Public Account Committee – 23rd April 2018
Wales Audit Office (WAO) Report on NHS Wales Informatics Service
Aneurin Bevan University Health Board Response
General Overview and Feedback
1. In general, the Health Board welcomed the audit and agreed with all the recommendations within the WAO report. The report reflects fairly the situation in NHS Wales and provides a focus on the role of the NHS Wales Informatics Service (NWIS). The challenges set out within the report require greater collaboration between Welsh Government (WG), NWIS, Health Boards, Trusts and other NHS Wales organisations and reflects the areas of improvement that have informed the agenda of the National Informatics Management Board (NIMB).
Question 1 -The Welsh Government’s leadership role for informatics in NHS Wales, including, for example, ensuring NHS bodes agree what ‘Once for Wales’ means in practice.
2. The response to this question has been split into two parts:
(a) Leadership
3. The Health Board acknowledges and supports the WAO recommendations and the WG response to this issue.
4. At a local level, the Executive Director of Planning & Performance has responsibility for the Informatics agenda, supported by the Medical Director as the Caldicott Guardian. The Clinical Informatics agenda is also well supported by an Associate Medical Directors and a newly established Lead Nurse for Clinical Informatics. The Health Board is also currently recruiting two Clinical Informaticists.
5. In December 2017, the Health Board established a new Transformation to Digital Delivery Board, which has service and clinical representation, as part of its overarching Clinical Futures Strategy. This Board is supported by a Clinical Counsel/Reference Group that ensures greater clinical representation and influence into the informatics agenda.
(b) Once for Wales
6. The Once for Wales principle and approach is generally well supported across Wales and in the Health Board. The Once for Wales recent Task and Finish process has proved a valuable exercise in bringing together expertise from across Wales to explore and define the way forward.
7. The Task and Finish Group has made much progress in 2017/18 in reaching a consensus on the meaning of Once for Wales and how NHS Wales should proceed. The meaning of ‘Once for Wales’ has been redefined and is about all parties involved in health and care in Wales working collaboratively to add value and deliver the strategy of a single electronic health and care record, ensuring that information is entered once and is made available to all those who need it, at the time and place they need it.
8. This work should provide greater direction to NHS Wales and should enable Once for Wales is implemented at a greater pace going forward as it is not about local and national systems but a common set of standards.
Question 2 - The work the Welsh Government is doing to better understand the costs of delivering its vision for informatics and how that could be funded given the downwards trend in spending on ICT and the £484 million estimate of the cost of delivering the vision for informatics on top of current budgets.
9. The Welsh Government has acknowledged the further work this requires in their response to the report, recognising a robust assessment of the investment requirements, predicted business benefits, alternative funding models and savings opportunities are all essential in addressing this issue.
10. The scale of investment set out in the Health Board Strategic Outline Plan that would enable delivery of the digital strategy was extensive and for the Health Board represents an additional £7m revenue and £11m capital each year. However, given the demand and availability of resources both in terms of workforce and finance, it is essential that we strengthen our prioritisation mechanisms to ensure we focus on the digital programmes that will deliver the optimum balance between cost and benefit at both a local and national level, utilising national and international evidence and best practice. Improved prioritisation should enable appropriate directing of resources to deliver at a greater pace.
11. The Health Board established a new Informatics Strategy Board in December 2017 as part of its Clinical Futures Strategy. The Board provides oversight of the digital agenda over the next five years and supports prioritisation of critical projects driven from the requirements of the service in the context of the National and Once for Wales agenda.
Question 3 - The extent of resourcing and investment at a local level.
12. The Health Board recognises the significance of the digital agenda and the opportunities it presents as a key enabler of innovation, change and efficiency across the NHS. It also recognises the importance of ensuring the safety and sustainability of our infrastructure, systems and information, and for patient experience and outcomes.
13. Whilst the national agenda has supported a number of key national programmes and priorities, the Health Board recognises its role in terms of investing in local services to deliver its operational and strategic agenda.
14. Over the past 5 years, the Health Board has committed a total of £9.248m, an average of 19.12% (ranging from 13% to 30% in 2017/18) of its discretionary capital each year on IT, alongside the All Wales Capital Programme investments of £8.275m. From a revenue perspective the expenditure on informatics has increased significantly from £4.01m in 2013/14 to £7.23m in 2017/18, an 80% increase over 5 years, with a total of £29.2m being spent over the same period.
15. Some specific examples of prioritisation and investment into the digital agenda as a key enabler of delivering our service strategy include the Welsh Community Care Information System (WCCIS), Digital Health Record and the patient flow pilot project.
