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Y Pwyllgor Cyfrifon Cyhoeddus

Public Accounts Committee

02/07/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Lee Waters AM
Mohammad Asghar AM
Neil Hamilton AM
Nick Ramsay AM Cadeirydd y Pwyllgor
Committee Chair
Vikki Howells AM

Y rhai eraill a oedd yn bresennol

Others in Attendance

Allison Williams Prif Weithredwr, Bwrdd Iechyd Lleol Cwm Taf
Chief Executive, Cwm Taf Local Health Board
Dr Jacinta Abraham Cyfarwyddwr Meddygol, Ymddiriedolaeth GIG Felindre
Medical Director, Velindre NHS Trust
Huw Vaughan Thomas Archwilydd Cyffredinol Cymru
Auditor General for Wales
Mark Jeffs Swyddfa Archwilio Cymru
Wales Audit Office
Mark Osland Cyfarwyddwr Cyllid a Gwybodeg, Ymddiriedolaeth GIG Felindre
Director of Finance and Informatics, Velindre NHS Trust
Steve Webster Cyfarwyddwr Cyllid, Bwrdd lechyd Lleol Cwm Taf
Director of Finance, Cwm Taf Local Health Board
Stuart Morris Cyfarwyddwr Cyswllt Gwybodeg, Ymddiriedolaeth GIG Felindre
Associate Director of Informatics, Velindre NHS Trust

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Claire Griffiths Dirprwy Glerc
Deputy Clerk
Fay Bowen Clerc
Clerk
Meriel Singleton Ail Glerc
Second Clerk

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

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

Dechreuodd y cyfarfod am 14:01.

The meeting began at 14:01.

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
1. Introductions, apologies, substitutions and declarations of interest

Welcome, members of the committee, to this afternoon's meeting of the Public Accounts Committee. Headsets are available for translation and amplification, should it be needed. Please ensure phones are on silent. Follow the ushers if there's an emergency. Do Members have any declarations of interest they'd like to make?

Yes, Chair. I'd like to declare that my wife works for Cwm Taf health board.

2. Papurau i'w nodi
2. Papers to note

Item 2, and a couple of things to note—first of all, the minutes from the meeting held on 25 June. Happy with those? Yes; the minutes are approved.

3. Gweithredu Deddf Cyllid y GIG (Cymru) 2014: Gohebiaeth y Pwyllgor
3. Implementation of the NHS Finance (Wales) Act 2014: Committee Correspondence

Item 3, and a number of papers in your pack; papers 1 to 8—information from the health boards, and also a letter from the Auditor General for Wales. In advance of this inquiry on the implementation of the NHS Finance (Wales) Act 2014, I wrote to all health board chief execs, seeking their observations, and that information has been provided. And the auditor general has sent updated figures from his 2017 report, as well as collating further information, and those are contained in the annexes to his letter. Happy to note those? Good.

4. Gweithredu Deddf Cyllid y GIG (Cymru) 2014: Sesiwn dystiolaeth 1
4. Implementation of the NHS Finance (Wales) Act 2014: Evidence session 1

Okay, item 4, and evidence session 1 on the implementation of the NHS Finance (Wales) Act 2014. Can I welcome our witnesses? Thanks for being with us this afternoon. Would you like to give your name and organisation for the Record of Proceedings—position, I should say?

Thank you. Allison Williams, chief executive.

Steve Webster, director of finance.

Great. I'll kick off with a first question. Before moving on to specifics, could you give us an overall sense of how tough it's been to meet your financial duties, and what the key challenges and pressures have been?

Okay. Perhaps if I could kick off, I've been a chief executive in Wales since 2003, across several different organisations, and I think it's fair to say that the demands on the NHS do get harder every year. You'll be very much aware of the increasing demand for healthcare generally, and the financial impact of that is inevitable. However, over the last couple of years, the settlements have been better than they were in previous years. But I think it's fair to say that, at the same time, the opportunity for efficiency savings, and certainly the opportunity to identify low-hanging fruit, gets harder. So, we have within Cwm Taf delivered a balanced financial plan; we have recently had our integrated medium-term plan signed for the fifth successive year. So, as we've stated in our evidence, we have achieved financial balance in our organisation, but that required significant effort, strategically and operationally, to deliver.

Relative to some other health boards, you've done very well in achieving that, so you've obviously got some good cases of good practice that would be useful for others to experience. Turning to the written evidence—thanks for providing that—could you explain a little more about the phrase, the term,

'Strong Board and Executive ownership of the importance of remaining in financial balance'?

How does that look in practice?

14:05

I'm fortunate that I've been chief executive in this organisation since 2011 and we've got a very experienced and very stable executive team within the organisation compared to some of our neighbouring health boards, who have had quite a lot of turnover at executive level. Up until very recently, because the maximum term for independent members on the board is eight years—up until then, we've had a very, very stable set of independent members as well; there's recent turnover because of people exceeding or reaching the maximum term.

I think, in my personal experience, that stability in an executive team and in a board allows you to take the whole of the board on a very challenging journey, which is about really understanding accountabilities but through working right the way through the organisation, ensuring that both your governance arrangements and your culture in the organisation, and particularly your culture amongst senior clinicians and senior managers, is focused on truly understanding and living the triple aim as was and the quadruple aim now, as identified through the parliamentary review.

That is the very critical balance between the cost of what we do, the quality of delivery and the performance that needs to be generated as a consequence of both of the above. It is how the board discharges the duty equally across those three domains that actually, in my opinion, is a measure of success of the organisation.

So, stability of the board, you think, has been, over the medium term and the long term, key to meeting those objectives.

I think it's a very significant factor. It's not the only factor, obviously. I think you have to have the right leadership. I think you have to have the talent amongst your team. You have to have your staff partnership organisations working truly in partnership with you, because your staff are so critical in the delivery of whatever it is that you need to deliver. But it is having that ability on a longitudinal basis to actually work through [correction: from] a starting point, which is about getting your systems and processes right and fit for purpose for your organisation, and then having the culture that goes with that, and those things don't happen quickly.

Is there a danger of a longer-term conflict in your thinking? Because you say on the one hand—well you say that you will slow or you plan to slow down investment in order to address slippage in savings, which is a very noble aim, and not all organisations have got the willpower to do that, but if that happens and works, is there a danger that then that could starve investment that in the future would make its own savings? I'm sure you've thought about all this.

If I start, and then perhaps Steve might want to comment on this. You have to get the balance right, because one of the challenges always is, when resources are very tight, if you're not careful, you could stifle innovation and you could also limit the strategic investment in change. Because we know that stepped strategic change will often require transitional investment to come in alongside, which allows you to make those changes. I think the trick around this is actually getting that balance right. But our board has taken a very strong view that we are constantly reviewing the balance between the two so that we can demonstrate visibly with our staff and openly with our community what we're trying to do around strategic investment, and at the same time that this isn't a free good, because we have a statutory duty to live within our means.

Yes, I just had—. There's a certain dynamic. I think the board and certainly the senior levels of the organisation are proud to be in a financially balanced position as well as being proud of the quality of the services. They don't want to lose that. Now, when it comes to that coming at risk because we might be behind on savings or we might have some pressures, then the dynamic that says, 'We want to invest in new services, we want to innovate and it's absolutely key for the future, but, to do that, guys, we need to deliver on these savings, because, otherwise, the thing that goes is financial balance'—. You're right, it's a balance, but there's an important motivational thing there.

14:10

Because if you were to get that balance wrong, then—. You might be the best performer at the moment, but then, five, 10 years down the line, suddenly you could see a different situation.

Absolutely, and I tend to think, in our case, financial balance has [correction: has not] been at the expense of not innovating or not developing services.

If I may come back on that. I think this is where the three-year planning and the integrated medium-term planning process brings in a discipline that is about laying out your medium to long-term plans and making the most of investment opportunities as and when they come along. So, for example, we have been very successful working in partnership with our two local authorities around the deployment of the integrated care fund, so that we don't look at opportunistic options for investment in an initiative-type way, but actually align that very clearly to the strategic direction of the organisation, so that we're constantly clear what the next thing and the next thing and the next thing is that is taking us on the improvement journey.

Yes, thank you, Chair. Under the NHS Finance (Wales) Act 2014, there's this new three-year rolling programme for reporting finances, but there's still an annual requirement to meet your allocation. Four of the seven health boards are not doing that. Is there any value in this new three year if, in effect, you're still working on an annual basis? 

Shall I start? There are two elements to the three-year planning. One is about the money and the other is about the service planning element that go side-by-side. Because you don't just plan your expenditure budgets and your financial position; what's really important is the discipline of planning your services on a three-year rolling basis. So, what it does give is a greater certainty than we've had in the past about the likelihood of future allocations, which is extremely helpful in terms of service planning. And Steve might want to say something further on the actual imperative around the in-year and the three-year financial duty. 

I was going to repeat what Allison said in a way. I think the three-year planning and the discipline of planning over the medium term is more important in many ways than that flexibility. I think if there was more certainty about future years' allocations then it might be easier to have an invest-to-save culture, but we're never quite—. We've got indications of future years, but we're never quite sure, so that lack of certainty is a bit of an impairment to really going more heavily into what you're saying there. As I say, I think the important principle is to be planning over the medium term, even without using that flexibility.

The fact that there has to be regular bailing out of health boards—I appreciate it doesn't apply to yours—would suggest that there's more to it than just the money. They're failing to 'land the jumbo jet on a postage stamp', which is the quote that we've been given. That's still not happening, is it, despite the fact that you'd assume that bringing in this new regime, with the three years, would allow better financial management. But, that's still not working for some reason. Just try and help us understand what the impediment is.

I think there are two elements to it. One is this whole, as Steve says, issue about real certainty about the quantum of future years' allocation. As you know, even Welsh Government doesn't have the degree of certainty that perhaps you would like about the absolute allocations for future years. Because, coming back to the point that the Chair made right at the very beginning, if you have that absolute certainty, you can take risks in year one around investment and strategic change that allow cost to drop out in years two and three. It's much more difficult to take those risks in a system where you're not absolutely sure about the future years' quantum allocation. It's very difficult for us to speak to [correction: for] other health boards. I know you'll be taking evidence from other health boards. Our experience is that if you asked us—and I think we've put it in our evidence—whether we've got a recurrent financial balance system year on year, our answer would be 'no', because when we implement saving schemes this year, unless the savings start to drop out on 1 April, we have an element of a gap in-year. So, we operate our financial position on looking for recurrent savings plans to meet recurrent demand, but also having to do things non-recurrently, so that we bridge the gap in-year. And that's tough, and it does require us, often, to make some really difficult decisions, but they're ones that our board is committed to making, because the duty is not an option; the duty is an imperative.

