|Adam Price AM|
|Lee Waters AM|
|Mohammad Asghar AM|
|Nick Ramsay AM||Cadeirydd y Pwyllgor|
|Rhianon Passmore AM|
|Vikki Howells AM|
|Alan Brace||Llywodraeth Cymru|
|Dr Andrew Goodall||Llywodraeth Cymru; GIG Cymru|
|Welsh Government; NHS Wales|
|Frances Duffy||Llywodraeth Cymru|
|Huw Vaughan Thomas||Archwilydd Cyffredinol Cymru|
|Auditor General for Wales|
|Mark Jeffs||Swyddfa Archwilio Cymru|
|Wales Audit Office|
|Rhidian Hurle||Bwrdd Iechyd Lleol Prifysgol Abertawe Bro Morgannwg; Gwasanaeth Gwybodeg GIG Cymru|
|Abertawe Bro Morgannwg University Local Health Board; NHS Wales Informatics Service|
|Claire Griffiths||Dirprwy Glerc|
|Meriel Singleton||Ail Glerc|
|1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau||1. Introductions, apologies, substitutions and declarations of interest|
|2. Papurau i'w nodi||2. Papers to note|
|3. Gwasanaethau Gwybodeg GIG Cymru: sesiwn dystiolaeth 3||3. NHS Wales Informatics Services: evidence session 3|
|4. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd||4. Motion under Standing Order 17.42 to resolve to exclude the public|
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 14:01.
The meeting began at 14:01.
I welcome Members to this afternoon's meeting of the Public Accounts Committee. Headsets are available for translation and for sound amplification. Please ensure that phones are on silent, and, in an emergency, follow the ushers. We've received one apology today from Neil Hamilton—no substitutions. Do Members have any declarations of interest they'd like to make at this point? Good.
Item 2 and we've got some papers to note. First of all, the minutes from the meeting held on 30 April. Happy to note those? Good. Secondly, I wrote to a number of stakeholders in March, inviting views on the auditor general's report on the NHS Wales Informatics Service. The views contained in the responses have been taken into account in preparing the briefing for today's session. So, are you happy to note those letters, and the additional information from NWIS?
On the letter from NWIS, Chair, I think it would be useful to write to the health boards just to check that they're content with those figures.
Is the committee happy to do that, to seek their confirmation on some of the figures in the table, particularly? Good.
We've also got a letter from the auditor general on the twenty-first century schools and education programme. So, happy to note that? Good.
And the Cabinet Secretary for Economy and Transport has responded to my letter, in which I requested a copy of the Cabinet paper from 27 June 2017, relating to the Circuit of Wales project. As we thought at that time, after careful consideration, that paper will not be released. So, there's some modifications that will be made to our report on the basis of that.
Item 3. Can I welcome our witnesses? Thanks for being with us today on our third evidence session on the NHS Wales Informatics Service. Would you like to give your name and positions for our Record of Proceedings?
I'm Andrew Goodall. I'm the director general for health and social services, and I'm the NHS Wales chief executive.
Rhidian Hurle. I'm a consultant urological surgeon with Abertawe Bro Morgannwg University Local Health Board, and medical director of NWIS, and I'm the chief clinical information officer for Wales.
Alan Brace, director of finance, health and social care [correction: social services] group.
I'm Frances Duffy, director of primary care and innovation, health and social services group.
Good. As I said, thank you for being with us today to help us with our inquiry. I will kick off with the first question. Overall, the auditor general's report found significant weaknesses across a range of areas. What's your take on the diagnosis in the auditor general's report and are current arrangements fit for purpose?
Thank you very much, Chair. First of all to say that I welcome the report from a system and from an organisational perspective. I think aspects of it are difficult, but I would say that I would recognise much of the commentary, not least that areas that have been highlighted for action and recommendations do represent actions and progress that I've been looking to instigate, particularly over the last 18 months to two years or so. You'll have seen that, with some of the recommendations, for example, around 'once for Wales', better use of the national informatics board, where in my response to the Wales Audit Office I highlighted that we were trying to address a number of those different areas.
I think, alongside the review that's been completed, I would hope that we can at least show progress in some of those recommendations. But there's also a context of us looking at a system that will need to improve the Wales Audit Office report, which is on specifics, and also the broader parliamentary review, which is going to translate into our response on the long-term plan for the NHS in Wales.
If I was reflecting on the report and the areas that it highlights, I think there are perhaps some areas that don't necessarily fully capture the scale of the system that we're overseeing. We've reduced the numbers of health organisations, so we have seven health boards and the three trusts, but perhaps it doesn't quite convey the system that's dealing with 79,000 prescriptions, 3 million out-patient attendances, 700,000 optician attendances, 19 million attendances in primary care—all of which will lead to hundreds of millions of data points that we're looking to facilitate and manoeuvre, and it's really important that we make progress.
I think, importantly, there is an opportunity for us, however, despite the history of how we've developed information and communications technology over the years, with a lot of focus around hospitals and the way in which our acute services are delivered. We have tried to make progress in areas like mental health and community services, including working more closely with social care.
I would like to promote that there are advantages of having a national organisation that has got a specific ICT role and expertise. But I think, importantly, it's necessary to convey that this is a system that requires us all to work together. So, Welsh Government has its own responsibilities in our oversight of the system. We do need the service, to make sure that it moves on, and perhaps a past that is about individual digital projects is now becoming much more broadly about how we transform the offer we make to patients within our system.
If I could just to interrupt there, do you think that—? What we as a committee found and were surprised by was the fact that some of these issues have obviously been knocking around for quite a long time and have been unaddressed to date. So, what confidence can the public have that—? You're saying now, you're sitting in front of us telling us, 'They will be addressed from now on'—what confidence can the public have that that will actually happen this time around?
I think the scale of what we're trying to do and some of the choices, so in areas like the community information system, recognising that there are ways that we can work differently; I think in some of the governance areas that have been highlighted; I think to give some confidence that we've made changes even while the WAO report was taking place. So, if we look at the redefinition of the strategy for Wales, back at the end of 2015—I took over the chair of the national informatics management board in April 2016. We've tried to introduce different arrangements in our oversight of the way NWIS works. I've tried to ensure that in the national informatics board it's a much more open arena for discussion, which isn't just about tracking progress, positively so; it's about highlighting risk and issues that we need to handle together. Having made progress in respect of developing the role of chief clinical information officers—in part why Rhidian is with us here today—. So, back in March I was actually announcing our all-Wales network.
So, I wouldn't want it to be seen that we've only just waited for the Wales Audit Office report to come in. We've tried to make a range of different areas of progress over the last two years or so. I think, ultimately, though, the big challenge that we need to look to address is: what is the scale of funding that we need to bring in for our transformation agenda for the NHS in Wales? And what is the component that needs to be supported with where we want to go on digital and with healthcare?
With the electronic patient record—that was first mooted 14 years ago. Why has it taken so long to get that up and running?
Well, 2003 is when the original concept of the electronic health record was put in place. I have to say, for the initial years—and I was within the NHS Wales system at that time—there were a lot of enablers that had to be put in place at that point, including, actually, investment in technology across Wales to actually get people to a common and level playing field—our ability to introduce the NHS-wide number, which we looked to introduce. So, I think, in the first few years, we were looking to put in a number of enablers. We then started with a series of national procurements on national systems, but we've always had to strike a balance between allowing some of the local developments to take place and being clear about the national systems that are going to be part of our architecture.
I think, although it may feel like there is slow progress, there have been some quite significant moments in our development of IT. We've moved from a system that has had every individual general practitioner practice having its own local system within its own practice to two key systems that are there and supporting the whole of Wales. We've had to develop specifications, working with our clinicians in a number of different areas as well. We've had to introduce the technology that's been necessary to deliver areas, whether it's in terms of archiving approaches—. It's not just about prospectively having systems that collect the data now; we've had to digitalise records over time. So, it is a very complex and challenging environment, I think, to do this.
And there's no danger that it'll get lost amongst all the other priorities and factors that are in the NHS at the moment.
I would hope that if colleagues have read the parliamentary review that they would have seen a very strong set of support for where we need to take digital in the future in Wales. So, I think that in terms of our transformation agenda, digital comes through almost as one of the strongest sections. In fact, the panel judged that they wanted to give some additional reflections on the digital agenda that was ahead of us, and I think that's given us a very strong endorsement for where we need to go.
We are currently developing the long-term plan that will respond to the parliamentary review, and it's very clear to us that digital will have a really strong part of the architecture in there, but I do think we need to change, perhaps, some of the culture and expectations around the way in which we use digital in Wales, if I can be open with all of you around the table. I think there is a danger of everybody tracking a very specific technical budget in terms of what they want to achieve, and I think what we're needing to do is actually lift up that this is about clinical change; it's about a practice of behaviour within the organisations and in the service, with digital actually being an enabler, as I said earlier, of what change and transformation should mean for patients.
Thank you, Chair. We've taken quite a lot of evidence around the 'once for Wales' notion and have found some discrepancy in the way that it's being interpreted. So, my first question is: are you satisfied that there is now clear agreement and a common understanding of the balance between all-Wales systems and local discretion based on common standards?
