Tuesday, 11 December 2018

Digital - a way to renew public services?

Digital solutions to problems have become commonplace, but there is a gap emerging between the digital expectations of citizens and the reality of Welsh public services.

When my son was receiving regular care from a consultant I asked if I could avoid the car journey and a morning’s lost school for him by Skyping into the clinic instead. The answer was no.

After accessing a GP service via an app on my smartphone within 8 minutes of checking availability, it’s a frustration to then spend 30 minutes repeatedly calling on the phone to get an appointment with my local NHS GP surgery.

These are just anecdotes based on a few of my own personal experiences, but they demonstrate that the digital expectations that have been set by our everyday experiences of Facebook, Amazon, Netflix and Google (the so-called FANG companies), clash with the reality of the way public services work.

Citizens expectations are being transformed online. If health, local government and other services fail to keep up with these changing demands, it could seriously undermine support for the values of public services in the future.

Of course there are complicated reasons why in each of these cases the system is the way it is, but the theme is that our services are often not designed with the needs of the end user in mind.

A series of reports over the last three years have set out a consistent picture of Welsh public services failing to capture the potential of digital approaches to improve outcomes. They set out a very similar picture of services falling well short of their potential to deliver easy ways for the public to use everyday services. The widespread use of faxes across the NHS, and the fact that even the smallest local authorities in Wales are using over 100 separate systems to deliver services, is a manifestation of a deeper problem.

After being a critic on the Public Accounts Committee of the performance of the digital arm of Welsh health service Wales - NHS Wales Informatics Service - I was asked by three Government Ministers (Julie James, Vaughan Gething and Alun Davies) to put together an expert panel to make recommendations for change across the public services.

The volunteer panel has an impeccable pedigree: Paul Mathews, the Chief Executive of Monmouthshire Council; Anne Marie Cunningham, GP and Associate Medical Director of NWIS; Mark Wardle, Consultant Neurologist and Chair of the NHS Wales Technical Standards Board; Victoria Ford, Director at Perago-Wales, a former Head of Communications for the DVLA and who was part of the team at the Government Digital Service (GDS); Dominic Campbell, interim Chief Digital Officer at Homes England and CEO of FutureGov, and Sally Meecham who has a range of experience carrying out digital change, most recently as Chief Operating Officer of the GDS.

In the spirit of the openness that characterises the culture of the digital approach I’ve been blogging throughout our deliberations.

Our report has just been published.

The first thing to point out is that we recognise that there is good practice across the Welsh public sector. Whilst some Councils have introduced things like putting its parking services online, and text reminders of bin collections, many are way behind. In the same way some parts of the NHS are innovating, in Morriston hospital for example the kidney dialysis service allows patients to make decisions about their treatments by giving them digital access to their information through their smartphone or computer. Other parts of the NHS are still in the pre-digital age - hospital appointment letters are still routinely posted, and it’s not possible to access services online.

To scale up and sustain this good practice the panel has recommended a significant programme of change.

We call for the appointment of a Chief Digital Officer for Wales and a Minister for Digital with authority right across the public services; a Digital Strategy that ensures problems are addressed from the point of view of the member of the public who will be using the service; and a team of specialist digital ‘squads’ that can be called upon to help organisations develop workable solutions.

The panel makes six recommendations to the Government:

1. Design public services around the needs of the user

2. Establish clear digital leadership in Wales

3. Develop and introduce digital service standards

4. Identify skills and capability gaps and develop a plan to close them

5. Create an approach to incentivisation and spend controls

6. Agree a clear and ambitious timetable for change demonstrating pace and scale

There are two main themes to our findings: leadership and know-how.

At the moment there is a gap at the top - very few of the leaders of our health boards, local authorities and senior civil service can be said to be confident digital leaders. In fact, most don’t feel embarrassed to admit they don’t really understand it. They will often talk about Digital as an off-shoot of IT. It’s not the same thing, technology is one of the ways digital change is implemented, the key bit about digital is designing services that work for people.

Those who are successfully adapting services use what they call an agile way of working. Their starting point is to properly understand what the problem is from the point of view of the person who is using the service. They assemble small teams with a mix of skills to jointly tackle the problem through every step of its journey: from end to end. These are teams of digital experts, often drawn from the commercial tech industry and combined with in-house government talent. Peru, Argentina, United States, Mexico, Canada, Italy and Australia are just a few of the countries with such units, joining the ranks of long-evolving government technology programs in pioneers like Estonia, Israel and Singapore. They trial as they go - they iterate. This has the advantage of identifying issues early and correcting them, reducing the opportunity for costly mistakes.They build a small solution, test it, fix it and try it again - at each stage referring it back to what the need of the end user is. They are open about their challenges and their failures. And when they get something that looks like it works they scale it up - or ‘build out’. And they keep iterating and improving.

This is different to the way most organisations - in the private and public sector - have come to address digital problems. Most think digital is about technology, it’s not: But leaders often use the terms digital and IT interchangeably, and tend to approach a problem that can be addressed through procuring an IT solution alone - often via a private sector vendor.

And the second theme is know-how. One of the main constraints (and there are a few) for real digital change is capacity - there simply aren't the bodies around with the mix of skills required to bring about change. The British Gas Data Science Centre in Cardiff have emulated the digital music service Spotify in assembling 'Squads' (or teams) of digital specialists who can be deployed across the organisation to work on solutions to problems that have been identified. These are multi-disciplinary and each has someone with similar skill sets - for example there's a User Researcher in each.

Each of these Squads cross-pollinates - the specialists don't just work in their own team but they also work across teams with their own expert peers working on other projects. This way silos can be broken down, and experienced shared - and the squads should have access to a wealth of public sector data.

The panel recommends that NHS Wales, local government and central government each host a number of multi-disciplinary Squads that would work on iterating solutions to user-identified problems.

