Cynulliad Cenedlaethol Cymru

Good afternoon, everybody. I'd like to welcome Members to this meeting of the Public Accounts and Public Administration Committee. I'd also like to welcome the Auditor General for Wales and her officials to the meeting. The public items of the meeting are being broadcast live on Senedd.tv and the Record of Proceedings will be published as usual. This meeting is bilingual and simultaneous interpretation from Welsh to English is available. We have received apologies from Andrew R.T. Davies. Can I ask Members if they have any declarations of relevant or registrable interest? None received. Thank you.

Item 2 on today's agenda is papers to note. We have eight papers to note. The first paper is a letter from the Llywydd to Senedd committee Chairs regarding the use of smart and AI-enhanced glasses in committee proceedings. This letter clarifies the Llywydd's position, which effectively repeats what he said is his position on the Chamber, and follows a discussion in the Chairs' forum on 8 October. The second paper to note is the letter from me to you as members of the committee on my position as Chair on this issue, which basically supports what the Llywydd says. Then we have a third—

Sorry, Chair. In relation to that, it is worth noting that in the UK Parliament, the issue is being discussed. I think in the Senedd Chamber, it was debated and discussed there as well, and I think the position was that we would take the position here, which is as it is, however—

It's subject to ongoing review.

Subject to ongoing review, yes.

The Llywydd is conducting a review, and once that review has been completed, if there's a change in the advice and guidance, then I will change mine accordingly, yes.

Thank you.

The third paper to note is a letter from the Llywydd to all committee Chairs outlining expectations when they hold another role in relation to Senedd business, such as political group spokesperson. It doesn't affect me, because I'm not a spokesperson. That's just a paper to note on that.

The fourth paper to note is a letter from the Chair of the Constitution, Justice and External Affairs Committee regarding the Welsh Government chief statistician's report on the well-being of Wales, which was discussed at their meeting on 1 October. We have the Chair of that committee as a member of our committee.

I'll be brief. My committee is responsible for monitoring the implementation of the Act. The well-being report that's referred to here came out on the same day as the committee meeting, so we didn't discuss it in a lot of detail, but we did highlight some concerns from that that we wanted to pass on to other committees. Specifically, it highlighted a fall in healthy life expectancy, widening health inequalities, decline in biodiversity, continuing levels of poverty, and worsening mental health amongst young people as well. The Act obviously impacts all committees, so we'd be keen to hear if this committee or other committees have any planned scrutiny. If you could let us know about that, that would be welcome. Diolch.

We certainly will do. I believe, Anna, you had a comment on this one as well.

Yes. Chair, whilst we're not directly looking at those issues that Carrie has highlighted there, I feel that our work on the public administration side and how Welsh Government is responding in the ways of working feeds into that, and it links to our committee's work. So, I'd be keen that we keep that in mind as part of our work.

Okay, noted. That's noted for the future work programme as well. Thank you very much.

The sixth paper to note—. I nearly lost my way there. The sixth paper to note is a letter from the Cabinet Minister for Government Effectiveness and the Constitution regarding his response to the sixth Senedd's Public Accounts and Public Administration Committee report on COVID-19. This letter is in response to the letter sent by us on 18 September following our evidence session with that Cabinet Minister, where we requested a detailed response to each recommendation.

Our predecessor committee agreed to undertake an inquiry into COVID-19 at the specific request of the Business Committee, despite this issue not being within its remit. Although the Government's response touches upon our public administration work, matters relating to COVID-19 in general are not within our remit either, and it is instead an issue that cuts across a number of committees.

The Welsh Government's response has already been copied to the Business Committee and the Health and Social Care Committee, so we're just noting the paper and awaiting anything further from those committees to see whether the Business Committee decides to pass it to us, like they did in the last Senedd.

The seventh paper to note is a letter from me to the Permanent Secretary regarding the use of public funds by Bridgend County Borough Council. I was contacted by an individual expressing their concerns about the use of £4.1 million of public money used by the council in connection with Welsh Government grant funding provided for the Caerau external wall insulation remediation scheme. Whilst it's not my place as the committee Chair to advocate or seek redress on behalf of individuals, I believe that there was merit in my writing to the Permanent Secretary for clarification, given our responsibility for the scrutiny of public expenditure. This seventh paper is a response from the Permanent Secretary.