I think that the split between having a national organisation through NWIS and also still expecting the development of digital through the individual health boards and trusts has meant that there have been some tensions in terms of people's common understanding of what 'once for Wales' means. We, as I said in my response to the Wales Audit Office, had committed to develop a 'once for Wales' approach and although that's been a part of the development of the electronic patient record in Wales, I think we did need to restate the definition. So, through last year—and we signed this off back in September last year—I'd asked a technical group involving colleagues from Welsh Government, from the service and actually from NWIS also to give us clarity on what a definition should look like for the future, and they have defined it, which is a focus around the ability to bring a single electronic patient record together. But I think it importantly clarifies that that's not about having a single system, and I think that does underpin the developments that we've made in Wales.
I think that it feels that it's not controversial to have a consistent approach to standards, and people recognise that the systems that we have in Wales do need to talk to each other and ensure that they can track the patient experience. I think it would be right to say that there has been some tension around the choice of systems that are designated as national, where there is a mandate that follows in terms of our expectations for those to be set. I think our approach in Wales is not to determine that everything has to be about a national specification or a national system, but there absolutely are key systems that should be in place to give us the architecture for Wales. So, that might be our approach to the Welsh patient administration system, for example, or the community information systems that have been introduced.
But some of this is also about consistency around records. So, I think the standards seem to be an area that we've pinned down. We have got a list of products and systems that we do expect to be commissioned nationally, but as organisations come to the end of an existing contract with their old systems, we'll be reviewing whether we feel that that should be added to the list or whether they are systems that just need to be able to operate in the context of where we're up to in NHS Wales. So, I could give you an example today that isn't a national system but would be an area we'd have to think about. As two organisations in Wales are having to replace their national theatre management systems, we'll have to determine whether that gets added onto the list. As a minimum, I think we need to have a clear, consistent and national specification, but it would be our choice about whether that becomes one of the core clinical systems for Wales or not, and at the moment that has been different systems in place across the whole of the health service in Wales.
Just before I go back to Vikki, Lee, did you have a supplementary question on that?
Well, a couple on the general area, so I'm happy to wait until Vikki's finished her questions. Thank you.
Regarding that new definition, then, is there a danger that the revised definition of 'once for Wales' is so all-encompassing that it is able to accommodate the contrasting views in different areas and different health boards without actually resolving the debate?
I think there could be a danger that, depending on where you are in Wales and which organisation you look to to interpret it in your own context—. I think, however, we are trying to be much clearer through our approach to the national informatics board to actually call those areas out. So, for example, in our last national informatics board, where we were looking to clarify issues, there are a couple of examples where I've had to clarify our expectations for systems. Although an organisation may wish to search for something a bit different, we had to be very clear that they would be inconsistent, actually, with the national systems that are being purchased. One of those was around the national community information system, and we are very clear that that is a national system for Wales. I'm hoping, though, that the national technical board that's been put in place—and we agreed that back in February of this year—will also be a way of helping that. So, that is resolution between the service, Welsh Government and actually the system, but will use the national informatics board to actually call out any areas where it's perhaps not as clear as it should be.
Yes. I've been contacted by a number of people as we've been undertaking these inquiries, and the general tone is that they're frustrated with the picture that's been painted in the official evidence we've been having—it's a very upbeat one, the general tenor is that things are in hand, and those practitioners on the ground are very frustrated that that does not represent the picture as they see it. In particular, on this question you mention of 'once for Wales', the feedback I've been having is not so much on the philosophical point but more on the competence point. And the feeling is, in the words of one who's got in touch with me: 'We have to manage hundreds of systems from dozens of suppliers, and NWIS is, by some distance, the least competent of those suppliers, and we are relieved that the WAO has eventually shone a light on them.'
So, it's not simply a question of philosophy, although there are, as we've heard from slightly different accounts, some tensions around that. But I guess the question for us as a committee is, given all the evidence we've had, and given the fact that it has taken 20 years just to get to the building-block stage of the patient record, and, of the 30 projects NWIS are running, only seven are on track, and many of them against revised timelines—the overall picture does not speak terribly well of the current set-up, and the tenor of the evidence we've been having is that it's fine, we've circled the wagons and we all want a consistent line on this to defend the status quo, and, actually, we're considering giving them tons of more money. Do you recognise that the frustration that the auditor general found in his evidence gathering still remains?
I recognise frustrations in the system, and, in fact, as you introduced that, you talked about local organisations reporting that they had hundreds of clinical systems. I think that there is something about the legacy that we've had in Wales. At one point, we had over 35 individual health organisations, they were operating systems that were very specific to their individual sites, and I think we've had to really move on from that kind of environment. So, a lot of the work and the delays that are often experienced—and I think, depending on the individual system, they may differ, but it is often the reconciliation of those legacy systems, because different contractual arrangements have been in place. And I think that's taken us more time.
I think that, as far as taking a national approach for Wales, that is perfectly feasible for a population of 3 million, and, with patients who inevitably will move across different pathways and in different settings, we should feel that we can institute an approach around a national 'once for Wales' approach. I'm mindful of the approach in NHS England, which, of course, is more complex and of a larger size at this stage. I know the National Audit Office were critical of an approach to try and buy a single individual system for the whole of England, but, if you look at the way in which they're developing a more local and regional premise to what they expect, the size of Wales as a 3 million population is very much fitting with the spirit of what we have in England.
I think there'll be a danger to expect, however, that NWIS's national role is to be the answer to all of the individual systems. We are reliant—50 per cent of the pairs of hands involved with informatics are actually spread and distributed within the individual health boards and trusts, and we do need to use that experience. But I think one of the problems that we have actually got is this variety of individual systems with different contract breaks that we've had to try to gather together and over time. So, one of the dangers for us, I guess, is: do we move at the pace of the slowest rather than have the innovation and momentum in the system that we would expect? I would like to find a way of addressing that, looking forward.
I think some recent systems where, I think, we have made sure that we are learning from some of those previous experiences would be—. Having got into the Choose Pharmacy approach, I think that was a good example. When we knew that we needed to invest more into the system and have real clarity, we were able to make an announcement two years ago, and I think we're now exceeding some of those perspectives on that one. Our approach to 111 as a national system for Wales—we've actually removed the fact that it's a negotiation point with the individual health boards, and we've determined that that will be allocated from a national approach, where we, effectively, top slice. So, I think we are trying to learn from some of those individual areas, but we have got too many offers available, I think still, for patients. And the real benefit for me was the move that happened from all of these individual GP systems in Wales down to two systems. I think it offered a better platform for Wales, a better opportunity, and better value for money, actually, for GPs in our system, and brought real consistency to the table.
I recognise all of that, but the central point of my question, though, is whether there is confidence in the system that NWIS, as currently constituted, is the right body to deliver these changes. And, based on dozens of conversations I've had, I've got to say that the system is not confident in NWIS.
So, I think if we look forward in terms of what we need to do next—. I think I can defend a range of governance that is in place for NWIS, the call for its inception at the time, which was actually to bring things together from this myriad of different organisational approaches, but, certainly, looking to the future, I think there is something—and not least highlighted by both the parliamentary review and the Wales Audit Office—which is: how do we draw this expertise and experience around the national table more so? And I think there is something—
But before we—[Inaudible.]—the purpose of the auditor general's report was to look at what's happened and the lessons from it, so let's not skate over that. I think we do need to understand what is currently wrong with the system and why there are so many frustrations. I think you're right to point out that some of the blame here does lie in the health boards, and I've certainly spoken to people in the IT industry, outside of Government, who say there are refuseniks in the health boards who simply frustrate progress. So, it's not all down to NWIS, but what I'm asking you to engage with is the criticism that is out there, both recorded by the auditor general and by anybody who's had the conversation at a myriad of levels in the health service, about the competence of NWIS to do the task at hand.
I think that NWIS has competence and capability. I know that it's struggled with some of its workforce. I'm pleased that, over the last couple of years, it's been able to expand that by 20 per cent. I think, to some extent, there is a broader challenge, as I said earlier, not wholly under digital budgets, but actually how we want to transform services, and sometimes I think that we have added to the list of expectations that we've expected both NWIS and the system to get on with in an individual organisation. I was a health board chief executive myself; you can make your own judgments about your priorities locally and what you want to invest in, but, on the national side, I do think that there's been a danger for NWIS that people have spread their expectations, and I think we probably distorted the ability to pull some of our systems over the line in a more considered way. Certainly, to learn from those lessons, as you've outlined, I think we've tried to introduce a different approach to how we both add to the list and make sure that, if there is going to be a new approach on any system, it is properly worked through, the benefits are clear, it can give us a return, which is either patient benefit or on the financial side, and actually will be funded if it's going to be something extra in the system.
Secondly—and we've just been going through this exercise, which can be quite painful at times in respect of how one prioritises the existing system—we've been going through a prioritisation process to make sure, actually, that we have to start thinking about what we take away from the system or find alternative funding sources as well. But I do think that the finance and the balance of resources that are available is one of the factors for how not just NWIS on its own but actually the whole system needs to operate. And I do think that there is a better chance of focusing that, particularly in response to the parliamentary review.
So, just briefly and finally, as far as you're concerned, there's no question about the competence of NWIS.
I believe that, in any organisation, there will be issues of capability and competence and the ability to move on systems to different levels. I think that NWIS has struggled to deal with some delays in individual projects, sometimes about specialism, sometimes about engagement in the system. I know, when we were looking to roll out some examples like My Health Online, for example, probably the timing of the national GP procurement approach got in the way of some of our expectations as to having a much stronger approach there. But I think, with all areas, we have to try to manage within the capabilities that we've got available, and I think that NWIS, like any other organisation, will have areas that it needs to develop and support.