The work in each sector would be overseen by a Chief Digital Officer of their own - a CDO for NHS Wales, a CDO for Local Government, and a CDO for WG (and Sponsored Bodies). These would double up as Deputy CDOs for Wales and, together with a Chief Digital Officer for Wales, would provide collective leadership across the Welsh public sector. Together they would provide expert scrutiny and support to teams, inculcate learning by setting digital standards and spend controls, and help upskill the workforce through scaling up good practice. And they’d be accountable to a clear Ministerial lead at Cabinet level.

This approach would place each part of the Welsh public service on an equal footing. There would be no question of the Welsh Government telling councils what to do, but instead working with them as partners to understand user need and provide capacity to solve problems.

Each of the multi-disciplinary Squads would share experiences horizontally across their peers working in different parts of the public services, so a user researcher working on a problem in Conwy Council would share experiences with user researchers working on separate problems in National Resources Wales or in Cardiff & Vale University Health Board for example.

This could help break down the silos within and across public bodies, and make best use of scarce resources. Open and transparent sharing would lead to the realisation of the ‘Once for Wales’ principles.

We need to use digital to enable us to ask for the public services what we actually want, rather than how to put up with what systems we are given. This is a big change agenda. It will require real leadership resources and a willingness to change. If we continue to fail to act on the expert recommendations that have been made we will waste more money and our public services will fall further behind.

We must not let that happen. We have a responsibility to act.

Lee Waters is the Welsh Labour AM for Llanelli and Chair of the Welsh Government’s external digital panel.

Sunday, 2 December 2018

Do we need a CDO for Wales?

We're reaching the end of the beginning of the work of the panel on Digital transformation of public services that I'm leading for the Welsh Government. I'm hoping our initial report will be out in the next week or so.

One issue we've been debating is whether Wales needs a Chief Digital Officer.

As I touched on in the last blog there is currently a gap at the top - very few of the leaders of our health boards, local authorities and senior civil service can be said to be confident digital leaders. In fact, most feel embarrassed to admit they don’t really understand it.

Most highly paid people in public organisations can talk easily about money, people and buildings. Some of the better ones actually recognise the importance of culture, but how many can, or more worryingly want, to tell the digital story that will drive their evolution? As one insider told us "Digital in public sector is still largely a space for techies and this needs to change. It needs to become the preserve of the majority, the people that know what life is like in the wind and the rain".

Very few public bodies have their own CDO, or board level leadership for digital. What's more, there is no Chief Digital Officer for Wales. While the Welsh Government has a Chief Digital Officer (who has done lots of good things from close to a standing start), her role has no budget, and its writ doesn't run much beyond Cathays Park - and does not extend to the NHS or Local Government. She's the CDO for WG, not for Wales.

There's a strong argument for having a ‘guiding mind’ for digital developments across all public services.

The real debate is over what that role would do. Should we be building a strong centre with powers to mandate, set digital service standards, and to veto duplication and waste across the public sector - much like the UK Government did when it established the Government Digital Service? Or should we have an evangelist that can promote best practice, encourage, lobby, tell a story, but without any powers to direct?

"The more centralised you go the more vulnerable things are to gridlock of decision making, budget cuts etc. I’d sooner see every public body commit to a serious CIO/CDO role on their management teams as well as a head of design (more importantly almost)" is the view of one experienced digital innovator.

But is it a false dichotomy? To see real cultural change perhaps we need a serious commitment from each public sector organisation AND a strong leader with status and power to guide?

The history of public sector organisations in Wales working together is not an encouraging one. If this debate gets caught up in the debate over who has 'sovereignty' it may be doomed from the start. Perhaps there's a middle way?

One of the main constraints (and there are a few) for real digital change is capacity - there simply aren't the bodies around with the mix of skills required to bring about change.

I blogged previously about the approach the British Gas Data Science Centre in Cardiff have copied from from digital music service Spotify. They have assembled 'Squads' (or teams) of digital specialists who can be deployed across the organisation to work on solutions to problems that have been identified. These are multi-disciplinary and each has someone with similar skillsets - for example there's a User Researcher in each. It's worth watching this video to see how it works

Each of these Squads cross-pollinates - the specialists don't just work in their own team, they also work across teams with their own expert peers working on other projects. This way silos can be broken down, and experienced shared.

It's beginning to work in British Gas, which still bares many of the characteristics of the large public sector organisation it once was. Could it work in the Welsh public sector?

If a group of these multi-disciplinary Squads was hosted in the centre working to a common set of digital standards, and under the direction of a high-status Chief Digital Officer, and were able to be deployed across the public services, could this be to a catalyst for wider change?

Friday, 23 November 2018

It's about leadership, innit?

So, I'll get to the point.

Leaders matter. Digital transformation is hard to do. And its impossible unless leaders 'get it'.


Digital literacy among the senior civil service of the Welsh Government, the Chief Executives of Local Authorities and Health Boards, and Sponsored Bodies, is generally poor. And the same is true of political leaders.

Digital transformation doesn’t succeed by chance. It takes decisive leadership that is prepared to challenge and be challenged, be resilient, make difficult decisions and focus on delivery.

The Welsh Government has a Chief Digital Officer (who has done lots of good things from close to a standing start) but her writ doesn't run much beyond Cathays Park. She's the CDO for WG, not for Wales. There is no ‘guiding mind’ for digital developments across all public services to spread best practice, or to set digital service standards, or veto duplication and waste across the public sector.

When Socitm assessed the digital leadership of authorities they found that most Councils do not have a Chief Digital Officer, with many still seeing digital as an offshoot of ICT. They found that digital strategies, where they exist (nearly a quarter of Council did not have one), “do not completely embrace the full potential of the digital agenda”. Local Authorities are not making the most of citizen data to design services, not using digital engagement to co-produce services, and not using open data as a key enabler. Socitm also found that there is too little benchmarking with organisations outside Wales.

This isn't a counsel of despair, its a call to action. And Socitm did find some good practice, but they argued that digital excellence will only be sustained where there is a culture change, development of digital skills at every level, and a strategy that is embedded across every level of a local authority.

