be addressed.
Some of that goes down to training. What we find is that, sometimes, people don't know what facilities are available, so they're doing workarounds when they don't need to do a workaround, or sometimes people are doing processes as they've always done it that way, so they still feel the need to, when, in fact, perhaps they don't need to do it that way now, because the technology enables them to do it differently. So, there's a range of complex issues involved in that.
I accept the point that, in doing that, we've got to continually engage with the users of the system, making sure we're picking up on what their requirements are, and reflecting that in the developments that are going forward, but it is a challenge.
Just to add to that, I think there's a really big question about prioritisation in some of this and how we communicate that. As I mentioned earlier, we're looking to improve the way we prioritise as a system, not individually, and the way we then communicate and understand the impact of those prioritisation decisions we'll make will be really important in that context. Not everybody will be happy about the way you prioritise issues, but we need to communicate it really well, and, as a set of organisations, we need to own that prioritisation. We've got some more work to do on that, and I think, as set out in the report, we've begun a process, we will have a first take at a prioritisation plan for this year, which is going to NIMB, the national informatics management board, and we will have a three-year plan. Now, we'll have to have quite a powerful communication strategy behind that to make sure we're clear with people what that means, because I think another point that's in here, in the report, is about the more and more priorities that get added, the more distracting they can be, so we just need to be really focused and understand why we're choosing to do things.
Okay. Earlier on, when you were asked about examples of best practice around the world, the examples that you chose were quite far-flung. Looking now more to a UK comparison, I'm wondering what are the key differences between NHS Wales's approach to developing the electronic patient record and other approaches in the UK.
So, again, in England, for example, what we're seeing happening there is that they've taken the approach of digital exemplars. So, they're looking at hospitals and foundation trusts coming together and developing products and implementing them there. So, they are very much looking at the different sectors and developing them on a hospital basis. So, there is a—. Clearly, the end functionality is very similar, but the approach is different, in that what is happening there is that they're evolving a situation where that hospital then has a record for a patient, but it isn't necessarily shared with other organisations around them. So, I would—. You can see very good practice in the rest of the UK, particularly in some of the departments and areas where you've got good lead clinicians who are taking it forward, but I think the scale in Wales is such that we can do that differently and we can have a one-record approach.
Scotland have taken a similar approach, in some ways, to us in Wales, and so have Northern Ireland—also, the Republic of Ireland have taken a similar approach—and are at various stages of doing a similar thing to us. We work quite closely with all of those countries as well to try and learn the lessons and share what we're doing as well.
If you exclude England, then, because the approach is so different there, comparing us to those other parts of the UK, how would you compare the rate of progress?
I think it's different in different parts of what we're doing. I think we've probably got a more universal coverage of electronic referrals, prioritisation, access to the primary care record in settings other than primary care. Our approach to community and social care, again, is further advanced in terms of the systems that we've got in place. So, I think we're making really good progress. There are still things that we can learn by working together. Indeed, we share some products with Scotland, in particular. So, some of the things that we use are the same, so we've got a development programme with them to make sure that we're doing that most effectively.
That was going to be my next question, actually—about whether you could work with other parts of the UK to develop or procure systems. So, could you expand on that a little for us?
Yes. So, we work with NHS Scotland on the electronic referral, and that's from primary to secondary care. So, we actually use their product, which has been slightly modified for the situation in Wales. So, we work with them quite closely on that. We also share lots of what we're doing on different projects. GP system procurement is one area where we've worked with the other nations to look at the specification, the procurement approach, what we've done, sharing the lessons learnt with those countries as well. So, there's a lot of work going on to try and make sure we're picking up that.
Great. Okay, one final question from me, then, Chair, if that's okay. So, the auditor general says—and other Members have referred to this loosely, as well—that the technology and the market have changed significantly over the past decade, and we know that the electronic record is something that has been worked on for longer than that in Wales. So, my question is: if you were starting out now from scratch on the development of the electronic patient record, what would you do differently?
