Y Pwyllgor Cyfrifon Cyhoeddus - Y Bumed Senedd

Public Accounts Committee - Fifth Senedd

23/04/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Adam Price AC
Lee Waters AC
Mohammad Asghar AC
Neil Hamilton AC
Nick Ramsay AC Cadeirydd y Pwyllgor
Committee Chair
Rhianon Passmore AC
Vikki Howells AC

Y rhai eraill a oedd yn bresennol

Others in Attendance

Anthony Tracey Bwrdd Iechyd Lleol Hywel Dda
Hywel Dda Local Health Board
Huw Vaughan Thomas Archwilydd Cyffredinol Cymru
Auditor General for Wales
Karen Miles Bwrdd Iechyd Lleol Hywel Dda
Hywel Dda Local Health Board
Mark Jeffs Swyddfa Archwilio Cymru
Wales Audit Office
Mike Ogonovsky Bwrdd Iechyd Lleol Aneurin Bevan
Aneurin Bevan Local Health Board
Nicola Prygodzicz Bwrdd Iechyd Lleol Aneurin Bevan
Aneurin Bevan Local Health Board

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Claire Griffiths Dirprwy Glerc
Deputy Clerk
Fay Bowen Clerc
Clerk

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

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

Dechreuodd rhan gyhoeddus y cyfarfod am 14:23.

The public part of the meeting began at 14:23.

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

I welcome Members to this afternoon's meeting of the Public Accounts Committee. Headsets are available in the room for translation and for sound amplification as well. If our witnesses have any trouble with those, we can help you out. Can Members ensure that any electronic devices are on 'silent'? In an emergency, follow the directions from the ushers.

No apologies have been received today. Do any Members have any declarations of interest they'd like to make at this point? No. Great.

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

Item 3. We have some papers to note. First of all, the minutes from the meeting held on 16 April. Happy to note those? Okay.

4. Gwasanaethau Gwybodeg GIG Cymru: sesiwn dystiolaeth 2
4. NHS Wales Informatics Service: evidence session 2

Moving on to the substantive item on today's agenda, can I welcome our witnesses to our evidence session on the NHS Wales Informatics Service? This is our second evidence session, so thank you all for coming in today to help out with our inquiry. Rather than me going through it all, would you like to give your name and position for the Record of Proceedings?

Good afternoon. I'm Mike Ogonovsky, I'm the assistant director of informatics at Aneurin Bevan Local Health Board.

Hi. I'm Nicola Prygodzicz, I'm the executive director of planning and performance at Aneurin Bevan health board.

14:25

Hi, I'm Karen Miles. I'm executive director of planning, performance, informatics and commissioning at Hywel Dda university health board.

I'm Anthony Tracey. I'm the assistant director of informatics at Hywel Dda health board.

Great. I'll kick off with the first question. Overall, the auditor general’s report found significant weaknesses across a wide range of areas. What's your take on the diagnosis of the auditor general’s report, and are current arrangements fit for the purpose of delivering an effective informatics service? Who wants to take that? Nicola? Karen?

Okay. Yes, I think the overall report has been well received. I think people understand and recognise a number of the issues that are raised in the report. I've also seen, obviously, Dr Goodall's response to that report accepting the recommendations that have been made, identifying that progress has been made in a number of areas, but there's still a lot of work we've got to do. Both Karen and I sit on the national informatics management board, and I think we've got a key role in influencing the work that needs to be done now in terms of addressing all of the recommendations that have been set out in the report and make sure that we are content that the future system that we put in place addresses the weaknesses that have been raised in the report.

The problems have been known about for some time, haven't they? So, how will the public have confidence that, this time around, the issues will be addressed?

I think there a number of issues. I think we need to make sure that we do address all the recommendations and that the new arrangements we put in place and the enhancements we make to the process are robust and that people feel assured by that. But also, in terms of our delivery, it is making sure that we do deliver on the plans that we've got in place now so that people do actually, as a user of the service and staff working in the system, see a difference in the speed and the pace at which we actually implement some of the future plans.

I think it was a really opportune checkpoint for the service and the Welsh Government. We're all part of the national informatics management board. We're now recognising the collective responsibility. We all agreed the report and discussed the recommendations and what that felt like from each perspective. We've made massive inroads since the fieldwork was done, which was about 18 months ago, I believe. You can actually feel that in the national informatics management board now. It's far more transparent. There is a real willingness to look at performance management and usage in a way that's more meaningful to both our clinicians and our patients, so actually questioning what the uptake and the usage of all our national systems are. There's definitely greater transparency in now drawing up a collective prioritised plan and work programme, and that's having its third airing today, actually. We're not at NIMB today because we're here with you. But they're effectively going through what that prioritised work programme will look like. There's no doubt about it—the NWIS work programme for 30 projects was too much, and now the service is actually sitting collectively and going through it and sifting through what the work programme needs to be. That's been our job of work for the past 18 months, really, in terms of understanding where our collective priorities are.

Steve Ham and Andrew Griffiths gave evidence last week to the committee, and they spoke about where the responsibility lies. How would you see that between NWIS and the local health boards? Is one more responsible than the other?

I think it's a collective responsibility, personally, because NWIS evidently have the expertise in terms of the national systems. But in terms of our responsibility at health board level, we've got to ensure that the key elements that ensure a successful programme are in place. We've got to make sure that hardware is there, infrastructure is there. We have to make sure that we can get the clinical engagement. It's more than just bringing in IT systems; it's about actually transforming services. So, that's obviously a board discussion in terms of what this can bring to the transformation agenda within health boards. So, obviously, NWIS has expertise, but it has to be collective in terms of the delivery on the ground.

And just before I bring Lee in, is there more that health boards can do to speed up the rate of progress, because we have been waiting some time?

There's always more we can do. I think the issue is that we're all in different places. So, it's about how you get the step change nationally, and I think that's what the work's been doing—actually understanding where people's baselines are, what their obstacles to step change and the win-wins for everyone would be, and that work is what's driving our prioritised national digital plan at the moment.

I wonder whether you could just help us understand what you think are the systemic problems, if you like. In the paper from Hywel Dda, it says that there is,

'Too much tolerance of delays in signing up to national initiatives, so creating delay in the overall national rollout',

and a,

'Lack of responsiveness to patient and clinical need'.

These seem to be pretty profound and fundamental statements, and it's good to hear there's progress and so on, but there's a danger we just superficially move on and say, 'All is well' when, actually, you're identifying some major problems here. So, I wonder if you could tell us a little bit more so we can understand what is behind those statements.

14:30

I think from our perspective, the reason why we put those statements in was to give an acknowledgement to the findings of the WAO report and to say that those issues were there. There wasn't a prioritisation. Effectively, there wasn't that collective thinking. Because of it, then, when delays came in, either because people had infrastructure issues within their legacy systems they couldn't address within the timeline, it meant that people had a domino effect waiting for their upgrades and that not being as transparent as it needed to be in terms of key enabling work.

What the WAO report has done is actually made us all step up to the table in terms of what our key issues are within the health boards, whilst still trying to then inform and be part of the prioritisation at the national level. So, that's what we were trying to do there; we were saying that there had been a downside. I think the work that we're doing now is addressing that, but it's been the last 18 months' work as part of NIMB.

Do you think that the culture's there within the health boards to be able to challenge NWIS and the Welsh Government on this? Because it seems to me you're all now saying in public that, yes, the analysis is correct and there are frustrations in the system, and the WAO report clearly identifies that. But that's not something that has really been much known outside of the system, and I just wonder is there that culture that isn't too cosy where there is robust challenge to address the problems that are, clearly, widely understood?

I've been involved as part of NIMB for the last two years, and I definitely think the culture is changing, where health boards are very much trying to influence all of the different elements of the system. We've got a local agenda to deliver. We've got our own plans. We want to make sure that we provide our staff and our public with a digital future as much as possible. What we've also tried to do with some of our recent projects is be absolutely clear about our responsibilities as a health board and our part to play, and, ultimately, NWIS and Welsh Government as a wider programme. As Karen described, we've all got a collective responsibility, and I think, going forward, more transparency about our interdependencies and our expectations is a key culture change from perhaps where we've been before.

But I just wonder where we would've been without the WAO report, and without the parliamentary review, which has thrown light on these issues—

And I personally think—

Can I just briefly finish? I just think there's a culture within a one NHS Wales that we're one big happy family together, where it's frowned upon to raise these issues outside of your committees. It's all very well all of you saying now, 'Yes, there's a problem. Yes, we're very frustrated.' None of this would've come out without these reports. So, how can you reassure us that you, as you say, as partners in this, have sufficient robustness to challenge when there is a tolerance for delay in the system?

Going back to what your issues are raising, I don't think there has been one happy, cosy family. We do challenge each other across the system, and I think the issues were evident in advance of the Wales Audit Office report. Some of them we recognise, some of them we're dealing with. I think it does help really strengthen the issues a lot, but we were already dealing with a number of these issues anyway.

From a health board point of view, we've got an information governance committee, which NWIS attends, and we try to use that opportunity to ensure issues that we have with NWIS are raised. We have regular meetings with them, where we take that opportunity to raise some of our issues with them through that collaborative approach across Wales. Many health boards, if they've got common issues, we work together against NWIS. So, I don't think we're all afraid to challenge each other. I think that's absolutely not correct. There is pressure in our system from us delivering services on a day-to-day basis to make sure—. And we know the opportunities that technology can bring to the way that we deliver care. It's about having a sustainable and efficient future and doing what the public expects. Therefore, that pressure on us means that we have to have those difficult and hard conversations at a national level as well.

But they haven't resulted in any changes, have they? That's the problem. Maybe now, more laterlly, things are beginning to change, but, for a long period, the frustration was building up and there weren't changes, because that's clear from the analysis and the WAO report.