Its much the same in the NHS. There is some great practice in pockets. I visited the Welsh Renal Clinical Network in Morriston hospital yesterday. They've created a digital transformation of the service delivered to kidney patients, including e-prescribing and patient access to their test results and treatment plans. Its saved time and money, as well as improving patient outcomes and the patient experience.

It can be done.

But they've achieved it despite, not because of the system.

The Wales Audit Office report, the Parliamentary review of Health and Social Care in Wales, and the recent Public Accounts Committee report all identified leadership and skills as a significant issue

The WAO report pointed out the problem of not having digital represented at board level in the Health Service. And PAC went further in recommending a review of the senior leadership capacity in terms of skill-set and governance within both NWIS and the wider NHS Digital Team. “We were not convinced that the senior Welsh Government officials and top NHS executives have the detailed technical understanding needed to give NWIS a clear direction and challenge its performance and decisions” the committee said. 

Scotland's Local Government Digital Office has a programme to equip current and future leaders with the skills they need to deliver digital transformation. Likewise their impressive DataLab has a stream of work focused on developing skills and talent, including helping senior leaders understand data and digital and their own role in harnessing it (I should declare an interest, they gave me some free socks).

Shouldn't we be doing something similar (not the socks bit)? Delivering digital capability to the senior leadership across the Welsh public service seems critical to me. The panel is considering recommending developing a mixed model of support for all senior leaders, including training courses and providing Agile coaches and mentors.

What would help do the trick?

And of course as well as up-skilling senior leaders, we need to do the same for the whole workforce. We need to create a People Strategy that can assess the skills, capabilities and ambition of our public sector workers, and provide the training and support that they need to deliver in the Digital Age. This is also an opportunity to create a diverse and inclusive public sector workforce.

What do you think would make a difference?

Wednesday, 21 November 2018

Does NWIS needs a reboot?

I've been blogging about each of the reports written for the Welsh Government in recent years on the state of digital in our public services as part of the digital panel I'm leading for the Welsh Government. My last blog on the subject covered the studies on digital in the NHS and summarised the findings of the Wales Audit Office Report, the Parliamentary Review and the WG's response 'A Healthier Wales'.

The final piece of the jigsaw is the Public Accounts Committee (PAC) report 'Informatics Systems in NHS Wales' (full disclosure - I was heavily involved in writing it).

The limitations of digital in NHS Wales have been features of a series of reports by the National Assembly’s cross-party Public Accounts Committee over the last two years. In its inquiries on hospital catering, as well as medicines managements, the committee uncovered delays of up to a decade in delivering IT projects. Following the Wales Audit Office report in January 2018 the committee held hearings before issuing a unanimous report, Informatics Systems in NHS Wales, in November 2018.

The report said NHS Wales was “still not fully ready to openly recognise the scale and depth of the problems”. 

The Welsh Government has yet to formally respond but a statement by NWIS suggests it will be defiant when it does.

In his foreword to the report the Chair of the Public Accounts Committee Nick Ramsey said "In 2003 the iPhone was yet to be invented and Google Gmail and Skype were yet to take off. It was in this same year that the Informing Healthcare strategy was launched, with an electronic patient record for Wales at its heart. The other technological innovations of that year have not only been realised, but leapfrogged several times, and yet NHS Wales remains far away from a seamless electronic portal for patient records...We trust our inquiry and this report will be a wake-up call to all those involved in harnessing the power of digital innovation to improve healthcare in Wales. We believe it’s time for a reboot".

The Public Accounts Committee said it was deeply concerned about the slow pace of delivery of modern informatics systems across the NHS in Wales; support and oversight arrangements suffer from underlying weaknesses, and - echoing the concerns of the earlier WAO report - added there’s a cultural problem which may be masking wider and deeper problems.

“Digital transformation requires an open culture, the Committee found that the culture at NWIS [the NHS Wales Informatics Service] was the antithesis of this. We are particularly concerned at the apparent lack of openness and transparency across the whole system…Troublingly this mind-set seems to be consistent with that of the health boards, and the Welsh Government teams working alongside NWIS, as the Committee found a collective reluctance to openly discuss the true state of progress” the committee said in the opening of its report.

Public Accounts Committee concluded that the way NWIS was seeking to achieve its primary project, a full electronic patient record, is outdated. “Though the 2003 vision for an electronic patient record is clear, “it is now quite old”. And by the time a full electronic patient record is achieved, key systems will be out of date”, the report said. It noted that the processes and tools for building software have significantly advanced over the past 10 years. For example the ability to access GPs via smartphones throughs apps stood in stark contrast with the NHS Wales GP application, My Health Online - “which is not delivering anything like the benefits it set out to achieve”.

Furthermore the electronic patient record development is based on acquiring separate systems from a number of suppliers. Whilst this was an understandable approach a decade ago (when the programme was begun) the Committee was very concerned about the NHS becoming increasingly dependent on the private sector. “Building our own systems can be a better solution than simply buying them in via large procurement exercises” the report said.

The PAC enquiry’s criticisms centred on several themes:

Leadership & Governance 

The Welsh Government and NHS bodies have not been intelligent clients of NWIS. Given the WAO finding that only 7 of NWIS’ 30 projects were on target for timing milestones, the Welsh Government must consider whether it can have confidence in the competence and capability of NWIS as currently constituted.

Despite their “evident dissatisfaction about progress” the report said the committee saw no evidence that health board executives are scrutinising the work of NWIS (indeed there was confusion amongst them about how they would do this).

NWIS’ lines of accountability for its performance are not clear. PAC noted that “there is considerable confusion around leadership of informatics in Wales with multiple individuals described in our evidence as having leadership roles and responsibilities”.

The committee said NHS Wales lags behind the private sector in having informatics and ICT expertise represented at Board level and were disappointed with the reluctance of health boards to consider this. “We understand the point made by the Chief Executive of the NHS, that other areas can make a case for greater representation at board level and there is a risk that adding more people leads to an unwieldy board. However, informatics is so fundamental to the future of healthcare that we consider the case for stronger board representation to now be compelling” the PAC said.

