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 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
“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.
Resilience
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.
Recommendations
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
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.
Resilience
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.
Recommendations
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
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