Item 6 is a debate on the Public Accounts Committee report on the NHS informatics systems, and I call on the Chair of the committee to move the motion—Nick Ramsay.

Motion NDM6948 Nick Ramsay

To propose that the National Assembly for Wales:

Notes the Report of the Public Accounts Committee—'Informatics Systems in NHS Wales'—which was laid in the Table Office on 8 November 2018.

Motion moved.

Diolch, Dirprwy Lywydd. Thank you for the opportunity to speak today about the Public Accounts Committee inquiry into NHS Wales informatics systems. Members will recall that last November, the Public Accounts Committee published one of its most damning report to date. In fact, 'scathing' was used to describe our 23-page analysis of NHS Wales informatics systems—NWIS for short. 

In committee, the chief executive responsible for hosting NWIS described its ambitions as world leading. However, we do not consider this to be the case, and in fact, our report highlighted a raft of problems with the dysfunctional, outdated IT systems that support our NHS. Our report made uncomfortable reading. Initiated by the auditor general’s report into informatics systems in NHS Wales, our inquiry found that many of NWIS’s digital projects are behind schedule, and some are only on schedule because their timescales have been re-ordered to show them on track. Lines of accountability are unclear, there is widespread dissatisfaction across the NHS at its performance, and major systems have repeatedly given up the ghost and with worrying regularity.

It's a matter of great concern to the committee that NWIS, first envisioned in 2003, has been unable to keep pace with advances in technology. While the technology products we have available—day-to-day use has changed beyond recognition in that time. Medical staff in Wales are still struggling with outdated IT systems that don’t deliver on their promises. And in fact, just after Christmas last year, it was reported that NHS Wales still has over 1,000 fax machines in use at hospitals and GP surgeries, with £550,000 spent on supplies since 2015, and one GP describing them as 'relics' that needed getting rid of. I'm sure you'd all agree that, particularly in a time when an e-mail offers a quicker and more secure means of transferring patient information, this is an unacceptable situation.

Sadly, these sentiments echoed throughout our inquiry. We heard how front-line medical staff are struggling with archaic and fragile IT systems. In some instances, this had led to treatments for chemotherapy and radiotherapy not being prepared on time; patients attending for treatment only to experience delays; and health professionals being unable to access blood test results and patient records. We even heard that some health professionals have resorted to paper-based records because ICT systems were simply not reliable enough. These shortcomings are also contributing to an increased likelihood of error and poor patient experience.  

We do not see how this can be addressed without a radical rethink. In 2016, the total cost of developing and rolling out the new systems needed across all Welsh health boards was estimated at £484 million. But the committee could find little evidence of where the money would come from and whether it would be additional NHS funding or found within existing resources. The budget NWIS operates with is utilised predominately for keep the IT system going. So, we need to find another way to ensure that the necessary innovation is funded.

Our inquiry has also raised serious question marks about the competence, capability and capacity across the health system to deliver digital transformation in Welsh healthcare. And yet, we discovered a culture of self-censorship and denial amongst those charged with taking the agenda forward, in NWIS itself, as well as its partners in the health boards and the Welsh Government. 

We are particularly concerned at the apparent lack of openness and transparency across the whole system. Digital transformation requires an open culture, but the committee found that the culture at NWIS was the antithesis of this. The auditor general’s report identified a pattern of the organisation being 'overly positive' in reporting its progress. The committee’s evidence gathering found examples of this again and again. Troublingly, this mindset seems to be consistent with that of the health boards and the Welsh Government teams working alongside NWIS, as the committee found a collective reluctance to openly discuss the true state of progress. 

We also found that witnesses were reluctant to be critical of progress or arrangements on the record. Some written evidence from two parts of the NHS was remarkably similar and the committee was left with the impression that we were getting a pre-prepared line. As a result, the committee could have little confidence in many of the assurances that we were given by NWIS and the Welsh Government. If the problems with NWIS are to be addressed, then an open and honest reflection on the current state of play and the barriers to progress is essential. Indeed, it is quite possible that this culture has prevented the committee from hearing a comprehensive range of issues and problems. In short, we remain unsure of the scale of the issues.