14:15

You said there's no certainty, which is true, but equally there's no jeopardy either. So, if the health board were to exceed its allocation, there's no consequence to that, is there? You simply get the money provided to you. So, how do you properly operate that regime, when you're not really playing with live ammunition?

I think the escalation system in Wales—. We have a number of organisations in targeted intervention, one in special measures. Fortunately, we're not in that position, but I think there is a high degree of pain, for the want of a better word, associated with those additional measures being put on those organisations.

It's not much of a deterrent, is it? If almost everyone's in special measures, it's not much of a shame.

I think that, from our perspective, we have had some advantage from being in a balanced financial position, and from our board's perspective, that is a very positive incentive to retaining that status within the current system.

Thank you, Chair. Looking at the funding per head of population, the Auditor General for Wales's report showed that, in 2016-17, Cwm Taf and Powys had the highest amount of funding per head of population. To what extent is that level of funding a factor in explaining why you've been able to meet your financial duties whereas other boards haven't?

Do you want to go first or shall I?

I mean, those allocations came out of the Townsend review, the proportionate shares, and that does reflect the combination of population, deprivation and all the other factors. So, we would think that that disparity in funding per head reflects the need.

It's very difficult. It's a very crude measure, just funding per head of population. All the populations are very different. If Hywel Dda were sitting here, they'd say it's much more expensive to deliver services in a rural community, and therefore there's a rural premium associated with costs in those areas. In Cardiff, they've got a very high transient population, which drives cost, and for us in our Valleys communities, as you know, we have very high levels of deprivation, and there is no one perfect formula. I know that many times over the years, the Government and the Wales Audit Office have looked at the funding formula, but I can assure you that the deprivation associated with our communities and the burden of ill health and the cost of that is very real, and is very different to some of our neighbours. So, I wouldn't draw any conclusion from the per head of population and the ability to achieve break-even.

So, if that funding formula currently takes account of the long-term health conditions in the Valleys communities and also the prevalence of mental health issues, all these sorts of things, are you concerned that any change in that funding formula could be a disadvantage to your current position?

If there was a change in the funding formula, we would be arguing very strongly that deprivation is properly acknowledged within that. I can give you a very simple example and, again, it's reflected in our submission. We talk about an ageing population driving costs in the NHS: people think about age as a chronological age. Actually, in health terms, age and the impact of ageing is very different. You have, in some of our deprived communities, 50-year-olds who have a greater burden of ill health than 80-year-olds in other communities. So, we are very keen that, whatever changes may or may not happen, the proper impact of deprivation is properly acknowledged.

And are you confident that any changes to the funding formula would still take a holistic view such as that?

Ultimately, it will be a decision for Welsh Government, but as part of any consultation on any changes that may or may not happen, then that would be something that we would be arguing very strongly for.

14:20

Thank you. Thinking about the transfer of services covering Bridgend as well, how are you planning for the financial implications of that, particularly in light of the fact that you're inheriting the services there from a health board that's currently in deficit?

If I start, and Steve may want to comment on some of the specifics. As you know, the Cabinet Secretary made a decision on 14 June. We have been scoping this potential for the last six months, and we had the first meeting of our transition board last week. Our understanding is that the basis of the transfer—. Because, if you remember, we are commissioner organisations as well as provider organisations, we are working on the assumption that the commissioner allocation for the Bridgend population transfers to Cwm Taf, and that will reflect the deprivation of the Bridgend population in the same way as it does all other populations across Wales, and we're currently working, then, through the provider costs that are attributable to the Bridgend population. It's going to take us a couple of months to bottom that out, but we expect that there will be an element of a gap between the commissioner share and the provider costs, and we will be working with Welsh Government to ensure that neither organisation or neither population is disadvantaged as a consequence of that, because this has to be a positive move that results in us sustaining, if not improving, the quality of care to not just the population of Bridgend but to the population of the remainder of Cwm Taf. So, still quite a lot of work to do, but we believe that there will be significant opportunities as a consequence of that, because of the synergies between the two communities—we've got very similar communities in the two areas—and the geographical proximity. We believe there will be real opportunities to work together across those communities to improve services for patients.

I can't say much more than that really. It's working through the detail of the allocation transfer and then the current cost base—both the provider cost base, but also the cost of commissioning services from other providers. So, it's quite a detailed piece of work that we're just embarking on.

Thank you very much, Chair. Good afternoon. In 2016-17, the health board came close to delivering its £14 million savings target. Did this target continue in 2017-18, and what good practice can the health board share with regard to achieving these savings?

Do you want to start?

Yes. I don't think we've got a unique panoply of wisdom in terms of how to do that, but we've got a particular approach, which is to identify what we believe are the opportunities across the different services in terms of how they compare with services elsewhere. So, it's not a standard percentage reduction in every service. We try and understand the opportunities for the different services, and then we work with them to maximise what they can achieve on those opportunities. So, that's our process, and the level of savings we've achieved in recent years has been in the sort of £10 million to £13 million range, which is a couple of per cent. That was something we were saying earlier: that gets harder each year you proceed, but that's our methodology.

How does your approach to putting directorates into 'recovery' work in practice, and how do you strike the balance between supporting them to identify and act on lessons learnt from the non-delivery of savings alongside holding people to account?

Okay. There are three ways in which we performance manage the delivery, not just of savings but of the quality and performance at the same time, because I think it's important to remember that anybody can make savings at the expense of quality or at the expense of performance. What we have to do here is deliver savings whilst maintaining quality, if not improving it, and also improving performance. So, we have a three-pronged approach where we look, as Steve said, very much at efficiencies and we benchmark. We benchmark very actively with upper quartile performance, not just within NHS Wales but in the NHS more generally. So, we've got some really strong intelligence about what the art of the possible is, so that when people are saying, 'We can't do that' we can give them evidence about where it's being done elsewhere and how it's being done.

I think the second thing is this ownership, and the ownership not just by the managers but by the clinicians. Part of putting a directorate into recovery—so, they have a plan; they have a target, which is intelligently worked out—is that, if they haven't got all the steps in place that identify how they're going to deliver that, we have a system of accelerated frequency of scrutiny. So, it's a bit like our own system of special measures and targeted intervention, where we'd get them in. Some of them would be in weekly and they would be given activities to go away and do and then report back to us weekly. And then there's earned autonomy, so as they are delivering more and more on what is required of them, then we are able to sort of take that scrutiny one step further away. So, that has been an important context for the way that we've worked with directorates. A bit like we are very proud of the fact that we are not in any escalation, then that is transferred right through the organisation into the directorates as well. So, that's an important part of our management approach.

14:25

Can I just ask, on that process you're describing, is that executive led or board led?

Executive led. We do have—. I say executive led because we do have a finance, performance and workforce sub-committee of the board, and the sub-committee of the board does two things. It actively manages the performance overall of the organisation on behalf of the board, but they also do deep dives into the directorates and areas that are not performing well, and—

What we call deep dives. So, what they will actually do is, as a committee, they will have a particular service in and they'll go right down into the detail and scrutinise at a much more granular level, and the executive with accountability for that service is there leading the process of being scrutinised. So, it's done at two levels in the organisation. So, the board, through that sub-committee, will call in those areas that are not delivering as well as they should be or are not on track.

So, it's exec led, but the board would scrutinise, in a way, and would monitor—

Yes. And they will do that by exception in the areas where the executives are not able to give the same level of assurance that they're absolutely on track with their plan.

It's quite all right. Thank you, Chair. In 2017, structural assessments of the health board noted that the proportion of non-recurring savings had increased during 2016-17. Could you update us on the position of what proportion of the savings were non-recurrent in 2017-18? And are you concerned about the level of non-recurrent savings at this stage?

Okay. Do you want to go?

Yes. I don't have the exact figures with me, but we could provide those afterwards. I'm not concerned that there's a rising trend of the non-recurring proportion. There always will be some, and that's the case right across the UK, but if it goes above a certain level then that is a concern. The other thing I would stress about our approach there is that, as Allison was saying earlier, we focus on the recurrent position as well as the in-year, so it's very visible to us if we are bailing ourselves out, if you like, with non-recurrent measures. We'd be very clear about that and what we'd need to do to get back on track from a recurrent position for the next year.

If it's helpful, if I may come back on that, we have savings trackers. So, we track in the organisation where the savings are. So, if, for example, a directorate identifies a strategic change that's going to deliver savings and improve quality at the same time, if they've got to go through a period of engagement with staff or with the public, those savings might not come out until, say, month 5 or 6 of the financial year. So, in year, there would be a non-recurrent gap that we would have to bridge, but, actually, once the scheme is delivered, the saving recurrently is delivered in the following year, if that makes sense. So, having that tracker, where we are constantly tracking what savings schemes are recurrent, but may only have been delivered non-recurrently in a particular financial year—that's very different to only delivering non-recurrent savings. And, in terms of the scrutiny that's undertaken by our finance and performance sub-committee of the board, they will have the visibility of that so that they can make that distinction. As a chief executive and a finance director, we would be very anxious if the savings plans were generating non-recurrent savings. We would be less anxious if the savings plans were delivering recurrent savings, but actually, the amount that's delivered this year has a gap in it, which means that we've got to plug that gap through non-recurrent means. I think that is a very important distinction to make.

14:30

Okay. Thank you very much. After so many years of having to make savings, is there very much left in the way of low-hanging fruit?

No. But that said—

I don't think there's much low-hanging fruit left anywhere, is there?

What I would say is that there are always efficiencies to be gained, which is why you'd expect any savings plan to be a combination of hard-nosed efficiencies, which you expect to improve year on year, an element of increased value out of what it is that you're doing, and strategic service change. And you'd expect any plan to be a combination of all three of those. If your plan is only going for efficiencies, then you're automatically going to run up against a difficulty, because with the low-hanging fruit gone, we would never take out £13 million a year through efficiencies alone.