Clearly, technology does move on, and I think that, clearly, if you were starting now, you would pick some different technologies to start with. However, what I would say is that things haven't remained static. We started off using one type of technology on the clinical portal, but as we've moved down the years we've changed the development tools that we use. We've changed the development methodology that we use. We've changed how we record some of the data items. We've changed the clinical classification system that we use. So, lots of changes are happening, and we do need a system that can adapt and change incrementally as we go along. What you're pointing out, I think, which would be terrible if this was the case, is that if you end up with a system where you've invested all in old technology, where there's no updating of that over the intervening period, you can get to a very cliff-edge position where you're then having to upgrade completely all of your systems, whereas in fact what we've done is we've taken a view that slowly is improving the underlying technology, and that goes to things to things like the data centre with the kit that we use, with our approach to how we host systems, the move to the cloud. All of those things are continually under review for each of the products that we've got and are part of our refresh programme.
So, would you say, in a way, this is a project that will necessarily be never-ending, because you will always have to keep pace with changing technology.
Yes, it's part of what we do as a society, it's part of how change will be driven, and we know that the cycles have changed and are getting shorter and shorter. I think one of the things that would be different if we started now is the options would be wider. I think the ability to interact with patients has changed fundamentally over the last five years. If we all look back 10 years to what we were carrying around as a phone and what we now do with it, and the ability to interact on a personal level with patients and staff, it has just changed fundamentally. That brings big opportunities, which we wanted to reflect in the strategy that we launched two years ago. I thought it was an important change to actually represent how that would actually impact. But it wouldn't change some of the requirement for actually having these systems in place to underpin it. I think it's really important we get these things in and, as Andrew said, we're not just blindly carrying on with those; where we think it's important to take stock, we're taking stock.
Vikki mentioned those far-flung, exotic examples that you've been looking at of practice across the rest of the world, and I think you said earlier that what you're trying to achieve here you won't see in any other country, in that particular model.
I think there are a few of us trying to achieve the same sort of thing, because it's fundamentally built on the sort of system you're in. Some of the examples that Andrew set out were systems where there's a big separation between the primary, the secondary and social care aspects. We've got the ability here to actually bring those things together, and I think what we want to do is actually get the best out of that, and I think there are some huge opportunities with the structure that we have to be able to do that and achieve those things for the patients' benefit and for staff.
Thanks. Lee Waters.
You'd hope if you were starting again from scratch you wouldn't take 20 years to get to the end result. It's a pretty staggering time frame, given you said how quickly technology is changing around us.
Well, I would go back to the point that I think it's difficult to say that there will be an end. I think this is a continual process, and what we are seeking to do is make sure that, incrementally, we are building the functionality, digitally, for the benefit of clinicians and, ultimately, for the patients.
I'm struck by one sentence in this report in particular. I'm sure you'll know it well.
'We also found that the reporting of NWIS's progress and performance to the Welsh Government and the public has tended to be partial and overly positive. Examples include selectively reporting information'.
How does that sentence make you feel, Mr Griffiths?
Well, I think that we have to see that within the context of the overall report. I think what it's referring to in particular is project progress. What we're seeing is that the particular example there was around where there had been delays in implementation and where the project reporting had indicated that it was red, but then there had been a change process that had occurred, which then reset that to green—
No, it actually quotes several different examples. It says,
'Performance reports in the public domain tend to depict a positive and optimistic picture. Where detailed figures are given, the context required to understand the data is missing.'
For example, My Health Online has 170,000 patients registered, and what you don't mention is that you're meant to be aiming for 872,000. It also says that the staff on the ground know the true picture and they know there is a disconnect between the picture you're presenting and the reality they have to deal with on a day-to-day basis and, as a result of that, they are losing faith in you. It 'contributes to reputational risks.' And the fact that NWIS doesn't openly admit to the true picture
'contributes to frustration and a perception that NWIS does not listen.'