We are concerned that neither NWIS nor the Welsh Government are fully ready to openly recognise the scale and depth of the problems. The committee is concerned that this cultural problem may be masking wider and deeper problems, which we did not uncover. We believe a fundamental change in behaviour from NWIS and the wider NHS digital team is required if progress is to be made.

The committee is deeply concerned about the slow pace of delivery of modern informatics systems across the NHS in Wales and the underlying weaknesses in support and oversight arrangements. It's apparent that nobody is happy with the current state of affairs and nobody seems willing to take responsibility for the challenges. NHS bodies are frustrated with the slow roll-out and problems with systems they have, and are concerned about confused accountabilities. NWIS is frustrated at the lack of direction from the wider NHS. However, for us, the greatest frustration is that digital can improve the NHS and it is not being utilised anywhere near enough. A simple example is that electronic records lead to better patient care and outcomes, but in too many cases, the NHS relies on outdated paper-based records. 

The committee found little evidence to show that the need to increase the pace of change had been picked up. The chief executive of NHS Wales’s acceptance of the Wales Audit Office report, which was published in March 2018—and in a letter to this committee, he referred to the 18 months of work undertaken. This suggests that the initial evidence was gathered approximately two years ago in September 2016. Now, the committee recognises that, while the auditor general was undertaking his work, the Welsh Government and the wider NHS were taking steps to begin to address many of the issues. Nonetheless, we remain concerned about the pace and urgency of action, as we saw little evidence of change.

Our report not only endorsed the findings of the Auditor General for Wales and the parliamentary review, but also made five recommendations of our own. We welcome Welsh Government’s acceptance of these recommendations and its commitment to a number of reviews to look at informatics and the development of a national informatics plan. However, we were disappointed that the response, yet again, did not seem to recognise the committee’s deep concerns about the slow pace of delivery of new informatics systems across the NHS in Wales. There still appears to be little recognition of the radical overhaul that is required and the urgency with which this needs to be delivered. We seem to be stuck in a long period of review with little change.

We note that the outcomes of the reviews will lead to change, but this needs to be achieved at pace as informatics in NHS Wales have failed to keep up with modern technology, and every day, staff within the NHS are struggling with systems that simply do not work. It simply is not good enough and the complacent attitudes of those tasked with delivering these systems in NHS Wales need to change. They must be open to the change that is needed and recognise that so far, the approach has not delivered.

The Welsh Government’s reviews and national informatics plan are scheduled for completion within six months, at which time we expect an update of the latest position regarding the plan. We will also wish to seek assurances that the Welsh Government and the wider NHS will act with the necessity needed to put in place the resources and practical changes required to improve informatics in the right timescale. We've invited relevant officials to attend a committee meeting later this year, in July, to provide us with a full progress update and to share with us the outcome of the reviews being undertaken. We sincerely hope that the committee’s report will kick-start the process of improvement and deliver to the people of Wales a modern ICT system to better deliver health services in Wales.

Jenny Rathbone. 

Could I withdraw my name, please, Deputy Presiding Officer?

Okay. Fine. Thank you. Mohammad Asghar.

Thank you, Deputy Presiding Officer. I'm grateful for the opportunity to speak this afternoon on the Public Accounts Committee's report on the informatics system in NHS Wales. The benefits of investing in new technology and IT are clear. Informatics can create a safer, more accessible and more sustainable healthcare system, helping the NHS to deliver better outcomes for patients and making more efficient use of financial and human resources. This report follows the previous documents by the Auditor General for Wales, published in January last year. He found that although the vision for an electronic patient record is clear and key elements are in place, there are significant delays in delivery. He went on to say there were key weaknesses in the arrangements to support and oversee delivery, and to ensure the system delivered the intended benefits. The auditor general made a number of recommendations, which, I am pleased to say, have received a very positive response from the Welsh Government. Following this report, the Public Accounts Committee agreed to hold its own inquiry into the informatics system in NHS Wales. It is very much the case that the committee's report is supplementary to that of the auditor general. During our hearing sessions, many concerns emerged or re-emerged. The main issues of concern remains the slow pace of delivery of a modern informatics system across the NHS in Wales and the underlying weaknesses in support and oversight arrangements. This concern is reflected in the frustration expressed across the NHS over delays in delivering electronic patient records, as well as concern about the resilience of core systems.