It wasn't exactly a 'yes', was it?
Back to Vikki Howells, I think, with the original line of questioning.
Thank you, Chair. You referred briefly to NHS England in one of your answers there. How do you think health boards in Wales compare to their counterparts not just in England but the rest of the UK when it comes to having access to an electronic patient record?
Perhaps if I could ask Frances to just give a general overview in terms of that, maybe that could allow for some compare and contrast with other systems, and perhaps I could bring Rhidian in just for a perspective around what that means on the ground in terms of clinician and patient experience.
We do spend a fair amount of time making sure that we engage with our colleagues, both in NHS Digital, the department of health, and Scottish Government and Northern Ireland. As I think I said when we were here before, there are some things that we've made quite a bit of progress on—more than our colleagues in other parts, and then vice versa.
One of the key things I wanted to highlight was the progress that we've made on being able to share information across organisations, which is a key part of the building blocks of our electronic record. My conversation with my colleague in Scotland just a few weeks ago, as they were about to launch their strategy, their update for their digital strategy—they're highlighting that that's one of the key concerns that they have, that their patients are maybe treated in Fife but their records are held in Strathclyde and you can't get to see that across the board. So, that's one of the areas that I think we've made quite a bit of progress on.
We also discuss and share with them. For example, in Northern Ireland, they've come to visit us to look at how we're organising and shaping our informatics across health boards, and with NWIS as they look at and review their progress and reshaping of their core informatics system. They, for example, have picked up and used our Welsh NHS bowel screening programme—they use that. We've taken some systems from Scotland and we use them. And a conversation I had last month with my colleague in Scotland about the challenge that we both face on a single electronic sign-on—and that's something we will work together on, and try to learn lessons from that.
I think, by and large, those systems mirror ours a little bit more than the NHS Digital one, which is a much wider system and much more dispersed, so we've got much more commonality in our approaches.
Just on the patient and clinical experiences, Rhidian.
Yes. Just to give you a little bit of background, I've worked in NHS Wales for about 20 years. I'm the son of a GP and I summarised notes as a teenager in the summer holidays, so I've gone from a written to a semi-digital to an almost completely digital practice myself. I would say that the time frames that people seem to be concerned about mirror very much what's happened in general practice. It took over 20 years to get general practice in a commercial model that was adequately funded with central Government funding—to get to a place where GPs could go paper light. In fact, only 90 per cent of GP surgeries across the UK were paper light by 2006.
If you look at my own practice, I'm now able to see people who have a patient journey that has completely changed. Previously, everything was combined within a health board, within a postcode. There were enough doctors and nurses and health professionals to provide those services at a local level. As a cancer surgeon now, I receive patients from a postcode, refer them to a different postcode, they go to another postcode and they come back to me. Previously, I found myself in the situation that I met them at the beginning of the journey, I saw them at the end of the journey, but I didn't actually know what went on in the journey. The national platform that you and we, in partnership, have delivered, now enables me to see that journey across all those health board boundaries. I can give you clear examples of how being able to see documentation generated in a different health board has changed my ability to provide direct care.
There will always be people—always be people—who will knock down this type of progress, because it changes their view of the world. I'm a clinician at the coalface for 50 per cent of my time. I've operated on over 1,000 people with bladder cancer. My ability to deliver care is better because of this national programme. I gave up 50 per cent of my clinical practice to be part of this programme, because I believe it is the right way forward. I know I'm justified in this view, because in my national role I meet other CCIOers across the UK. I have had the pleasure of spending some considerable time with Keith McNeil who was the CCIO of NHS England, who sat in digital health in the Department of Health. He said, 'How are you managing to do what you're doing in Wales?' I said, 'It's about people, it's about partnership and it's about political will'. Now, I'd like you to reflect on that, because we in Wales have a culture of putting ourselves down. Actually, what we are doing is a game changer for patient care.
Thank you both, and you're obviously both proud of the progress that's been made to date. If I could ask you to reflect on perhaps where you think we should focus our attention—one area that you think perhaps we could focus our attention to learn more from other parts of the UK—what would you say to that, Frances?
One of the discussions I was having—it's about providing that single sign-on, which we know is something that practitioners would really value. So, it's sharing some work together with Scotland on that. I think what we are all discussing at the moment is the opening up of an online platform for patients who will be able to access more their own health record, plus be able to get different information that can help them take more control of their health. That's something that we've been working on for the past year, building a business case for that. I know I'm about to visit NHS Digital in the next month or two to have a look at the progress that they're making on their online platform and it's something we keep in touch with Scottish colleagues about as well. So, I think that is one area that I think our focus this year needs to build on, in line from the other areas.
I hope there'll be a chance, though, for us to also promote some of the learning that we're doing around the community system, just because of the complexity of working through an arrangement, working with local government and with the NHS, and trying to create those contractual relationships across the whole of Wales. So, as much as we need to link up on some of those areas, I do hope that some of the more unique and distinctive decisions we've made in Wales will be a chance for us to promote some of that learning for other colleagues too.
Thank you. Just one final question from me, then: the auditor general says in his report that the informatics market has changed since NHS Wales first developed plans for the electronic patient record. I'm sure you're fully cognizant of that fact. Your response says that you'll review the market, but, in your current view, are there any specific technological and market developments that we aren't keeping pace with?
I think it's a very fast and evolving area, and I know that underpins the extent to which delays have had an impact over the years. It's just seeing the way in which technology has changed. But there are some specifics to look at. Open-source technology is the way in which we need to develop those. At the last national informatics board, we received an update on some of the choices around using the cloud, for example. Clearly, we're in a world where users have access to apps and their own technology, and I think we need to be much more flexible around how citizens would get on with their day-to-day lives, and make sure that we're able to bring in some of the difficult experiences that people will have as they come into contact with the NHS. So, I think there are definitely some things to learn from there.
The other thing I think we would be liking to promote is the ability to develop some greater examples of digital innovation, working with other suppliers and those that are developing products in Wales. So, we've actually created an approach around a digital ecosystem, and we'll actually have another discussion on that over the forthcoming weeks, not least with individuals and suppliers and other sectors who have an interest in this arena as well. So, I think there is a lot to go at, but certainly, it feels like the pace of technology change is getting quicker, and increasing year on year, and we do have to find a way to be more agile whilst pushing over the line some of our existing systems, because we do need the core functionality for patients.
I want to just go back to what Mr Hurle just said about expecting it to take about 20 years to get the new system in place, given that was the experience with the GPs, and we shouldn't talk progress down. Given the state of change in digital and artificial intelligence, and the pace at which developments are going—. It takes us 10 years to get a catering system in place, 20 years just to get the building blocks of medical records, and Mr Hurle from NWIS seems to be quite content with that sort of pace—it's what's to be expected—whereas the world outside is moving way beyond that. I can now see a GP within 20 minutes on my phone, but My Health Online, which you seem very proud of, is achieving nowhere near what it was set up to achieve, and still is a very clunky, simple piece of kit.
I think there are opportunities to get in this. I think that My Health Online, although it has provided a technical offer for all practices, hasn't delivered the numbers that we wanted, even if they are a growth in terms of the original numbers. We certainly do need to have a system where the access points for patients aren't simply about the signposting and the ICT in there. We are overseeing a system in the NHS where, actually, what it will do is to filter people to be in front of the front-line clinician, and I think that's a distinction from some of the technology that is on the market. But I don't think the intention was to defend that it's taken 20 years in culture, decision making and the individual contractor status of practices to work through the GP system. I was just being open to say that we know, however, even though we look back, that the pace of technology and change is happening much more quickly, and we do need to be agile around that. What we can't do—
What we can't do is just start from today changing over the overall system when we have a level of investment in all of our existing structures. As I said earlier, we still have many of these legacy systems in place. We have to translate all of those, in terms of the shift of the patient record, across all of those at this stage. So, looking forward, we do need to find a way of actually being able to move with the system and the developments much more strongly. But, looking backwards, it has been a genuine problem for us to overcome.
Yes, but that's my point. We're not agile. I see from Mr Hurle's body language he seems anxious to make a contribution here. I don't know if you'd like to say something.
Well, machine learning and AI has its role, and that role will get greater. One of the advantages of the approach that's been taken is, ultimately, the data will be within an infrastructure that can be mined in a way to understand what the benefits are, both to the individual and to the health population and to the communities that we serve. This is something that you don't get if you go down a commercial structure view. If you look at what happened in NHS England, which cuts it up into five different areas, individually, those areas were funded to compete against each other. There's no reason why commercial companies will work together. They want to dominate the market—
Well, this is important in understanding where we want to get to. We want to get to the position where your data and my data contribute to the population's well-being, and this path will—
I understand that. Nobody's arguing that it should be done on a commercial basis. But you're asking me to trust an organisation, and you cite as an example of success My Health Online, which was meant to have 872,000 patients, and now has only 170,000 patients. That's just people who've registered. You don't know how many people are using them. So, Dr Goodall is saying that the system needs to be agile. I agree. My question is, given all the evidence before us, whether NWIS is agile.