It recommended a review of the senior leadership capacity in terms of skill-set and governance within both NWIS and the wider NHS Digital Team. “We were not convinced that the senior Welsh Government officials and top NHS executives have the detailed technical understanding needed to give NWIS a clear direction and challenge its performance and decisions” the committee said.


The Committee heard that some of infrastructure in the NHS’ data centres was over seven years old and needed replacement.

There were 21 outages of national systems between January and July 2018 – one outage every 9 days. PAC recommended the Welsh Government set out a clear timetable for putting the digital infrastructure of NHS Wales on a stable footing.

NWIS reported that it had been working on replacing this infrastructure over the past two years. £1.32 million funding had been provided by the WG to upgrade the WLIMS (Welsh Laboratory Information Management System) infrastructure, upgrading data storage and replacing 7 year-old hardware which is over seven years old. The committee regraded the proposal by the Director of NWIS to spend a further £6m on replacing servers as “throwing good money after bad, when the alternative is to switch existing system to a modern Cloud infrastructure”.

The report found that NWIS needed a greater focus on undertaking routine maintenance, but was struggling to manage the tension between funding innovation and maintaining legacy systems. “It is a no-win scenario with either more delays to much needed new systems or risks of serious incidents and outages. This is essentially robbing Peter to pay Paul and not an acceptable or sustainable position” PAC reported.

This approach was typified by the experience of CaNISC, the online computer system for Cancer Services. PAC uncovered that CaNISC has a red risk rating because Microsoft stopped providing support for the system in 2014. Witnesses flagged concerns that it is a cyber-security risk as there is additional work to plug security holes and apply “patches”. The Committee was concerned that it has taken so long to reach the stage of having a business case, when it must have been clear long ago that it needed replacing.

PAC found that the evidence received on service outages and resilience was a microcosm of the wider picture. “Funding is stretched, with NWIS balancing the competing priorities of sustaining infrastructure while under pressure to deliver new systems. There are deep concerns about the lack of clarity around accountability and responsibility when things go wrong and putting things right again. We heard of delays in NWIS, in this case in producing reports on the incidents. We also heard of difficulties in sometimes getting NHS bodies to engage with NIWS in identifying the causes of problems. We remain concerned that the issues around system outages have not yet been fully resolved” the PAC report said.

The Committee said it saw no substantial evidence of take-up of Cloud services from NWIS, nor grasp of the opportunities presented by the Cloud. It also said it not see sufficient evidence of a deep level of Technological or Digital understanding, and little evidence that the benefits of Cloud computing are being fully identified.

Funding & Procurement

PAC said that without significant additional resources it do not think that an electronic patient record can be rolled-out in a reasonable timeframe. But added: “By additional resources, we do not necessarily mean new money for the NHS that would otherwise go to other public services. A key rationale for the electronic patient record is that it makes services more efficient and reduces mistakes, which are costly to put right. The NHS as a whole needs to take a longer-term, collective view of investment in informatics, on an invest-to- save basis”.

The committee was told that the cost of delivering the vision in each NHS body and NWIS’ contribution to National systems is tentatively estimated at £484 million on top of existing budgets, with £195 million capital and £288 million revenue. Of this £484 million, £196 million is identified as needed by NWIS, with the rest required by Health Boards and NHS Trusts. The Welsh Government accepted the Auditor General’s recommendation to carry out a full cost-benefit analysis of the investment. This is tied to wider reviews of the overall approach to infrastructure and system design and prioritisation.

“NWIS is currently overstretched and improvement requires far more than simply pouring more money into the existing organisation, which is unlikely to achieve significantly different results” the report said.

PAC said the Welsh Government should be very open-minded when looking at the funding options for NWIS. “It is clear that there needs to be a shift away from CapEx towards more revenue-funding. Also, we have the view that Digital / IT is still seen as a cost-centre, rather than an opportunity to improve patient care and experience, and reduce the overall Administration and Clerical budgets” the report said that a simpler and more transparent arrangement is required.

During the inquiry, the Welsh Government agreed to adopt the Government Digital Service design principles under a new Welsh technical standards board. The standards adopted by the Welsh Government are based on the principles of the Agile approach to developing digital services. However, the procurement processes run counter to an iterative approach. The ‘5 case model’ for business cases may be too rigid as it involves specifying everything up front. The Committee welcomed the work the Welsh Government is carrying out with the NHS England and the UK Treasury on how to adapt its business case process to allow it to take full advantage of the digital approach and agile approach to developments.

Capacity & Capability 

The Public Accounts Committee said NWIS needs between 5 and 10 new senior leaders, and the roles of NHS Wales Chief Information Officer and NHS Wales Chief Clinical Information Officer need sufficient authority and prominence within the Health Service.

Capacity also needs to be freed up within the system. There was criticisms of health boards for not sufficiently freeing up clinical time, so that clinicians can getting involved in developing and testing new systems; it noted that the Auditor General’s report found that NWIS’ staff are frustrated at the difficulties they experience in getting clinicians to engage. However, PAC added that leadership should not fall to a small group of interested clinicians.

The report noted threats to NWIS’s existing capacity and capability as a result of the persistent criticisms that it had attracted from the reports cited above. PAC said the scrutiny had created reputational damage which had “impacted the attractiveness of NWIS as an employer in a market for technical skills which will always be very competitive”. The Committee argued that a more radical solution be considered. A lot of the work of NWIS is not NHS-specific (this includes cyber security, Cloud computing and software development processes), much of this is undertaken across all of the public services in Wales, especially South Wales which already has well regarded Digital functions such as those at the DVLA and ONS.


1. The Public Accounts Committee receives six monthly updates from the Welsh Government on progress in implementing the digital recommendations in the Parliamentary Review and the Auditor General’s report in order to enable it to revisit these issues.

