In part one of this series, I introduced the “Informed health and care – A digital health and social care strategy for Wales” and talked in broad terms about the importance of a coherent strategy - a specific action-focused plan - to deliver that vision.

In this part, I try to articulate the importance challenges we face in delivering the vision, concluding that essentially, we need to balance centralised planning and control with support for innovation and change, particularly given the new technologies on the horizon which offer the potential to transform how we configure and deliver care to our citizens.

We need a coherent plan to deliver our vision. In part 3, I discuss the best way to meet those challenges.

What are the challenges we face?

So what are our challenges in delivering the vision today? We can look to the recent Welsh Audit Office report; this has raised important concerns about healthcare information technology in Wales including:

Highlighting the inherent complexity of deploying information technology across a large complex system, spread across multiple organisations, with staff operating out of hospitals, GP practices and in the community.
Significant delays in delivery of projects
Lack of strategic prioritisation
Disagreements between some NHS bodies and NWIS in relation to delivery and the meaning of “Once for Wales”
A need to strengthen leadership
Weakness in governance arrangements, lack of independent scrutiny and unbalanced reporting of progress
Inadequate funding
Inconsistent planning with a need to aligning plans across organisations
Issues of information technology staff capacity.
Issues of clinical engagement and dissatisfaction.
Concerns about the quality and functionality of many national systems
Unclear lines of responsibility in relation to delivering and monitoring the benefits of projects.

Similarly, we must also consider what challenges our services will face in the future. Healthcare is ever-changing and there are a number of transformative and disruptive influences in health that, together with new technology, are driving and will continue to drive new ways of working. I wrote about these in my disruptive challenges series of blog posts. Are we confident that we have an environment in Wales that is primed to take advantage of current and future technologies?

Changes in model of care:
- Management of multiple long-term health conditions, cross-disciplinary teamwork, non-health partnerships including social care and third-sector
- Shared care and shared records
- Remote monitoring using modern technology including wearables and the “Internet of things”.
- Focus on health outcomes and prudent healthcare, a need to support big data and real-time analytics and embed artificial intelligence into management and clinical practice.
Patients as active participants:
- View and contribute to their own records, recording their own aims and objectives and target outcomes
- Communication with the healthcare team
- Control the sharing of their information for direct care, for service evaluation and for research via consent and robust citizen identity services
Hospitals without walls:
- Increasing availability of personal mobile devices, wearables and smart home monitoring
- New commercial models of care and software provision

The Parliamentary Review of Health and Social Care report, published in January 2018 highlights the need for a seamless health and care system in Wales, centred around the citizen irrespective of where they live with the avoidance of creating artificial barriers between services and organisations.

It highlights that service redesign can be enabled by the appropriate use of digital technology. In addition, it explains how frontline innovation across different parts of Wales has already emerged and the importance of being able to disseminate good practice once proven stressing the importance of adopting continuous quality improvement methodologies to create a learning health and care system. Similarly, it recognises that different localities across Wales do not need to operate in the same way or that services must be identical.

In that report, similar concerns to that from the WAO were raised :

Simply put, activity is just too dispersed and stretched, and lacks overall commitment around a unified vision and set of priorities.

At the same time, the report draws out the seemingly conflicting goals between local variation and harmonisation and standardisation. We want to support innovation, appropriate variation in services and the delivery of a thriving digital ecosystem supporting local industry and at the same time reduce needless variation, share good practice and harmonise across systems?

I do not, for example, want patients to be disadvantaged because the technology used in one health board is different to another and the information available is incomplete and the pathway of care disrupted. This is why Wales has committed to working together to adopt common information services and I expect all parts of the NHS in Wales, supported by the Informatics Service, to adopt them

Dr Andrew Goodall, Chief Executive, NHS Wales.

How can we deliver these two seemingly mutually exclusive goals?

The answer, of course, is to understand that coordination and central control can be applied differently depending on what is being discussed.

Thus we should seek coordinated policies only when the gains are very large. There will be costs to demanding coordination, because it will ride roughshod over economies of specialization and more nuanced local responses. The brilliance of good organization is not in making sure that everything is connected to everything else. How that road lies a frozen maladaptive stasis. Good strategy and good organization lie in specializing on the right activities and imposing only the essential amount of coordination.

from “Good Strategy Bad Strategy”, 2011 by Richard Rumelt

Our strategy must therefore take into account a need for national coordination for some areas of our work and yet enable innovation and variation in others.

We need a coherent plan to deliver our vision. In part 3, I discuss the best way to meet these challenges.