Thank you. In February, the Cabinet Secretary for Finance stated that he was confident that the Welsh NHS, in the round, would keep within its budget for 2017-18. However, he noted that this would be partly through brokerage from health boards that had kept within their means. As Cwm Taf is one health board that has kept to the budget, how much has it had to provide as brokerage this year, and do you think this practice will continue?

Well, we brokered £3 million, I think it was, from the last financial year into this financial year. So, that was part of our plan for this financial year. We don't have a plan to do it again this year.

Okay. Looking through the auditor general's report and his update letter, they describe a short-term approach to savings with very few savings early in the year, savings ramped up in the final quarter apply and then back to the drawing board for the next year. Is this cycle one that you recognise in Cwm Taf and, if so, what more could you do to take a longer-term approach to planning and making savings?

What I would say, going back to your earlier question, is that the low-hanging fruit is fast disappearing, or the more transactional savings where you buy a widget at a lower price—the very simple things—those are disappearing. So, we need to develop more transformational productivity improvement schemes, and that is harder. It's harder to change services fundamentally on the ground. It needs different skills of managers and clinicians. So, that's the sort of territory that we're trying to get into and we have got to that, to some extent. We need to get into it further. I think all health boards are trying to do that. I think the success of the NHS in getting into that territory and really making changes on the ground in the way that services work is going to be a big indicator of our success or failure going forward.

If I may come back on this, some of our significant successes around delivering cost reductions have come through transformational change. Transformational change is difficult for all the reasons Steve has said, but also it is difficult because it's about delivering services in a different way, which requires a different conversation with the public. And one of the real opportunities that the NHS now has in the next couple of years is the outcome of the parliamentary review. The opportunity for the transformation board and the transformation programme—and also some money through the transformation fund—is about how we can pump prime some big strategic change. Because one of the things you sometimes have to do is put in a new model at the same time as you're taking an old one out. It can be very difficult to put a new one in and take an old one out at the same time, and the transformation fund can actually smooth that process of transformation not just financially, but operationally as well. So, I think it's one of the real positive opportunities now over the next couple of years that I'm sure, at some stage, we'll be back in this committee having a conversation about. 

14:35

Thank you very much. Have you had to make tough choices on savings that have impacted on levels of quality of service, and how are you responding to the auditor general's recommendation to widen the use of your quality impact assessment tool and expand its scope?  

'Yes' is the short answer—that we've had to make some tough choices. But what I would say is that our board is very clear about the test that we apply in approving big changes that are going to reduce cost, and anything that's going to impact adversely on patient care is not something, as a board, that we would support. I think the trick here—and If I take, for example, some of the opportunities that we've had with mental health services in the last few years—is that by developing new models of care that are actually better for patients, improve outcomes, improve quality, we've actually managed to take a significant amount of cost out of old models of care. So, an intelligent system of cost reduction doesn't sacrifice quality. A salami-slicing approach to cost reduction will impact on quality and we, as a board, are not prepared to do that.  

Okay. Thank you. What have been the main examples of service transformation in Cwm Taf over recent years, and how well have these performed in terms of actually delivering the same or better service for less?

I'll give you a couple of examples. We've probably got lots, but I think one of the early examples was around secure mental health services. We were spending a lot of money putting people who were very poorly into secure mental health services. By developing a new model of supported recovery, which we delivered locally ourselves, we were able to de-escalate patients out of high-cost secure mental health services and, actually, there are some real success stories where some of these people are now living in the community in a supported environment, and doing extremely well. 

Through the integrated care fund, we have worked with our local authority partners to develop something that we've called a 'stay well at home' service, where significant investment was made in services that allow people to be very quickly turned around at the front door of a hospital and home with packages of care, avoiding hospital admissions. That's given us more than 40 bed equivalents. We've been able to take costs out of other parts of our system. 

I think some of the examples that we've got demonstrate to us that they only work when you do it on a whole-system basis. So, cost shifting between health and social care doesn't work, because you're just moving the cost somewhere else in the system. This has to be about how we work together to spend the totality of our resources in a much smarter way, which actually means, ultimately, that the patients get a better service and our costs are reduced.    

Thank you. And finally, how are you managing to find the financial headroom to fund service transformation projects while also meeting the immediate service and demand pressures?

It's a really hard one. As I said earlier, the service transformation fund is going to help. We have taken some opportunities by repatriating activity that has helped to start the wheels moving in some of these places, but also in the plan itself. 

I think it's a really important question. We've invested quite a lot over the years, and it's a gradual process investing in what I would call capability—so, nurse rostering, medical rostering and our information teams. We've improved our information teams, our use of business intelligence and IT. All of those things cost money, but they do pay off in the longer term. We're very conscious about, when we're doing our prioritisation, as well as improving clinical services directly, then investing in enablers for us to work more efficiently, and therefore better, both clinically and financially. So, I think we've done a lot of that, because we've made it a priority.

14:40

I think there's another element to that, which is getting people into the mindset of invest-to-save. And we have been fortunate in being able to secure some invest-to-save money from Welsh Government itself, and that has enabled us to put some new models of care in, which have then generated savings further down the track. But, actually, if you get your staff particularly into a mindset of invest-to-save, what you can do is very clearly then track your ability to take some risks over here, but you've got the confidence that the costs are going to come out over there. And that comes back, again, to having the capacity and capability in your teams to be able to do that kind of planning.

The other thing I think that you'll see if you're tracking the expenditure through our system is that what we've been doing over the last few years around our RTT—referral-to-treatment times—activity is that, where we were quite heavily dependent on fairly high-cost outsourcing to meet targets, year on year we've been bringing that down by investing in more sustainable internal service models, which give much better value for money, and then that ultimately releases costs to be able to do other things.

Thank you. In terms of invest-to-save, as I understand it, the Welsh Government programme has to be repaid—so you'll make a case for investment, you can release savings, but if those savings don't quite emerge in the way that you anticipated, then you're at risk. Is that an impediment to organisations taking that risk in finding those savings? Would a different model be more likely to produce savings?

There's that Welsh Government funding, and we've participated in that over the years, but I think we also do that internally. So, clearly, when you invest to save, you've got to be pretty sure it's the right investment, or at least you've got to have proper scrutiny of it. You will have to take some risks, but you don't want to throw your money about into schemes that aren't strong enough. So, that process of evaluating them, and making intelligent decisions on what to back, and what not to back, is pretty important—whatever the funding source of those schemes.

But does that unwittingly create a risk-averse approach is my question.

We try and avoid that. I think we've been pretty positive around investing in strong invest-to-save schemes, because I think it's really important. So, there will be the danger of that—I don't think we've experienced that.

I think the other element to that is that invest-to-save is a specific mechanism, which is about, as you say, the upfront investment, and the savings pay back that initial investment. I think the transformation fund is a different model again, which is some non-recurrent, almost pump-priming money to oil the wheels of service transformation, and you don't have to pay that back. But there would be a clear expectation then that that transformation is delivered, and then you identify the funds to keep that service model going in the future. And I think that's another positive step that will perhaps, in terms of—if there is any sense of people being risk averse in organisations to that, the fact that you've got to then generate the saving to pay for it long term perhaps will feel less challenging than to generate the saving to pay for it long term and to pay back the initial investment.

And is the threshold for that transformation fund different to the threshold for invest-to-save?

We don't know yet. I think that that will become clearer over the next few months. But we found, even internally, we have a very small pot of money in our plan—you can see it in the detail of our plan—for investment each year. We prioritised against that. We look at risk, we look at quality improvement, but we also look at whether we can invest somewhere that will save something somewhere else. For example, we invested in a sports and exercise consultant—medical consultant—working with our orthopaedic teams, which cost us internally the salary for a consultant, but actually saved us more than that, because he avoided a number of people needing orthopaedic operations. But you almost—

Are you able to demonstrate that? Do you evaluate that?

Yes. But if you're going to do that successfully, you have be clear what your evaluation criteria are and how you're going to measure it before you do it, because then you've got a clinician who is very clear about the expectations on them.

14:45

You mentioned in your evidence, and you mentioned it briefly earlier as well, about the redesign and productivity-based savings needing the right capacity and capability to deliver that, and you mentioned what you've been doing to put some of that in place. But the key bit in your letter is having sufficient capacity to deliver at the pace required, and I guess you could add at the scale required. There doesn't seem to be—given that you are in surplus and given that everybody else is not, where is the pressure coming to you from Welsh Government or your own board to scale that up to deliver those savings?

Okay, just to be clear, we're not in surplus, we're in a break-even position.

No, because if you look at the financial position over the three years and the way that we're making the investments—if you look at our plan over the three years, it's a break-even plan. I think, again, there are two bits to the capacity and capability. One is people, and actually having people with the skills, and some of that is really, really challenging, to be absolutely frank. It's becoming increasingly difficult to recruit directors in the NHS—

I think it's not so much the pay rates, but I think there have been a lot of changes with pensions, with HM Revenue and Customs regulations, where actually, for people who are at a second-tier level stepping up to be directors now, it's not—these are big, really tough jobs, and it's not worth people's while in the way that it was several years ago. So, we're having people making career choices now not to step up into these big jobs. I think we've got a bigger job to do across the NHS, and the public sector more generally, actually, to grow skills, because the future need for transformation requires a very different set of skills than the ones, perhaps, that we originally trained with. So, we've got a big piece of work to do there.

What we have done, though, as Cwm Taf, is we've provided support into other organisations. So, we've shared our methodology for turnaround, which is what we started with as a health board when I was made chief executive, and the three-year plan that we had there—we've shared that. We've been and shared information with the board in Hywel Dda and with the board in Betsi. We've provided a lot of information to our health board colleagues, but I think that we do recognise that good practice probably doesn't travel as well as it should within the NHS. There are probably elements of good practice elsewhere that we would benefit from. What we do very actively do, though, is take Wales Audit Office reports and other reports into other health boards, whether they be governance reports or whether they be financial reports, and constantly test our own systems and processes against any recommendations that come out of those reports as well.