We had hoped that the pace of change would have increased since the auditor general's report a year ago. However, this is not the case. In too many cases, the NHS still relies on outdated paper-based records. The NHS Wales Informatics Service is frustrated at the lack of direction from the wider NHS, but we've found that the NHS still does not openly recognise the scale and the depth of the problem. This may be indicative of a wider potential problem, which may reveal further matters of concern that are not yet apparent. What did become apparent was a lack of openness and transparency across the whole system. Some witnesses appear to be reluctant to go on record as being critical of the progress made, or of the arrangements in place. The auditor general found that NWIS was 'overly positive' in reporting progress. Deputy Presiding Officer, their complacent mood does not sit comfortably with the committee's finding that many digital projects are behind schedule, and others only on schedule because their timescales have been amended to show them on track. Shifting the goalposts does not address the problem. The sheer pace of technological change means that the continuing delay could result in the NHS in Wales being run on outdated IT systems.

In addition to the strong endorsing of the existing recommendations made by the auditor general, this report makes five recommendations. I welcome the fact that all five recommendations have been accepted by the Welsh Government, in particular the request of the committee to receive six-monthly updates from the Welsh Government on progress on implementing the digital recommendations contained in the parliamentary review and the auditor general's report. This is essential if we are to speed up progress and deliver an IT system that is fit for purpose and delivers better outcomes for patients in Wales. I was lucky enough to meet Dr Alice Groves last week. She went to America with a group of doctors who went on a fact-finding mission especially to see this informatics system in America, and the American doctors were shocked when they were told that the NHS in Wales is still using outdated fax machines and, in some instances, that operations are being cancelled in NHS Wales operating theatres because the files for the patients were not received by the operating theatres. What I heard from Dr Groves was that we are miles behind in this field of NHS service in Wales, and we should follow a little bit and learn something from the US health service in Wales also. Thank you.

Having been absent from this place for some time, I sometimes find myself reflecting on my return about what has changed and what has not. I remember having to deal with a constituency situation where information could not be transferred effectively between two hospitals in Carmarthenshire. The upshot of that was, in fact, that the patient, who was a young adult—his parents were given his records to drive from Llanelli to Carmarthen. Not a very safe use of anybody's data, but absolutely the only way that they could get the information through in time. I did not expect to find myself, Deputy Presiding Officer, returning to this place after such a length of time to see that we still have, as this report highlights, outdated IT systems. The fact that we still have anybody using a fax machine—I don't think I would remember how to use a fax machine if I was called upon to do so—has been quite a shock to me, and as the Deputy Presiding Officer knows, I am not easily shocked.

I won't repeat the points that have been made already in Nick Ramsay's admirable contribution to this debate. There is no need to rehearse the issues; the issues are there clear enough in the report for everyone to read. But it is worth reflecting that we're not talking here about a theoretical debate or about something that's purely technical; this affects people's lives. The Velindre Cancer Centre reported that one patient did not receive chemotherapy treatment as blood results were unavailable and that there was a delay in radiotherapy treatment for eight patients. These are real patients; these are real people's lives.