On the My Health Online example, I think that the offer available has allowed technically all of the practices to offer that, but I think that the practice and some of the culture around the choices that people want to make—. Effectively, My Health Online is a mechanism for offering a range of services from within an individual practice. So I think we have given some of the flexibility there. But for whatever reason, practices are not fully choosing to do it. Now, I certainly think there are also some other problems with My Health Online. I think the registration process that it requires is actually something that you have to work through, and can take significant contact. I think the fact that we still have some inability to make sure that the range of services are fully populated there, and the GP contract at the moment, although we've made it available through that, is an issue. And I think that we will need to take stock of where we are with My Health Online, which has given us a platform so far, but in the current project management arrangements we have been asking for, what do the next steps look like? So, if the ceiling is looking like it's 222,000 people who are utilising the system, we feel it should be more—
But it seems to have gone back, Dr Goodall. The letter we've had from Andrew Griffiths this week is showing it at 219,275, so it seems to have fallen back even from the figure the auditor general reported. Why would that be?
I don't know. I'm within 3,000 of the number that Andrew's given, though, so in terms of—
I think My Health Online gives a 100 per cent technical solution, but it's about how people want to access the system more broadly, and I do think we need to—
Sorry, but I don't think you're engaging with the direct point I'm making. Doesn't it alarm you that this system that your colleague from NWIS, who is here giving evidence for some reason alongside the Welsh Government, is telling us—
He's the chief clinical information officer for Wales.
But the purpose of this session is to scrutinise the Welsh Government, and NWIS seem to be sitting alongside the Welsh Government. Anyway, that's a separate point, but it does kind of underline our point about the confusions of governance. But just in terms of specifically My Health Online, it's helpful that Dr Hurle is here from NWIS because perhaps he can explain why My Health Online seems to be losing numbers, rather than gaining them. It's way off where it should be. He's quoted us an example of success and the letter his colleague has sent us is showing it's fallen back several thousand already. I just wondered why that would be, given that it's so successful.
I'm happy to say that it's a national system for Wales that we've utilised, and that we do need to make some progress on it. I also believe that My Health Online is going to have to develop into a different product, which needs to be agile enough for people to be accessing it from their smartphones—FootnoteLink
I'm sorry, but the purpose of this session is scrutiny by the National Assembly on the Welsh Government, and I'd be grateful if you could directly answer the points we're making here. Why is it slipping backwards? Mr Hurle is with us. Perhaps he can tell us.
I'll give you some reflections, seeing as my wife's a GP and runs a GP surgery, and I've got GP colleagues. One of the functionalities related to My Health Online is the ability to book appointments. Now, unlike the example that you quote where you can ring any GP, that system that you favour doesn't have any access to your previous records, it doesn't have access to the history of everything that you might have been through, and for certain things it's very useful. The triage system that is developed by GP surgeries to control demand relies on a human contact, therefore the ability to open up all your appointments doesn't necessarily allow you to serve the population that you actually need to see. Not everyone in that population—. I'll give you an example. If you take the average 80-year-old, who has three chronic conditions, they will be on at least half a dozen complex medications—
It's not falling apart.
But the figures you've given us are less than the figures that the auditor general—
And you will see with any app, any technology, that functionality goes up and down as it changes to users' requirements. I dare say you do it yourself. I dare say you take apps off your phone that you found useful and put other ones on that are more useful, because it's human behaviour.
I understand all of that, but the question at hand here is our confidence as a committee about whether NWIS can deliver this agenda. You yourself have quoted My Health Online as an example of success. The figure that you've meant to have achieved is 872,000. The auditor general found that figure was, in fact, 220,000. NWIS themselves are now telling us that it's 219,275. So, I'm simply asking why that is. You're going in the opposite direction from where you should be going, and you're asking us to give you hundreds of millions pounds more to deliver an agenda where you've been unable to catch up on existing technologies, not new technologies.
Frances—on our Welsh Government approach on My Health Online.
On that one, My Health Online, the reports that we've had in on the numbers and the usage have highlighted to our national primary care IT board, which is a group from the primary care practitioners, that there is an issue about the use of My Health Online. The production of that system—technically it's there, it can be used, but what we have seen is, 'What's the engagement with the GP practices, and what's their wish to use that tool?' There have been some instances where, as GPs have looked to create a different triage model to support people making appointments, trying to ensure that people are not just automatically going to a GP if there might be a more appropriate person available, that has not sat well with the developments of where we are with My Health Online.
That's something that the project board, which has a senior responsible officer from the service, and is led by the directors of primary care, are looking at, because as well as having a technical system you have to then work out why are people using it, why are people not using it. The programme board itself, in its last meeting, recognised that the ambition of the numbers that we had originally set out has not been realised, so, therefore, they need to stop and look at what is the product doing and why are some GPs using it. Why is it very successful in some areas, but in other areas it's not? It has been taken up quite considerably for the use of repeat prescriptions, but not perhaps on the making of appointments.
The introduction this year of being able to see your summary GP record may be part of a way of helping us improve the use of the system. But the project board itself, who report back up through to the national informatics board, are actively looking again at where we are with the My Health Online programme, recognising that we haven't made the numbers that were originally set out.
Thank you. That's helpful. The central criticism from the WAO report was that NWIS's reporting to Government was overly positive. And I must say, based on the last five minutes, I'd say that that hasn't changed.
From a reporting perspective, I think where we have been struggling from a system perspective is to have a balance between what has been implemented in individual organisations and what is the aggregate position for the whole of Wales. Deliberately having taken over the chair of the national informatics board back in April, what I've wanted to do is to make sure that we have a balance for, on the one hand, the national approaches, and to understand where each individual organisation stands as well. And I think that has given us a much more realistic view of where things are happening. Equally, it's created, I think, a much more open environment for the risks that we're collectively managing, and when Frances referred to the senior responsible officers within the system, we've deliberately distributed those, so, again, it gives you a balance of SROs who may come from a service, or from NWIS, or from a Welsh Government perspective, depending on the individual area. I think it's really important to bring that collective experience around the table. But I would try to ensure that if the national informatics board's role is to oversee the delivery of the informed health and care system for Wales, that it has to understand what its problems are within the system, as well as try to build on some of the foundations that are in place.
Just on this reporting point, I was just re-reading some of the report. Do you accept that some of the delays have just been phenomenally bad? Correct me if I'm wrong, but the Welsh laboratory information management System, WLIMS—or however you say it—that's seven years since the original decision to procure a national system, and it still hasn't been fully implemented. GP2GP, first discussed six to eight years ago, won't be delivered until 2020. I defer to your knowledge of the wider context and how we compare, but are we saying that's normal, those kind of delays, 23 out of the 30 projects actually seriously, significantly behind the timeline? And we're world leading. If we're world leading, then the world has a problem, surely. I'm not trying to be facile about this; I'm trying to really understand how bad the problem is.
I think, again, I would say it's the difference between looking at what a local organisation is up to in delivering its agenda, and then lifting our expectations for what we want to deliver for the whole of Wales. And, inevitably, a mechanism that involves how we look to implement, whether in parallel or in sequence, across seven health boards and three trusts, is something that will be different from simply a local organisation deciding whether it has the funding or not to get on with its own local plans.
There have been complexities about the approaches. So, for example, with the Welsh LIM system, which is our pathology information system for Wales, at the point of implementation, there were very significant changes happening around the practice of our pathologists in Wales and our pathology staff. So, there was a loss of time there that probably affected around two years' worth of the roll-out, because it wasn't about the technology or the implementation of the system. It was a change around terms and conditions actually for all of the staff who were working. And health boards had to revert staff to underpin their local rotas at the time.
However, with systems, there will be tend to be some issues around technical support that is necessary. So, looking at the Welsh community information system that we are working on at this stage, we have developed a specification that has meant that, for the first time, developing a community information base for the whole of Wales, working with our NHS staff, whether it's a district nurse, or a health visitor, and making sure that it captures their kind of needs. So, although local government were able to have specifications based on their existing social care systems, we have had to start from scratch and have a product that has been working hand in hand with the developer on this. So, there will inevitably be delays on these areas. Not to defend some of those original delays, but sometimes you will have things working against you at the time of rolling it out. Now, whether they could have been delivered better if they were held in one single organisation, and getting on with it in the local system, I don't know.
So, there are a lot of context-specific, sometimes localised, reasons that explain particular delays, but when that gets repeated—. I mean, I'm sure you'll accept that the suspicion and probably logic suggest that there is a systemic problem—it becomes a pattern, doesn't it?
Yes, but I think it also raises two issues. One is whether we have found the funding available to do things at the speed that we would wish, and I think that is a general ask around the funding environment we have got. Whether it's access to capital or our revenue, we have to work within the budgets that are available there. The second bit I would say that maybe has distorted some progress, and that we've tried to learn from on recent systems we're taking up, has actually been about how you manage the business change on the ground, the change of the clinical practices that need to be supported. So, with the Welsh Community Care Information System, the fact that we have looked to put in the business change support alongside the roll-out of systems has been helpful for us, to look to introduce as part of our implementation process.
Just before I bring Rhidian in, on the other point that Lee was referring to, which is the requesting of reporting and the criticism of reporting, some of the delayed—and correct me if I'm wrong, and if I've misread the auditor's report—projects were then, under the traffic-lights system, reported as 'green' because, essentially, as the delay continues, the original timetable gets recategorised to be more, I suppose, useful for management, but it's not particularly useful, then, for the likes of people like us, I suppose, who have to hold you to account. I think that the report says there's a real issue of reputational capital then, because, if people—some of the ones who may have contacted Lee—read in a report that everything's fine, et cetera, but their experience on the ground is different, then ultimately you lose credibility as well.
