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:


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