The eighth and final paper is the response from the director general for local government, housing, rural resilience and sustainability to this issue, which provides a response to each of the questions asked in my letter.

Members, are we content to note the content of the papers? All content. Thank you. 

Item 3, NHS digital transformation, evidence session with organisations representing patient experience and digital inclusion. I'd like to formally welcome the panel to today's meeting. The committee has agreed to undertake an inquiry into NHS digital transformation and received a briefing on this issue from Audit Wales at our meeting on 28 September, where we also agreed our approach to this piece of work. We'll undertake the first of two evidence sessions to this inquiry in today's meeting, and the first panel we'll be hearing from is comprised of organisations representing patient experience and digital inclusion. I'm pleased to welcome the first panel, and I would like them to introduce themselves for the record, please. I will start with Hannah Rowlatt. 

Hello. I'm Hannah Rowlatt, policy and campaigns officer at RNIB Cymru.

Hello. I'm Laura Phillips. I'm a project manager at Cwmpas. 

Hi. I'm Ben Eaton. I'm the deputy chief executive at Llais.

Thank you. I'd like to remind everyone that this meeting is bilingual. Headsets provide simultaneous translation from Welsh to English on channel 1 and sound amplification on channel 0. So, let's get going. I shall start with the first question, and I shall direct this to all four of you, but I will start with Hannah for the first response, if I may, please. When NHS services move online, what evidence shows that patients are generally benefiting rather than simply having responsibility for accessing services transferred to them?

I think that there's a real challenge when we talk about digital transformation, because digital transformation often means digital only. We're seeing from blind and partially sighted people that there's a difference in the experience that they receive because they might want to receive those services offline. From our research, we know that around 37 per cent of blind and partially sighted people do not use the internet and don't have access to it. And that rises. For people over the age of 75, it's 47 per cent. It's very difficult for us to talk about those benefits for blind and partially sighted people when we know that not many of them are going to be able to access digital services.

Our other challenge is that lots of digital services are not designed accessibly for blind and partially sighted people. Their accessibility needs are not considered at the point of design and those services are not co-produced with blind and partially sighted people. It's even from the very simple, like when you go to your GP surgery, you might have to check in via a digital screen that doesn't have any accessibility on it, or you might have a ticker, like a visual display that tells you what room to go to or when your doctor is available to see you. But if you're a blind or partially sighted person, you just can't access those. So yes, there are benefits for some people, but there are also some real challenges.

If I speak for myself, I am one of the people who is very digitally engaged, I'm very digitally capable. For me, there are loads of positives to digital when it's done well. One really good example of what that looks like is the transformation we've seen recently around ordering your prescription. For me, that process before the digital transformation was really difficult. It was a physical piece of very small paper—tiny writing. I had to tick a very small box to say what I wanted, whereas now I don't. I can just go onto the app. It works really well with my screen reader and reads that information aloud. I can order. I know exactly what all the drugs I take are called now, which I never did before, because they were very small on the paper. It even tells me my dosage. So, I know and I have that constant reminder, which before I didn't have access to, because that information was inaccessible. So, we have a lot of challenges, but also a lot of benefits that can come from good digital transformation.

Thank you, Hannah. Laura.

I did a lot of reflection as far as digital transformation is concerned, and I think that for me and for other members giving evidence to the committee here, inclusion has to be a real cornerstone of that digital transformation. What we tend to mean at Cwmpas within the Digital Inclusion Wales programme is access to appropriate devices, affordable data, whether you're at home or out and about, alongside the skills, confidence and motivation. A lot of people may not reach that minimum when it comes to accessing, generally, the internet, and so that means, as Hannah has mentioned, that there are real-world barriers for people engaging with digital health transformation if we don't think about that real baseline to begin with.

The other thing to consider is good use of public service and the value that that has. If we don't make sure that transformative services are inclusive from the get-go, it means that not only online services but offline services and non-digital routes can cause higher additional costs because things are done differently in different health board areas, different GP clusters. One of the things to consider is a lack of duplication, because services are different wherever you are. Even with accessing things like your primary care versus secondary care if you're hospitalised or whatever that is, there can be a bit of a disconnect there. So again, the transformation and inclusion message doesn't just come from members of the public and patients; it's also about the workforce and are they ready for that level of digital transformation and are we providing the right level of support to benefit everyone and to make sure that there is that good public service value from an inclusive perspective.