I could refer to an example within the health board with the Welsh community care information system, which has been—. We've been having conversations and trying to get our plan in place for that for some 18 months now, and many of those issues have been around making sure that when we've got a very clear plan, we understand the resource implications. It is clinically driven, and driven from the service. They're involved in the design, and it is a complex system. We're talking about 4,000 users and we're not going to be able to do it just as a health board. We've got huge dependencies on NWIS as part of the integration agenda and we have been working really closely with them around a memorandum of understanding about the part they need to play, our part, what the national programme—. And all of that was happening in advance of the report, because we recognise, from some of our lessons learnt from the past, that unless we address some of those issues with this new system, we might come against problems further down the line. So, I think there are some examples where we can show that we are doing things differently.

14:35

And I think, in lots of ways, we've really benefited from a really clear policy view now in terms of understanding what well-being of future generations and what our responsibility to work together collaboratively really feel like, and where the parliamentary review will take us, as a journey. So, as Nicola said, it has actually allowed us to press back in terms of knowing that the pace, scale and ambition within this means that digital has got to be part of our priorities going forward. So, I think a different conversation has emerged with the different policy direction in the last two or three years as well.

Very briefly, then, if I may. We've talked about the pace, scale and ambition of change and you've mentioned that there are planks in place now that weren't there previously. What else would be necessary, in your view, on a national level, to increase that pace and scale, bearing in mind the huge agenda in terms of austerity and cuts in Wales?

Just briefly, I think some of them are set out in the audit report, but I think we do, absolutely, need to be clear about what the priority programmes are. We are trying to do too many things, sometimes, and spread our resources thinly, and we need to be really clear about where our investments need to be and what benefit we get, again, from a user, whether that's staff or the public, and how all the systems will work together. So, I think the issues around the governance and leadership are key issues, really, as recognised in Dr Goodall's letter. There's more work to be done around that and I think that's absolutely critical. So, for me, getting that accountability performance management right and getting that priority list so that we're clear about what we're going to deliver, by when, over the next few years, I think will give us greater pace.

We're drafting a national informatics plan at the moment with our key priorities and milestones for delivery and what success looks like in terms of benefits realisation. There's a lot of work ongoing at the moment—a task and finish group—in terms of really being clear about what that benefits realisation will need to look like for both the patient and the clinician.

Really, from our perspective, aligned to that is looking at how we can get innovative sources of finance together to get behind that to give us the pace that we're looking for, and I think what's helping in terms of the parliamentary review, in terms of health and social care, is that it does mean that we can look at our integrated care funding, it does mean we can look at invest-to-save and it does mean that, for us, we're looking at what we can get from the city deal. We've got to be far more innovative on the digital platform—work outside of the NHS and work collectively and collaboratively with other partners, and then, with all the prioritisation work that we're doing now, we can actually get the pace and the step change that we want in it.

Just before I bring in Vikki Howells, I should have thanked you earlier for the evidence you provided. The committee was a bit bemused going through both papers. You'd expect there to be similarities because you're both health boards, but, if I can take paragraph 17 in Aneurin Bevan's evidence, for instance, it's a carbon copy of paragraph 23 in your evidence. So, was there a common author to both of these reports?

No. I think it's probably the fact that we both sit on NIMB. So, we have been speaking to one another because we've got different perspectives, Nicola and I, as directors of planning anyway, with digital in our portfolios, so we were trying to, as much as we could, say where we had consensus as health boards.

So, you liaised with each other when you produced—. It's just that, as I say, you often see similarities in reports, but with this, I just wondered whether there was a common document, for instance, that you both had access to as health boards. I mean, that would probably be—.

No. We shared our evidence in an open and transparent way.

Yes. We did; we shared it.

Just to follow that up, had there not been encouragement from Andrew Goodall that the health boards take a common approach in responding to this?

No. We've not been in correspondence with Dr Goodall since we were requested to come to the Public Accounts Committee. But Karen and I, obviously, sit in with directors of planning and informatics and we work very much on the same page from a health board perspective, and we sit on the national informatics management board, and, naturally, we collaborate on many issues of our business. Obviously, we were sharing our thoughts about the report, which we've done previously. But obviously, we're coming from slightly different perspectives from different health boards with different issues, so we've obviously got our own local issues as well.

Okay. That's funny, because I've seen the minutes of a meeting in which Andrew Goodall said that a consistent response was needed.

14:40

I think it's going back to the fact that the discussions that we've had over the past 18 months—it has been a collective and a collaborative way of actually holding the mirror up that came from the auditor's report and actually saying, 'Okay, what do we and don't we agree with?' So, we have walked through the recommendations as a NIMB collective, and I think it was to try and say, once and for all, 'Are we going to move together on this?' And I think that's been very helpful.

Well, I, personally, am not aware of any issues where we disagree. I think we all—I think, to be honest, we've got quite a consensus on the issues that need to be addressed in terms of a more robust system, going forward. So, I'm not aware from prior to the audit report, or now, where Hywel Dda and ourselves and some other health boards—. We're in different places with different systems at a local level, but the general consensus of a way of moving forward to implement the digital strategy—. I think there's a general consensus. I don't think it's an issue across health boards where we've got huge disagreement.

Right, I've been promising to bring Vikki Howells in now for the last 20 minutes, so, Vikki Howells.

Thank you, Chair. 'Once for Wales', it's a lovely slogan, isn't it? But, behind the scenes now, is there a shared understanding and agreement between health boards and NWIS as to what 'once for Wales' actually means in practice?

I'm going to give Mike an opportunity to come in, because he's—. But, before I bring Mike in, I think what is important for us is—and we're very keen in the health board to do this—. Once for Wales is, for me, you take a user perspective, whether that's a member of the public or whether that's a member of staff, and this is about, when somebody has an interaction with the health service or social care, their record is there—every interaction, whether it's in primary care, ideally social care, or whatever hospital within Wales, you'll be able to see that record, and, for the member of staff, they can see the history of that patient. That's ultimately what we are striving to do, and I think that's very much what the focus of the 'once for Wales' discussion has been about, moving away from just perhaps a system focus. But I'll let Mike give a little bit more, perhaps, context to that.

It's how we get the system to actually work to achieve that though, isn't it? That's obviously where the issues are.

Yes. I mean, obviously, the system in terms of the NHS is very big and very, very complex, very multifaceted, as well. So, where we're getting to, I think—and we're making good progress with the initiation of a technical standards board that's been pulled together now by Welsh Government colleagues to start looking at taking a standards approach. So, without trying to get too technical, you worry more about the standards and the content and less about the application. So, if you like, we build three-pin sockets and we know that they fit with a three-pin plug. Because applications can move quickly, technology moves very quickly, and, in the public sector, in the NHS, we know we're behind the curve of some industries. But we've also got to make sure that it's safe.

We're certainly seeing in Europe, in Scandinavia, colleagues in Scotland and Ireland, that we're all getting to that place—in England as well—in terms of addressing common standards. That becomes really important when, like us, we're on a border and some of our patients move across for primary and secondary care to England and vice versa, and, for Betsi Cadwaladr, where tertiary traffic tends to go the north-west of England, then it's a common set of standards that you need to be able to do so that you can translate from one context of care to another safely and efficiently without very complex integration.

But, even before we get to the stage of cross-border working, isn't it the case that even within Wales now we've got so many different workarounds—? The Wales Audit Office report refers to this, that boards are putting in place their own workarounds because the NWIS system is so slow to come to fruition, and lots of those workarounds don't talk to each other, even within Wales.

Without taking a standard-based approach, you could buy a single application for Wales or develop it, but without using it in the same way. This is where the usage and the business change and the clinical change become really important. If we're not using the same terminology in terms of SNOMED coding or ICD-10, then we're going to be comparing apples and pears when we're moving information, even from one department to another within a health board. So, the idea of 'once for Wales', certainly from an Aneurin Bevan perspective, was to really try and promote the adoption of standards on a national basis. So, even if we are using different systems—we operate a lot of systems underneath the national umbrella, so there are 242 different IT services that we run in Aneurin Bevan, in addition to supporting the national programme. All of those make up the electronic patient record. It's not a case of getting delivery of a system—as Karen said—and switching it on. All of those systems need to be able to integrate and talk to each other. It's a tall order and there's a legacy of a number of years where standards weren't in place, but, along with the rest of the UK and Europe, we're now looking at adopting the same standards and being able to implement systems that talk to each other.

14:45

Some do, some don't. I wouldn't want to go through 242 in terms of the services that we use, but there's a SNOMED programme that NWIS are hosting, and, any procurements that we do, we're now looking at which standards from a technical perspective in terms of integration, but also from an information perspective in terms of the content that we're putting in it.

I think the key thing is really that our main technical systems that deal with patient care all link and speak to each other. As Mike rightly points out, there are 242 in Aneurin Bevan, we have 160-plus systems, and our main clinical systems that deliver patient care do speak to each other. I think it's quite right, over the last 18 months, two years, we've been looking at developing that a lot further. I still think there is some more work that we can do and we're in the process of doing that, and that's the kind of message that we want to get out there to the public, really. That's what we're trying to do.

Okay. And Hywel Dda university health board's written submission identifies several problems with 'once for Wales', including tolerance of delays, legacy infrastructure and lack of response to patient and clinical need. Are you confident that these problems have been or are being overcome?

Yes, I am confident as part of the work we've been doing as part of NIMB. There's no doubt about it: the past 18 months we have been working towards a collective vision in the work on 'once for Wales', reframing that definition, actually understanding the baseline, the legacy systems that people are actually dealing with. The philosophy in terms of having common standards and common information—technical and information—standards are really important now in how we go forward.