So, it's not just one example. It's a pattern of behaviour that does not reflect well on you. So, I ask you again: in terms of that sentence, as this is an agreed report from the Wales Audit Office—so we can assume that many of the edges have been smoothed over in that process of back and fore with the Wales Audit Office—the fact that this is what's in the final report is pretty damning, isn't it?
Well, certainly, I'm not happy with that situation, and I'd agree with you there. What we want to do is make sure that we're representing the true picture. I think, in the example you quote about My Health Online, certainly we were not hiding the fact of the number of people that had registered. I do accept that in the particular communication piece that had been put out, what it set out was the factual position of how many people. It didn't then go on to say how many people we were intending to get, but that wasn't seeking to misrepresent anything, and certainly—
It says you are consistently putting the positive complexion and not truly reporting the challenges that you have.
I accept what you're saying, and I think what we've done is a couple of things there. We've sought to look at those reports to make sure that they are truly reflecting the whole picture and not just the positives, and, in our monthly reporting to Welsh Government, we have changed some of the reporting in order to make sure that the project progress reporting is better and that, where there are changes, those are highlighted. We are also seeking to put any figures that we set out into context. So, as an example of that, where we are now reporting progress on electronic referrals and discharge summaries, what we're doing is putting those figures in the context of the total number of referrals and the total number of discharges, so that there isn't a misunderstanding that seems to imply that we've completed the task, because that isn't what we're seeking to do at all.
Who are you accountable to?
To Welsh Government and then also to the health boards and via the national informatics management board.
So, lots of people, then.
Yes, there are—
But nobody in particular.
Yes. Well, I'm accountable to Frances Duffy in Welsh Government, who is the director of primary care and digital.
Yes. And also to Peter Jones, the deputy director of digital health and care.
Yes, I work with Peter closely.
And also, I guess, you have some accountability to Steve Ham, as the host body.
Yes. So, the accountability to the host is different to the accountability to the Welsh Government. So, the accountability to the host is very much around how we do things, particularly around procurement processes and organisational processes. The accountability to Welsh Government is how we spend the money, how projects and services are progressing.
Just humour me here a little. So, a report like this comes out, which, in any normal organisation, would be seen as a significant event in the life of that body. What have been the consequences to you, as the director of NWIS, from this report? Who's been holding you to account? In what way has Steve Ham held you to account with this report?
Well, I think we've got to recognise that this report was into informatics in the NHS in totality, and not just NWIS. We have done a lot of work together.
But for the bits that you're responsible for, which is quite a lot of it—again, I appreciate the tactic today is to say that this is a whole-system issue—but in terms of what you're responsible for, to take the spirit of what I'm asking, the bits where you're falling down, as an organisation, and you as a leader of that organisation, who holds you to account for that?
Well, there are a number of people who hold me to account for that. Frances Duffy is one, Steve is another, and we have worked hard on this report, reviewing it—
In what way does Steve hold you to account?
Well, we've had lots of discussion. He can talk for himself—
Well, why doesn't he?
I was going to say that I suppose I've got a few roles in this.
One is that I'm the chief executive of the host organisation, and, as Andrew said, in terms of the context of this report, Andrew's accountability to me as the chief exec is purely around the statutory requirements for an organisation around a policies process, legality—
It's not performance.
Not performance, definitely not performance.
Is that satisfactory for you as the host body?
It's not a unique situation.
Because there's collateral damage in a report like this, isn't there? This reflects badly on you as well, and if you're saying you don't really have much control of what they do, because you just do pay and rations, it doesn't put you in a great position.