2. The Committee recommended that the Welsh Government set out a clear timetable for putting the digital infrastructure of NHS Wales on a stable footing.

3. The Committee recommended a review of the senior leadership capacity in terms of skillset and governance within both NWIS and the wider NHS Digital Team.

4. Any additional funding apportioned to NWIS needs to be tied to reorganisation to achieve the improvements that are required.

5. We recommend that NWIS look to increase its work with other public bodies, including those from UK Government. This approach could work on a number of levels, from the sharing of good practice on recruitment to the creation of Government Digital Service which could work across multiple agencies

Saturday, 17 November 2018

Can we fix it? Yes we can!

So I think we’ve established that things aren’t where they should be, and we’ve known this for quite some time. So what’s holding us back?

Stripping it back to first principles I think there are two key issues emerging: leadership, and the concept of who services are designed for.

On leadership, it is commonplace for a Chief Executive of a Health Board or a Local Authority to admit (without embarrassment) that they don't really 'do' Digital. When pressed, most will talk about digital interchangeably with IT. Many of our public services leaders are still on analogue mode. That has got to change (more on that in another blog post).

On the concept of who services are designed for, I was struck by a conversation I had with the leadership at NWIS. When I asked if they had people specifically working on User Research I was met with blank looks. Whilst they do have people engaged in research and there is some user feedback, there are no posts in NHS Wales - or in Welsh Local Government - dedicated to understanding, designing or testing services from the end user point of view.

Worse still, I don't think there's a clear idea of who the 'user' is for many of our services. Indeed, reading the Welsh Government's key document of the future of the NHS A Healthier Wales: our plan for health and social care, you could be forgiven for thinking that the users that the system is being designed for are the clinicians not the patient.

In contrast the Scottish Government have adopted a new Digital First Service Standard which has the need to understand user need as its first principle

I visited Edinburgh and met the team working on a new Scottish social security system, they explained how on this major project they were putting a strong emphasis on User-Centred Design.

This is clearly easier to achieve on new projects (or 'Greenfield' to use the GDS terminology) than it is on legacy projects (or 'Brownfield'), and they acknowledged they had to make trade-offs as this very complex project is implemented to a hard deadline, but the philosophy behind it is clearly the right one. 

The team have developed a user engagement strategy and have embedded User Centred Design professionals in service teams. By consciously building design capacity, and fashioning multi-disciplinary teams, they are working to change the culture of how public services are thought about.

Instead of approaching digital as we traditionally have thought about IT projects  - where once we've procured a new system we've regarded the problem 'fixed' and safely left alone until the system becomes outdated (at which point another big private sector IT system will be procured) - the ideas of continuous improvement familiar to industry should be applied.

I heard a similar story at the British Gas Data Science Centre in Cardiff. The utility company have a Data Science team based in Cardiff working on projects for the company right across the world. Whilst the utilities are private companies they still resemble the large siloed organisations they were when they were in the public sector, and we can learn from the way they are evolving in the digital age. Peter Sueref, their Data Science Director, explained how they have drawn inspiration from digital music service Spotify. To implement Agile in bringing about digital change the Data Science team have emulated the Squad approach used by Spotify. It's worth watching this video to see how it works 

Could this work in public services?

The current plan for Welsh Local Government is to appoint a Chief Digital Officer based in the Welsh Local Government Association. Should we instead be thinking of a central squad of digital experts that can work across public services (health and local government included) that would use agile project and development methodologies to work on practical problems identified from within the sector?

I'm attracted to the idea, but what do you think?

Wednesday, 14 November 2018

Health checks...

The only thing dull about last week's Public Accounts Committee report into 'Informatics Systems in NHS Wales' report was the title.

I played a part in writing the report but I'm no longer on the PAC and my focus has shifted to what we do about the problems it catalogued. As previously noted, I'm chairing a panel on Digital transformation for the Welsh Government and blogging what we're up to and thinking about as we go. And rather than reinventing the wheel I've been looking at the reports already published (but not yet fully acted upon) to see if there are conclusions and recommendations we should revisit.

And guess what? There are!

In this post I look at three reports on digital in health: the WAO Report, the Parliamentary Review and the WG's health strategy 'A Healthier Wales' (I've read them so you don't have to!). And won't add my commentary at this stage, but I'll let you digest my summaries, and simply quote Meatloaf: "Read 'Em and Weep".

Wales Audit Office report

In its January 2018 report Informatics systems in NHS Wales the Wales Audit Office examined the performance of NWIS, the NHS Wales Informatics Service, in delivering an electronic patient record over the previous four years. This vision was initially described in the 2003 Welsh Government strategy Informing Healthcare (albeit without a deadline being set), and revisited in 2015 strategy for digital health and social care which found NHS Wales ‘still working towards the goal of delivering a comprehensive electronic patient record’. “In that time, the global informatics market has changed significantly. In the USA, in particular, there has been rapid progress in rolling out electronic health records, albeit in a very different healthcare system. More generally, there has been a growth in open source technology, which is available to use and develop for free, and also greater joint working between different providers of applications to ensure they can communicate with each other” the report said.

The Auditor General for Wales looked in detail at the delivery of six projects by NWIS as indicators of the wider approach to informatics and found that while the vision was clear the delivery was marked by significant delays.

The Wales Audit Office found that NWIS allocated 10% of its resources for new ‘projects’ with the rest ring-fenced for pre-existing national systems or contracted services. Of the 30 projects that NWIS was rolling out, just seven were on target for timing milestones.

The Wales Audit Office concluded that ‘NWIS does not have a clear strategic approach to prioritising which new systems to include in its programme or for prioritising resources to those already in the programme’. Indeed, it found that attempt to prioritise “generally result in NWIS having more, not fewer, priorities”.