And you can have knock-on effects from an implementation that has been effected in one single organisation, and the overall programme being knocked back, but then have a very straightforward implementation, actually, for the next organisation that's taking it up in Wales. So, it is true to say that we have to recalibrate some of those expectations for the local implementation, but we need to still have our sense of oversight. Frances, do you want to comment just on the way we try to maintain our own oversight of the progress, and how we've tightened things up?
Well, there are two things. One of the things we're tightening up in lessons learned is the lessons learned from across Government service on digital programmes that are about being quite explicit about the time and effort you put in to developing your business case in the first instance, being clear about what the benefits are, and then how you're going to roll it out, and your management process. So, NWIS, and the chief executives with the help of the ADIs, have tightened up and reviewed the process for creating business cases, to avoid the situation where we'd look to a technical requirement but haven't actually properly, as Andrew was saying, thought through what's the change process in each health board.
But, secondly on that, on the question of the slipping of dates, all of our main projects now have got an SRO and a project board. I know that people from the service and people from Welsh Government are overseeing around that. It is their job to look at the progress of the projects and to sign off and agree the implementation plan, and to flag up if there are any issues. One of the things that I have done—and we had our six monthly review with NWIS on Friday—is, when we had set through our milestones, to ensure that we have a full list of any milestones that have changed, and then, looking at those milestones that have changed, we'll look through what the key reasons are and try to identify which are the ones where, sometimes, it is about engagement with health boards, sometimes it's engagment with suppliers, something we've procured, but perhaps the supplier has not been delivering, and so how have NWIS then managed that through the contract management? Sometimes it's a lack of staff, or new priorities come in.
An example of that earlier this year was when we had a couple of quite serious cyber incidents, which meant NWIS reprioritised some resources, and that has a knock-on effect. What we've tried to do is to ensure that all of those reprioritisations or any of those changes to milestones are fully agreed and are transparent with the programme boards that are there. So, I think we have, over the last 18 months, made progress in getting that better sense of milestones, and we are also ensuring that NWIS publish their annual plan, which sets out the detail of what they are doing each year, on the internet, from this year, once it's agreed. It's always been available within the NHS, but we think that's something that could be made more widely available.
As opposed to the intranet.
Yes, thank you very much indeed. Thank you very much, Andrew. My question to Rhidian is, our GP practices and hospitals are the best in the world. We know, for treatment, there is no quabble, no problem. But, GP practices, why is there so much difference? One is using quite a lot—the ageing population in Wales is growing, there's a diverse society here, they're not digitally literate people—and totally relying on digital, and another practice in report is not. So, basically, why are there so many differences between different practices? Why is that there?
At the primary care interface, where your clinician is looking for information, that is all digital. So, I don't recognise that there are GP practices in Wales using paper notes to record. Virtually all the practices in Wales have the ability to send their information electronically into secondary care. I myself am able to vet referrals. I've done over 2,000 in the last year. Within that system, it gives some real benefits to that digital communication pathway: the fact that bits of paper don't get lost; the fact that you can give advice to your primary care colleagues; you can ask for more information; patients don't have to come to clinic; you can move them from what is classed as stage 1, i.e. the consultation, to an investigation before they see you, to minimise the number of times that a patient comes.
Primary care has some pressures, absolutely, but I go back to what I've said in many forums, which is that the ability of healthcare professionals to care for patients is dependent on the information that they have to manage the risk. Medicine isn't black and white; it's about risk management, and clinicians, in whichever care context they're in, the more information that we can provide them, the better they can manage that risk ultimately for better patient care.
The IT system at the dentist—they ring you or they at least send you a text message a day before the treatment. On the other hand, there is no such thing where the surgery does that.
Well, actually, we have introduced that service as part of the two new systems that were brought into Wales over these recent years. There is actually a text function that is in place for practices. So, I think what we need to distinguish is where, technically, practices actually have the ability to do these things and to use the systems in place, but it remains a management issue for that practice about whether they choose to utilise it. So, we would hope that, of course, they become engrained approaches that are in place. That was actually one of the benefits of the two systems that were developed in Wales when we procured them—that we had additional functionality like those text messaging services that were part of the system and the offer—but we need more of the practices to want to use it and to comply with those approaches.
Adam, had you finished your questions or did you have any more to ask?
Yes, well, if I come on to leadership, then, in these complex programmes of change, would you accept, Dr Goodall, that having clear lines of accountability and a clear leadership structure is helpful?
I would agree with that, and, in the context of the review that was undertaken, the opportunity to improve some of the governance and accountability, I accept, and I've said so within the recommendation about our ability to respond to that. There has been governance in place around both NWIS and the way in which ICT is a responsibility of the health boards and trusts in Wales. I think we've had to adapt some of those mechanisms, and certainly the environment that we're in now feels different from when things were first established back in 2010. As you'll be aware, the parliamentary review has also instigated the opportunity for us to take a stronger look at what a national executive function of the NHS could look like in terms of the oversight and what it has around the table. But we have got arrangements in place. I think we have to balance where Welsh Government's role is discharged for oversight, where the service has its own responsibilities and where NWIS needs to provide some of that technical support.
So, you've acknowledged again that that, I don't know, alphabet soup of 35 different health bodies wasn't helpful and you've streamlined, but do we still have some unfinished business really here? You probably hinted that may be so, because we have—I'm going to get the titles right now—an NHS Wales chief information officer who is also the head of NWIS.
And then, Rhidian, you're the NHS Wales chief clinical information officer and the medical director of NWIS.
Right. I'm a little bit confused already, but I'm easily confused so maybe that isn't a fair test. Do you think, essentially, that we have a problem that digital is not given the sufficient authority and prominence within the overall system, because NWIS sits within a hosted agency, the chief information officer isn't part of the NHS Wales executive leadership board and so, in essence, digital doesn't have a place at the top table?
I think that is potentially a problem and it's an area that I think we do need to look at, in part instigated by the Wales Audit Office review but also similar reflections that have come from the parliamentary review. I think, for me, digital is beyond just accessing the technology; it's the way in which it's utilised to improve patient outcome and the support that we provide for our clinicians in whatever setting they're discharged. So, I think there could be a danger of trying to always ensure that a very specific and specialist voice is around the table. I've had other reviews, for example, that say that we need to have a further range of primary care voices around the board tables in Wales. If we're not careful, we will end up with just an additional cohort of people when part of the management oversight we need needs to be quite tight and focused. But I accept that I would want to make sure that, as we move forward in our system in Wales, we need to have access to digital expertise from a range of areas, and that may include, through NWIS or discharge of those information officer roles you described; I do need it from the service. We also have opportunities to access it from Welsh Government of course, and we actually have a Welsh Government chief digital officer who has been playing a role around our mid-year and end-of-year reviews and sits on the national informatics board as well.
I'm just reading my notes here. So, we have the two roles that I previously referred to. We have Steve Ham as the lead executive with responsibility, and then we're going down a sort of jargon tunnel now: joint owner of the strategy—it says here, in my notes, anyway—with Peter Jones of Welsh Government, and, Frances, you oversee the NWIS delivery. It sounds a bit messy. Wouldn't it be better, Dr Hurle, if you don't mind me saying—I really appreciate his passion, his authenticity and his robustness. I'd have him on your board because, you know, he's not going to take 'no' for an answer if he feels that this important work isn't getting the support that it deserves. Isn't there benefit in having a single voice, a single owner of a strategy?
I there is potentially a benefit in doing it. For clarity, for myself, in respect of my oversight, I'm chair of national informatics and I'm really clear that my director with responsibility is Frances. So, from a Welsh Government perspective, Frances actually oversees the range of responsibilities here. I'm clear about Steve's role, which, for me, specifically is the hosting arrangement for that to be accommodated within Velindre trust. He happens to have the lead chief executive role, which I see more as a bridging role out into the NHS and therefore has a voice to give on behalf of colleagues around our table. But I accept that the recommendation of the review will allow us to tighten up these issues and I would like to align that alongside some of our choices that we may have about responding to the parliamentary review call.
Isn't evidence of the effect of this slightly messy governance and leadership structure that you currently have the fact that it has appeared very, very difficult for you to set priorities? I think you've probably tacitly admitted that because you've just approved a new prioritised national plan and it's using the language of the parliamentary review of stopping, starting and accelerating, or you certainly have referred to that in your letter. Can you tell us, briefly, what you intend stopping and what you intend accelerating?
And, perhaps, if I could add to that where, if we want to make progress, there may be a need to access some level of resource or support or funding as well. Because, I think, the choices that we've had previously—as, hopefully, I've openly said earlier—is that I do think that our information requirements for Wales have gone beyond the capacity of the system to step up to, and that would include NWIS as well.
I think the development of the prioritisation process was quite important because it was also not just to be done the Welsh Government's side—we wanted to make sure that the system actually owned some of the choices to be made. There are basics around dealing with the essential parts of the system, so we do need to keep the existing ICT structure in place. Certainly, as we've manoeuvred through things that we must do, that we should do, that we could do, there are some areas that will need to be highlighted to the Cabinet Secretary, which would be, maybe, choices to drop these outside of the system, or it may generate an alternative discussion. So, Frances, I don't know whether you just want to articulate the process around this, but I know that we'll be giving advice shortly to the Cabinet Secretary and, obviously, we'll need to make sure that he's aware of some of the choices to be made, or at least are recommended by the national informatics board.