So, what are you doing, then, to develop the skills you've identified internally?

As Cwm Taf, two years ago we took what was quite a bold step at the time and made some direct investment in a management training scheme. We brought six young graduates that we recruited through a UK process, where we had several hundred applicants, and put them through very rigorous testing. We've put them on a two-year development programme. The first cohort have come out in February of this year, and these are people who we are tracking to be fast-tracked through the system. They've been given significant skill sets. We're just on our third cohort and we're just recruiting for our fourth cohort. We've also recruited for ABMU and Powys and Cardiff. So, we're helping other organisations in that context.

This is at graduate level. This isn't going to address your director-level problems, is it?

Not for six or seven years, but we've got to do the long term and the short term at the same time—

Sure, but back to my original question, which was how you would address the problem you've identified about capacity and capability at pace and at scale, and my question was: in the absence of being under special measures, where is the pressure coming from to ramp that up sufficiently? You answered to say it was a problem with capacity and skills, and your answer to that subsequently was that that is seven years away. So, what do we do in the meantime to help boost that capacity?

All right. One is how we're sharing resources across organisations. So, for example, the Cwm Taf chief operating officer is on secondment into Abertawe Bro Morgannwg University Local Health Board to help their team in the context of some changes and turnover that they've had. So, we're sharing resources. We're building some capacity through the NHS collaborative, which is a collaborative expertise to support the various health boards, and also we've got some training and development programmes in for our own staff.

I wouldn't want you to think that this isn't a continuing problem, because it is. I've recently tried to recruit a director of nursing, because mine is retiring. I've gone to UK recruitment and we haven't been able to identify a suitable candidate, so we're going to have to go again to look at recruitment. It's a challenge.

14:50

I hear what you're doing to help others, which is great and responsible, but I'm less clear about what you're doing to address the problems you've identified yourself in terms of your own organisation.

Sorry, I'm probably not understanding your question, Lee. You're asking me what we're doing internally in our organisation to grow capacity and capability.

Sorry. We've also got three development programmes: developing our senior nurses; developing our middle managers—so, we've recently gone through an organisational change process to identify the next-tier talent; and for our assistant directors. So, we've got development programmes in place for them as well. 

And it's reasonable to assume this is an NHS-wide issue. 

Thank you, Chair. Going back to the boundary change, in your earlier answer, Allison, you stressed that this has to be a change that doesn't just deliver continued good services to all the residents, but enhances them as well. So, what impact do you think the boundary change will have on the clinical services strategy?  

Within our IMTP, we are expected to outline a 10-year clinical services strategy. We're now, for the next iteration of our IMTP, which will be the 2019-20 financial year, going through a process looking at what that will mean now with the Bridgend population and with the Princess of Wales Hospital in the health board. I think that gives us several opportunities, and the first is that, if you look at the planning base for a population, most of the royal colleges will tell you that you need a population of about 400,000 to 450,000 to be able to have a critical mass for even some of the more specialist services that you would wish to provide. Bridgend coming into Cwm Taf gives us that critical mass, which should mean that we can provide more services locally within the health board boundary area to avoid our patients having to travel. I think the other thing that it does is that it gives us a critical mass of clinicians that you can actually develop a greater sub-specialisation of services to the benefit of patients. But also, one of the real advantages for us is that Bridgend have done some really great work locally with the Bridgend local authority around services for older people and for learning disabilities and mental health that I think we can learn a lot from in Cwm Taf, working with Rhondda Cynon Taf and Merthyr Tydfil councils. But vice versa, I think we've done some really, really good work in Cwm Taf that we can translate across.

I think that, to some extent, we're not going to know until we've really got under the bonnet of it all, but the intention is that our future clinical strategy will enable us to develop more sub-specialist services within the area for our local population. 

Thinking about that critical mass that you referred to there, would there be any areas now where patients are currently having to be treated outside the health board that you have in mind to provide within the health board in future?

Nothing specifically as we stand at the moment, because we've got a big transition programme to go through, but I think there will inevitably be some opportunities. What we've got to look at is the pathways of care, that even where there is still a requirement—and for some things there will always be a requirement for patients to go into a very highly specialised centre such as Cardiff, but, actually, the pathway of care means that they only go for that very specialist bit of their treatment pathway that they have to go there for. When we have a bigger critical mass, the intention is that the vast majority of the pathway will be delivered very locally for patients.

14:55

Your evidence has been very interesting, and it certainly conveys an impression of calm efficiency and stability. You've got an enviable record in Cwm Taf in respect of the medium-term financial plan; you've had one approved right from the very outset of the new financial control system that was introduced. Can you tell us what the principal challenges have been in achieving that record, and how does it differ—the current system—from the financial planning system that preceded it? Does it make life more difficult for you or easier?

I think if we go back to year 1 of the IMTP process, it felt very top-down in the organisation, we were learning, we were almost in a position where it was very board led, with intelligence from the grass roots of the organisation, but it didn't feel like it was owned throughout the organisation. Over the last two or three years, what we've been able to do is—. Because each year there's another iteration of a plan, because you wouldn't expect your plan to be scrapped and started again, because it's a three-year rolling plan, what we've been able to do is we've been able to grow the IMTP process from grass-roots level. So, rather than it being top-down, we've got an element of top-down, bottom-up, and the gap where it meets in the middle gets smaller and smaller every year, and that is one of the real beauties of the IMTP process. I think what we've also learnt over the last couple of years has been the real value in connecting that to the joint planning with local authorities, and a maturing of relationships and a maturing of the planning system that means that, actually, you should have a read-across between, particularly, what we're trying to do in health and what's trying to be done in social services in the local authority. So, I don't think there's any magic bullet, but you've also got to have really good planners who know what they're doing.

Well, certainly, your experience is very different from other health boards. Obviously, my region is partly in Betsi Cadwaladr and Hywel Dda; well, and Powys as well, which is a different case again. Demand and capacity planning are the key challenges in the health service generally. What lessons can these other boards learn from you, without wanting to make you sound as though you've been blowing your own trumpet? I mean, clearly, you've been successful in meeting the objectives that have been set by Welsh Government, and others haven't, so there clearly must be lessons that they can learn.

Steve will want to say something about the demand and capacity planning in a moment, but I will put a rider on this: we've still got a long way to go. It's still very much in its infancy. We have made a lot of progress, but we've still got a long way to go.

Yes. We're not where we would want to be. We've moved a long way in that period. I think some of it is using them in anger. So, if a directorate comes and makes a proposal, and it's not supported by their demand and capacity planning, they have to sort of go back then, because that is their plan, to try and militate against the tendency that does exist, and we've certainly had this: you do the planning, you put it on the shelf, and then you get on with what you were going to do anyhow. So, getting these plans mainstreamed and really used, and then, in the process of that, it becomes more important to people. It has to more accurate, it has to be more correct, because it is how we're going to run our business. So, we've sort of been on that journey. We've not gone all the way there, but making it real, I think, is a big part of it.

Perhaps I'd like to give you a very real example. If you take endoscopy services—and this may not be a great example—if you know broadly how many endoscopies you're going to need to do a year for what indication, you then have to look at how many endoscopy lists that you need, what level of staff that you need, how many cases you get on a list, you use your benchmarking data, and what that starts to really flesh out for you is, actually, operator A is highly efficient, because they do a lot of endoscopies on their endoscopy list, but operator B may not be as efficient. And so, coming back to Steve's point about data, you have to really understand your data, what you're trying to do, and then use that in active dialogue with your clinicians.

This is really into the detail in a way that we're not used to in the NHS. But if we've got to deliver better services for our patients, which we must, whilst maintaining the quality and also in the reality of the financial resources that we've got to deliver, this is the business that we have to be in. And it is new territory. It goes back to the fact that these are new skills for people in challenging the status quo.

15:00

I don't underestimate the challenges you face, as indeed all health boards do, but this system of three-year financial planning, which also goes in parallel with the annual accounting system that everybody has to work to, produces other challenges for you. Can we go back to the points that were raised earlier on about how you integrate these two systems together? Do you make clear when you submit your plan for approval that, whilst you are aiming for balance over a three-year period, there will be in-year gaps that may need to be plugged? So, you could find yourself, obviously, not in balance in every single year. If you do have to provide that, in years 2 and 3, you have to make up whatever gaps there may be in year 1, is that something that you plan for or are you just—perhaps saying 'on a wing and a prayer' is the wrong way of putting it, but is it mere speculation?

I mean, it goes back to Mr Waters's question earlier on really. In practice, our plan is to be balanced each year or only very slightly off because maybe we're not confident enough to make a deficit one year that we can then recover the next, because you have to be very confident, especially if you've got some uncertainty about each year's allocations. So, we do try and balance in each year, but in doing that we're very clear about the recurrent position as well as the in-year. So, essentially, we've got a three-year plan with the first year worked up in a reasonable level of detail, and the other two years are sort of more high-level and not worked up in the same level of detail, but they are worked up to a level, and we roll that forward year on year.

It wouldn't be surprising if you weren't able to achieve a balance in every single year because, going back to the point you made about invest-to-save, obviously, if you have some upfront investment that is going to produce revenue returns in subsequent years, you wouldn't expect everything to balance automatically in that situation.

I think one of the challenges for us that we shouldn't underestimate is that degree of uncertainty about what the costs and funding are going to be in subsequent years. I'll be honest with you: it would be a very brave board that would, at the moment, put a plan forward with a significant deficit in this year on an assumption that that could be recovered through actions next year. You'd have to have a very, very robust and detailed plan to enable you to do that in the context of not being absolutely sure, for example, of what the pay award's going to be next year, whether the pay award will be fully funded, whether there are any other pressures that are going to pop up in the system that are unforeseen next year. It would be a lot easier if you could generate a surplus in year 1, with an understanding that you'd have a deficit in year 2 that would see the investment there. But I think there's been too much volatility in the funding of the NHS—not within Wales, but more generally, in recent years—and the cost dynamics to make that the sort of brave and bold step that an individual board could take.

Thank you very much for that. Can I return to something in your written evidence? Your written evidence says that you're clear as an executive team about this being an integrated plan. Could you expand on what that clarity means in practice? What practical processes do you employ in planning, communication, decision making to enable you to keep a focus on the overall picture?