The Auditor General found considerable frustration within NHS Wales, with many of the barriers known to have previously impeded progress in the past still being reported as part of its review. Frustrations on the part of both the health boards and NWIS were having a significant negative impact on the relationships between them: “NHS bodies are deeply frustrated over the slow speed of delivery of national systems. NWIS staff also reported some frustration at what they saw as a lack of direction and engagement from health boards, particularly clinicians, in designing and rolling out new systems’ the WAO found.

They also found disagreement within the NHS on what the ‘Once for Wales’ principle means in practice. “The description of Once for Wales and interoperability in the 2015 strategy are ambiguous and there are competing interpretations across the NHS. On the one hand, there is a view that Once for Wales means that all organisations must accept national systems developed or procured by NWIS. However, there is also a view that the emphasis on interoperability means individual organisations can develop or procure their own systems, provided they are compatible with national systems and those in other organisations” the WAO report said.

There was further disagreement on the point at which a system was considered delivered, for example, NWIS considers the Welsh Clinical portal to be ‘live’ however, health boards were reporting that Doctors found the functionality difficult and were instead continuing with paper referrals.

The report found significant weaknesses in NWIS’ governance arrangements including a lack of independent scrutiny and unclear lines of accountability. Reporting of progress and performance to the Welsh Government and the public tended to be ‘partial and overly positive’.

The report noted that the NHS had been under-investing in digital capacity for some time. In 2003 the independent review of the NHS by Sir Derek Wanless had recommended that the NHS across the UK should be spending 4% on ICT. However, by 2010-11 total spending on ICT across the NHS (including by NWIS) stood at around 2% of total expenditure, whereas NWIS’ 2016-17 budget is around 0.8% of health spending (excluding depreciation).

Parliamentary Review of Health and Social Care in Wales

At the same time as the Wales Audit Office was reporting so too was the Parliamentary Review of Health and Social Care in Wales which published its final report in January 2018.

Whilst noting that there is much to commend regarding the established of core digital and infrastructure and shared services arrangements in Wales, the expert panel noted the concerns and frustrations of users and providers of digital services in Wales. “Activity is just too dispersed and stretched, and lacks overall commitment around a unified vision and set of priorities. The principal concerns include integration challenges (centred around the need for common standards, and data and systems interoperability), information governance, cultural and behavioural issues, and the limited capacity and capability to deliver change and innovation at pace” the report said.

Led by the previous Chief Medical Officer for Wales, Dr Ruth Hussey, the Parliamentary Review Wales stated that Wales has “a real opportunity to better leverage its technology and infrastructure assets to deliver a transformed and seamless system”. It set out ten recommendations for change, one of which was to ‘Harness innovation, and accelerate technology and infrastructure developments’ (Recommendation 7), and it set out detailed proposals in an annex to the report.

Its core principle was that all technological innovations should be grounded in four mutually supportive goals – ‘the Quadruple Aim’ to: a. improve population health and wellbeing through a focus on prevention; b. improve the experience and quality of care for individuals and families; c. enrich the wellbeing, capability and engagement of the health and social care workforce; and d. increase the value achieved from funding of health and care through improvement, innovation, use of best practice, and eliminating waste.

It set out the following detailed proposals for change:

• ‘Progressing at pace’ the Digital Ecosystem project developed by NWIS (NHS Wales Informatics Service) and the Life Sciences Hub, providing NWIS and Health Technology Wales with platform access and analytics to accelerate innovation and support product adoption. The focus should be on initiatives which have the maximum impact and reach and generate the most beneficial outcomes, are scalable, support individual and community-based care, and are readily integrated and adhere to common standards.

• The Welsh Government, together with all digital and infrastructure service delivery organisations in both sectors, should reassess their strategic priorities and the opportunities for more collaborative and consolidated working in the light of its report. This should include enhancing and accelerating the Technology enabled Care Programme, as there may be a shift to primary, social and community care initiatives and associated technology enabled care.

• Clarifying the ‘Once for Wales’ policy, and agreeing prioritisation criteria to be applied to all existing and candidate initiatives. This should underpin a robust ‘stop, start, accelerate’ review to better focus efforts on a smaller number of key system user-centred initiatives, including regional and local exemplars with ‘national promise’. This requires an aggregated and rationalised view of the full portfolio of digitally-enabled initiatives. Core national ‘foundation’ initiatives, including the Electronic Patient Record (EPR), the gateway/portal for citizens and professionals to access multiple information sources and services, and initiatives delivering significant efficiency benefits, should take precedence.

• Common standards and platforms should be mandated whenever possible across both health and social care sectors to support interoperability and integration in the future. They should explore the opportunity to integrate and consolidate local authority, LHB, Trust and national infrastructure and systems (which will require a new funding model). Legacy systems should be replaced via an Infrastructure Refresh Plan aligned with a national infrastructure ‘route map’, although the immense challenge here should not be underestimated. Robust infrastructure, system and information security (which includes cyber security) must be of paramount concern, with clear and agreed protocols and principles in place to meet all legal, regulatory and advisory requirements, and with response plans regularly tested.

• Health Education and Improvement Wales (HEIW) should oversee the development of a cadre of trained clinical informaticians and leaders, who in turn can help strengthen efforts to develop a learning health and care system, and quality improvement expertise. Social Care Wales (SCW) should also ensure that training in digital skills is a priority. The Welsh Clinical Informatics Council (WCIC) representatives could potentially develop into a leadership group of Chief Clinical Information Officers. Programme and project teams should be multidisciplinary from the outset, with appropriate medical and social care involvement and system user input. Users should champion and lead the delivery of new systems, with a keen eye on the challenges of adaptive change (as highlighted in the Wachter report).

• Both NWIS and NWSSP (NHS Wales Shared Services Partnership) should have greater national presence and authority linked to a strengthened national executive and look to extend collaboration (e.g. e-learning). The hosting and accountability arrangements at the Velindre Trust may no longer be appropriate. The Welsh Government should evaluate alternative models for consolidated national governance, including the HEIW arrangement, as well as the leadership seniority and governance board presence of both organisations. This should include considering leveraging the remit of NWSSP to deliver wider public services in Wales, but will require legislative change for NWSSP to provide services beyond the NHS.

