Informed Health and Care: Delivery
“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 and look to changing how we work to meet those challenges.
A partnership for delivery
Here is my five-step plan to deliver the strategy:
1. Change our metrics
Metrics, quantifiable measures of progress, are important indicators of what we want to achieve and so must represent those ambitions. Our National Informatics Management Board (NIMB) in Wales uses delivery of certain products into different health boards as a measure of success, but is that appropriate? We need to focus instead on value and outcomes for our population, and therefore change our metrics to represent solving problems.
This approach forces us to step back and focus on the problems we are solving with information technology and ensures that we don’t become blinkered into adopting a certain approach that will delay realising value for patients and professionals.
2. Change our governance and ownership
We have health boards working to deliver care for their citizens but a separate organisation, the NHS Wales Informatics Service (NWIS) acting in multiple, potentially conflicting, roles as a source of IT expertise for the service, as a source oversight and assurance, as a supplier of software and supplier of infrastructure. The Welsh Audit Office (WAO) report strongly criticises the governance arrangements and the imbalanced reporting of success and progress.
Don’t we need to consider instead, a partnership, owned by the health service for the health service working to increase cooperation and collaboration providing top-down governance and assurance separate from an any organisation with supplier status? Surely we need a strategic assurance group able to set broad principles and define, maintain and assure technical and information standards for use across NHS Wales and its partners?
We must encourage trust, collaboration and cooperation to encourage bottom-up working to solve real-life local problems and share good practice among peers. This means getting the right balance between governance and delivery, whether those projects are delivered in-house, by collaborative working groups working across and for NHS organisations or by third-parties.
3. Change our architecture and our team structures
The current architecture in NHS Wales is built from an enterprise service bus (ESB) messaging service but much of our software integration is bespoke and point-to-point and there is a lack of robust automated unit and integration test environments offering end-to-end assurance of proper functionality. There are significant delays between design and getting software to end-users, limiting feedback on quality, performance and failing to identify user need by iterative ongoing continuous improvement and iteration.
We need to modularise our architecture and realise the productivity and safety benefits from combining development, testing and operations into cross-functional teams with shared common goals to deliver discrete modules of functionality that can be independently developed and improved with loose-coupling with other components. A change in architecture should prompt us to create task-driven teams bringing together expertise from our existing functional units with a single goal: delivery of quality software to solve our problems, create value and as a result, improve the outcomes for our population. We need to see information technology as a tool for continuous improvement and service transformation and we need to speed up and isolate modules of our information technology work in order to delivery and improve.
Such an approach builds on our existing work to adopt a standards-based approach to our healthcare enterprise architecture.
4. Change our culture
We need to adopt the UK Government Digital Service (GDS) design principles and focus on openness and transparency in our work.
Healthcare information technology is hard, and we need to be able to step back and re-evaluate our progress and our plan for delivery, bring in outside expertise when needed and justify our decisions with a clear and informed appraisal of our options, without conflicts of interest. This relates, of course, to the changes we need in governance; an organisation who runs two data centres itself is unlikely to be able to make the difficult decisions to switch to using commodity cloud providers or to judge itself against agreed service level agreements.
For example, I was asked to take “down this blog” as my posts on strategy and technical architecture were perceived as criticism and this was “particularly difficult” to tolerate as I was working (at the time) for the NHS Wales Informatics Service. How can that be right? We must encourage and foster debate, be transparent in our decision making, which, after all, will always be a compromise and balance between advantages and disadvantages, and recognise that we should bring in expert help when appropriate in order for us to make the right decisions for Wales.
5. Change our focus
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, or those areas of work that can be easily provided by third-parties. We need to prioritise our work and focus on delivery of value and improved outcomes. We must focus on user need.
We must recognise that technology evolves quickly and so we must build culture and architecture to encourage and enable innovation and partnership working recognising that our population can benefit from a digital-first approach to healthcare, whether directly in their interactions with out services or indirectly as a result of better planning, scheduling and clinical decision support. Our ecosystem should be focused on building tools and frameworks to make the work of both internal and external developers, safe, productive and efficient.
Similarly, we must raise our focus away from only healthcare in Wales and recognise that we must exchange meaningful information with partner organisations in other regions and in other disciplines.
Finally, we must become focused on being data-driven, so that we focus firstly on the capture and analysis of clinically meaningful structured and semantically interoperable data, and use those data to shape and improve our services. Similarly, our information technology developments should, themselves, be driven by data, by usage and by metrics of performance, stability and security. The data driving our work should be meaningful and standards-based.
On “Once for Wales”
On trust and innovation
- The paradox of ambition
- The paradox of control
- The 5 Os of healthcare IT - objectives, ownership, openness, optimise, organic
- Platforms 1/3. Standards and interoperability
- Platforms 2/3. An API-first approach
- Platforms 3/3. What we need to do next
- Focus 1/3. The importance of strategy : focus
- Focus 2/3. The challenges we face in delivering the vision
- Focus 3/3. Pragmatic solutions to those challenges