The other thing to consider is that digital inclusion isn't linear. With the pace of change of not only technology but an ageing population and the way that we utilise digital skills, I think we're really at risk of even younger people not being able to do the basics of potentially what those of us that have been using technology for a really long time can do—so, are we missing out on those skills and usability for a range of different circumstances. That's me. 

Thank you very much. Ben.

I think the only thing I'd add to what Hannah and Laura have said is that where it's reported to us that it feels like it's transferring responsibility to people is when they're not supported to get online or to use the software or the app that's provided to them. I think, for many people, there are benefits. They report to us that it works well, it's convenient. When people can get online in rural areas, it helps. Telemedicine helps there as well. So, I think there is quite a lot of positive evidence coming back, being fed back to us, but when it's a condition, not an option, and then you hear about some of those barriers, that's when it feels like responsibility has been transferred onto people. We'd like to see a bit more support for people that can't do that easily.

Thank you. And finally on this one, Rhian.

Thank you. I think I'll just look to add to what's already been said. I think digital transformation should increase choice rather than remove it. It should add an additional option for people to access healthcare. And it should reduce inequalities, rather than exacerbate them.

We know here in Wales, from a recent report that I've published, that one in five people over the age of 75 are not online at all. Wales has a higher level of digital exclusion than elsewhere in the UK, and our older population are the group that are least likely to have those basic digital skills. But this is about more than connectivity. It's about skills, it's about confidence, it's about support that's available for people to be able to access.

I think digital transformation has the potential to improve access to healthcare, but, for too many older people at the moment, it's presenting a real barrier in terms of the basics that have already been mentioned, in terms of booking an appointment, ordering repeat prescriptions, being able to be updated in terms of your journey through the health system, and there's an assumption that people have other people who can support to do that. And we also know that, as an ageing population, we're an ageing population of people who are ageing without children or that family support. So, with that reliance on others, we're making that assumption. Digital is no longer optional. It's become essential to access everyday and essential services. So, this is more than a question about digital inclusion; it comes down to equalities, rights and independence.

Thank you very much. Iain. 

Thank you, Chair. I've got one question, with a follow-up as well. The first part is to Laura, and the second one to Ben, if that's okay.

So, the first one to Laura: Audit Wales says that around £216 million a year has been spent on NHS digital technology. From your work, when NHS Wales claims that a digital service is saving time and money, are the costs of digital exclusion properly measured? For example, does it count patients who cannot complete the online process and must then telephone or attend in person, as well as the time and cost transferred to relatives and unpaid carers? And if those costs are not being captured, can NHS Wales reliably claim that the service is delivering genuine efficiencies?

That's a brilliant question. I think your point about unpaid carers is that we know that it isn't, I guess, appropriately costed. We know that unpaid carers give back to society, and their communities, and the people they're caring for without financial value. There's no way that we can put value on that. So, in a nutshell, no, I don't think it's being properly, I guess, costed, or observed from that perspective, but what I will say—let me just have a think, sorry—is that there are definite wider implications, wider considerations to be made when it comes to digital transformation. If it is just transformation for efficiency's sake, then that's a completely different story to transformation that's happening for the benefit of patients and citizens and communities. And I think that there's a much wider discussion on what is the pounds and pence cost saving versus what our communities and our patients and our citizens are able to do for themselves when it comes to both digital and non-digital routes. I think, to echo what Rhian's mentioned, having that choice and that opportunity is really, really important. Yes, there are definite savings when things happen online. But there are also the implications if we don't consider inclusion at the beginning of that journey, where those savings are greatly reduced, because there's the going back and forth with additional training, whether it's for staff members or carers. If we consider things like the NHS Wales app, the emphasis of that was with GP practices to provide, whether it was verification or support to patients. And that's got a cost that potentially wouldn't have been considered when the transformation was looked at. So, inclusion will help to overcome some of those additional costs that are sort of unintended.

Right, okay. Thank you. And the follow-up then to Ben is: what evidence has Llais received from patients who have been unable to complete NHS processes digitally? Are suitable alternatives consistently available, or are patients instead experiencing delays, additional work or exclusion as a result?