There's no doubt about it, we have got a few workarounds. We're waiting for a radiology upgrade. That was one of the things we were talking about in terms of our workarounds. But what we're trying to do is make sure we can operate within the platform, the Welsh clinical portal, that we can migrate when we get our upgrade. It's just when you're in the queue sometimes it's a bit frustrating, but I think the thing about the prioritisation of the digital plan is that it should make the waiting time for system upgrades much less, because we should do it all together and create that common step change together. That's what I'm hoping that we'll get out of the new, revised plan in terms of our digital strategy.

Thank you. Mike, you were referring earlier to England. How do you think Wales compares now to other parts of the UK in terms of rolling out the electronic patient record?

It's a very big question. I think that there are relative strengths and weaknesses within each of the home countries. Everyone's taken a very different path, and, as we know, Scotland's been through some significant change in how they're delivering national and local systems, and England certainly has very publicly changed how they've gone about it. I think on a local level there's more autonomy, and obviously some trusts and regions in England have had pump-prime of funding to global exemplars—in Bristol, for instance, where we've got some colleagues that we talk to—where they're able to really aggressively equip all their staff with mobile devices and start to deliver applications on a faster scale, as it appears. But, having said all of that, I think that we're also ahead of the game and we shouldn't do down some of the achievements that we have made in the last 10 years and in the last two years in terms of—you know, the primary care record being available in secondary care is a very big deal and it's used very heavily, particularly in places like emergency departments where patients may not be able to describe accurately their problems, and now it can be looked up very quickly, the drugs they're on, any allergies, et cetera. But I wouldn't say that we're ahead or behind. I think it's that a very different approach is taken. I think Scandinavia, potentially, is an area where, in terms of standards, they have a greater maturity in terms of where they've got to on a regional and national basis.

And, to the rest of the panel, do you think there's anything that we could be doing to learn from or to work collaboratively more with other parts of the UK?

I think there is, yes. I think in the last evidence session Andrew and Steve rightly pointed out Scotland. We've done quite a lot of work over the last five to 10 years with Scotland on the Scottish Care Information Gateway, and getting their referral system into Wales. So, I think, yes, we definitely could learn from them. We have contact with Scotland and we have contact with Northern Ireland and Ireland as well around how we can develop systems and develop services going forward. So, definitely, yes, there are lessons to learn. I think they're learning from ourselves as well. As Mike rightly points out, the GP record in an emergency care setting and elective care setting now is a huge breakthrough. We've got clinicians now that can see the GP record, which they've never had before. They don't have that in Scotland, they don't have that in the other parts of the UK, so they're trying to learn from ourselves as well. But there are definitely things we can learn from our neighbouring countries, yes, definitely. 

14:50

Okay. And a final question from me, then. In the auditor general's report, he points out that the informatics market has changed since NHS Wales first developed plans for the electronic patient record, which is no surprise when these were plans that were first mooted in 2003. Is the approach in Wales still right and are there any specific technological or market developments that you feel we're not keeping pace with?   

I think we're at the beginning of a journey with machine learning, deep learning, artificial intelligence. We are making some progress now. We've got a good modelling collaborative in Wales, and our academic partners are actually quite strong in this area. And we've just agreed some partnerships with some industry partners in an R&D perspective to see how we can start applying that to some business models, including radiology and wound imaging, where we can start to look at how we're going to move forward. 

I think we probably haven't been as aggressive as we could have been over the last decade to do that, but, as you've heard, there are a number of competing priorities, and I think putting in the infrastructure and getting some of the basics right is important. And I think for us to really leap with things like AI, we're in a very unique position in Wales where we do have national repositories, and, if we implement standards alongside that, then I think we could have a global reputation in terms of progressing that forward. 

Yes, a couple of quick questions. Just on that last one, when the NHS is still the country's largest purchaser of fax machines, it's a little difficult to have too much confidence that we'll be at the cutting edge of AI machine learning. Do you think that NWIS is the best placed body to do this, because we know that 90 per cent of their budget is running existing systems and only 10 per cent is on innovation? Do you think there's a case for splitting those two functions out?   

I've got some sympathy with NWIS's position in the terms that the WAO report pointed out. They've got a number of different roles, and I think that there's often a tension between those roles. I think where we want to get it to, and we're certain that we want to influence this, is to have more of an ecosystem where in a local health board you can be a bit more agile. You're doing things on a smaller scale; you can prototype. So, for instance, we're working with some commercial partners around electronic patient flow and capture observations—on a small footprint, but we're evaluating that with our health board colleagues and with NWIS, which is something that if we tried to do that on a national basis straight up then the costs are pretty astronomical, and we need to bottom out where the benefits lie. 

In terms of fax machines, I'm afraid I don't recognise that from my position. We still have the use of fax machines, mostly as a redundancy in the advent of needing to do business continuity, but we've certainly made great strides in clinical communications between primary and secondary care and out-of-hours through the use of things like the Scottish SCI Gateway, which has been implemented pervasively, and, certainly from our perspective, digital dictation and sending electronic communications back to primary care from secondary care.  

You don't routinely use fax machines in your health board, do you? 

I think that fax machines are used where they're needed. I don't recognise your point that we're the largest purchaser of fax machines. 

Well, the NHS as a whole is. In terms of your standards point from earlier, clearly, the NHS in England learned from its disastrous roll-out of IT the importance of setting standards. Now, NHS Digital, as I understand it, and the Government Digital Service have a respected set of standards that are seen to be helpful. Why is it we can't adopt those? Do we really need to reinvent the wheel?  

From a personal perspective, no, I don't think we need to reinvent the wheel. We need to look to other areas where there are exemplars where we can share best practice. I do think we need to do it in an informed way and we need to look at the evidence, but I think the more that we look outside, hopefully, the faster that we can go in terms of delivering for our patients. 

14:55

Okay. That's not a terribly illuminating answer. Does anybody have any idea why we're not doing it?

Potentially because we're integrated health boards. And the work that we've been doing in terms of delivery against the Welsh clinical portal has been to actually bring together primary care. In the eventual fullness of time, community care will be there. The standards that we will be adopting will be going across the whole pathway. Now, that's not to say that we shouldn't adopt standards that have had some rigour obviously in other parts of the UK; we can look there, but because we're looking at often a patient journey right through the pathway, and we're operating as integrated health boards and sharing our information in that way, it means that the kinds of things you've got to do to ensure that the look-ups are consistent, that each sector is actually talking about the right patient, the kinds of things that I think Andrew spoke about in terms of the information governance and ensuring patient safety, those things would have to be worked through too.  I'm not saying it's not achievable or deliverable. It's not something we've not come at; it's because we've come at it from the angle of an integrated health board and an integrated platform of delivery in NHS Wales. 

As I understand it, the English standards are fairly high level, so they wouldn't preclude you from adopting— 

No, probably not. But they'd maybe not cover the whole work area that we cover, in terms of primary, secondary and community. 

It's fair to say that in England, Scotland and Northern Ireland, we have developing standards. So, there are lots of different layers: Professional Records Standards Body and clinical coding standards, and then up to in terms of how you develop user interface standards that would be in a clinical application. So, again, it's sort of multifactorial in terms of where we are collaborating on a UK basis, or even a European basis. But that was the point of trying to bring in the technical standards board. So, alongside the Welsh information standards board, we could start to actually say, 'Right, well let's adopt those. Let's look at those and process them, understand how we'd apply them to our landscape' and—

But there's no good reason why you couldn't be using many of the standards in England at the moment. 

It's the difference between employing the use of standards on a local basis and then taking that so we can do it on a national basis. And, as Nicola said, for the electronic patient record to follow the patient from health board A to health board B, we need to make sure that we're doing that collaboratively. 

Just to add to Mike's comment there, we are using the same technical standards as England. So, the same messaging fabric that is in England, we've adopted that in Wales and they've adopted some of our messaging fabric. So, the message between one system to another system, we are adopting—

But not the NHS Digital, the Government Digital Service standards?

The technical standards they use and the messaging fabric behind that, that's what we have been looking at to adopt from an NHS Wales perspective. I think what we're trying to talk about is the standards between each of the systems, the look-ups, et cetera, how the systems actually interact with each other. The actual pure messaging fabric goes below that. From a purely technical viewpoint, we are kind of standardised across NHS Wales and NHS England at that point. 

Yes, but a little earlier, Mike had said he couldn't think of any reason why you weren't using the English standards. We can't be doing both. We can't be both using them and accepting that we're not utilising them. 

I think there's two dimensions to the standards debate. I think there's two dimensions to the standards. There's the technical standards, i.e, the way the systems talk to each other, and also there's a standard if you point around how the systems are created, et cetera. Does that make sense?

I was trying to answer specifically against what you're talking about in terms of whole GDS. 

And, so, what we haven't done is said, 'We are now employing GDS standards in Wales.' What Anthony's pointing out is that, by use case, we are looking at using industry standards in terms of application protocol, interfaces—

Thank you, yes. He's answered a question I didn't ask, so thank you for answering what I did ask. 

I suppose to sum up and provide some assurance, we don't want to recreate the wheel and reinvent the wheel on things where there's good evidence that already exists. I think it's about taking some of that, those standards that already exist, putting them into a Welsh context, so that we can move forward as quickly as possible as a general principle of what we're trying to do. 

Yes, indeed. And, finally Chair, I was trying to establish whether we were doing that, and the answer to the question is that we're not doing that. We are adopting some technical standards, but the overall system standards that England developed, we haven't adopted them. 

That's what we're trying to achieve as the part of the 'once for Wales' agenda, in terms of implementing the standards board. 

And to me, a key part of the standards board is to look at that. 

We need to move on. So, I'm just trying to bring Adam in. Did you have a quick supplementary?

Yes, very quick. Thank you very much. Thank you very much indeed for this and all your statements. Last week, Estonia was mentioned, that their system is going to be somewhere in Wales, and I heard you a few times, Scandinavian, a skills sector, training centre, and confidentiality sector; there are a lot of other areas you have to cover with two systems, from two different parts of the worlds. Have you prepared for it?