When we say it's an integrated plan, it's not a financial plan and a financial plan alone. An integrated plan has to be service driven, so that you're very clear about the impact on quality and performance and you're really clear about the financial consequences of that. When we are developing the directorate bottom-up plans, they're actually RAG rated—so, red, amber, green rated—against their ability to demonstrate that they can meet the quality requirements, the performance targets and the money. We won't approve a plan, and we won't approve our own plan as a board, unless we're satisfied that we've got alignment of all three things. No point having a balanced financial plan that doesn't deliver your performance. No point in having a plan that delivers your performance but doesn't deliver the money. That's what we mean when we say we're very clear it has to be integrated.

15:05

Yes, very good. It looks as though you wanted to add to that.

Can I just add to that? Yes, it's sort of easy to say, less so to do. I think, when we started on this journey, then we would have said we wanted an integrated plan, but there would be chunks of our performance improvement aspiration that weren't joined up with the financial plan, or elements of a workforce plan that weren't joined up with another part of the plan. So, it does need some very deliberate sorts of steps, checks and processes to make sure that, as you develop it, it is one thing, and it reconciles literally across the different aspects. I don't think we're sort of 100 per cent there now, but we've been through a lot of a process to get to that bit where everyone knows it's integrated and we check it's integrated. I wouldn't understate the, sort of, that's not easy to do that.

And there's a bit of a mantra that if it's not in the plan, it's not planned to be done. So, if there are opportunities for investment, whether that would be short-term or long-term, capital investment and revenue investment, our view is that it all has to reconcile back to your plan. Because, if the integrity of your plan is good enough, then there should be a visibility of everything you intend to be doing, particularly in year 1, in your plan.

A lot of the health service problems nationally in the UK come from the inadequacy of planning sufficiently far ahead for anticipated needs, as well as, obviously, funding difficulties year to year. From your perspective, does this system in the NHS Finance (Wales) Act help you to plan more for the long term than was previously the case, or are you just simply carrying on doing what you were doing anyway?

I think the discipline of the three-year planning has been helpful in really focusing that integrated approach to planning. I think what we've got to do, as it matures further, is link that very much, particularly to the national workforce planning, because we know that some of the biggest challenges that we face are around the workforce, how all of that's linked to the commissioning of education, and how we even link it back into schools and what is the workforce we're trying to grow for Wales for the future. I think there is more that can still be done, but the short answer is that it's a lot better than it was, but not perfect.

Thank you very much. I'd like to change focus now from asking questions about what you do, to what others are doing to you, as it were. In your written submission, you refer to a lack of detail on future allocations. The auditor general's 2017 report says that the Welsh Government was providing indicative future allocations. Are you saying they've stopped doing that, or are you asking them for something more firm or detailed than they're providing?

No, I think that it would be lovely, wouldn't it, if I knew today exactly what money and what the costs are that I'm going to have next April, because that would enable me to really plan in an intelligent way. I think that it has got better year-on-year. I think having the entirety of your allocation upfront at the beginning of the financial year is incredibly helpful. There are still other moneys that come out later in the year. It's getting better because those are less than they used to be. So, you've got that more certainty upfront; because the more certainty upfront you've got, the better the decisions that you make. If you have access to money later in the year, the chances are that you might make decisions that are short term rather than make strategic decisions. There's always going to be an element of in-year allocations, there's always going to be an element of hypothecated allocations linked to Government policy, but I think the longer-term view that we can have of that, and the more certainty, then the better the planning that we will deliver for the NHS in Wales.

Can you give us some idea of the scale of those withheld allocations?

15:10

In the grand scheme of things, they sound like large sums of money, but, proportionally, they're very small. So, if you're talking about a £6.4 billion allocation for the NHS, you're talking about a few tens of millions that may come later in the year, linked to specific performance issues, linked, as you know, sometimes, to winter pressures, more money is being made available; linked to waiting times targets, more money is made available. But that's a natural part of the business that we recognise and the challenge that the Welsh Government has to make with its own allocations as well.

Does the Well-being of Future Generations (Wales) Act 2015 impact upon you in practical terms, or, again, is this a broad statement of general principle that seems to be a statement of the obvious and you'll be doing what the Act requires of you in any event? Or has it actually made you focus more on future generations' interests than might have been the case before?

I think there's a bit of a mixed bag there. There's an element of this that you would expect the NHS to always have been considering, which is the future health of the population. I think where it's starting to focus the minds more is around the public services board table, which is the joint agenda with partners. I think we're going to see more in the prevention space that is at a partnership level—you know, discussions about well-being in a very different way. I think it has prompted us to think more consciously in terms of some of the impact assessments of what we're doing. But I'm afraid the NHS is always going to have this dynamic tension between what we do to help the health of the people who are here now versus what we need to do to help the health of the future generations. If you take cardiovascular disease, for example, whilst we need to be investing in improving the cardiovascular health of the next generation, we've still got to be treating the poor cardiovascular health of the current generation. So, there is a dynamic tension in health, which is slightly different to what would be experienced by some other sectors.

So, that means promotion of healthy lifestyles and eating and all the other things that surround the morbidity figures in these different areas.

Indeed. But I think, through the public services boards machinery, we're very clear that health is but one partner in that agenda, because, if we're trying to tell people about healthy lifestyles, we've already missed the opportunity. It's how this is done in schools, in communities and in life generally, and is not just seen as the domain of the health service. 

So, this takes us back to the main point that you made earlier on—the integration of health into the other public services that are provided across the board.

Indeed.

Good. Thank you very much.

Thank you very much. In the auditor general's report of 2017, he mentioned two areas for improvement. One was change management, which we discussed, and the next was implementing the digital strategy. In your paper to us digital isn't mentioned at all. I was wondering if there's a bit of a blind spot when it comes to digital.

There certainly isn't a blind spot. We did a lot of work last year on the development of the digital strategy, which Steve actually led, so I don't know if you want to comment on that, Steve.

Yes. I think we've got, as have many health boards, a pretty strong vision of what we want to do, but it does need a lot of upfront investment, again, capital investment, in particular, of a scale that is more than the health service is able to invest at the moment. So, I think we need to develop compelling plans that make that investment case, but it is an upfront investment to get those gains. So, in our case, we think we do have a set of plans and proposals, but we couldn't do it on our own. The scale of capital investment is just way beyond what—

But you're confident that it could produce savings, are you?

I think it will produce both clinical improvements, but also savings. And it's one of my strong beliefs that that sort of efficiency argument from IT that is made in most sectors is not strongly enough made in the NHS, and I think we can; there definitely are savings. How much they contribute to that cost, and whether they outweigh that cost—. But there are certainly efficiencies that go alongside the undoubted improvement in quality and safety.

15:15

But, given what you said earlier, why isn't invest-to-save an avenue that you're looking at to deliver that?

It's capital. Our own internal ability on invest-to-save is revenue; the Welsh Government scheme is revenue, largely.

And is the transformation agenda the same? Is that revenue as well?

That's revenue, yes. So, to promote IT, there would have to be pretty large-scale capital investment alongside some revenue investment.

There is a real opportunity there, and certainly officials in Welsh Government are very mindful of this and are looking to see what opportunities there are. But, for example, we know that, as the demand for care grows—because it will grow; whatever we're doing, it's going to grow—one of the real advantages of digital is it can help us to manage demand in a different way, and we know that there are lots of technological solutions that can help, particularly to keep people well in their own homes for longer. I think there are opportunities working very innovatively with, for example, housing providers to look at how we can help with joined-up planning for smart housing for the elderly. There are those opportunities, but, even just something as practical as the medical records and moving from a paper record to a digital record, the cost of that is enormous.

So, can I just clarify: there's no capital funding available for digital transformation?

There is some IT capital that's ring-fenced within the all-Wales capital programme every year, but I think one of the challenges for the NHS going forward is how we accelerate that at a pace and expand that ability to identify funding streams at pace so that we can make some of these step changes that need to happen.

Because digital isn't just about IT, is it? Mr Webster responded in terms of investment in IT, but digital is about far more than just kit.

Oh, yes, and, when I talk about IT, it's kit, it's software, it's change management.

It's all of that. Culture is a big part of it.

If I can give you a very small example, children with chronic skin conditions would often deteriorate quite significantly and end up spending a lot of time in hospital. Just by putting a governance mechanism in with mobile phones between parents and the specialist nurses, actually they can use digital images and amend care plans in real time so that we're able to prevent those children's conditions deteriorating. So, there's a lot of that already in place.

Okay. Sorry, forgive me, we're up against time. There's a lot I want to get through.

You mentioned the difficulties around the all-Wales patient record, which, as well as costing a lot of money, is taking an inordinate amount of time. I think it was 2003 that was started. The parliamentary review identifies a whole number of areas where digital can be used to improve service. Do you as a chief executive have confidence that NWIS is able to deliver on this agenda?

I think that there's an element of what NWIS needs to do. There's an element more about what we need to be doing to drive NWIS, so it's not just NWIS. I think that one of the outcomes, as you'll be aware, from the parliamentary review is looking at what the NHS executive function needs to be going forward, and I think NWIS and digital services are going to be critically important in that. So, I think we are going to see a need to see some significant changes there, but, as health boards, we have to take some responsibility as well to be driving that in partnership with NWIS, or whatever NWIS will look like in the future.

I completely agree with that. One of the issues the auditor general's report on NWIS identified was overly positive reporting. In terms of the major incidents that there have been, the data outages in January and March, have you and your health board and your patients been affected by that, and how?

We have business continuity plans in place—all health boards will—for managing difficulties. I think it's fair to say that we often end up reverting to paper and pen and the telephone, because we've become very dependent on the IT systems for real-time reporting of information. So, yes, most definitely they had an impact on the way that we were operating services during those outages, but not an impact that meant that there was detriment to patient safety. It just requires an awful lot of work when the systems are back up to then recover the position and make sure that we've captured all of the data and got all the right information. 

15:20

How can you be confident it hasn't impacted on patient safety? 

Because the issues when these things happen are more about how we make sure that we're getting test results, we're acting on blood results, we're acting on the various clinical information, and we resort to doing that manually when the IT systems are not able to deliver that for for us. 