I think, from what we're told, it's a mixed picture. I think we do hear—. If we take the app, for example, what functionality is available depends on where you live, and it depends on what the GP practice has switched on. So, I think prescriptions is almost entirely on, but getting appointments, getting vaccines, communicating, seeing your online communication, that varies. So, people, sometimes neighbours, talk to each other and compare. I think we also see that, for some people, it doesn't work. So, with the check-in, one of the examples is—we spoke to someone—a British Sign Language user, and the check-in at the Grange at the emergency department wasn't accessible to them, so they couldn't do that and there wasn't actually an alternative in place. They had to find a member of staff to then try and do that manually. So, I think it's a bit of a mixed picture from what we hear. There are particular issues in the border communities with using services that are commissioned in England, for secondary care in England. So, we hear quite a lot from Powys residents that they have to have two apps on their phone because the apps don't talk to each other. So, some of those are real practical things that we hear about.

I'd say people report to us that they see the NHS as the NHS. They don't see it as their GP, including England sometimes, if they're regularly accessing that as part of their healthcare journey, so they expect information to flow with them and test results to come back to their GP. They don't understand that there are over 1,000 different systems in Wales that aren't talking to each other. I think, when that frustration and that barrier has come up, that's what we hear quite a lot about.

We do hear about it working well as well. I can think of one example, for a family who were supporting their daughter through a dermatology treatment. She was on the waiting list for about a year, but she'd go to her GP and they were able to use the phone in the GP's to send pictures to a specialist, and they'd instantly work with them if there was a flare up. So, we do hear positives, but, on the whole, it's that frustration about what people feel are logical things not working for them.

Okay. So, based on your responses, are you going to make any adjustments then to try and navigate these slight little things that are cropping up?

From our perspective at Cwmpas and the Digital Inclusion Wales programme, we work, in this example, with health and social care, across the nation, to work with organisational strategy. So, previous iterations of the programme have considered things like citizens who are at risk of exclusion, workforce capability and, like I say, the iteration that we're in now is much more focused on that organisational strategy. A thing that we consider is how we can make sure that everybody is taking responsibility for digital inclusion. We know that it can't be solved by one health board or one organisation or one team of people. Often times, digital is put into a basket of, 'Oh, it's IT's responsibility' or 'It's a resourcing problem'. Actually, what we're working on with organisations is making sure that digital inclusion is part of that strategy. So, how do we get people to understand the different barriers that they face, and then how can we help them to overcome them?

We're working much more closely to avoid those duplications as well. So, we're working with not just healthcare services, but organisations like Social Care Wales and individual providers to make sure that there is that consistency of delivery, support or systems in place to make sure that that is sustained and, again, that there's a lack of duplication and making sure that there's shared responsibility across the board.

Okay. Thank you. Thank you, Chair.

Thank you. Alun.

Could I ask you a bit about Digital Health and Care Wales and how you engage with them, and your experience of engaging with them? How receptive and proactive do you think they are, particularly on those digital inclusion issues that you mentioned?

I'm going to throw two questions into one, because I can. What safeguards are you looking for in terms of ensuring, as digital apps are developed, that they are not disadvantaging some groups? I was minded by some of the things you've said already, in terms of—I think Hannah was talking about the balance—that digital is good in some occasions, not others. Others have mentioned that it shouldn't be just a condition, it should be an option. And I'm also thinking in terms of how layers of exclusion can impact—an older, blind person who speaks Welsh, how do they react to the different ways that they could be excluded? Sorry, there are probably about five different questions there in one. [Laughter.] I'm happy for you to take any of that and roll with it. Hannah, I don't know whether you want to go first.

Shall I go first? Yes. So, in terms of Digital Health and Care Wales, I think I've seen over the past couple of years a change in how they do engage. Previously, their engagement was focused on the app and the development of that, where they have now changed their strategy so that it's more organisational wide. However, sometimes, it does feel a bit tokenistic, where we're asked our opinion on something but then we don't necessarily see what happens as a result of that. You feel like you're being asked your opinion, but then it might not go any further. So, I would love to see more engagement across all of the different projects and products and services that they operate, but also more inclusion of different groups of people. So, a lot of the engagement—and this is the same for lots of organisations—is done on the organisation's terms, not on the terms of the people that they're there to support. So, there are—and, I'm sure, across Wales—lots of different kinds of user groups and opportunities that they could be reaching outside of the organisation to go and ask people what it is that they want and find out how things are working. And I'm sure organisations like mine and others would be really happy to facilitate that, but that's not always something that happens.