I have a real interest in making sure we improve things for lots of reasons. One is for any impact it might have on the trust, but more importantly is my lead chief exec role in terms of informatics. I need to make sure that we're actually engaging differently in this agenda, and we have lots of conversations about that level of indirect accountability that Andrew has to me. We've put in quite a lot of the things that we've talked about earlier to actually work past some of the issues that have been raised in the report. We have improved the report, and at NIMB for example, to actually make sure that we don't miss things out and actually that we report more accurately. So, my direct oversight of Andrew and the team is not about performance, but there's an indirect route that we work in, which is—. I'm the joint SRO of the strategy and the lead chief exec as well. As Andrew said, his line accountability is to the Welsh Government and the director of primary care and innovation.
The reason I ask is twofold, really. One, in this sense, is that you are a large body, you have 600 staff, you spend hundreds of millions of pounds every year. How are you held to account for that? Because you describe—and the audit office report talks about this too—. There's a lack of an expert client, if you like. The people you describe in Welsh Government have no background in digital. They're civil servants. They'd have no particular expertise to be able to challenge you. They rely on the information you give them, and the auditor finds that the information you give them is overly positive. Mr Ham has a lead role for the whole system. He represents a health board that specialises in cancer and is entirely unrepresentative of the other health boards in terms of its make-up. You're not analogous to the other health boards. You're quite different in scale and in what you do. So, you're the lead official for the whole of Wales when you represent a health board that is untypical of the others. So, your ability to be able to speak authoritatively on this has got to be constrained, and the people you're accountable to—and I'm still not entirely clear how they hold you to account—have no real expertise in this area.
There are lots of mechanisms in place to counter some of what you've said. We meet regularly with the health boards. So, we have SLA meetings with the health boards, we have engagement visits with the health boards, we do our planning jointly with the health boards. So, in the three-year plan development, we meet with a range of people in the health boards to make sure that we are aligned to what they're doing, and also we are there to describe the progress that we're making. So, there are various ways in which that accountability is set out, not least at the national informatics management board where all of those people come together.
Which has been criticised also in the report as being open to improvement.
Yes, and indeed, we recognise some of that and we've made some changes to make sure that that is better.
Because what the audit office report says is that your
'ambiguous status is unsatisfactory.... It does not benefit from the open challenge that comes from having independent board members scrutinise its performance and strategy.... Also, in other NHS bodies the chair...is accountable to the Cabinet Secretary..., the link between NWIS and the Cabinet Secretary is unclear.'
So, the ability—. When you take 20 years to do something, there's frustration in the system, and this is all captured in the report. The conversations I have at board, executive, GP and pharmacist level, universally, are critical of NWIS. This is a common theme over several years of conversations that I've been having, but the ability of the system to hold you to account and get that to change just isn't there—the bits of wiring don't link up.
I think what's really important—. We recognise that the situation needs to improve and we've accepted the recommendation. The letter from Dr Goodall has set out that there will be a review of how that governance works and I think that will be really important to work past those frustrations, as you said.
But it's taken an audit office report and a parliamentary review to get you to respond to this and that's perhaps a reflection of the lack of scrutiny of you. Even though there is widespread dissatisfaction with your performance, there's been no lever available to get you to shift. At last there is one, but from what I'm seeing from the evidence you've submitted to us, the primary answer you're putting forward is, 'Give us more money and we'll carry on as we are'—using primarily the same governance structure that you have.
I would say that the parliamentary review is an opportunity to look at the governance structure. And we have committed—. There's been a commitment to review the governance arrangements and I think that's helpful. So, it's not for me to set out my own governance arrangements—
Well, you are. That's the problem.
No, we're not setting out our own governance arrangements. That is something that we are—. I work within an organisation where the governance has been set out for me and we recognise some of the points that you've made and we have reflected on that and that is what will be reviewed through the parliamentary review process.
This is my final point, Chair. The governance structures that are in place are unclear and they aren't open to scrutiny. I was looking last night at the NHS digital website for England. They have a board, their minutes are published, I can read the discussions they're having and everybody in the system can do the same, and we can't do that in Wales. Instead, we rely on reports from you, which the auditor general finds are not accurate.
Well, I can only repeat, really, that the governance arrangements are being reviewed and out of that, hopefully, you'll see some improvements.