What I want to concentrate on in my contribution today, Deputy Presiding Officer, are the issues of culture, the issues of the apparent inability to admit that there are serious issues, the tendency to move the goalposts instead of admitting that projects are running behind time, and simply not to acknowledge that there is a problem. And I will repeat this that Nick Ramsay said. The report says:

'Our inquiry has raised serious question marks about the competence, capability and capacity across the health system to deliver a digital transformation in Welsh healthcare. And yet we discovered a culture of self-censorship and denial amongst those charged with taking the agenda forward—in NWIS itself as well as its partners in the health boards and the Welsh Government.'

Now, I think that's a very, very serious charge. I was, therefore, pleased to see that the Welsh Government was accepting the committee's recommendations. But when I read the detail of that acceptance, it seemed to me that we were once again being told that everything was all right because the Welsh Government was already doing what the committee had said that it needed to do and that everything would be absolutely fine. Well, we only have to listen again to Nick Ramsay's contribution today to know that that isn't the case. And it isn't just me commenting on this culture. I would quote to the Minister his Labour—and now ministerial—colleague Lee Waters, saying,

'Digital change isn’t just about technology, it’s about a change of culture. It’s about being open. It’s about using data to solve problems. Instead of designing services from the viewpoint of what a health board or a local authority thinks a citizen needs, a digital approach involves designing services that meet the needs of the end user.'

And I think that's absolutely—absolutely—correct. I am not reassured by the Government's response yet, and I hope that the Minister may be able to provide myself and, more importantly, the committee members who have done this very valuable work with reassurance that things from now on will really change, because they certainly have not yet.

Now, I think the six-monthly reporting to the committee—and I am particularly glad to see that the Government has committed to do that—. It is unusual for a committee to ask for that on an ongoing basis, and I think that does show how seriously they take these issues, and therefore so should we all. I think that would be important and that's very welcome. More important will be to see whether or not the Minister is prepared to abandon his apparent complacency and be ready to take a robust lead in delivering change and creating a culture that can accept challenge. Whether he can, or whether he will choose to do so, remains to be seen.

I now call the Minister for Health and Social Services, Vaughan Gething.

Thank you, Deputy Presiding Officer. I'd like to thank the committee for their report and the debate today. We may not agree on every single issue at the end of it, but I think there is a shared ambition for our digital future within the world of health and care. Of course, 'A Healthier Wales' puts digital technology transformation and basic, essential use at the heart of transforming health and care. I'm clear that it is our ambition to have the investment, systems, skills and leadership in place to deliver that.

This is a key aspect of our daily lives, and, of course, health and care is no exception. Our challenge is catching up with the reality of how we live our lives. People expect information about their care to be available where and when it is needed, and that is what our national approach aims to provide. I do recognise concerns over the pace of delivery, the stability of our systems and leadership. I made a clear commitment in 'A Healthier Wales' to accelerate digital change for the benefit of society and, indeed, the wider Welsh economy. The Government's additional investment of £25 million of capital and £25 million of revenue for digital in the next financial year will make a significant difference to help us to drive that change. To ensure that we work with increased pace and focus on priorities, we now have a three-year national informatics plan developed through engagement with health boards, trusts and policy officials, and we will focus on replacing cancer, eyecare, pathology and hospital pharmacy systems. We'll increase investment in technology to aid the mobilisation of our care professionals and the delivery of an online service.

It is worth remembering that, in Wales, we have taken an incremental approach to developing IT systems for the NHS. When Informing Healthcare was set up in 2003 it had an annual budget of £30 million. In contrast, in England, the national programme for IT was cut short after spending £7.3 billion and the National Audit Office reported that money spent on care record systems did not represent value for money. In addition, the Major Projects Authority concluded that the programme in England was not fit to provide the modern IT services that the NHS requires.

We already have achieved a range of things in terms of digital delivery. Our national systems allow professionals across health and care to access a single, up-to-date view of the patient's care record and for images to be shared across Wales. The level of services is improved, time is saved and risk and cost reduced. Wales is one of the first countries to use a national test results service, meaning that test results are available where and when they're needed, regardless of organisational boundaries. I've seen for myself, as I hope Members have, too, the difference that Choose Pharmacy makes for patients, who can now get prescribed medicines from pharmacists in an emergency without reference to a GP because they have access to the patient's information. That system is now live in more than 95 per cent of eligible pharmacies, and for a change in an IT project, it is on budget and ahead of schedule.