Fortunately, they've been very, very short term, and when it's very short term what you do is you pull people from all of your other places to make sure that you're tracking that. I think that I would be far more worried as a chief exec if there were any outages that were more prolonged, because I think that's then when you would have risks in your manual systems. 

So, are you able to trust the NHS Wales Informatics Service data centres? 

I think up until the recent incidents I wouldn't have had any cause to have any concern about that, because our experience was positive. I think that what's really critical now is the learning from the recent incidents to make sure that that confidence is restored going forward. At the moment, we've had some positive reassurance, but I still think that we've got some further work to do to make sure that that is absolute from our perspective. 

I think, whenever you've had an experience like that, there is a small element of doubt, but what I can say is that the assurances that we've had so far have been generally positive, and we have to work with colleagues in NWIS to ensure that (a) our business continuity and (b) the integrity of the systems are robust going forward.  

Because Abertawe Bro Morgannwg University Local Health Board wrote to Velindre NHS Trust to say that they didn't feel they'd had a clear explanation from NWIS, but you feel you've had one, do you?  

I think what we've had is we understand what precipitated the particular events that caused the most recent difficulty. I think what we have to be assured about is that that absolutely can't happen again. 

So, did you have a clear explanation or just an outline? 

I think we've had—. I'm not an expert if I'm honest with you. Our own head of IT has given me assurance that the explanation of what happened we understand and we are confident that that's been put right. The bit that I couldn't sit here and give you 100 per cent confidence on is, 'Are we assured yet that those problems can't happen again?' And that's the piece of work that, obviously, is important so that all of us as health boards have that assurance.  

Because I'm looking at the report ABMU submitted to their own board, and they didn't share your confidence on patient safety. They said these

'outages created a serious governance risk and patient safety risk for the organisation'.

So, ABMU think they've created patient safety issues, but you don't. 

I think what we need to understand is that you will have business continuity mechanisms in place. If we're entirely reliant on electronic systems and we don't have business continuity arrangements in place for when they go wrong, because you have to, because you can't ever be 100 per cent reliant on anything, then, obviously, there is a risk associated with that that is mitigated to a large degree by your business continuity arrangements. I think any time there is a failure in IT, a failure in your electricity supply, a failure in your water supply, that inherently does create risks, but it's then your business continuity arrangements that mitigate that that are important.  

Our business continuity arrangements are in place, but, as I said just a little while ago, they're very, very labour-intensive and reliant on paper and pen and people on the telephone. So, for a short period of time, you can have confidence that they're robust. For a long period of time, I think that they would constitute a much more significant patient safety risk. 

15:25

So, you don't share the BMA's concerns, then, do you?

I do share their concerns that it is a risk, but what I'm saying is that our business continuity arrangements can mitigate that risk in the very short term, but they can't mitigate that risk for any prolonged outage. 

Beyond the two major incidents in January and March, have there been any further incidents that have affected Cwm Taf?

Not in terms of those particular types of IT failures, no. 

There will often—. You can have power interruptions for—. We've had some works going on in Prince Charles Hospital, where we had some power interruptions and your systems go down for—

Not from NWIS, no. 

We are virtually—well we are totally out of time. So, all that leaves me is to thank our witnesses Allison Williams and Steve Webster from Cwm Taf health board. 

Thank you very much. 

Thanks for being with us today. It's been very helpful. We'll send you a transcript to check before we finalise it. That's very useful. Thank you.

Do Members want a break or do you want to run straight through? Okay. We'll take a five-minute break. 

Gohiriwyd y cyfarfod rhwng 15:26 ac 15:33.

The meeting adjourned between 15:26 and 15:33.

15:30
5. Gwasanaethau Gwybodeg GIG Cymru: Sesiwn dystiolaeth 4
5. NHS Wales Informatics Services: Evidence session 4

Welcome back. Can I welcome our witnesses for item 5, which is our fourth evidence session on NHS Wales Informatics Service? Would you like to give your name and position for the Record of Proceedings?

I'm Mark Osland. I'm director of finance and informatics at Velindre.

Hello, good afternoon. I am Jacinta Abraham. I am the medical director for Velindre NHS Trust, and I'm also a clinical oncologist, specialising in breast cancer.

Hello. I'm Stuart Morris, associate director for informatics.

Great. I'll kick off with the first question. Could you briefly talk us through the systems affected by the major incidents and their importance to the trust? Who wants to take that? Mark.

I'll ask Stuart in a moment to speak in a little bit more detail about the systems that were directly affected. I think the committee would have had sight of the board paper that was presented to our board at the end of May, and that was basically on the basis of the increasing frequency by which we were experiencing system outages. We felt it was necessary to bring our board's attention to that issue and discuss in some detail what we may do in terms of trying to enhance our business continuity arrangements, basically as a result of that frequency. As a general comment, I think it's fair to say that we would expect to experience some system issues from time to time, but the increasing frequency, obviously, was quite concerning. Hence we had a discussion at our IM&T committee and subsequently took it to our board. There were a number of instances, particularly in a four to five-week period, which concerned us during the period of April and May. I think that you will have seen a list that basically shows quite a number of different types of instances as well. So, I just wanted to say a little bit of the background to inform the committee of that. But in terms of the nature of those instances and specific circumstances, perhaps I can ask Stuart to talk a little bit about them.

15:35

In terms of primary systems, our primary system of use within Velinde cancer centre is CaNISC—it's the cancer information system, which is used across Wales. The majority of incidents have affected that. That said, we have been impacted by another system as well, which is the Welsh laboratory information management system, the WLIMS. So, those combined, they both interface with each other, so we get feeds from WLIMS into CaNISC. So, when we talk about a national CaNISC incident, it's not necessarily that CaNISC has gone down itself; it's perhaps the interface between the two that has caused that problem as well. In terms of CaNISC, we are probably the biggest users of it, within Velindre. We use it as our patient administration system as well as our clinical system, which records all the treatment information and so on. So, those are our core systems. We do also hold local systems, which have thankfully not been affected in the same way by the national incidents.

Thanks. How often does the system prevent clinicians from accessing information? How often does it go down to prevent that sort of access?

Over the last 12 months, we've captured our major incidents—I think it's appended to the report—and we've seen, through a quarter, up to seven incidents, but in some quarters it's been much smaller, at two or three, and in quarter three of 2016-17 we didn't see any at all. So, it can be variable. I think the purpose of this report was that we'd seen an unprecedented increase in that during April and May, and that obviously caused us concern and we needed to understand why some of those things were happening on a more regular basis.

So, during April and May, was it going down weekly, or daily?

There was a period of time where there was some sort of disruption almost every day for a week, which obviously put quite a lot of strain on the service.

What did that mean? What does the cancer centre look like when that happens?

I think the issues with the system weren't necessarily related—all those things weren't related. We were getting information back from NWIS colleagues around what they thought the problem was at that time. Then, the cancer centre has to react differently depending on that. So, if CaNISC is available but test results are not available within CaNISC, then our default position is to use the Welsh clinical portal to access those test results. The problem with CaNISC and the Welsh clinical portal is that, as CaNISC acts as our patient administration system, our demographic feed is from CaNISC into WLIMS. If we lose that, then we have to search for test results and we have to use an advanced search function, which means it does take a little bit longer to get those test results. 

So, the system itself, CaNISC itself, is around 20 years old, I understand. So, what are the plans for replacing that and what's the time frame and the costs?

You're absolutely right—it's an old system. It's our main system used by our clinicians and our staff. It acts as both the patient record and the patient administration system. It's over 20 years old, but I think it has benefited actually from progressive developments over the period. Whilst it is an old system, it does actually give our clinicians the functionality that they need to do their work. That said, the actual system itself is what they term as 'end of life'—it's out of support by Microsoft now. We're well aware of the need to actually transition away from the CaNISC system and move towards systems used nationally—so, the Welsh patient administration system—and to also enhance the functionally through the Welsh clinical portal to give us both the clinical record and the administration system in the future. We have got a plan to do that. We've got an implementation period, which is going to be over the next, probably, 18 months to two years. I think that we shouldn't underestimate the work involved here—it's quite a significant IT and, indeed, cultural change project. Because a lot of the change projects that we actually implement, as you will be fully aware, are a lot about the behaviours and the skills in terms of change management as well as the IT systems themselves. So, we have got a plan and we obviously are keen to transition as quickly as we can. 

15:40

So, just to summarise, it's a 20-year-old system, it's no longer supported by Microsoft, over the last quarter it's been going down on almost a daily basis and it's going to take two years to replace it. Is that all correct?

We estimate that it'll take between 18 months and two years, yes, because of the actual complexities about actually migrating to the national system. We take that period, really, from evidence that we've been given elsewhere from other health boards that have actually implemented the Welsh patient administration system.

And in the meantime, are you concerned about patient safety?

We're concerned to have, obviously, systems availability. Obviously, in terms of, actually, when the systems are not available, our primary concern, as I'm sure you can appreciate, is for patient safety. And we have got, obviously, business continuity arrangements in place when these systems go down, but, obviously, the frequency by which this is happening does concern us and that's absolutely true. And that's why we have been doing quite a lot of work simultaneously with the national systems, in terms of enhancing the functionality within the Welsh clinical portal, which we've rolled out to our clinicians as an element of resilience when the main CaNISC system that we use now goes down. I'm not sure, Jacinta, if you want to talk about patient safety.

Yes, I'd be happy to speak on that. Just a couple of things, if I may. Firstly, to say that the paper was written and reflected how we were feeling at the time—11 outages in a four-week period—and that did have an impact. The context, however, that I would like to make is that we do operate with slightly different systems. The in-patient service, in fact, still uses paper, so was not affected in the same way by these incidents. Our delivery systems for chemotherapy and radiotherapy both, again, operate independently, so therefore were not affected by this.

So, there was a proportion of activity that was continuing—and, most importantly, the delivery of treatments for patients—during this time. However, it's not to understate the impact that it did have on patients having to wait longer. We had lots of communication processes around that, communicating, updating with patients, providing refreshments if they were having to wait longer and, clearly, having a system to prioritise those that were less well when these impacts were happening. And also there's our superbly resilient staff, who do have to cope with the interruption to the day that this does cause, and I think that is reflected in the paper.