• NWIS, in particular, should review and rebalance its resourcing profile such that design, development and support activities are ‘rightsourced’ with the optimal balance of internal digital, health and social care staff including clinicians and front-line staff, third sector, third party, system users, industry and academia. They should explore opportunities to better pool and share LHB, Trust and NWIS IT resources. Wales should look beyond its national boundaries and exploit co-operative alliances with other national health bodies with a similar agenda, including NHS Scotland where a close relationship already exists.

• We would support the recommendations from the Informatics Task Force and the resulting Statement of Intent from the Welsh Government to develop a national data resource, with workstreams focussed on information governance, national data resource, clinical information standards and workforce development. Health and care systems must take full advantage of the value that data and information offers to underpin new systems, drive decision making, improve health and care quality and exploit future business intelligence and data analytics initiatives. This will require health and social care professionals to be fully reassured regarding the integrity, security and sharing of data, and for citizens to be fully informed and to have provided appropriate consent.

• NWIS should finalise and share its design, development and service principles, including agile development opportunities, ‘process before technology’ considerations, evidence based redesign, inclusion, user involvement, and outcomes-based benefits assessment principles (for example, Government Digital Services (GDS) have a set of digital service standards).

• NWIS and NWSSP should adopt a common, staged and disciplined business case process to underpin prioritisation and investment decisions, in part to ensure that initiatives genuinely add value, and not workload, to professionals and service Innovation, Technology and Infrastructure users. Independent gateway assurance and post-implementation outcomes based benefits realisation and ‘lessons learned’ reviews should be mandated and shared, together with clear internal communications to manifest the value of initiatives to staff, citizens and system users. NWIS and NWSSP should have leading roles on the NWEHVIG (NHS Wales Efficiency and Healthcare Value Improvement Group) to help raise productivity, reduce unwarranted variations and waste, and promulgate best practice (including regarding the Carter report recommendations, where NWSSP is already fully engaged with the NWEHVIG).

• We understand that NWIS’ 5-year 2016-21 Informed Health and Care strategy requires substantial funding on an all-Wales basis. If so, both prioritisation and technical and allocative savings are all the more crucial, and we would wish to see this clarified, and to understand the impact this may have on the funding envelope for other work. The Welsh Government, NWIS, and Finance Directors should evaluate alternative funding models, including assessing the opportunity to consolidate and integrate LHB, Trust and NWIS infrastructure, systems and resources, and the reinvestment of cashable benefits from change initiatives, and optimise the mix of capital and revenue funding sources. The Welsh Government should consider if core ‘Once for Wales’ funds should be pooled and ring-fenced rather than allocating a subset to LHBs. We assume there is a full current asset register for NHS Wales and professional procurement and contract management processes in place.

• The existing internal digital maturity assessment should be supplemented with external benchmarking assessments of both NWIS and NWSSP vs. peer organisations and ‘best in class’ to highlight areas of opportunity. This should include resource profiling and stakeholder feedback elements to improve co-production and alignment.

A Healthier Wales: our plan for health and social care

In its response to the Parliamentary Review, A Healthier Wales: our plan for health and social care, published in June 2018, the Welsh Government recognised the role of technology in detecting illness sooner, supporting better clinical decisions and delivering personalised care which “instead of waiting for something to ‘go wrong’, our system will use all the tools available to ensure that things ‘stay right’”.

It did not, however, address each of the specific recommendations of the Parliamentary Review.

The Welsh Government reiterated its aspiration to bringing information from different providers together on an integrated platform through a single electronic patient record. “Having all the information needed about the individual, or about groups of similar people, will deliver better outcomes by helping clinicians at every level to make better decisions” the response stated.

It committed to ensuring “delivery at pace locally, across organisations and nationally”. It said its ambition is to provide an online digital platform for citizens, to give people greater control and enable them to become more active participants in their own health and well-being. “This will help people to make informed choices about their own treatment, care and support: finding the most appropriate service for their needs, contributing to and sharing information about their health and care, managing appointments and communications with professionals, and working with others to co-ordinate the care and treatment they need, so that it is delivered seamlessly” the response said.

It acknowledged that Digital technology develops at a very rapid pace, and it expected to see new opportunities and challenges throughout the life of this plan. “We cannot predict fully what those will be, but we will be more agile in how we respond to emerging technologies such as artificial intelligence, machine learning, precision medicine and genomics” the report said.

It concluded:

“We will invest to develop the skills we need within our own workforce, for example to make better use of clinical informatics, and to drive digital transformation projects. We will also ensure that our digital architecture, and the way we work digitally, is more open to the outside world, in ways that support economic development in Wales, and which offer exciting career opportunities, as well as improving health and social care services. To do this we must focus our efforts through a revitalised ‘Once for Wales’ approach which sets standards and expectations and where common platforms are mandated where there are clear benefits of doing so”.

And set out a series of measurable action points:

Tuesday, 6 November 2018

Are Councils making the most of digital?

So as part of an attempt to open up with work of the panel on Digital transformation that I'm leading for the Welsh Government I'm blogging what we're up to and thinking about

I'm conscious that there's already quite a bit of analysis out there on the state of digital in local government and the health service. In my last post I revisited David Jones' report from 2015, and in this post I'm looking again at the report on the digital maturity of Welsh councils.

In April 2017 digital consultants Socitm advisory published the findings of their research on digital maturity in Welsh local authorities. They assessed how Councils were performing in six ‘digital dimensions’.

When it came to digital transactions - the extent to which citizens can request services from the local authority website - Socitm found that Councils are not keeping up with the expectations of the public. No local authority provides an end to end, seamless transaction for all service requests. Whilst broadly comparable with councils in other parts of the world they said Welsh local authorities’ direction of travel over the last five years is more volatile than the UK as a whole, and lags significantly behind the customer experience citizens now commonly have with the private sector. Whereas sites like Amazon digitise the whole shopping process, from picking a slot convenient to them, adjusting an order, making payment and providing feedback, councils tend to digitise part of the online transaction, like reporting a missed bin collection and the rest of the process remains paper based.