GPs in Wales are able to use one of two centrally managed IT systems to provide everything from desktop support to managed print services, hopefully allowing GPs to focus more of their time to treat people in their care. Patients are increasingly able to make use of digital technology to help their own care and treatment, from booking appointments online, ordering repeat prescriptions and accessing data from their health records. There is, though, much more to do. The introduction of text reminders, as one example, has helped to reduce the number of missed appointments.

Our approach to digital systems supports a system where health and care are integrated and they must have the citizen at the centre. So, the Welsh community care information system has already gone live in 13 organisations and I'm clear that I want more to come on board progressively until we have the whole country covered, to deliver a shared view of the patient, of the person, to colleagues in health and social services, to improve safety and the quality of care. This is the first time that such a programme has been delivered on a national scale anywhere.

I'm very grateful to the Minister. I'm wondering if you can provide us today with—. What you've been saying is very positive, and we'd all welcome that, I'm sure, but can you provide us with the latest figures with regard to outages in the current NHS system? If you're not able to provide those figures today, would you be prepared to write to Members in that regard? Because that is, obviously, absolutely crucial—the positive developments that you're describing today won't work if the systems keep crashing.

I'll come to outages later in my remarks. In Wales, we're developing an online directory of services that aggregates information from across health, care and voluntary sectors to make it easier for citizens to find information on services relevant to them. As outlined in my response to the Public Accounts Committee, a review of NHS digital architecture is under way, and that will guide plans for how the architecture is developed for the future to take account of advances in the marketplace and best practice from elsewhere. We still want to be a learning and open service. I'll be acting on the review's report, which is due before the end of this financial year.

As we become more reliant on our systems, in what is a complex environment, it is doubly important that the systems are safe and resilient, and there were a number of outages last year. NWIS have now stepped up to maintain and upgrade our systems, and I'm pleased to report that there have been no major incidents with IT systems since the start of September last year. I've also increased investment in cyber security and established new processes in the event of cyber or system failure.

But delivering the change that we're looking for will require the right level of digital skills and leadership within the health service. That requires looking across the whole system, not with a focus on just one organisation within it. As promised in my response to the Public Accounts Committee, the review of informatics governance in the NHS has now been completed and its report has been submitted to the Government.

Simple points solutions will not work. We need rather more radical, multiple and co-ordinated actions across all parts of the system. There is widespread support for change and a clear recognition that now is the opportunity to create a more resilient and responsive system that is genuinely fit for the future.

The review makes a series of recommendations for both the short and medium term under four key themes: establishing a chief digital officer for health to strengthen national digital leadership; creating a new standards authority and mandating informatics standards; establishing a new digital development team to support innovation and to accelerate the pace of delivery, with priorities set nationally; and to bring together the current dispersed regional and national informatics services in a shared service arrangement for data infrastructure and delivery.

I will, of course, publish the report in due course. In the meantime, I've asked my officials to work with the health service to consider the recommendations. I will update Members before Easter recess on our response to the review's recommendations. Of course, it's not just the digital skills and capability of our workforce that are important. We must be mindful of the impact on our citizens, in particular those who may have difficulty taking advantage of new services. I therefore have committed £3 million for a health-focused element to our digital inclusion programme over the next three years to build a network of champions in the service and in the community. We will continue to look beyond the boundaries of health to bring benefits to our citizens. NWIS is working with colleagues elsewhere in the public sector, and the digital health ecosystem for Wales is fostering collaboration between the service, academia and industry to drive innovation. Whilst not losing sight of the achievements, I know there is much more to do. I am confident that we will deliver a healthier Wales, with improved digital capability and access at its heart.    