I think, to reassure you on patient safety, if a decision could not be made about a patient's treatment, it would be deferred. We do, in Velindre, have a robust reporting process for clinical incidents and I can assure you that there have been no serious, untoward events that have been recorded during this time. That is a priority for us.

Just before you go on there, Dr Abraham—Lee Waters, did you want to come back, briefly?

Yes. I'm sorry if I'm cutting across colleagues' questions here. I just want to query something that we've just been told, because the serious incident report says that one patient did not receive chemotherapy treatment, blood results were unavailable, and there was a delay in radiotherapy treatment for eight patients. You've just tried to downplay that. The incident report doesn't quite tally with your account. 

So, what I'm saying—. I did say that patients' treatments—there were no significant serious incidents as we classify them. So, there was no harm done as a consequence of that.

15:45

Well, not receiving chemotherapy is potentially harmful, isn't it?

The delay was not significant to cause harm.

With that particular patient, they were rearranged within 24 hours.

Right. And then the delay in radiotherapy for eight patients. Was that also not significant?

It was a matter of days for them. Obviously, what we did was to prioritise the rebooking of those patients at the first opportunity. We may have, in fact—there would have been movement around bookings of patients to make sure that there was no compromise.

But then the board report to Velindre board said:

'Decisions made without all information to hand, requirement for retrospective checks to be made,
leading to an increased likelihood of error. Poor patient experience'.

So, I'm not sure whether there's been a powwow since you submitted this paper to try and alter the import of what you've been saying, but there does seem to be a change of tone at the very least between what's been submitted to us and what you're telling us now.

Not at all. I think what the paper has prompted is an in-depth review for each of those incidents clinically, which we've called for, and as a result we've reported internally on what the impact has been on a daily basis for each of those incidences and outages. It was a frustrating time, but I can assure you that there wasn't a major impact across the board.

Well, if you're making decisions without all the information to hand then that's a major clinical risk, isn't it?

Yes, it is—

I'm not downplaying it. What I'm saying is that I'm giving you an assurance that there is business continuity that allows us to operate within a safe and governed environment, because that is our responsibility, to make sure that we can do that in the event of—.

Yes, indeed, but there are also patient safety risks here, which both papers identified, but you seem to be downplaying that.

I would say that the potential for patient risks exists as soon you cannot access the full case note, and I think there's no question about that. I think that—

That happened 11 times over a four-week period and it's going to be two years before you can put a robust new system in place.

As far as I'm aware, there is progress being made. There are a couple of things that I should mention. One, and Stuart might want to pick up on it, is the business continuity enhancement that we've put in, which is to have access to a PDF format of the case note in a secure location, which clinicians and health professionals in the organisation can access in the event of—. The second thing is that there is, working with NWIS colleagues, a process in place to have the CaNISC case note summary available in the Welsh clinical portal architecture. And that we aim to see in—is it September?

In the autumn of this year. So, the paper tries to set out a couple of immediate actions that we want to deliver over the next six months into the autumn. One of those, as Dr Abraham described, is the case note summary, so that would be then available within the Welsh clinical portal. At the moment, it's only available in CaNISC. Another one—I may have poorly articulated it—is the reliance on the PAS information for the Welsh clinical portal. At the moment, if we don't have CaNISC, it makes that searching a lot more difficult within the Welsh clinical portal. What we are aiming to do is have a Welsh clinical portal that doesn't rely on that and we can have a much more efficient search. And the final piece that we're focusing on over the next couple of months is working with health board colleagues, actually, to deliver our documents, our clinical letters. So, our clinical letters are currently stored within CaNISC. What we want to be able to do is create them in a document management system that will then populate the Welsh care records service and by default then make that available within the Welsh clinical portal.

How long is it since Microsoft ceased to support your system?

In 2014, they ended formal, if you like, 24/7 support. Since then, there are support arrangements. That is done with NWIS colleagues. But clearly that's not an insignificant length of time.

Has the lack of supportability been an influence upon the problems that you've had, or is it something else?

Not as we believe to date. What I would say is that when incidents do happen, given its age and given the situation that CaNISC is in, it does take longer to recover. It's not necessarily as a result of the Microsoft lack of support, but it's the age of the system. Changes take longer to implement, in effect. When I was describing the WLIMS interface—the pathology test result interface—what we are finding is that it takes a lot longer for that to catch back up within CaNISC. So, if we lose CaNISC for a period of time, it could be a number of hours, and it has been days, before that information is then back up to date within CaNISC. That doesn't mean we've lost it, because it is available within the Welsh clinical portal. Those sorts of things are a factor, I would say.

15:50

Microsoft systems are problematic enough, even when they're brand new, so goodness knows what problems you've got going back 20 years. I know you're waiting for detailed reports and it may be difficult for you to give a hard and fast answer to this question, but can you say to what extent there's a common cause to the various outages that you've suffered in recent times? Where is the problem? Is it a national infrastructure question, a local infrastructure question, or is it a combination of both? Are you able to give us any idea?

In terms of what we've had in information back from NWIS colleagues—and that's typically whether it's been in a meeting format, some verbal conversations, or through e-mail correspondence—when an incident occurs, we do a local triage of our systems and our infrastructure to make sure that there aren't any issues that we can identify. The national team will then do something similar. In all of those instances, we've not identified anything wrong with our local infrastructure. CaNISC sits within the national data centres. In terms of the issues, we haven't had a common theme. I don't want to get too technical, but it could be a server issue, a firewall issue, a Citrix server issue, or network outage, but it hasn't been a consistent set of causes, from what we understand. That said, during this period when we've set out the number of incidents that have occurred during April and May, we met with the senior NWIS management team—the directors—to discuss some of the issues, and they did inform us, albeit we haven't had a report on that, that there were some underlying issues, which they've now, over the last four weeks, made a conscious effort to resolve. The experience to date is that we haven't had a major incident in June. We have had some small service outage. Nothing has been identified as a major incident. We've had 15-minute interruptions on two occasions, but the work that they are doing at the moment does seem to have taken effect. Whether that's a coincidence or related, at this stage we're just not able to say.

How would you evaluate the costs of these outages that you've had? You said a moment ago in that one example that it was just a 24-hour delay, or maybe less than 24 hours to sort out one of the problems that might have occurred. Is that typical, or is that unusual? Are you able to evaluate the cost both in terms of patient care and safety, and also maybe financial?

I'm not sure if we can answer that question qualitatively, but it's certainly prompted—. We've not been in this space before, and it has prompted those questions, which I think are really valid. We do obviously rearrange appointments, and things happen and changes have to occur, but I guess, on a scale of this kind, I'm not sure if we know the answer qualitatively. But it is something, as part of our business continuity now, we will collect and have that data to hand.

Because obviously, if this is going to continue for up to another two years—and who knows, it may be longer than that; these timetables are notorious for slipping—it could impact significantly upon patient care.

I agree. I think it would be inappropriate for it to continue for so long. I think we do need a solution, which we're working hard towards. As a clinician, I use the system and I see patients. What's important to put into context again is to say that the clinical portal does give us information on diagnosis, pathology, radiology and bloods. Our chemotherapy prescribing system is separate, and that gives us information on doses, blood tests, cycles of treatment and intent. Our radiotherapy delivery systems, again, are separate. So, in a sense, we're fortunate that we have other support systems in place, but that's not to say—. We do need a robust and resilient electronic patient record—absolutely. We are working incredibly hard—

15:55

What sort of timescale? You said you'd appreciate this as soon as possible. What sort of timescale?

Well, I'd like it now. In the autumn, we have a solution that is going to be transformative, meaning that we—also because that will mean that the health boards can see our records. At the moment, that's not the case, so that will be—. And we will be able to see GP records, which we haven't been able to view so far. So, there's leadership in this, and I think it's just to highlight that we have invested in clinical leadership. We've identified a chief clinical information officer. We haven't appointed them, but we've had somebody doing lead IT clinical roles—a deputy and a lead—since about autumn 2015, and that was in my previous role as clinical director. I felt it was important to prioritise this. We do need to push and we do need to provide clinical leadership, and I'm not going to be waiting too long.

How robust are your back-up systems for information, given that there is a risk that's going to continue for a significant period of time? There's no problem with the ultimate retrieval of this information, evidently.

So, this is what we've now enhanced as a result of this run of incidents, really. As clinics are planned in advance, we are now capturing the record in a digital format, in a PDF format, storing that in a secure file so that we've got those records available, in the event of something happening.

Thank you, Chair. Going back to patient experiences for a minute, I've got some evidence here from Macmillan talking about what happens when patients turn up for scans if the information isn't available. It says that, in that case, which is obviously a very anxious time for a patient, the appointment would have to be cancelled and rescheduled. Is this something that you're aware of from your own work?

I think, again, it depends on the individual patient and the context they're being seen in, because it is possible to get access to radiology reports on the clinical portal, so it depends on in which health board they may have been seen. Stuart might be able to say more about the actual Radis in Velindre.

So, our radiology system is local to us, so it hasn't been affected in the same way by those incidents. We don't store that in the national data centre.

Looking at clinicians, then, and the impact of this on them, obviously clinicians are extremely hard-working, and we rely on these people to deal with some very difficult health situations. Your report says that clinicians prepare clinics routinely as though they assume that the systems won’t be available. What does that actually mean in practice? Can you talk us through that? 

So, again, I think we've drilled down, through our investigation, to find out exactly how many times and exactly in what circumstances that happened. I think there were two cases where that was recorded, and I think these were clinicians who were anticipating the next morning's chemotherapy clinic, and because they were concerned that we might not have access, they were reviewing those individual cases, opening the case notes and looking at them, and doing some preparatory work in thinking who was coming, 'What do I need to get ready upfront—any results that I would need to look up?', for example. So, I think that was a kind of proactive response from resilient and hard-working clinicians to try and pre-empt what might or might not happen the next day, and I think that was part of what was going on in that 11-outage period—that people were starting to think of alternative ways to be more productive. So, basically, anything to continue business as usual and reduce delays for patients.

So, the evidence we have here from your report says:

'Consultants preparing every clinic (often in personal time at home) in the expectation IT systems cannot be accessed'.