One of the actions that we took forward, back in 2016, was bringing together not just the informatics experts within the health boards, but at our Team Wales event bringing together the chief executives, the clinical directors, the chief nursing officers—the whole senior team—to look at what were the challenges of driving forward what is an ambitious programme for digital change in Wales. And one of the key things that came out of that was a set of actions that we would take forward through the national informatics board, and part of that was the prioritisation exercise.
Prioritisation on such a wide scale is quite a challenge and it's something that we recognise has taken some time to take forward. Part of the steps of that is being clear about what's in the NWIS annual programme, making sure that's shared with health boards as part of their annual process, but also, importantly, each health board then produced its own strategic outline programme for the first time, looking at its expectations and plans through its integrated medium-term plan. What was the strategic outline programme that they should have for digital infrastructure as well?
Over the past year, we've spent some time and brought in extra support to the system to help with that, to try and balance these things together. As Andrew said: what are the key things that are there that need to keep the basic system infrastructure in place? Where's the next step of development and new ideas? We've made sure that we've brought in the voices of not just the health boards through their strategic outline programmes, but also voices through the Welsh clinical information officers, so we've got a clinical voice. We've taken soundings from our unscheduled care board, the planned care board, the number of delivery implementation plans that are condition specific. What's the extent of the ambitions? Because, one of the key things that we've had to cover and embrace is the extent of digital enhancements that were going on. So, that has been quite a key step and it did take quite a considerable time to bring all that together.
Having done all that, then we started to prioritise that into what are the things that we must do. So, we must make sure that we've got things in place to deal with some cyber security and the general data protection regulation, all the things that we should be doing, making sure that we've got the mandated systems that we talked about earlier from 'once for Wales'. Are they rolled out and have we got a plan to ensure that everybody's doing that? And then the next level are things that you could be doing. That was work that was presented at the national informatics board—
It was in April.
—last month, in April, and where we've given an initial indication of what we think the priorities are for this year. That's then been discussed and shared amongst the system to come back, to double-check whether we've got the right priorities and whether everyone agrees. And that then sets out the key things that we'll take forward this year. In that, it does highlight areas that are not necessarily things that we would stop, but are things that may not be done this year. So, that allows us to get into that prioritisation discussion.
We're listening to you speak, and I don't, for one minute—. It's easy to sit here, sometimes, and be blithely critical, so please accept that qualification about what I'm going to say. And it's not a criticism of any individuals. It sounds as if—. Do you feel sometimes, yourself, that actually part of the issue is—? The NHS sounds like command and control from the 1950s and 1960s. I listened to them, and again, it's not a criticism, but it sounds as if we're still in the age of IBM and mainframe computers, you know, in terms of the culture of the organisation and decision making. Whereas digital, of course, by its very nature—technically, actually—is a distributed technology, but also in terms of its culture and agile, which is where some of the language of stop, start and accelerate comes from. There's a huge clash of culture here, isn't there? You're trying to overlay this digital technology on an organisation that, in itself, in some deep sense hasn't gone digital.
Yes, I think we've been trying—and, again, I've seen this improving over this last couple of years—to call and declare areas. So, perhaps, in the past, individual organisations may have drifted on something that is clearly a national system, and just to step in and say, 'That is the national system' and go for it. But I do think that we can learn some different techniques. As I said earlier, some of the work around the digital ecosystem and wanting to demonstrate an ability to get alongside organisations becomes quite important to us, and I don't think that we've had the full skill set around pushing into the agile environment and really stepping up with the methodologies and the tools that need to be in place. I do think that's an area for some real focus around skills, which I don't think are wholly within the informatics world; I actually think that they are challenges for the way in which organisations behave. So, I would agree with you that we need to move on.
Having said that, we have expected an awful lot from the system over time, and part of the process that we've just gone through—and there will be advice going up to the Cabinet Secretary to determine—about areas to switch off within our system, may also mean about us needing to look at how we may want to allocate other transformation funds more differently. So, it's not just about a digital pocket. Just as a sign of how we try to act differently: when we had £10 million of extra capital available last year, we chose that one of our focuses was going to be to drive our national systems over the line and make sure that that was very clear to people, rather than just add a whole series of other asks into the system. And I think we need to build much more on that kind of clarity for the system, to make sure we can actually discharge these things and make them happen.
Thank you. Just to take that on, on the governance, just the extent to which the Welsh Government can be an intelligent client in all of this, and how it exercises the scrutiny. Just extending Adam's questions: where is the digital expertise within Welsh Government to be able to understand what's going on here? Because the auditor general found, as I mentioned, that NWIS are being overly positive in their reporting. How is it that the Welsh Government are equipped to spot that?
So, I think we've tried to do it, on the one hand, via the system. So, I would say that I've wanted to make the national informatics board a more open, risk-based approach that is able to scrutinise and look at the challenge collectively as a system. I think, secondly, we've tried to introduce a much tighter performance, oversight and management of NWIS, in terms of using the mid-year and the end-of-year reviews, the monthly and quarterly figures. There are colleagues, beyond Frances's oversight as a director, who have digital experience in the central team. This is the civil service overseeing the mechanism, however, so we don't suddenly try to match very large numbers of staff out there in the system. We try to draw in that digital experience more broadly. But I think that an area that we have tried to utilise over this last 18 months to two years in particular is to be able to use the broader skills of colleagues outside of the group itself: so, the mechanism to draw in the Welsh Government chief digital officer, the ability to bring in on the informatics agenda, the chief statistician, to bring a different level of expertise. The chief digital officer is also present now around the national information board, and there are obviously Ministers who'll have broader responsibility for digital and public services as well.
So, this is a broader issue in terms of the expertise of the civil service. The chief digital officer is Caren Fullerton, I believe. Is that right? She doesn't have an expertise or background in digital. Frances Duffy, as I remember—her background is in railways in Scotland. Peter Jones, who's the deputy director, has a background in publishing, as I understand it. So, where is it at the senior level? You mentioned the national informatics board; as I understand it, those are health board executives who have other roles. You may have a director of planning there, who as well as that is also responsible for digital within their organisation. Given that, is the heft there, generally, to hold NWIS to account on an area it is not an expert in?
Again, I think this is where we've tried to change things over the last couple of years. I would say that colleagues like assistant directors of informatics, who do have a specialism or background in ICT and technology, may have felt slightly adrift of some of the discussions happening. That's why we introduced an information planning and delivery group, where they are very visible around the table. You're right to say that the representation around the national informatics board is mixed, so we do have a set of individuals ranging from informatics specialists, to those that represent NWIS, some Welsh Government key roles, and also, actually, directors who do have a responsibility. And I do think that the mix of responsibilities there is helpful. I think there is a challenge about making sure that when we do need to answer questions, we do have access to the specialist area. My own background, one of my early roles and jobs was as an information manager. I have managed ICT areas myself in terms of responsibility, both at a departmental level as well as nationally—
It's always important to develop some of the specialist support and make sure it's available within your teams more broadly.
Okay. So, if you do have the skills, and you insist that you do, why is it you've not been able to spot NWIS's overly positive reporting of its position?
I think we had spotted that in terms of changes that we've made in the reporting over the last couple of years in particular. So, when the Wales Audit Office review was commissioned, we wanted to ensure that it was an opportunity for us to address some of the areas of concern that we'd had around some of the governance and accountability within the system. And I think we've been quite open along the process to be utilising this process, and then being able to draw in the parliamentary review to do so. So, I think that we've been able to, as I said earlier, even around the national informatics board, get more stuck into the risks through the eyes of senior responsible officers that aren't always about NWIS individuals—they are people from within the service—to be able to call out and declare it. And I do think that we've been able to demonstrate how we've managed it.
On the other hand, there are some examples where I think we do need to rely on that expertise to be available. So, certainly, on the cyber security approach, when those attacks happened in Wales, I think there was a real advantage actually of having a national infrastructure in place and us being able to deploy some of that consistency expertise pretty rapidly and quickly. So, I am accepting that there were deficits, I think, in terms of some of the voices around the table before, but I have absolutely wanted to bring a much more service perspective to the table, alongside the NWIS expertise.
So, just in terms of the structures of governance then, Frances Duffy mentioned that NWIS is now going to be publishing an annual report on the internet. How is that open to scrutiny? Because the criticism of the auditor general was that there's an ambiguous state that NWIS has, which is unsatisfactory and doesn't benefit from the open challenge that comes from having independent board members to scrutinise its performance.
So, I think we've tried to address two parts of that by that more open, general approach, which is not just the national informatics board but the supporting mechanism. It means that you can get the clinical views feeding through the clinical information council, that we can have the informatics directors, and they are represented around the informatics table as well. I do think, and I would accept, that there is an issue around the hosting mechanism that is in place, in terms of it being within the Velindre mechanism, but that doesn't necessarily open up to our more normal independent member scrutiny. And I think that, as we look at what our choices are for the future about bringing in that aspect, we've got a few areas to reflect on. Are we going to pull something in that brings in a broader public service challenge around where digital is going? That's the use of some of the internal Welsh Government roles that are available to support. Could we utilise the independent members who have roles within the health board, who have a responsibility for the information and technology development? And is there an ability to draw them more into the room to discharge some of that function? Because they could act as more of a bridge, I think, with the individual health boards. We can certainly find a way of manoeuvring that through, linked to whatever our response will be on a tighter national executive function for the NHS in Wales.