Thank you. Can I now call on Nick Ramsay to reply to the debate?

Thank you, Deputy Presiding Officer. Can I thank all of the Members who've contributed to today's debate? It might have been a little shorter than some debates that we have in this Chamber, but I think that all of the points that Members made were well made and to be welcomed.

There have been some recurrent themes that have been touched on by all Members, starting with Mohammad Asghar, who mentioned the issues of transparency and the need for openness. I think we need to know the scale of the problem before us, and to accept that so that we can find solutions—that's key. And that's what PAC reports like this are here to do: to shed light on those areas where things are failing—respecting the fact that there are other areas where progress is being made and success is happening—those areas that are failing, like in this area, need to be put right. 

Helen Mary Jones reminds us she's not easily shocked, but you are right to be shocked or taken aback by this report. It is a hard-hitting report—I don't make any bones about that. It is a scathing report. It doesn't hold any punches, because it is reporting on the evidence that we received, and deep concerns that were in some sectors about the problems that we're facing with the informatics in the NHS. As you said, Helen Mary, this isn't a theoretical debate. It's actually, as I speak here now, as you spoke earlier—out there in Wales, it is affecting real people, it's affecting staff and it's affecting patients. Perhaps 50 years ago when computers were, well, certainly in their infancy and informatics probably wasn't even imagined, these sorts of issues were obviously not relevant. But now they are. They're relevant to other areas of life and they're increasingly relevant to the health service.

I'm glad, Helen Mary, that you quoted Lee Waters—Lee Waters, a previous member and a valued member of the Public Accounts Committee. I know that these are issues—a different hat on now, of course, so you're not part of this debate today, but you put a lot of work in with the rest of the committee and that's to be welcomed as well. Digital transformation, when you quoted Lee, is about being open. That echoes Mohammad Asghar's earlier comments as well. That's what we're trying to achieve here. 

Turning to the Minister's response—and I think it's a well-meaning response, as Helen Mary said, it's a response that contained a lot in it to be welcomed. Thank you for the spirit that you delivered it in, Minister, and thank you for your evidence that you gave to the committee. I'm pleased that the Welsh Government has accepted our recommendations. I'm pleased more than anything because they need to be accepted. You're right: we all want improvement in this area.

The issue that we have—one of the predominant, overriding issues—is the pace of change. It cannot be right that Assembly Members who were here back in the early days of devolution, when we were discussing exactly the same problems, have now come back and everything is as it was. That can't be right. So, pace is the issue. Yes, there have been improvements, yes, things have moved on in some areas, but it needs to happen quicker. We need to have capacity. We need to have a capacity within the Welsh Government, within the NHS system—a capacity and the skills that are required to put this situation right. The committee wasn't convinced that that capacity is there at the moment. There was evidence of capability in the system—we had a long discussion about the difference between capability and capacity—but there were concerns about the scale of that capacity. 

Outages—Members mentioned the number of outages. I'm pleased to hear there haven't been any since last September because, quite frankly, with the scale of some of the outages that were happening, they were really holding the system back and holding progress back. That has to be sorted out so that we can move on.

There is support for change—within the Welsh Government, dare I say, within this Chamber itself—of course there is support for change across the board. We all want this sorted out. It is going to take money, but it's also going to take a change of mindset—or a moving on of the mindset is probably a better way to put it—because there is undoubtedly a desire, amongst all the stakeholders that we took evidence from, for this position to be improved. But we're nowhere near there yet. We're on a road, but we want to get where we're going far faster than we are. Let's give the NHS the informatics system that it deserves. Let's give the people of Wales, patients and staff the system that they deserve and need. We've waited a long time. I plead with the Minister to employ your commitment to this to make sure that we do get an improvement in the informatics system that we all want to see. 

Thank you very much. The proposal is to note the committee's report. Does any Member object? Therefore, the motion is agreed in accordance with Standing Order 12.36. 

Motion agreed in accordance with Standing Order 12.36.