15:00

I think that—. Sorry, could you—?

Last week, it was mentioned by one of the witnesses in Wales that Estonian programmes—that was mentioned by one of the witnesses here. So, today you've been saying about Scandinavian—Iceland being one mentioned. So, I'm a bit concerned. You know, two different systems. These days, the word is on cyber attacks, and all that, skills sector, training, all these areas, confidentiality in the systems. So I don't want siphoning out all the private, confidential information to the one, to another, and then goes to the other side of the world. That is, I think, bits from all different programmes, which doesn't look sensible.

Apologies. So, we're not off-shoring information or work to European partners, or to anywhere else. There are quite strict rules, and we've got a non-executive committee that oversees us specifically for security and information governance within the health board, and obviously Caldicot guardians and security responsible officers, et cetera.

What we do try and do is to get some learning from other areas, and so you develop contacts on social media, and we've been talking over Skype, over the last 10, 15 years. And we are aware that, in terms of the adoption of standards, these standards are sometimes global, or on a European basis; they are open source and they are being developed by the community, if you like, in terms of health informatics. So, it could be from Australia, or Denmark, that you're picking up pearls of wisdom, and trying not to duplicate all of the effort again. The challenge then is how you adopt that on a national basis, and take that forward. Scandinavia, Denmark in particular; I am aware of where I have had conversations with counterparts, started the journey of standards adoption in terms of semantic, or language, standardisation, about five years ago. And so they are a good place to learn from—bitter experience, as well as the successes and failures that they've had, and very open about it. So, they've been really helpful.

I think, generally, it's accepted, if we look back over the period since Informing Healthcare in 2003 first put health informatics, as it was known then, at the forefront of public policy, that progress has been slower than any of us would have wanted. Do you think that one of the reasons for that has been a leadership gap at the national level?

I'll answer as much as I can; I stopped being involved in informatics hugely since 2003.

I think some of the issues that are picked up in the auditor general's report, for me, are often—and also in our evidence statement—around, perhaps, what is not always a leadership issue; it's very much sometimes about over-optimism, in terms of what we can deliver, spreading too thinly some of those resource issues. And possibly, I think, we could have had strengthened accountability around when projects are going off track, being able to come in quickly, taking actions to get them back on track. They're multifaceted, when you look at some of the programmes—some are linked to the suppliers, sometimes it's a resource issue, sometimes it's the complexity of us trying to do things on an all-Wales basis. But there's nothing I particularly could pull out as just a leadership issue—I think there's a combination of those factors that has led us to where we are.

I'll bring you in in a minute, if I may, Karen. Just on the strengthening accountability when projects go awry, how do you think, practically, that could be done better?

I think some of the recommendations of the audit report are helpful in terms of how do you put perhaps more of an independent kind of scrutiny in. I think, in health boards, we've got our own day-to-day business, but then we have independent members. We have sub-committees where we have to provide a lot of assurance to some of our board members, and I think it's recognised in the report that because Enfys is quite unique in its structure, that might be helpful. I think: what's the role around the national informatics management board? We've talked about some of the improved performance management reporting and how we strengthen that, going forward, and I think, right at the outset, having a much stronger benefits case about what we're expecting to deliver by when, so that it's much easier to see when we're going off track. And I think they are some of the key learning that we are now trying to put into our business cases, going forward.

15:05

And similar to Nicola, really, I've only been in the hallowed world of informatics since 2015, and what I can see before then is the fact that when there was organisational change on the kind of level that we've had, to create the big integrated health board, what it did in terms of the IT platform was quite astronomical. There were four instances of Myrddin in our health board. In other words, every hospital had its own Myrddin footprint. So, having to walk back into what are very, very, very big systems, and trying to standardise them at a local level in order, then, to create the ambition and service the ambition of the Welsh clinical portal, it is quite a navigation. And with that, then, also, come the funding flows and also the vision to go forward, which 2015 brought us. 2015 helped us in terms of actually making us understand it, that we had to respond digitally through three or four lenses in terms of the work streams, and now it's being reinforced, which is really helpful, with policy and things like the well-being of future generations and the parliamentary review. So, all of those things are getting us to where we always wanted to be, which is a single record, but the way that you had to literally redesign the platforms to get there was quite a navigation. So, I think it's less leadership and more to do with the reality of dealing with a complex system on the ground.

Okay. One of the themes that emerges out of the auditor general's report is the need to be better at prioritising, and it's echoed in the parliamentary review, which has called for a 'stop-start-accelerate' review on informatics, so you know what I'm going to ask you now. What would you stop? What would you start? And what would you accelerate? 

Oh, that's really mean. [Laughter.]

Maybe give us an example in each, so we can roughly have an idea of your thinking.

Okay. I think one of the biggest issues that's coming out of us going through this prioritisation process is that everything is a priority to somebody, and when you start trying to take priorities off the list, it's extremely difficult, because we are ambitious and there are so many things that we want to do, and when you know the technology exists out there, we want to make a real difference to every group of patients and our staff.

The stopping is the harder bit, but I think we've got to stop some of—. Some of the smaller projects can be quick wins and make a real difference, but I think we've got to try to assess the projects that we're currently doing and try to have a better understanding of what impact that's going to have on benefit and stop some of those where, perhaps, the impact is less so, so that we can redirect those resources. I couldn't list off what particular projects there are, because there are so many, but it's something we're even having at a health board level, because some of those issues are mirrored at a health board level. We're talking about 240 different systems, and we've got so many projects, and we've started talking about which ones, if we stopped today, would have less impact, and let's put our efforts into those with a bigger benefit.

So, we've put a lot of resources. We talked about the Welsh community care information system. This is not a system development; for us, this is a key enabler of how we work differently with social care going forward, and it's very much got to be service and clinically driven. So, we have redirected and put some more resource into those types of systems.

We've got to make sure we do sustainability. If we've got key systems that are going out of life, we've got to make sure we replace those, and we've also got to make sure our infrastructure is fit for purpose, because there's no point bringing lots of new systems in if you haven't got Wi-Fi, you haven't got the hardware. So, we're having to make sure that sustainability is first, and then we are looking at those systems where we think they support the service agenda.

We're trying to make sure that the prioritisation of the digital agenda is driven by the service, not by the informatics teams, which is absolutely why we are making sure that we do that we do that in Aneurin Bevan—and also at a national level, where we've referred to the increasing role of clinicians now in terms of the clinical council and how we need them to ensure they are informing what are the priorities for health.

I was interested—. The 'stop' one is probably the most difficult, isn't it? In the private sector, they talk about killing projects. It's probably not language we'd want to adopt in the NHS, but the ability to actually end projects quicker is part of a business mentality if it's not delivering. Do you think sometimes in the public sector maybe there's an unwillingness—? Because there have been sunk costs, you've spent a lot of money on a project, and even though it's probably not going to deliver the benefits that you wanted, you still continue with it regardless. Is that part of the problem? Do you recognise that? There's no sentimentality in the private sector, is there, about a project? Whereas sometimes people can become quite invested in a particular piece of software, but the world has moved on and there's a better product actually maybe available somewhere else.

15:10

We would like to be able to adopt the kind of fail-fast way of working. It's really difficult to throw funding into innovative projects when you're in a position where there are so many competing priorities to meet patient need in particular in the health service. I think that's where we have to—. We're university health boards. Many of them are crying out for research and allowing us to get a proof of concept, to deliver on a proof of concept with them. I think that's where we have to go in terms of having confidence about how we proceed going forward and going into that more commercial, private sector fail-fast mentality.

It's very hard for us to do it alone in the NHS because there's so many competing priorities. There are medicines, there's our workforce—good places to spend money. The digital agenda then is always only improved by actually seeing how innovative and how much it can add value, but I think we've got to use a different route-map to do that, to get into that way of working that you're trying to draw us to, which we would agree is the better way to work, and it will be to use things like universities, develop it through research and education, and to take it through our small and medium enterprise mentality, through our institute for life sciences, those kinds of things. So, I think that's where we can get the window into digital transformation in the health service, and do it without actually depriving our patients of much-needed resources.

Thank you. Just a couple of quick questions about leadership structures at a local level. The auditor general's report makes the point that—. I don't think any health board has a dedicated single person who has a dedicated ICT role. That is true in both your cases. Do you think that's a problem?

At board level, sorry. A dedicated board-level executive director. I should have been clearer. Is that a problem?

Reflecting on the report fairly recently again, and thinking about my role—where I also cover planning and performance and obviously informatics, with quite a broad agenda—I think what is important for me is around making sure you've got a really strong assistant director of informatics and the team around that in terms of the technical expertise. I think what is important is in terms of the director who sits on the board. What's key is making sure there's a clear strategy, and actually it does align quite well with planning, as you need a really clear strategy: how are we planning to deliver that, what are the benefits, and whether you've got a proper programme approach. For me, it's about making sure you are appropriately representing the benefits that technology can bring and you're making sure that the board are well aware and understand what the digital agenda can deliver.

I personally have found that possibly not being a technical expert yourself and trying to get the board to understand what the digital agenda can deliver in non-technical language is really important, and that's something I've been working really closely with Mike and the team on—how we make sure this isn't seen as an informatics issue. This is a board issue, and in order for them to engage in that agenda, they need to understand it. It is technical and it is complicated and therefore it's trying to put the vision into a user's perspective in terms of how will you be able to use information from a staff perspective. That, I think, has seen a change in the engagement by the board.

So, I don't think you need to have a technical expert on the board. I think you need to have good clinical—. I think your medical director needs to understandably engage in the agenda. We've got a dedicated assistant medical director who kind of champions the digital agenda and we are trying to bring more people around him as well to make sure there's good clinical representation that's representing the technology agenda. But I don't think you need to have a dedicated IT specialist sitting at the board. That's my personal view.