Question 4 – The effectiveness of governance and accountability arrangements in light of concerns identified by the Auditor General and the recommendations of the Parliamentary Review to bring bodies such as NWIS within a strengthened central NHS Wales Executive function.
16. The Health Board supports the WAO recommendation and acknowledges the WG response to this issue. Further work is required to strengthen the clarity and accountability of NWIS role in delivery of the digital agenda and NIMB needs to play a key role in addition to local and national governance arrangements in setting out priorities and expectations of NWIS in the future delivery of the strategy.
17. The current National Informatics model is complex and the multidisciplinary role that NWIS fulfils from authority through to supplier, together with its hosting arrangements, as highlighted within the Parliamentary Review, confuses lines of accountability. Therefore, the governance arrangements should be informed by more independence and that there is a requirement for greater objectivity and transparency.
18. As NWIS provide services which Health Boards/Trusts are dependent upon for successfully discharging our statutory obligations to our populations, it is therefore essential that Health Boards and Trusts are able to hold NWIS directly to account on this delivery.
Question 5 - Local leadership, including clinical leadership, and NHS bodies’ perspectives on the factors behind slow progress in delivering the electronic patient record.
19. In general terms, the Health Board would consider the following factors as key contributors to the slow progress in delivering the electronic patient record:
· High levels of optimism at the planning stage with insufficient business change planning at the outset, which should be clinically and service driven. This is referred to under other responses and the need for transformation first and business change capacity being a key learning point from projects such as this. This has been a key area of focus in some of our more recent projects and system implementation.
· Appropriately identifying the full resource implications of successful implementation at the outset and workforce recruitment issues.
· A growing programme of priorities that compromised the delivery of the key projects as existing workforce resources are then too thinly spread.
20. All of these issues have been recognised at both a national and local level and inform the approach to future projects as set out in other areas of this WAO report.
Question 6 - Workforce challenges, including recruitment and retention of ICT specialists.
21. The Health Board recognises and acknowledges the workforce challenges the informatics sector face not just from an NWIS perspective but also at local Health Board level. The WG response sets out that this is also a broader public sector challenge and how Health Education and Improvement Wales (HEIW) and the Welsh Institute for Digital Innovation will help address some of these issues.
22. Agenda for Change, the NHS pay structure, is not responsive to market trends and rightly awards more points to direct clinical care. However staff are often attracted to an ambitious programme with development opportunities alongside other benefits of working for the NHS. These need to be a core component of our recruitment and retention strategy. Many of the future resource requirements to support digital innovation will include roles such as business analysts, project managers etc. as opposed to just IT specialised skilled staff.
23. More specifically, the Health Board has built relationships with the University of South Wales, Cardiff University, The Software Academy and Alacrity to support our recruitment challenges and workforce sustainability.
Question 7 - Getting greater clarity about whether the intended benefits of investment are being achieved.
24. As set out in the WG response, progress has been made over the last 12 months in establishing a benefits framework and toolkit across NHS Wales as part of A Planned Future Workstream of the Digital Strategy.
25. It is recognised that NHS Wales and NWIS will need to ensure appropriate investment in Clinical and Business analysis and grow its business change capacity. This investment needs to be appropriately identified in all future business cases and has been a key learning point from previous projects.
26. The Health Board has ensured that recent business cases have fully considered the cost and capacity required for business change and is very much focused on the Nuffield principles of Transformation First with the digital solution acting as an enabler which is a key criteria for future success.
Summary and reflections in context of Parliamentary Review
27. In summary, the digital agenda provides significant opportunities to transform the health and social care services of the future.
28. A number of the issues and challenges within the WAO Report were also considered by the Parliamentary Review into Health and Social Care report, “A revolution from within: Transforming health and social care in Wales”, published in January 2018.
29. It recognises the significance of technology and the need to maximise the benefits and innovation of technology to accelerate efficiencies in care, decision support, making care accessible to the public and supporting the wellbeing agenda, all aligned with the Quadruple Aims defined by the Review. Recommendation 7 of the review sets out the need to harness innovation and accelerate technology.
30. The Parliamentary Review report also recognises that we have been moving towards a more integrated system for a number of years and there are many good examples of new models of care that are already working in Wales. The challenge is how we can be more radical and ambitious, to accelerate the pace in moving to a genuinely seamless system. Following the Parliamentary Review report, we are working with the WG and other organisations in the health and social care sector to develop a plan of action that will deliver the best services to the people of Wales. The right governance structure, a robust clinically led prioritisation programme and clear and innovative funding models are all key requirements for the future agenda with “transformation first” at the heart of system redesign.