Because the frustration the auditor identified within the system, within the health boards, is there clearly doesn't seem to be much buy-in from the health board. One chief executive said to me that dealing with NWIS was like wading through treacle. So, there's clearly a tension there between the centre and the periphery, isn't there?
There is a tension, absolutely. I would also recognise that tension, though, in terms of our oversight of health boards and trusts in Wales, in terms of their own performance management aspects. So, there is something about the way in which we have to orchestrate the overall system in Wales and make sure that there is performance management oversight of everybody's roles. And one of my requirements is to make sure that there is as much clarity in the system, and I do think we need to improve that and give clarity, but I also have a responsibility to bring the system together cohesively as well, so that the constituent parts work as most effectively as possible.
Fair point. Just a final point from me, just on the future governance arrangements. A traditional health board will have independent members, they'll have a chair who's accountable to the Cabinet Secretary. There's nobody within NWIS who's directly accountable to the Cabinet Secretary. Will that be important as you're designing your new system?
I think so. I think there are two sets of changes to come. One is how we will facilitate that informatics voice around the table, however we choose to do so, whether it's organisationally led or whether it's through individuals vested with that expertise. And we do need to think about that. And there is absolutely something about the mechanism through which appointments that are more down the independent route may be able to help out in this arena. Now, at the moment, the extant structure with NWIS has not allowed that and it's not been necessary to have stepped in, given that this is the arrangement that was put in place back in 2010, but I do think we've got a chance to just review that more differently. And there are other examples in Wales: the way in which, beyond just the chairs of health boards and trusts, we look at our specialist services and the mechanisms in place there, the emergency ambulance commission, where a more independent perspective has been possible to bring in around the table. So, I've not come to a final outcome, a determination. Again, that will form part of the advice to the Cabinet Secretary. But I do think there is an opportunity for us to genuinely address those issues.
Thank you very much. My question is to Dr Goodall first. Can we expect the Welsh Government to commit the additional funding necessary to fund electronic patient records, estimated at just under £0.5 billion—it will be £484 million to be precise—on top of existing budgets in the near future? Why has the NHS had to wait since 2016 for the Welsh Government to commit on this spending?
If I could start, Chair, on the question, in response, and then I'd like to just bring in Alan and Frances, as is necessary, perhaps starting with Alan.
First of all, just to be clear about the exercise that we went through, when the plan for Wales, 'Informed Health and Care' was refreshed—and that gave the ongoing commitment to the electronic patient record—there was a need to have some understanding within the system about the consequences and costs that would be needed for the future. Now, traditionally, I think that we have hampered some of the assessment that's going on in Wales by expecting people to simply only comment within the budgets that they have available to them, and I felt that there was a need to actually develop that more strongly, so that people could genuinely think about the things that they wanted to do and how quickly they wanted to do them. So, this has been a very open exercise, to actually generate out this sum of funding. This may not, in the end, be the right or final number. I think there are certainly examples where the £484 million that you've indicated, which was part of that original assessment, has already been addressed, even with some of the capital funds that we've been putting in over the last two years, and some of the ongoing budgets. So, it's not just an amount of money sitting there without anybody addressing it as this stage.
But I think this comes back to my earlier point, which is where digital fits into the transformation agenda. I think there is a genuine danger of our system looking at ICT as waiting for the next little bit of allocation coming in only for technology—an expectation that Welsh Government will just sort it out and pass it through the system. I think we need to look at digital as an enabler for patient outcome and for better clinical services. So, I do think we've got some opportunities to deal with that differently. First of all, on at least using that reference point on the exercise that the service has done, which was actually part of what I wanted to happen for that greater openness about some of the pressures within the system. But I think, Alan, there's a need to make sure that the finances work more broadly than just on the digital agenda, and that might be a possible way in which, as we've settled on a much more stable financial system in general terms, we can start to make some different choices about our allocation.
Yes, and just to make a general comment: I guess where that £484 million came from a couple of years ago, it was a fairly high-level, five-year forward view, primarily done by the informatics community and NWIS. And it looked at everything from how you increase patient information, community and digital working, all the way through to administrative transactional systems, and what could be done in that area. And I guess it wasn't therefore prioritised.
The more surprising bit for me was that if you look at the paper that was produced, it talked about significant benefits—it would drive service change, improve outcomes for patients, significantly increase clinical productivity and performance, and actually drive innovation. It gave a high-level stab at some of that—a 10 per cent increase in clinical productivity, but it never really went to quantify that any further. And to some extent, that was always the difficulty with it. It would be a fairly straightforward decision, if £484 million investment delivered £1 billion-worth of return on that investment. It would be a fairly straightforward decision for us to make. But it didn't really go much further than probably a bit of a one-dimensional view and a more technical exercise of stacking up costs against some of the system's implementations.
What we've been doing since is obviously making some of those investments. So, you will find, over the last couple of years now, we have progressed some of those developments. The way we progress those developments are through fully worked-up business cases that do capture both the financial and the non-financial benefits, and then we make decisions based on that. So, for example, over the last two years, we've put about £41 million of the all-Wales capital programme into some of these ICT developments. We've invested capital through the integrated care fund. The new Velindre hospital development will have £6 million-worth of investment on the first business case around the infrastructure. There will probably be further investments on the transformation of cancer services. The new Grange hospital has got about £5 million approved already around some of the ICT developments there. And, obviously, you've got things like the city deal emerging now in Swansea bay, which is emphasising significantly digital investment, and, obviously, ABM health board is a key partner in that, alongside Hywel Dda.
So, we are making progress, but I guess that was a very high level of earn—I think the auditor general's view picked up on that. It does need, I think, a lot more firming up. And, as Andrew said, in response to the parliamentary review, I think, through the long-term plan, we're going to have to capture that a little bit more succinctly, I think.
Thank you, Mr Brace. Do you believe that NHS Wales is on target to achieve a largely completed electronic patient record by 2021? Is the funding that is currently being provided to the project sufficient or adequate, or is it insufficient to ensure the project will be completed on time?
So, I think we've had to learn about whether a good intent to make progress has been underpinned by some of the level of resources. So, in the early days of the community information system, I think that we had made too much of an assumption that this was simply about the technology itself being switched on, which is why we looked to bring in some of the additional funding opportunities like the integrated care fund approach, to make sure that some of the business change processes were in place. I think we need to continue to access some of the funds going forward to make progress on this, and certainly continue to make developments.
I think there are some large-scale, outstanding issues. So, when I was asked the earlier question about what we may need to do or choose to do, we have invested, over this last 12 months, in the first phase of e-prescribing in Wales, located in ABMU, just to be the start of a national roll-out mechanism, and we've put funding in alongside that. But it's very clear, to capture the benefits of that system, to make sure that we are able to get the return on the investment that's being made, that we'll need that to be supported, and we may need the potential for other transformative funding to be made going forward. So, there are still some inherent problems in the system.
I think that, looking back, the completeness of the position has shown that we are falling short on some of the all-Wales and the aggregation of areas, but, actually, there are some organisations that are getting quite close to having a more complete electronic health record. So, when we started to pursue these individual organisational presentations, I remember Abertawe Bro Morgannwg University Local Health Board presenting at the first meeting, and you did get a sense that, actually, there was a possibility to have not just some foundations in place, but, actually, to really start to bring together these areas. But it's still not the complete package at the moment.
Frances, I don't know if you have any reflections on the electronic patient record, but it almost feels that it's a 'will never be completed with extra opportunities to come along', but I do think we need to be clear about the core part of the systems and the architecture that's in place. So, perhaps Frances first, and then Rhidian.
And I think that's been one of the interesting parts of the national informatics management board, where each month, or at each meeting, a health board then puts forward a much more detailed picture of how far they have gone in implementing the record. We've seen, for example, in Cwm Taf, as an example of a health board that has taken on quite a few of the national systems, making progress in its digitisation of records. And they have set themselves quite an ambitious target within their own strategic outline plan of moving to a fully digitised system over the next few years.
The ability and the big revolution has come in secondary care, because they've been behind the curve. Just to give you an example, ABMU, which has 2.1 million case note records—the average case note record, in a paper record, in the NHS, is about 90 pages. In some of our health boards it's over 500. Amalgamation of health boards, three hospitals joining a third or a fourth one, means more hospital numbers, four volumes of notes. What we've been able to do—and it is live now—through the Welsh care records service, is that I can directly input—I can have a telephone conversation with you about your results. I can directly put in what I've said with you, and that is visible across the whole of Wales. So, if you present three hours later in accident and emergency, the accident and emergency doctors can see what was put into that record. Now, that's as close as you're ever going to get to an electronic patient record.
If you combine that with the work that we've done with the General Practitioners Committee Wales, and making available the Welsh GP record, I can now see your GP record. I can see anything that's happened to you in terms of a blood test anywhere in Wales, I can see your radiology reports virtually everywhere, and by the middle of the summer, I will be able to see them from everywhere, and your care record. Those are the foundations of the ability of clinicians to manage care—the imaging, the pathology and the care record. And that isn't something that NWIS has delivered. That's something that NHS Wales has delivered. That's the effort of the associate directors of informatics across the health boards trying to drive change. That's the effort of the clinical leadership that is maturing within those health boards, and it's due to the hard work of people and our staff within NWIS.