15:15

I've got a similar portfolio to Nicola. I obviously couldn't do my job effectively without Anthony's expertise by my side, really. I think what Nicola's trying to allude to is the fact that it's what digital brings to service change and transformation, and I don't need to know how it works, I just need to understand what the outcomes are, what success will look like sometimes for our partners sitting with us at board—so, social services and local authorities—and to ensure that we can translate that through the digital agenda. I think it's the planning position. Actually embedding digital clinically in planning terms is really what's essential for the role. 

In Hywel Dda you have appointed a chief clinical information officer.   

Could you say a little bit about how that is going to contribute and how it fits in with the overall leadership structure locally? 

We did have one prior to the current incumbent who's just joined us in the last couple of months. But effectively where we see a difference is—obviously we're going out in terms of transforming clinical services—we can see in particular how community services need to join up with our primary and secondary care record. And effectively, what the clinical champion does is to first of all make sure that the kind of mobilisation for the workforce is there, both in the hospital, because many of our services are not as mobile as they need to be within the hospital—consultants being able to do things at bedside—. That's the lens that our CCIO brings to the table. He has an ambition for us to be paperless. We are saying we think we have to go 'paper-light' first, because of the fact there will be things that we'll have to work through in order to ensure that clinical safety is maintained. So, 'paper-light' is where we're going. He's got an ambition to mobilise community staffing. At the moment, as Nicola's been talking about, our Welsh community care information system is a long time coming. We are definitely looking forward to that in terms of the richness of information it will bring, especially to our demographic—the frail and elderly—who are served by community staff in the main. So he brings all of those things to the table. 

That's very helpful. Could I just ask, in going back to both your answers in terms of the board level, is this a digital expert who has deep expertise in this field or is it someone that actually can speak everyday language to everyone else within the team? 

The CCIO role in particular?   

I think it's a mixture for us in our health board. I think our CCIO can translate some of my talk into normal language and speak to clinicians on my behalf and identify that. Our CCIO has got a very keen interest in technology and it's one of the reasons why he applied for the post within our health board. So, for me it's been a great help in translating what our strategy is into a clinical view and understand what a clinical view is and translating that back into what I need to do from an ICT perspective. So, it's been a great help for me. 

We have an associate medical director of informatics, who is now part of the CCIO network, and is an orthopaedic surgeon and has been in that role for a number of years. I've obviously got an empathy with that; I'm a registered nurse by background and have come into this field over the last 15 years because I can see the potential, as my colleague Robin does. So, we take a real team approach to looking at it. The CCIO was really important in terms of patient safety assurance and advice on information governance, and we have a very well engaged programme board, and are establishing now a local clinical council where we can help prioritise against benefits.

I think the key thing in terms of where we are now is trying to strengthen that. I think if you go back to things like Nuffield's 'Delivering the benefits of digital health care', it talks about an engaged board being really, really important. I think that we have now a structure in place where we are accountable to our clinical futures board, that it's part of that blueprint, that footprint, of a clinical and business model that we want to achieve, rather than pushing IT products that we hope might be helpful. So, it's making sure that you've got the transformation bit first and that you've got the digital actually looking at how it enables that to help staff. 

15:20

Most of the future vision studies in this area say that digital is one of the areas where there's going to be the biggest healthcare gain in the future, in terms of better engagement with patients et cetera. Do you think eventually we will get to a position where this is sufficiently important that we will have a dedicated digital person on every health board in Wales?

It's difficult to answer that question. I think what we've got to have confidence in is that the structures and the plans we come up with will deliver that digital vision over the next period—you know, the key milestones over the next three years, five years, 10 years. Every meeting I go to, every conversation I have, it's all about technology being a key enabler for the way we deliver care in the future and helping us sustain some of the increasing demand on services. That's a real challenge about how you free up clinicians to help us design and implement the change. But I think it's less about having a digital person sitting on a board as to have confidence that we've got a robust plan and the right people prioritising that with strong clinical engagement and robust accountability structures. 

I'm interested in that, because that's not the finding of the auditor general. He specifically concluded that

'NHS Wales lags the private sector in having informatics and ICT expertise represented at Board level.'

You set that aside, do you?

I think what the auditor general's report says is that that's something that should be considered by boards, in terms of that is something to think about because that isn't—

'Considerable scope to strengthen leadership.'

So, it's a little stronger than that, I think. 

But I think it is about making sure there's strong leadership for the informatics agenda at the board. 

Well, he goes some way beyond that. I'd invite you to reread paragraph 16 of his report. I'm not sure you're fairly characterising his analysis there. Where it matters, I think, is in terms of the ability of the boards to challenge NWIS. One of the, I thought, striking conclusions of the report was that NWIS is not being entirely straightforward in its reporting of its performance. It said:

'We do not think the information gives those responsible for overseeing NWIS and the public sufficient balanced information to understand progress.'

So, if NWIS are not being entirely straightforward in giving the full picture of their status and there isn't the expertise at the board level to enable board members to challenge that, is there not a gap there that feeds into some of the weaknesses we've been discussing up to now? Isn't that why it matters to have expertise at board level?   

The way I read the report on page 16—. I think we do accept there's considerable scope to strengthen leadership across NHS Wales around this agenda, and there are a number of factors and ways we can do that. I was talking specifically about, in a local health board, do you need digital expertise sitting on the board? I don't think it quite says that. I think what we've got to have—

Well, he's here. We can ask him. But my reading of it is:

'NHS Wales lags the private sector in having informatics and ICT expertise represented at Board level.'

That would suggest to me he might think it would. Is it in order to ask the auditor general to arbitrate in our dispute over his words?

I think we're pointing out the fact that there's been certain evidence that informatics is becoming really crucial in how we drive forward a modernised health service. Is it right that it stays in one centre of expertise? How is that centre of expertise held to account? We argue that, actually, if you had health boards with really strong leadership in this area, in terms of strengthening their presence on the board particularly, NWIS, as a client, in a sense, of each health board, can be held to account. 

Just to add to that, I think what is a potential way to strengthen leadership is having a director who has perhaps got more capacity to address that overall agenda, which I think is probably a key issue for consideration—that it isn't one of a number of other roles and has more time. I think that's some of the point as well. 

Well, the point specifically made in his report, and now confirmed, is that the auditor general thinks it should be represented at board level. Do you accept at least that that's what he says? 

If that's absolutely what is recommended, then I think that would—

From my experience of sitting on a board, I think that in itself will not resolve the issue. I think it's about having all the other things we've just talked about and having a director who has got a strong recognition—

Yes. Absolutely. Maybe. 

But the central point I'm trying to make is that NWIS's governance—. Because the report does highlight some significant weaknesses in NWIS's governance. Do you feel that the way that NWIS is governed adds to the problems we've been discussing?

15:25

Yes, I think that—. NWIS's governance—the director general's reply on that I think is for Welsh Government to work through also with the hosting body, and I did watch with interest last week's session on that. What we're interested in as members of NIMB, of which Welsh Government and health boards and NWIS form a part, is more about, actually, having a set of deliverables, a prioritised plan that we collectively hold each other to account for. The actual governance position, in terms of independence and the model that that takes going forward, is basically to be addressed as per the reply from Dr Andrew Goodall.

So, when you reassured me earlier that there wasn't going to be a common line based on the director general saying you need a common line, you've quoted me what the director general has said—

I think I'm confident that the issue for us is, 'Are we having a collective step-up to the deliverables that need to happen in informatics through NIMB?', of which all three parties are a part—Welsh Government, NWIS and the health boards. And, sorry, trusts—there are four parties. And, yes, I'm confident of that. And that is more of an issue in terms of governance. Governance is nothing without outcomes and delivery. I know it's a cornerstone of good management, but, ultimately, I see us transacting governance, holding each other to account, through the NIMB process, the national informatics board.

Yes, okay. So, do you not agree with the auditor general's conclusions on governance, then?

I think the auditor general's view on the fact that—

[Inaudible.]—this is. The view about the fact that we—. We step up better as individuals and organisations with independent scrutiny and check and challenge, but that can be something that is in a forum, that is a different organisational structure, or it can be something that is going to be transacted, as it has been—that I can see and have evidenced in the past 12 to 18 months—at the national informatics board, where we're actually looking to understand the deliverables of all parties in the digital agenda. That's my view on it. 

Okay. The problem with the national informatics board is it's not open and transparent, is it, and one of the recommendations—or criticisms the auditor general found is that NWIS's ambiguous status is unsatisfactory because it doesn't create an open challenge coming from having independent board members who are able to scrutinise its performance and strategy? It doesn't produce an annual report, it has 600 staff, it has a £200 million budget, or something of that sort, and there's no way for us as the public and people who scrutinise to be able to see what's going on. You sit on that board, but as we've already discussed, there's clearly a cultural pressure, from the Welsh Government at least, to take a common line on that—I think we've had some evidence of that today, not least your carbon-copy evidence you've submitted to us. And your responses to me aren't entirely clear-cut on this, given the conversations I've had with board members and executives in both your health boards not quite telling me what you're telling me today. The view that I'm getting, both from the auditor and from the people in the NHS who I'm speaking to, is that NWIS's governance is a problem, the auditor general's analysis is correct and greater openness and transparency would be helpful. So, can you just clarify for me, on the record, whether or not you agree with that?

I think what I'm trying to say, and obviously not articulating it very well, is that, evidently, the auditor general's perspective on governance is right, and I think that is what we've all said, as part of NIMB and as part of the return. We've agreed a collective position and that's gone through much debate at the national informatics board. So, it's not a carbon copy—it's a debated position in terms of what would be best and where we need to make inroads. From a party that's party to NIMB, as a board, I've got to make sure that we can deliver on our statutory objectives as a board, and NWIS is a key part of that delivery position. I feel we can hold that more ably to account now through the plan that we're trying to develop, which will be more prioritised, more focused and will have performance management, and we're seeing those behaviours, and have seen them in the last 12 to 18 months of NIMB. So, that's why I'm saying that that's where I think it's more important for us to be able to independently scrutinise and challenge, and we do so, and we are doing it effectively, without actually getting involved with the formal governance arrangements, which are for Welsh Government to resolve.