I hope so.
Just on this, you made the point that the governance arrangements and structure are basically set out for you, determined for you. Who originally set those governance arrangements out and who could change them?
I expect it's Welsh Government arrangements that are being put in place. I would say that beneath that overarching structure, there are lots of mechanisms that we have to make sure that individual projects and individual work streams are being held to account in a myriad of ways by the different organisations.
But, the fundamental point—. I mean, this is a policy decision that was made by the Welsh Government some years ago, and if there are weaknesses that have been pointed out, I don't doubt that that would ultimately be a policy decision by a Minister.
To change, yes.
Okay. Are you done, Lee?
Oscar? Actually, no, I think it's Neil first—sorry. Neil Hamilton and then Oscar. No, I was right the first time. Oscar. I shouldn't have doubted my order.
My question is in relation to finances. What work is being undertaken with local authorities to ensure that they are fully working towards the implementation of these systems to ensure coherence across health and social services? Are any changes to the local authorities' systems taken into account for your cost estimates?
Are you referring to the cost estimate for the whole digital strategy?
Yes. There have been some elements of local authority costings within that, but not completely. We do work with social care in particular, quite closely, particularly on the Welsh community care information system, and so the implementation of that is going in across local authorities and within health as well. So, we are working very closely with local authorities.
Would you be able to share any information on the tendering process of the system implementation with us?
So, the tendering process for the community system.
Yes. That procurement was completed a number of years ago. It was a procurement that was led by Bridgend council, but it was a procurement that was led on behalf of the whole of Wales, and so all of the organisations, both local authority and health organisations, were named in that procurement, and the procurement process involved representatives from each of those organisations, both in the development of the specification and also the evaluation of the final product.
Okay. And what impact has the reduction in NWIS’s budget had on its ability to deliver informatics services and how have you prioritised between delivering new systems and maintaining existing systems?
I think our priority has always been on making sure that our operational services are running and are resilient and safe. Then we've had priorities to look at the rest of the budget and we've done that through the planning process. I think, as Steve referenced earlier on, we've recognised that there needs to be improvement in that planning process, largely because prioritisation normally ends up with adding things on, not taking things off. So, we recognise that that actually puts us in a really difficult position, because if you have increasing demands, then that doesn't help you to get to the end of some of the projects. So, we've looked at the prioritisation process and, as Steve referenced earlier on, we've got processes in place to make sure that we are being clear about what we're doing and what we're not doing within that overall budget picture.
Okay. Given that the extra £10 million funding you refer to falls short of what NHS bodies and NWIS estimate is required, what are the consequences for delivery of an electronic patient record if the Welsh Government cannot provide the significant extra money required by you?
We're working with Welsh Government closely on a financial strategy, and we recognise that, particularly within information IT, some of that is about the nature of the funding as well. So, traditionally there's been a very capital-intensive funding stream for information technology. That is increasingly moving to a revenue basis, so we're currently having discussions around each of the elements of the strategy—about the costs, and how we look at pacing those in line with the available resourcing.
Thank you. And how reliable is the £484 million estimate? Could it be considerably more or less in your view?
I think it's a reasonable outline estimate of the cost. What we clearly want to do is, whilst that is the overarching picture, we will be working in detail on the individual programme items to firm up those costs before any commitment is given on the funding for those. So the last thing we want is to start on something that then ends up costing a lot more than we estimated.
There'll be a lot of work over the next six to nine months linking in with the parliamentary review, the prioritisation piece of work, to work out what it is we think should be in that plan for the next three years. We've got some choices to make about which order we do things in and which things we want to make live over that period, and it will affect the scale of that number. It was an early figure, it was done for the purpose to kick off a planning discussion, and I think we need to link in the prioritisation, and I think we need to be as clear as we can about what that number ought to be. We then need to get into a resourcing and benefits discussion about how the two things will come together, and how we prioritise the individual aspects of the plan over the three to five years that we're talking about.