Would you stand by that, then? 

The evidence that we have suggests that it was not every consultant doing that, but there were some consultants who prioritised and decided that that would be appropriate for the clinics they had. I think it's about the complexity of patients, it's about the type of clinic that you are doing. For example, if I was doing a new patient clinic, it would be a population that I hadn't met before and most of the information I would be able to retrieve from health board systems. So, if it was a chemotherapy patient, it's likely that I would have seen them several times before, so I'd know quite a lot about them, but I might want to look up what the last annotation was in readiness.

I think Velindre is a different organisation. Our population—we tend to know our patients relatively well, and many of them we're not meeting for the first time. I'm not trying to say there is no impact. We need to understand the impact. We need to support our staff, and that's one of the important things, and support our patients, and that's what the business continuity really was all about. We would not need to do any preparation. We have access now to a PDF folder that will give us contemporaneous history and annotations, and that's the enhanced business continuity moving forward. We don't want to be in that position.

16:00

No, certainly. So, if one of your clinicians has done a full-day shift and then is going home and having to prepare these kind of notes by hand of an evening, how confident would you be that when they come into work the next morning, they are refreshed and ready for the day? Because it sounds to me as though they would be stressed and overworked.

I think I would agree with that. I think our advice has been to clinicians that they should not be making decisions if they were not feeling able to, and that message was clearly articulated. It would be safer to delay a patient or defer a patient if we were not able to have all the information we needed to hand.

Which goes back to the impact on patients as well, then, doesn't it? What is the level of frustration among clinicians about the state of the informatics system in general, and the issue of the system failures in particular?

I think that events of this particular time—clearly, as I said, the paper that was written in a sense reflects the mood and the feelings of clinicians and staff at the time. I think that what people have engaged with is progress, the future, wanting a better system, seeing that, actually, there is an improved system in sight that is tangible. Minutes of our consultants' meetings will reflect on this very well. We would have recorded updates, we have a standing item for improvements with information management and technology, and as I said, we've fortunately had a couple of very engaged clinicians who've worked very closely to drive this progress. So, people can see that there is a future very near that they can be part of to enhance, really, what we're trying to do here. I think that's what we're focusing on—getting that sorted, but enhancing our business continuity so we are operating within a safe environment. That's absolutely key.

Okay. One final question from me, then. The report refers to a high-profile case of a doctor who was struck off. Could you explain a bit more about the case the report is referring to, and what specific lessons around IT systems the trust should be looking to learn from it?

I think this is a high-profile case that most of us would have heard of. This is the Bawa-Garba case that's been in the press, of a junior doctor who really—. I think it was a very complex case, it's on the General Medical Council website, there's lots of dialogue about it. It was certainly not one issue that resulted in this case and this doctor being struck off. It was multifactorial, but one of the points that is documented in the case is the junior doctor not having access to the full complement of information. I think it was put in the paper really to concentrate the mind that things can go wrong in the event of not having all the information, and therefore business continuity is so key, reminding people to make decisions appropriately.

That doctor was struck off, partially due to not having that proper information?

It was one of the contributing factors, but there were lots of factors. It is a case that you can easily look up.

Presumably he wasn't struck off for that, though. There were mitigating circumstances—

He wasn't. It was a mitigating—. I think the way we may have presented it in the paper perhaps slightly gives the wrong impression there. But I think it was trying to alert you to the fact that things can go wrong. That's what we want to avoid.

Yes, and it still suggests—. I understand there were other factors as well, but it still goes to suggest—if that was cited as one mitigating factor, it raises the profile on how important an issue it is and that it's sorted out. 

16:05

It is a case that is being discussed all of the time, so it is at the forefront of all of our minds for a number of issues, including cover on wards, on call, workforce challenges, et cetera. So, it is a case that we are talking about all of the time—it's right up there—and anything that potentially can go wrong, the Bawa-Garba case will come up. That's where we are at the moment, unfortunately. 

You've said several times now that when you wrote the paper you were very frustrated, and you cited various examples of how that frustration manifested itself, but you've also said in the last month that there have been no major incidents, and NWIS have responded to you sending out the alarm signal, I guess. So, do you feel that now they're being more attentive, if I'm reading between the lines of what you're saying, it is addressing some of the issues, and does that not suggest that if they were more attentive before then this could have been headed off at the pass? 

I think that's a really difficult one to answer because we don't really know the detailed root cause at this stage. What I believe is that, through this series of incidents, they've had more investigation and they've got further into a problem resolution. I think it's a fair point to say, 'Should they have done that sooner?' That's possibly one for them to answer in that sense, because I'm not fully sighted on what they're actually doing to fix it. All I can tell you is that we've experienced this period of less disruption as a result of changes they've made. 

I feel for you from the evidence you've given. You've been put in a very difficult position. I'm just wondering, had this been a different piece of kit, like a scanner or something, that had this level of unreliability and consequences that you've outlined, would you have expected a different response from the manufacturer who was servicing it than you've had from the IT?  

In terms of CaNISC itself, the infrastructure that it sits on is new, or newer; we replaced that in 2017. That work was done. We didn't replace everything that interacted with it, but we did replace the core tiers of it, so it's new equipment. This is just the downside of the way in which the application has been designed over the 20 years. 

And just in terms of the fact that it's now out of support from Microsoft, and has been since 2012, I think you said, does that make it more susceptible to cyber attack? 

You're absolutely spot on. Sorry to correct, it was 2014— 

It was 2014—my apologies. I wrote it down wrong. 

—in terms of Microsoft ending support. But this is the one thing that I think makes it a red risk for us, if I'm honest, in terms of—. If Microsoft issue a security patch that has to be applied, and CaNISC for whatever reason is unable to take that, then clearly that does give us—. So, you're absolutely right. In terms of cyber it does present us with a challenge, if there is a circumstance where Microsoft issue a patch that CaNISC doesn't like.  

Can I just say as well, I'm aware it's very stuffy in here? We are on the case. I'm glad you're a doctor—I might need one very soon. [Laughter.] I think we're going to hold the door open to see if we can—. I think there's some issue with the air conditioning. 

Sorry, Chair, he was saying something quite significant there. There's a red risk of a cyber security attack.

Yes, I'm aware, but I'm actually feeling like I'm going to pass out in a minute. [Laughter.] So, if you could repeat that. 

So, just to clarify, the red risk is the CaNISC replacement, and one of the impacts is that if there is a cyber patch that Microsoft need to deploy, we could be in a position—we don't know, we haven't been to date, but we could be in a position where CaNISC wouldn't like that. 

Actually, that is why we need—. I think we've tried to articulate that we need to remove CaNISC from operational use as our system. I appreciate that's another two years. We will be mitigating in terms of continuity over the autumn, but the process to replace CaNISC will take some time. 

So, as well as the clinical risks we've discussed, the pressure on staff we've discussed, there's now also a cyber security risk, and you're going to have to live with all those things in parallel for the next two years. And yet, at the beginning of your evidence, you were downplaying the severity of the situation. I don't understand. Is there something going on behind the scenes where you've been encouraged to downplay your concerns here? But your concerns, once set out, are actually very significant. I don't understand why you're not being more forthright about them. 

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I didn't think we intended to downplay the situation at all. We are concerned about the reliance that we need to place on the CaNISC, which, as we've said, is a 20-year-old product, and we are very keen and very conscious of the need to quickly move off the system and onto the national PAS system and better use of the Welsh clinical portal. We have got a plan to do that. I think it's fair to say that, ideally, we would have preferred to have been further down the line in that transition period off CaNISC. Unfortunately, we're not. We are where we are today, but we certainly don't downplay the urgency and the need to actually move from it, and we are actively working with NWIS and others to do that as quickly as we can. 

We've indicated the time period that will take, but these are large, major change projects that we are embarking upon, and we hope to do it as quickly as we can. We say two years; we hope to do it within two years. But we wouldn't like to put a definite time frame on it because of the nature of these changes. 

Thank you very much, Chair. Most of the questions have been answered by the doctor, but still, I'll ask them. When do you intend to make a decision on which of the options in your board paper you will pursue to make the system more resilient?

So, we have made that decision, which is what I described in having a PDF format of the case note that is in a secure location, which will be uploaded in readiness and will be available for clinicians and health professionals to access, and that should help with most of these factors that we have raised as concerns.

Thank you. Can you give the committee an update on the decision you have made in response to problems with the informatics system?

So, that was what I was trying to articulate earlier, in terms of that we've met with the NWIS directors, we've worked through those options that are set out in the paper. The decision was to go for the PDF example and deliver over the next six months, or by the end of the autumn, those three additional options I described earlier around utilising the Welsh clinical portal and presenting CaNISC information within the Welsh clinical portal. 

All right. Now, this is a difficult one: would it be fair to say that all of the active options are in essence introducing inefficiency and extra cost—back-up and duplication of systems—in order to address a lack of confidence in the underlying systems?

Probably yes, one, or all of the above, but I think it's where we are. 

Yes, I think it's true to say that we wouldn't ideally have wished to have embarked on any of those options. We need a reliable system. Unfortunately, as we've obviously discussed here this afternoon, we're not in that position, and there's no doubt that deploying some of those options will, in fact, create more work. It will create additional cost. We haven't quantified that cost at this stage, but it's inevitable that that will be the case. But I repeat that we obviously want to do this in as short a period as possible. 

Thank you. Do you believe there should be more investment in the informatics systems to keep them running efficiently and beneficially, or are they looking to replace it entirely?

I think, in terms of whether there should be more investment in informatics systems, I think that's a fair observation to make. I think it's like any investment in any of our services—it's key to actually demonstrate the benefits and the difference in outcomes that it makes. And, so, like any other investment consideration you make, it's a cost-benefit analysis that you have to do. I'm well aware of the high-level figure that was bandied around in terms of the next five years' investment that may be required. It was nearly £0.5 billion. That was very high level. Those figures do need firming up. And five years hence is a long time to try and estimate or determine what technology you might need to deliver your service. So, that will change—that's inevitable. But I think it is a decision of choices, like any investments that we make. But in terms of more investment, I think that the underlying message from me would be, yes, certainly, I think that would be welcome.

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