15:30

I might have more confidence in that, with respect, if you didn't come here with a party line. I appreciate you're all sitting in this committee and you're trying to work to common objectives, but this is the Public Accounts Committee of our national Parliament. And when two separate health boards come to us with an agreed line in advance, which you've just repeated again, it really doesn't assist our ability to try to understand the issues from the individual health board point of view. 

Can I just—? I think, first of all, I'm most certainly not coming with a party line—I'm coming with my own health board's perspective on this. I think what is important, just to answer your question specifically, I think, is that the issue of governance and accountability has been raised by the auditor general, which I fully accept. I think we have, as set out in Dr Goodall's response, saying that there is a programme of work linked to the parliamentary review that will review the governance arrangements—that does give greater transparency, great scrutiny and greater accountability—that's what's in his response—. As a member of the NIMB, and as a director of the health board representing informatics at the board, I would expect future arrangements to look different to what they are now. I would expect them to be revised and reviewed to enable some of those scrutiny arrangements—that transparency that we go through as a health board. I think we recognise that NWIS has got unique arrangements—it's a unique organisation within that—and I think the report has now highlighted some of the issues that that possibly presents, and we need to make sure that we strengthen that accountability and transparency to address some of the issues in the report. So, I would expect a different accountability and governance structure once this review is completed, which doesn't look like it does now. 

Thank you. Would that be resolved, do you think, by the suggestion of putting NWIS into a central NHS Wales executive?

I haven't got a set view, at this point, of exactly what that looks like. I'm more concerned with whether we feel that there is a level of independence and scrutiny. Do we feel the performance management framework is robust? Do we feel that the reporting lines are clear? That's what I would be looking for in whatever structure. Where that actually sits I'm less concerned with than the function, which, all of it, will help NWIS and us have much greater clarity about what's expected to deliver by when.

Thank you, that's helpful. Just a final specific question: there's been the issue of NWIS's status when things go wrong—when there are serious incidents—and the fact that NWIS doesn't have a formal status. It's been raised in some reports—it's sometimes a barrier to dealing with those incidents, around patient safety and reporting them to health boards. It has to go through Velindre rather than through NWIS itself—is that an issue in the incidents that you've had to deal with?

As you know, there have been a number of incidents this year, which have helped us to think through some of those issues in a bit more detail. I think it does add another layer of governance for us to go through. I think the learning from some of those events would be absolutely key to feed into that accountability and governance review, to ensure, especially as we go forward—I think one thing we do recognise, and that comes up in the report, is business continuity, and how we make sure, especially with the environment we're dealing with now, that we've got very clear business continuity plans. We understand the role of health boards and we understand the role NWIS plays, and I would expect that review to pick up those issues, because I think it can—there have been times when, perhaps especially when we're faced with new situations, it's less clear. I don't know if you'd agree with that, Mike, or if you want to add anything.

I'm not aware of a patient safety issue being withheld or going through channels, to be fair. An alert will come out if there's a potential issue, and our own Putting Things Right team, along with the informatics, will look at how we do that analysis and, most importantly, at how we take immediate steps to address any risks that any patients might be exposed to.

In terms of things like the data centre outage, clearly those things don't happen often, thank goodness. So, there were some meetings that we held afterwards about how we can be more slick between us. We have a 'once for Wales' infrastructure in terms of elements of cyber security, traffic going in and out of Wales, that are controlled outside of a health board. Also, equally, we have health board infrastructure, where we run local systems and some national systems as well on a local incidence. So, getting those, to translate it back into the clinical, almost like a resuscitation algorithm, where everyone absolutely knows what they're doing—we're still working through how we get that more slick. As you saw, it was something that was managed, but I think, always, it would be rather complacent to think that we did a perfect job collectively.

15:35

Thank you very much, Chair. I normally ask some questions regarding finances. What work is being undertaken with local authorities so that they are fully working towards the implementation of the system to ensure coherence across health and social services? Are any changes to local authority systems taken into account of your cost estimates?

In Aneurin Bevan, we are joining our local authority colleagues in signing a deployment order for the same system, and we've established an agreement now where we're using some of our regionally allocated funding for a regional programme office, to try and identify where we've got potential issues or conflicts between how we've deployed, so going back to talking about standards or different languages that could incur things like patient safety risks, but equally where we can achieve potential economies of scale in terms of shared teams or even shared infrastructure, going into the future. Nicola chairs the Welsh community care information system programme board, and also within the local authority, we have a regional board that reports to the partnership board within Gwent. So, we have an accountability trail back to a joint health and social care regional programme board that would then help us with priority and direction.

Would you be able to share any information on the tendering process for the system implementation?

I'm afraid I wasn't directly involved in that, so—.

Okay, fair enough. If the Welsh Government cannot find the additional funding that is required to deliver the informatics strategy, can health boards find funding themselves by reprioritising or through invest-to-save?

That's exactly what we're trying to do as a health board—to look at where we can look at more innovative sources of funding. We're doing it with a lot of our regional collaboratives, so we're doing it with both Swansea and with Powys and Gwynedd—Betsi Cadwaladr—looking to see how we can pool funds, effectively, to ensure that we can move at pace and innovate digitally. We are obviously pooling our integrated care funds, which are health and social care funds, to see how we can get the service transformation that supports the digital agenda. I co-chair the Welsh community care information system in my part of the world, with a director of social services in Ceredigion who has already implemented the system, and there is a lot of learning there in terms of what we can do differently. It's about really getting our staff, who already work incredibly well together on the ground, together in terms of what it means to the patient, which is what WCCIS is trying to do in terms of benefits realisation, to ensure that there isn't a revolving door of either social services staff and health staff going to a patient's home all asking the same questions, which is what we're trying to avoid, going forward. That's the opportunity this new system brings.

We're looking at exploratory talks in terms of how we support that system together 24/7, because it's a 24/7 requirement. What's the kind of expertise we can bring together in order to develop it, going forward? But we're really clear: first and foremost, it's got to be getting our community and social care staff in the room, which we did. We did a big launch back in November, where everyone was invited to go through what it would mean for them as a system, and from that, then, you begin to see, 'Oh, yes, well, we don't necessarily need to put more funding in that particular area; we've got the capacity and capability already and it just means a few tweaks here and there, and that's an advantage.' So, we're working through that process. We haven't signed a deployment order like Aneurin Bevan, but we're definitely in the process of having a very firmed-up business case at the moment.

Thank you. The estimate of £484 million required to deliver the strategy is built up from figures estimated by individual health boards. How robust were the estimates you submitted, and is there a risk that the actual cost will be significantly higher?

Obviously, it is an estimate, but it was a significant estimate—you know, £484 million is a huge sum of money as well. I think the teams in the health boards did the best job possible to identify what we felt that investment would need to be in terms of both the infrastructure sustainability plus implementing the four elements—the key elements of the strategy. So, I think it's a fair assessment. It's an assessment that, actually, at this point, is significantly unaffordable and therefore we need to consider how we prioritise within that as we've talked about, and linked to your previous question, Welsh Government need to consider in terms of their own priorities in terms of what they want to put against that, but as a health board level we have our own responsibility to implement the digital agenda, and therefore working nationally and locally we need to try to prioritise what resources we have to be able to try to—that stop-start accelerate to make sure we get the best benefits.

15:40

Yes. You've partly answered my question, the next one. While both your health boards report some recent increases, why have health boards not prioritised spending on informatics more? Does it reflect a lack of confidence that the investment will deliver savings or long-term benefits?

I think, for our health board, it just reflected the fact that we came together as a health board with very different kit, very different expectations of how systems should work together, and we've had to work through that and just trying to get the what we call the 'infrastructure' right. As well as then developing some of that infrastructure, we've actually got Wi-Fi now enabled through all of our hospital sites, and those kind of ambitions have almost come into play in a very short window of time—really, since 2009, if you really think about it—in terms of trying to make sure that we have infrastructure that's fit for purpose.

We've also got the fact that our IT life—we've had a lot of kit that was well out of life and we've had to work on trying to get our kit [correction: desktop kit] to about an average now of three years [correction:  three years old]. It's got a three-year life cycle at the moment. So, working on that infrastructure in readiness for the next steps in terms of the clinical portal and things like bringing on the new community information system, there's a lot of background, invisible work, behind-the-wall work as we call it, really, and now we're into the front-facing, patient investments that need to happen, and that is going to open up a different avenue of funding requirements for the health board in terms of patient-held devices, wearable devices. So, that's why I was speaking earlier and saying that we've got to be innovative and work through with our partners, both in the universities as well as areas like social services where we're dealing with the same patient or client group and seeing what we can get collectively by pooling our resources together. That's an increase in our digital applications that we've never had to face, so, no, in the competing priorities of what health boards need to deliver against, it is a hard one to find, but that's why we have to be innovative and look to see how, collectively, we can work through it, and collaboratively. It is going to be a step change for us in terms of digital investment.

Thank you. And the final one is: how do the plans for improving informatics in your health boards align with those of NWIS? In particular, could you explain how you align informatics aspects of your medium-term integrated planning, recognising that Hywel Dda has not had any approved three-year plan yet?

Yes, thanks for that. [Laughter.] I think if you look at my evidence that was submitted, and point 8, I try to outline even though, yes, we have not had an approved three-year integrated medium-term plan, all of our capital plans and our informatics plans have been three to five years regardless. We've worked on the same platform as everyone else in order to ensure that we knew the steps in terms of the route-map that we would need in terms of investment. So, whilst we haven't had approval of a plan, we've been working within a three-year planning context. If you look at the submitted evidence, you can see that we have tracked both the national developments that we expect to receive over the three years and also our local developments that will dovetail with it. So, we're doing the national developments and then aligning some of our local products with that, and you can see that, effectively, we are working to the NWIS route-map, irrespective of the fact that we don't have a three-year plan.