All right, thank you. Could NHS bodies themselves find extra money from their allocations and if so, why have they not been able to do so to date?
I think we've had two reports, one for Aneurin Bevan and one for Hywel Dda, and I think there's a reflection there that they have found extra funding over the last two years. I think the case for digital is getting stronger, and I think that's been really important—that we've worked on that. The benefits that come out of the digital agenda are really significant, and I think again the parliamentary review and how we set our ambitions for the future will drive that even further. So, some of those decisions are starting to be made. I think we need to build the case around the £0.5 billion, or whatever that number becomes, in terms of the benefit that we can actually deliver out of it. And I think we will then need to have a conversation about how we resource that plan with Government, and as 10, 11 statutory organisations in Wales about how we deliver against that, and in the context of local government. So, it's not just the NHS; we're going to have to have the conversation with NHS and local government in this about how we prioritise the plan.
Finally, is there any scope to reprioritise existing resources within NWIS?
Absolutely. There's always scope to do that, and I think we've been particularly looking at priorities. It is something that we do try and keep under review, but we've gone through a particular exercise now to do that.
Now, Neil Hamilton.
Right, thank you. The NHS has never set a formal deadline for a full digitised record to be achieved, and I understand the difficulties of predicting these things. But are you confident that, collectively, NWIS and NHS bodies can deliver all the systems and infrastructure required even if, to go back to Oscar's question about funding, Welsh Government is able to provide the necessary funding? And can you give me some kind of idea of what sort of timescale we're talking about, given the saga that Lee Waters very colourfully illustrated earlier on in terms of the 20-year timescales? I will be 90 in 20 years' time, if I survive, so clearly, nobody would have set timescales of anything like this kind of length. So, you've learned a lot from your experiences in recent years, and everybody's got sympathy with you and the nature of the task. So, again, just to repeat: are you confident that you can achieve what you have set out to achieve in a reasonable timescale going forward from here?
Yes, I think there's a real ambition to achieve that. We recognise the opportunity and the benefits that will come out of implementing a digital view of the world, both for ourselves and particularly for our patients. So, I think the ambition is there. As Oscar highlighted earlier, the training is a fundamental part of this. We've got to focus on the training and the change aspects that go with that in the individual organisations. So, I think the ambition's there. We certainly have the will. We need to build some of the skills around this, and we need to have a clear view of the future.
I think as well it's important to point out that we do work with a lot of different partners in this endeavour, so there are lots of different companies, specialist companies that we work with, to make sure that we, one, are getting the best advice and also that we're getting some of the best products to be used within the NHS in Wales. So, I think, as Steve said, the scale of the ambition is there, I think the will is there to do it, and some of this is about the pace and the delivery and the funding coming together.
Just to look at some of the parts of the whole here, the roll-out of the radiology information system 2 and the Welsh laboratory information system took 11 years and seven years respectively. Can you give us any more detail about why these timescales developed as they did, and what lessons you've been able to learn from those two particular examples that will enable you to apply them to the other work that you're now doing and, hence, to telescope the process?
So, again, I think that both of those implementations you referred to have been incremental, so whilst there certainly have been delays longer than we would wish to have, then as we've gone through that implementation there have been functionality and different labs and services that have been switched on through that process. So, it wasn't a cliff-edge situation. I think one of the big lessons on the laboratory information management system has been how long the standardisation has taken. So, as we've been putting in a system across Wales, then the biggest part of that work was getting the different staff groups to work together to look at standards for tests. So, previously, reference ranges, what they call different tests, were different in every laboratory. So, clearly, there was a standardisation piece of work that was desirable for its own end, not just to put the computer system in. Those processes took a lot longer than we anticipated. I think also, in terms of the legacy, what was previously in place, lots of the systems were not fully documented in all of the links that they had to other systems, and so when we went in to then replace that, we found things that we didn't expect to see, which then meant that there needed to be further development in order to ful