Forgive me if I'm going off course here, but the staff of NWIS are part of the NHS. They believe in what we believe in, in terms of patient care. They're part of that cog. It's like the backroom staff in the NIMB project; they may never see a patient, but their ability to process those results, to help front-line clinicians deliver care—they are part of the NHS, and we shouldn't forget that.
I think the trick is going to be to just be explicit about the core parts of the system needed to deliver the electronic patient record, rather than some of the additional items that need to manoeuvre their way in, because they could be better for future outcomes as well.
Just finally, Chair—thank you very much—how will the Welsh Government work with the NHS bodies and NWIS to set out a clear and agreed medium-term funding plan for local and national ICT programmes?
I think it builds on, I hope, some of the evidence that we've been giving here. There has to be clarity on accountability in the first place. I've tried to make sure that there's a much more open set of conversations happening. We have a national informatics plan for the first time. We require health boards to be very explicit in their integrated medium-term plans. Although NWIS isn't required to deliver one, we've made that an expectation of them as an organisation, and part of that isn't just writing it in a room by themselves—they have to do that by working, actually, across the system to produce it. I think we will have some reflections to make centrally in terms of advice around funding opportunities, the choices to be made in the system. What we need to make sure, though, as Alan was describing, is that it's not just investment for betterment of the system—we have to have a clarity on what the return is for benefits to patients, for value for money, or better clinical practices in our system. And I do think we need to retain that discipline, rather than just move to the next piece of technology that may just have a short term.
Yes, just a quick one, just reflecting on what we were talking about on the finances earlier, you were talking very much in terms of capital expenditure and business cases—the sort of traditional approaches to procurement, whereas, arguably, digital requires a different mindset. Nobody is mentioning Agile in this context, nobody is mentioning user research, or user need. So, back to the discussion earlier about whether or not the skills and the approach is there—you assured us it was, and then you went off talking in very old-fashioned terms about procuring big systems, whereas we know these big systems take a long time to bring in. Is there not a need for a different approach, a more agile one, a more experimental one?
Alan will have a view on it, but I do think we are caught, in some respect, because part of the business case process that we've put in, if you like, reflects on old experiences, across public services more generally, where we've needed to be more protective, and more clear on the outcomes for the future, to make sure that the money is lined up, and that we deliver. So, I think some of the hurdles that are in place, which discharge good procurement practice, probably are in response to difficult reviews over the years, whether they are internal to organisations or not. But, absolutely, the environment we're in requires us to think differently about the way in which—should a business case go through many years of development? By the time that you've done that, you've actually moved on from the technology that was extant and around at that time. So, we have been trying to change our general approach to capital in Wales, but we've also tried to introduce a focus around digital that may yet make it more amenable to quicker change.
Yes, and there will be elements where we're doing a big sort of laboratory information system that may feel that there is fairly significant capital. But as an example, and it was in that £484 million assessment, there was patient connectivity in hospital. So, in the capital programme last year, we made sure all hospitals had Wi-Fi connectivity for patients. So, I wouldn't want you to think that, just because we're calling it capital expenditure, it's necessarily an old-fashioned infrastructure.
But, in terms of learning the lessons of where things have gone wrong in the past, have you learned the lessons from, for example, the Government Digital Service system in Whitehall, which has succeeded in England in bringing in significant change from digital, which was about bringing people in who understood this stuff? Have you learned from that, because we seem very reluctant to embrace GDS standards in Wales—we seem to feel we need to invent our own? But what lessons have you learned from that process?
Frances, do you want to comment first on the digital side of things?
A couple of things here. On the standards, we do have a Welsh informatics standards board [correction: Welsh Information Standards Board], and we do work across the UK, and sometimes wider, on ensuring that we use standards that have been agreed, rather than just reinvent our own.
On the point about Agile, one of the examples I wanted to quote and refer you to was the development of our online platform for individuals for that access. That's something that we have done last year, which has started with that inquiry work, ensuring that we're engaging with citizens, to understand what it is that they want to achieve and how they would use the system. So, instead of moving straight on, we had a little bit of a review. Instead of moving straight onto a new platform—a new NHS website—we have taken that step back. We then developed that inquiry into what people would want to use and how they would use it, and that's informed the development of the business case. We would expect that to be rolled out in an agile methodology.
We have shared experience with colleagues in NHS Digital, talking about agile working, how far they have moved with that and what impact that has on the development of business cases. So, we both share this idea of how you develop a business case where, traditionally, you might have wanted to see the full extent of all of the benefits of the roll-out, when you know that, with digital projects, you have to take that step-by-step approach. So, we're working on learning lessons with them.
Those standards you said that we've developed in Wales—are those published standards?
Yes, they will be.
Well, one of the key standards that we have been moving on is the systematized nomenclature of medicine standard. So, that's for clinical information and how it's inputted into our systems. That's something that has been set up by the NHS in England, and we have taken it forward in Wales. We have made some slight adjustments to reflect some different clinical approaches here, but that's a standard that we will be taking forward.
On the technical standards, which are, I think, a little bit where you're coming from, there is the introduction of the technical standards board that we set up just a couple of months ago to make sure that we have got that shared approach to technical standards in the development of different projects, and with the development of our ecosystem, which is NWIS in partnership with life sciences, and that is about sharing an open platform to encourage people to—
The technical standards—
They're not routinely in the public domain. I'm happy to reflect on that, because, from my perspective, that just provides clarity. I think some of the ecosystem work that we've been doing is to make sure that, with potential partners and those wishing to develop, there is more openness and transparency about some of the choices that could be made.
Just finally, the Scottish NHS, as I understand it, adopted the GDS standards recently. Is there a reason why we haven't done the same?
We can take a look at that, and look to issue those and support them in the public domain.
I'm not quite sure what you mean by that.
We appreciate the brevity of your answer, because we are almost out of time. I want to get to Rhianon Passmore—so, Rhianon.
Thank you, Chair. In regard to the fact that there's been much discussion around reflection and the changing shape of the future possible governance of the whole digitisation agenda, and bearing in mind the scale of change and the fact that the NHS is a juggernaut anyway—and we seem to be dealing with many different juggernauts in this landscape—how much is it being led strategically from the top and how much of it is being led from the parliamentary review or from the auditor general? How can you reassure me in particular that we have a full grasp, in terms of this agenda and the importance of it, with many competing priorities—I absolutely understand that?
I would start—not just to go back to the past and the original inception—with the restatement of intent with the December 2015 'Informed Health and Care' strategy, which was about ownership and started with ministerial expectations and a set of parameters for the service to step up into, including what ICT support would mean for organisations, for clinicians and for patients. So, that was the starting point for it. I think we have utilised openly, I think, working alongside the WAO—it's been helpful to have reflections on the system more broadly and on the governance side. So, we have looked to address a number of issues as we've made progress over the last couple of years. In part, that has required us to be much clearer about some of our central expectations, and that works both ways. On the one hand, it's about where permission is given for organisations to develop a local system that can connect with others. It's also about leading from the top, in your language, as you described it, about declaring which systems are part of the national approach for Wales.
If I could just cut in, because time is very limited, in regard to—you mentioned earlier your mandate with health boards. How much of a stick have you got to be able to roll this digitisation agenda forward? How much of it is in your control and how much of it is cultural within the organisations?
I think we've been dependent on having a focus around what local organisations are looking to implement themselves, accessing national support where necessary. I do think that we have an opportunity to be very explicit and clear with some of the central support and guidance, which has emerged from this and has come through from the parliamentary review.
So, is it explicit and clear—the expectations from health boards in rolling out to national systems?
Yes, I think there are explicit recommendations, but I think, as we respond to the parliamentary review, we will be able to describe the national oversight that will make it very clear about accountability.
Sorry to interrupt, but why do we need the parliamentary review? Why can't we be doing it on our own?
Because we will be responding to that with a long-term plan, and that will lay out the clarity of our national oversight and structures and where the accountabilities and the responsibilities lie.
I would expect for us to have clarity, and a series of national systems in place that we will have been clear about empowering organisations to have some of their local support. I would hope that we'd have a mechanism in place to be clear about how citizens use the systems in Wales, and I would hope that, from a national perspective, we'll be much clearer about the funding formula. I do think that one area that maybe has been distorted is—we may need to be clearer about areas that we allocate our national resource to deliver across the system, rather than leaving it within the hands of individual local organisations to decide, and I think that will be something that will be much clearer for the system.
Great. Thank you. Can I thank our witnesses, Frances Duffy, Alan Brace, Dr Goodall and Rhidian Hurle for being with us today? That has been really helpful. We'll send you a transcript of today's proceedings before it's finalised, just for you to check.
Chair, thank you very much. Diolch yn fawr iawn.
bod y pwyllgor yn penderfynu gwahardd y cyhoedd o eitemau 5, 6 a 7 o'r cyfarfod heddiw, ac o eitem 1 o'r cyfarfod ar 4 Mehefin, yn unol â Rheol Sefydlog 17.42(vi).
that the committee resolves to exclude the public from items 5, 6 and 7 of today's meeting, and from item 1 of the meeting on 4 June, in accordance with Standing Order 17.42(vi).
Cynigiwyd y cynnig.
Can I propose, in accordance with Standing Order 17.42, to meet in private for items 5, 6 and 7 of today's meeting, and item 1 of the meeting on 4 June? Okay.
Derbyniwyd y cynnig.
Daeth rhan gyhoeddus y cyfarfod i ben am 15:36.
The public part of the meeting ended at 15:36.
The current version of My Health Online is now accessible on smartphone and tablet.