15:45

I'd like to explore the impact that the delays that we've been talking about and the issues with systems and functionality have had upon your staff and patients. In the case of Hywel Dda, the auditor general reported that the planned merging of different instances of radiology information systems is significantly behind time because of delays in bringing about a new integrated system in Cwm Taf. It's interesting to see why those delays took place in Cwm Taf; it's because they inherited two different instances of information systems from the predecessor boards and the two main hospital sites haven't historically been using consistent codes when entering radiology activity to those systems, which meant you then had to merge and integrate and standardise the databases, and that all took longer than had been anticipated. The result was that they didn't actually complete their new system until June last year and NWIS couldn't release their team to start on you until that had happened. So, how has that specific example of radiology impacted on your staff and patients?

I will hand over to Anthony, but I will just tell you that what's worse than two instances is three. So, we have three instances of RadIS. So, that's part of our issue, but I will hand over in terms of what we've tried to do to mitigate the delay.

In terms of the patient impact, there's no patient impact; it's just three different systems. Each of the systems runs exactly the same way, but you quite rightly point out the issues that Cwm Taf have got around different look-ups et cetera, different data tables. We've got the same issues as that. So, what we've done, since we were aware of the delay in Cwm Taf—we've done all the preparatory work and the readiness work to allow us then to go to one system when the RadIS team in NWIS are available. What we've done is put money into the radiology team to understand some of the data quality issues and see whether we can resolve those first of all so that when we do get to our merger, our merger will be as seamless as it can be. So, we're trying to pre-empt all the work, all the lessons that Cwm Taf have found, in turning to ourselves, but in terms of the patient impact and the commissioning impact, they've been running the three systems in the different sites for a number of years now since 2009, so there's no direct impact on them. The impact will be when we merge those systems together, and there might be slight changes to the way they work due to having just one system.

So, how far have you got then in making progress with this merger, and what timescale are you working to?

We've started work with NWIS already. We started work with them in April to work on how we can get that merger. There's a 12-month pathway to get to that place of merging all three systems together, but I think we'd done at least three or four months readiness work before we started work with NWIS in April. The key really is getting all the radiology teams together. I ran a group with the radiology teams to get them together to understand some of the basics of different ward locations and consultant names et cetera, and we've tried to streamline those already in the systems that we've got access to already in RadIS behind the scenes, waiting for that merger. So, I think we're five or six months ahead of where we thought we'd be. So, we're waiting for the NWIS team now to start the process, and I believe we should get it done in eight to 12 months, which is a lot shorter than it was in Cwm Taf and Cardiff and Vale. 

Thank you for that hostage to fortune, and we'll see how it goes. Another issue that I'd like to look at is the laboratory information system. Again, the auditor general has reported that the pilot was considered a success, which was done in Hywel Dda, but then he reports that,

'on rolling out the system nationally, it became apparent that what worked in the pilot area did not work nationally as it did not cover the broader range of more complex tests undertaken in some other health boards.'

Well, the inference of that is that Hywel Dda was the wrong health board to choose for a pilot. How do we get—maybe it's shutting the stable door after the horse has bolted, but how do we get NWIS to choose the more suitable pilot areas or boards for these kinds of complex projects?

I wouldn't say that Hywel Dda was the wrong health board to choose. What I think we've got to learn is that some of the complex tests that were available in some of the larger health boards, like Cardiff and Vale, the tertiary centres and ABMU, weren't available in Hywel Dda, and perhaps we should have been mindful of that when we did our testing internally. I think if you go to test everything in the largest health boards in the country, nothing will ever get developed, and it will have even more delay in our pace. I think taking the LIMS forward was a brave step for Hywel Dda. We were the first health board to take all functionality of LIMS, and I think it was testament to the teams there. They did a lot of testing. I think that paved the way, then, for the other health boards to do less testing, apart from, obviously, the complex reports that were identified by the auditor general that we weren't processing in our pathology department.

15:50

Yes. And do you have any observations on this from Aneurin Bevan?

In terms of the impact of—?

So, on LIMS, for our part, clearly there was a large proportion of unplanned expenditure around our clinical scientist colleagues in terms of testing and validation. Pathology is a very heavily regulated—quite rightly—industry, and I think perhaps we hadn't really factored that into the planning as thoroughly as we should have done on a national basis. Certainly then that created some issues. With LIMS, obviously, I think as well it's the concurrent running—I think, as you heard about last week—of local systems. So, it's going back to benefits realisation. For us to reduce costs, for us to start to realise some of the benefits, we need to be able to finally switch off some of the legacy systems. That's proven challenging, although we are now just waiting for one last piece of the jigsaw to be able to do that.

How long do you think it's going to take to complete the project?

We understand that there's now an agreed path in terms of delivering LIMS. I don't have the specific plan to hand, but I'm happy to follow up with that in terms of where we are.

Okay, thank you very much. I'd like to move on now to the community care information system as well. I wonder if you could update us on progress there, in your respective health boards.

Yes. So, we've been working quite closely with the supplier—CareWorks as a supplier—that, since last year, is ready to sign a demployment order, and we've been extremely thorough, as a health board, to make sure that we've tried to mitigate all the risks that we are foreseeing that could be a problem within that implementation. So, we signed the deployment order with the supplier, I think, just over a month ago. So, we are now on the implementation. We've been very clear. We've worked really collaboratively with NWIS recently around a memorandum of understanding about the interdependencies that we need in terms of some of the things they need to deliver for us as part of that implementation. We've been working with the national programme more generally in terms of some of the standardisation work, and we obviously set up the regional programme board that Mike alluded to to make sure, as a region in Gwent in particular, that we are working together and we get the benefits out of this as integrated health and social care. It's 4,000 users altogether for our organisation, and it's not condensed in one hospital setting. It is across many clinics, many different kinds of locations, and we are therefore doing this in a four-phased approach. We are starting with our mental health services, where we're anticipating we will go live with the new system from next June—June 2019. We've got really good service engagement. We have—

In 2019. It's a 15 to 18-month delivery once you've signed the deployment order. We are very much working with the services, because this isn't just about a new system. This is culture change. We have got to work with the teams about using the technology differently, and we are obviously seeing this as a huge opportunity, working closely with social care to join up the way that we work together. So, we're really pleased—. It has been quite a longer process then we planned, but we feel we're now in a—. It's not without risk. The health board has invested significantly in this. I think, going back to your earlier question, we're really grateful for the procurement of the broader system and the contract, but, for us locally, in order to implement this properly, we have invested in business change project managers, additional teams who are working closely with the service, and therefore we are implementing this as a significant project, and one of our key kind of flagship projects now around digital in the next—. The programme goes on just over two years.

We're not so far ahead. I have been bringing all the teams together in health and social care. We do have a regional implementation board. That comprises all three directors of social services of the—

I co-chair that with Ceredigion. Ceredigion local authority has already got the system, so that's helped us to actually understand what the interface opportunities are and also how the system works, get people on the ground to champion the change. I would say that we're at the stage of totally socialising it with all community teams—there are about 30 different types of staff groups involved in community working, and that's before social services staff. What we've got to do at the moment is, obviously, between us all, understand what benefits can be realised from it, because it is a significant investment. For us, it's about £4.8 million revenue and £2.6 million capital over a five-year period—so, a significant ask, really, in revenue terms for a health board that has already got challenges.

So, what we've been doing is, we've been co-designing the benefits to be realised with, basically, service users and then doing a check and challenge on that basis with the boards. We're in the early stages of socialising, we've had Powys—. Carol Shillabeer, who's the national SRO, the senior responsible owner, for WCCIS came to our launch day. We've had social services from Ceredigion's viewpoint saying how impressed they are with the system and what it's doing for them. We've had all of the staff groups from mental health right through to district nursing in the room as well. We've taken it to board in January and taken it to board committees subsequently. I think we're watching, in terms of those health boards that have already gone a bit further—in particular Aneurin Bevan, they've signed the deployment order—but I'd say—. Obviously, we've got the traction there but I think we're probably about 12 months behind.

15:55

So, does that mean, in 12 months' time, you're saying it'll be complete?

I think in 12 months' time, we'll be in a position—. Because, at the same time, we've actually been doing a wider piece of work as a health community with our partners in terms our transforming clinical work, understanding, effectively, how we would prioritise this, and just trying to get all the readiness work—. As I said, some of it can be done because we've already got a local authority that's implemented and we hope to learn from that. But I think, really, it's just trying to get ahead of the curve, but, realistically, it'll be at least 12 months [correction: at least 12 months before we will be in a position to sign the deployment order].

Okay. And, lastly, I'd just like to go back to something that was touched on in Vikki Howells' questions earlier on about staff keeping their own databases because they feel unable to rely on the national systems. Can you tell us whether this is still a concern for you, and what, in particular, you've been doing to try to solve this problem?

Yes, it is a concern and an issue because, ultimately, from an information governance perspective, you would want to make sure that every viewing of a patient record, every use of patient information, is safe and secure. So, we have been doing astronomical bits of work, as every health board, I'm sure, in Wales, in order to be compliant with the general data protection regulation that's due to drop down on 25 May. We have been identifying where those databases are, exactly what the scale of the patient information is on them, who is the owner of that information, and what are the data-sharing protocols. Some of it is totally above board—to support research, development, improve patient care—but we're increasingly trying to say, 'No, this needs to be corralled into a safer patient [correction:  patient data] environment'. We've deployed the the national intelligent integrated audit solution, NIIAS, to make sure that the culture of governance [correction: information governance] comes into play and there should not be these workarounds, because they don't have the security that we want them to have. And we're on that journey of actually doing the audits to ensure that we can comply with the GDPR in May.

