“Informed health and care – A digital health and social care strategy for Wales” sets out a clear vision for the use of information technology to support the provision of healthcare for citizens within Wales.
This vision is split into four key themes:
- “Information for You”
- “Supporting professionals”
- “Improvement and innovation”
- “A Planned future”.
“We want a future where staff, service users, patients and carers are empowered and better informed, where organisational boundaries are not a barrier to effective care, as information is available electronically and joined-up, and where innovation and improvement can flourish built on a solid technical infrastructure and a safe environment for those who work in or are served by health and care services in Wales.”
The key question for us to answer is, what are the challenges that must be overcome to deliver this vision? As part of that process, we must identify current and future impediments to successful delivery. It is easy to fall into a trap of thinking of the “Informed Health and Care” strategy as an finished product instead of what it is, a set of high level goals which requires us to build a tangible and specific roadmap bringing together multiple strands of work into a truly cohesive vision.
Likewise, we must be honest about the economical and political environment in which we work, acknowledging the limitations in resources. We face a multitude of potentially conflicting demands and interests; as such, delivering the “Informed Health and Care Strategy” requires us to not only understand what we must do to achieve those goals but critically to understand what we must stop doing.
So, what is our strategy to deliver the vision?
Difficult choices : we cannot do it all
NHS Wales must face some difficult choices. For too long, external factors have resulted in incoherent and inconsistent delivery or projects, frequency orthogonal to delivery of the wider vision; in many cases it has been driven by the budgeting process and the availability of funds in any single financial year.
A coherent plan to deliver the strategy needs more than a list of disconnected and incompatible goals but instead a clear understanding of what needs to be done and what doesn’t need to be done; we must know when to say “no”. Instead, we focus our limited resources on specific tangible actions and make some difficult decisions to prune areas of work that do not support delivery of the wider vision.
… you should have a very short list of the most important things for the company to do. Then you will have a basis for moving forward.
As such, we need a coordinated all-Wales approach that permits all stakeholders to work cooperatively and collaboratively with clear lines of responsibility and governance. We need to re-organise our approach to healthcare information technology taking into account the steps needed to deliver the vision, the principles of enterprise architectural design, modern information standards and interoperability, modern quality improvement methodology and user-centred design.
I believe that the only logical response to the Welsh Audit Office report is to re-imagine the relationship between the NHS Wales Informatics Service (NWIS) and the health boards. Such a re-imagining requires us to stop ignoring the, in my view, currently incoherent set of responsibilities and divisions of labour that exist within Wales.
For example, is NWIS a standards and governance body, a consultancy, a software development house, a provider of a computing platform, a user experience and design shop, a procurement specialist, a business intelligence and analytics service or a provider of information technology infrastructure? Who is responsible? Who takes the credit for successful delivery and who takes the blame when something is not delivered? If we cannot answer such questions, we have to question our governance and organisational structures.
In addition, while it makes sense that the “Informed Health and Care” strategy is divided into four workstreams, I believe it is incorrect to assume that the safe and efficient delivery of those objectives is necessarily delineated into separate workstreams. Such separation works only if work may continue semi-independently without consideration to other projects. There are, in my opinion, too many common goals and solutions to solve those goals that cross-cut those workstreams to consider them independently.
Instead, we must consider a “target architecture”, an enterprise master-plan which lays out an overall set of systems and functions that will support delivery of our shared vision. For example, understanding the similarities and differences between providing information for patients or professionals provides important insight into the shared data and software components that must serve both sets of requirements. For example, patients and health professionals need to see past and prior appointments and entries on waiting lists; there is no doubt that there are shared needs that cut across those workstreams.
Similarly, transformational change, enabled by technology, must be driven from the bottom-up, from those who deliver healthcare permitting incremental development and innovation while at the same time lowering risk. When a project is small and developed incrementally in an agile-way, our risk of failure is minimised. Likewise, don’t we all know that we must have top-down governance to ensure that solutions are standards-compliant, fit-for-purpose and safe as well as checking that developments are not orthogonal to the overall strategic vision so eloquently described in four workstreams of the Informed Health and Care Strategy?
As such, we need an all-Wales plan to deliver the vision that balances the need for centralised planning and yet enables local innovation. The paradox, put simply, is that currently we appear to have centralised the day-to-day management and delivery of individual projects and yet high-level strategic and prioritisation decisions are decentralised, haphazard and dependant on capital funding with little or no consideration or control as to how those projects will fit into a wider technical all-Wales architecture. We have, in essence, failed to create a plan to delivery the strategy.
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