Socitm assessed the digital leadership of authorities. Most Councils do not have a Chief Digital Officer, with many still seeing digital as an offshoot of ICT. They found that digital strategies, where they exist (nearly a quarter did not have one), “do not completely embrace the full potential of the digital agenda”. Councils are not making the most of citizen data to design services, not using digital engagement to co-produce services, and not using open data is not seen as a priority nor is it used as a key enabler. Socitm found that there is too little benchmarking with organisations outside Wales, and whilst there is some good practice, digital excellence will only be sustained where there is a culture change, development of digital skills at every level, and a strategy that is embedded across every level of a local authority.

The appetite for being Smart with Data exists in most organisations the report found, but data maturity is low. ”Big picture, holistic, intelligence based decision making is not well evidenced across the 22 local authorities” Socitm said. Councils manage most data in silos and do not use it effectively to drive faster decision making and service design. The research found ‘substantial appetite’ for more work on data mining and interest in developing a single citizen account portals. However, no local authority volunteered to become part of the GDS (Government Digital Service) pilot for a single system for verifying identities online, preferring to wait for a more mature version of the product, Verify, to emerge.

Citizen oriented design, the fourth digital dimension examined by the report, is where digital services are being designed from the point of view of what citizens want (as opposed to what the local authority thinks they need). Instead of actively involving citizens in redesigning and changing processes from the start to the end, Councils are primarily focused on achieving short-term savings by moving some transactions online (often procured from private sector vendors). Furthermore, in contrast to other parts of the UK, Councils in Wales are making little use of the GDS design framework because of a lack of awareness or capability to use this approach.

Levels of digital exclusion are higher in Wales than in England and need to be addressed through access (network infrastructure initiatives, as well as making equipment available), skills, motivation and trust to maximise levels of digital inclusion. Socitm found this is widely recognised in local authority strategies but despite efforts to provide access to Wifi and computers in public buildings, along with digital learning sessions, digital exclusion remains high across most areas of Wales. They conclude that addressing it is “an expensive ambition’.

The final digital dimension assessed by Socitm was Digital Staff. The report found a lack of evidence that councils were embedding digital skills into their workforce strategies and thinking ahead of the need for digital skills and capabilities in the future. Digitised workflow was present though not mature, and the approach was often driven by property asset strategies to minimise the number of buildings they had manage. Too few were using cloud computing, there was little evidence of the automation of staff processes, such as submitting expenses, nor of the use of digital tools such as Facebook or WhatsApp for collaborating. Socitm said there are likely to be good opportunities for further digitisation of internal processes but 8 of the 22 councils said they did not have sufficient capacity to deliver their digital requirements, The report found some enthusiasm for a central team of digital specialists that could be shared between local authorities to help them grow their own talent in this area.

Socitm report concluded that digital maturity will never be complete as new possibilities emerge in the marketplace any authority that rests on its laurels will drop down the digital maturity ladder. Its potential use in reducing on services is not being exploited and Councils need to think beyond websites and fragmented process digitisation to truly add value, Socitm said.

As part of the research project each Council was given their own results from the Digital Maturity self-assessment tool to review their own strengths and weaknesses, and encouraged to inform the Welsh Government on recommendations they were particularly enthusiastic about. It is not clear if this has happened.

The report made a series of recommendations:

Short term initiatives

Digital events - digital networking and learning events, addressing a CEO and Director audience, as well as Digital leaders and practitioners. These events should not be exclusively Wales focused; they should be used to inject wider thinking and challenge with speakers from other geographies and sectors as well.

Establishing a Virtual Digital Hub (an on-line forum for discussion and document sharing as the foundation to bring together the local authorities around the digital agenda and establishing joint priorities) would support more digital networking events.

Facilitated collaboration There is a need to enable greater collaboration across the local authorities in such areas as:
  • Shaping the digital strategy for the nation, helping to inform the Digital First strategy.
  • Digital toolkit development or adoption of GDS standards. 
  • Establishing priority projects; smart data solutions, on line account, account verification. 
  • Digital skills development. 

Longer term considerations

More shared systems - Each local authority is currently investing in their own digital initiatives. With budgets under pressure and a need for savings an investment strategy would accelerate the delivery of the nation’s digital agenda, more common platforms, joined up procurement activities would help accelerate the digital agenda across the local authorities.

Tactical digital solutions - Areas of common platform in the medium term could be the investment in a single tool in the following areas:
  • Web chat solutions 
  • Single email system 
  • HR, Finance and Payroll systems 
  • Social media listening and crowd sourcing tool 
Infrastructure and digital inclusion - The rollout of super-fast broadband “Superfast Cymru” is a critical enabler to the digital agenda. Like other UK Broadband projects there remains an issue with the hard to reach locations and with “take-up”, where the infrastructure is deployed to the pavement hubs, but citizens choose not to procure it for themselves. Further consideration is needed in relation to those areas that will not have super-fast broadband; plans on addressing black spot areas is key.

Digital citizen insights - There is a substantial appetite to deliver collaborative solutions for managing citizen data and delivering citizen insights. As well as providing a better digital citizen experience, this also can drive better service design. There is an opportunity to explore this; to manage this with pooled data at a Welsh citizen level, rather than at an Individual local authority level. Such a project could drive down costs and deliver more citizen insights, as many citizens are citizens of more than one local authority. It could also form the basis of a truly valuable repository of open data. While protecting individual citizen anonymity, such open data could inform planning and regeneration both from a public sector and a commercial provider’s perspective. A collaborative approach to citizen insight, driving down cost and ensuring consistency, would be welcomed by most of the local authorities that participated in this research.

I'd be interested in your thoughts on these finding and recommendations. Are they fair? What do we do about it?