In answer to the earlier questions, Mr Tracey said that clinicians are—. The clinical systems don't have any safety issues with them, as far as I understood your evidence, but there is, clearly, in terms of data security, a potential problem if there are—was it 160—different systems, as you said earlier on, which are operating maybe simultaneously and multiple entries of data and circumstances that you may not be geared up to control.

I think most clinicians are clear that Myrddin, which is our basic patient administration system in Wales, has got to be robust and it's got to be something that, clinically, everyone can place reliance upon. I think what we've got in terms of workarounds is when people have taken parts of the data set in order to inform maybe clinical practice, or maybe to inform research, and what we've got to make sure of is that we safeguard the patient information within that. We've done all that we can to ensure that the main currency of patient care is in a secure environment, and that's on the Myrddin platform. We're trying to change the culture in terms of people's viewing of that information to make sure that they only view it if it's appropriate that they do so. And that's part of the learning that all organisations, I think, in Wales have probably gone through and it was right to do so as part of the development of the Welsh clinical portal, where so much more information will become available. So, I would say that our concerns at the moment are these little data sets where people, in the main, have taken them forward in order to do some much, sometimes, needed research, but we want to ensure that that is in an environment that is more secure.

16:00

So, you have to know who is accessing this information and what use it's being put to and that all has to be logged and, indeed, approved.

Yes, and we've had 12 months of digitally safe campaigns. NIIAS—in terms of pressure around, 'You mustn't look at your own record, you mustn't look at family records, you mustn't look at neighbours' records'—. So, we're trying to drive in that culture of compliance and explain what information commissioner office fines look like and feel like in an organisation where we actually want to spend it on front-line patient services, not on fines. So, we're doing lots in order to change the culture of information governance. We have a lot of support from our Caldicott guardian, who is our medical director, in that endeavour. And we have got what I call a speed awareness training course, that, if you are found to be viewing a record that you shouldn't be viewing, you're called in and you go through a course of information governance. And, little by little, we are making significant progress and we do put that into public domain.

Good. And, how about Aneurin Bevan, if I could ask you the same questions?

I'll let Mike pick up with a bit more detail, but one thing we have particularly been quite keen on is having an information asset register. So, we have ensured that we've got—I'm sure Hywel Dda have as well, but we've got a complete list of where we know the staff have databases to ensure that we've got security around that. Sometimes, people do that without needing to do it as a workaround, because the system can deliver things, so it's about making sure that we're using the systems we've got as effectively as we can, and sometimes it's about a bit of training and investment in those clinical teams to be able to make sure that we use our existing systems appropriately. But I think having that complete list of where we've got separate databases is absolutely key as part of our information governance process. I don't know if you want to add anything, Mike, to that, but—. 

I think we're all probably taking similar approaches, because GDPR, obviously, is a bit of a unifying force. We've had, for some time, a stewards' programme—for six years—and that is now covering all clinical areas as well as corporate functions, where there's a lead who we provide more support and focus and training to and that's been recognised by the health board as well as being very successful. Obviously, we use the same NIIAS system for the national applications that we're running, which gives you an alert against a rule-based engine. If something looks inappropriate, then now it gives you a push notification to say, 'You'd better go and look at that', rather than trawling through audits. 

We've increased the size of our information governance team in light of GDPR, and, of course, as we said before, we're accountable to our information governance committee, to our independent members, who scrutinise what we do in terms of our processes and standards, but also in terms of our risk register, because we take a risk-based approach, then, to prioritising.

The other thing I'd say is that the other value of the asset register is that it provides you with an insight of why people might be doing workarounds. Some of them, it's because they're not aware that they can do these things on a system, so it allows you to follow up, but it also gives you an idea, in terms of priority, of what's an unmet need, for example, in terms of clinical colleagues or HR or corporate services as well. So, we try to take it in a sort of—you know, it's not just about regulation, we should also be then providing a service to address the needs that aren't being met.

Because we are virtually out of time, but, Rhianon Passmore, do you have some closing questions?

I'll be brief. I would, personally, actively welcome any debated synergy between different parties within NIMB. So, I just wanted to place that as a point. In terms of the multitudinal pressures that you face in regard to—whether it's governance or projects—queues, delays, around, for instance, radiology, how important a step is the new technological standards board and plans to progress and pace? You can be brief, if you wish.

16:05

I think it's important. I think, as we've said within our evidence that we've submitted—written—what we need to see is the recommendations going through on a more global scale, as Nicola said. It's not one cause for any issue that we've had. But I think the technical standards board is going to start to give us that opportunity for sustainability. The standards by their nature should—

So, not in itself the answer, but part of that mixed ecology of portfolio.

I'll move quickly, then, onto these lines of questioning. So, how are you as individual health boards, then, encouraging your clinicians to be more involved in the roll-out of the national systems? Could you be brief as well?

Okay, so very briefly, two things: our assistant director of informatics obviously sits on the national clinical council and is also doing some work with the medical director of NWIS to make sure that we are sharing some of that local knowledge in with the national. We also have set up—we've got a new kind of digital delivery board, which is about taking forward the strategy, and, as Mike mentioned earlier, we're setting up a clinical council within the health board to get broader clinical representation that then feeds up into our strategy to enable us to prioritise locally. So, I think we are trying to expand more and more. But also it's not just about medical staff—it's nurses, the therapists, all of the different clinical professions that we want to have a voice as part of the digital agenda.

Just to add, I think it's more a case of clinicians bashing our door down to get moving. There's a real appetite with staff. They do their own research, they're experts in their own fields, so they are fully engaged. It's a question of how we meet all of that demand.

Okay. So, in terms of, for instance, the pay structure, is that a potential barrier within 'Agenda for Change'? Because what you're saying is that you've got the engagement, so what is missing in terms of that expertise around ICT? And do you feel you have the expertise?

I do feel that, collectively, we have the expertise.

We have the capacity to deliver against the priorities. You know—

We'd like to keep everybody happy and do everything at once, but that's just not being realistic, and I think, as the audit report reflects, trying to do too much means that you probably don't achieve. So, it's a question of engaging and being able to reconcile against risks that you need to manage, in terms of clinical risks, or in terms of benefits that you can provide to that service or patient.

So why, then, is there so much—? And it's endemic, not just in this area, but why is there so much variation between different health boards around the issue of the number and grading of ICT staff, or do you not recognise that? Obviously, you can only speak to your own, but—.

'Agenda for Change' quite rightly gave a weighting to clinicians who are providing face-to-face care. So, it's a sort of points basis that you collect through a job description. So, for the people who aren't providing face-to-face care then, against budget responsibilities, et cetera, it's limited as to what you can legitimately pay staff. In an environment where we're down the road from Cardiff, often staff will move between health boards or between NWIS and health boards—there's a difficulty in competing also with the private sector. So, what we've always said is we're more of a Charlton Athletic than a Manchester United in terms of what we need to focus on is bringing people through and acknowledging the fact that some very bright people will be equipped with the right competencies to go on and go to another area or two, or to be promoted.

Okay. So, if there was any significant ramping up of funding—obviously you have to look at the climate across the UK—would that in any way engage the recruitment of more qualified and experienced staff across the NHS, not pertaining necessarily to ICT? It seems a bit of a logical question to ask.

16:10

Some posts are easier to fill than others. So, some areas are quite specialised and there are literally 150 people, potentially, in the UK who might be able to fulfil those. 

So, in that regard, I think I'll ask Nicola, going back to ICT expertise and the numbers and the capacity that there is. There is variation across health boards, so what's the answer? 

Yes, I think there is variation. Whilst 'Agenda for Change' has got a clear methodology, there is often at times variation, especially when you go outside of the clinical roles, and I think we can't get away from that. I think the biggest issue is your question in terms of if we had all the funding if we wanted, there is a workforce challenge, as recognised in the auditor general's report. We are competing with the private sector, which has got different pay arrangements, and we do need to think more creatively, as we've said in some of the responses. So, I think capacity is an issue for us. 

I think what is key, when you look at some of the lessons learned, is that there is a need for IT specialists in any of these projects, but a lot of what these projects need are project managers. They are business change people, where possibly we haven't got the same limitations around the market. And I think what we've got to be really clear about is when we're looking at these projects, what are the skills we need and making sure that we make best use of the IT specialists where there is a market issue. But we have got to continue the work that's been mentioned in our response around working with some of the universities, be more creative about how we train, and what we offer as an NHS—we offer a different type of career, and there are other advantages. And I think the more you've got a well-developed vision, a strategy and a clear direction of where we're going, people are attracted to come to be part of that.  

I think we have—. You know, I'm talking especially for Aneurin Bevan, and I think now with the national digital strategy, we are much clearer about where we are trying to go and the pace at which we want to do that, but we know we've got more work to do to, I think, get the bigger sell to the workforce.  

'More of a Charlton Athletic than a Manchester United'—I think that's the quote that I'll take away from this. Thank you for that. 

That brings our session to a close. That was a marathon session and we got through all of our questions, in one way or another, so well done. We'll send you a copy of the transcript before it's finalised, just for you to check for accuracy, but thanks for being with us today, Aneurin Bevan and Hywel Dda health boards. 

Thank you for the opportunity.

5. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o'r cyfarfod
5. Motion under Standing Order 17.42 to resolve to exclude the public from the meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o eitem 6 o'r cyfarfod ac eitem 1 a 2 o'r cyfarfod ar 30 Ebrill yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from item 6 of the meeting and items 1 and 2 of the meeting on 30 April in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

Can I propose, in accordance with Standing Order 17.42, to meet in private for item 6 and items 1 and 2 of the meeting on 30 April? 

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 16:12.

Motion agreed.

The public part of the meeting ended at 16:12.