In terms of the use of the app for people who are blind or partially sighted and Welsh speakers, again, that's quite a specific area for them to focus on and look at. Do I think that those voices are involved currently? Probably not. Does their engagement strategy cover that? Probably not. Would I like it to? Yes, definitely. And I think, in terms of something that I would like to see happen, actually as part of their assurance process is that they have a check by real people that all of their products are co-produced right from the start and it's not something on the end. That's definitely how we feel about accessibility; it's something that's considered at the end rather than at the beginning, and then there's always a compromise. We were talking there about the cost. There's always a cost to retrofitting. So, if you design a service and then you find out, 'Oh, God, it doesn't work for all of these people', you're going to have to spend lots of money redesigning it. So, yes, we would love to see that: more people engaged with, more co-design, and that there's more of a kind of patient check-off—a tick to say that it is approved and actually meets people's needs.

Just to, I guess, echo what Hannah said as far as DHCW are concerned, as Cwmpas, as I mentioned, we've delivered a lot of digital inclusion programmes and we were involved in what was formerly their patients and public assurance group, and involved in feeding back the beta testing of the NHS Wales app. I'd agree that co-production needs to be right at the beginning. It's very, very good that they had groups where you can, as patients and public representatives, whether that was patients with lived experience or organisations like ours that look into digital inclusion on a wider scope, actually have that feedback loop closed, which is, 'You said; we did'. I think that is potentially what is missing with DHCW. I think they do a lot of really great outreach. I know that they're developing digital champions that are going out into communities and GP clusters and practices to provide support for the NHS Wales app, but the app has existed for years before that. It's almost backfilling, a little bit, like Hannah said—it's retrofitting inclusion into the app that really should have been there at the beginning, even at beta testing phase, even before you launch and all of those sorts of things.

I know Helen at DHCW is really passionate about digital inclusion. It's whether that is all feeding down into the delivery of all of the projects that are happening. I've worked with DHCW on a number of their different digital transformation projects; I don't think I've worked with them on all of them. So, there's definitely that little bit of a disconnect between who is leading particular projects and their emphasis on digital inclusion and that role that it plays within digital transformation.

Yes, I'd echo that; I think that Digital Health and Care Wales are quite responsive to us. On top of our involvement with the patient group, if we make formal representations to them, they take them seriously and they move them forward. But what it does highlight, even for me, is an understanding around accountability. So, I went to them with two representations: one was about the NHS Wales app and what was switched on, and the other was about a diabetes app. Both of them, they were no longer responsible for controlling what was being done in the apps—it was the GPs for the app and it was an NHS Wales Performance and Improvement programme for the diabetes one. So, I think it does highlight a bit of a gap. We didn't know where to go, I'm sure the public don't know; 'Who is responsible, is it DHCW or is it my health board?' So, I just thought I'd add that.

Yes, I'd certainly echo the point around accountability. I think organisational boundaries shouldn't blur where that accountability actually sits. And I think that's one of the reasons that digital inclusion should be a core component of any digital transformation programme. It should be costed into that design phase and there should be somebody who is responsible and accountable for inclusion, as part of any digital transformation programme.

But just to come back to the question and a couple of the points that you made there. When we talk about co-production, I think that co-production needs to include individuals who are digitally excluded, so that we're actually thinking about what the issue is that we want to solve, how those individuals could be supported and what their views are, input into the design, the testing and the evaluation of any digital programme.

I think one of the things that you asked about was reassurance or safeguards. When we're developing new apps, new technologies, how are we ensuring that age bias isn't being built in in terms of algorithms? We talk about those algorithms in terms of the other protected characteristics; we don't always think about them from an age perspective, and we risk replicating those biases within the digital technologies that are emerging.

I think there was an earlier conversation about alternatives. So, digital should be one option, but if we're not making those alternative avenues visible and of good quality, and if we're not making sure that individuals are aware of those alternatives, then people feel that it's become digital by default, and that causes anxiety, that causes stress, and it transfers that across to the individuals themselves.

And then, just finally, on artificial intelligence and the technology, how are we building that into our resilience planning, so that if there is an impact on our digital infrastructure—? What patient-facing resilience are we building into our systems, so that we're not just thinking about the systems themselves, but what does that mean for individuals? So, thinking about communications, thinking about trusted messages. Because, for many people, one of the fears they speak to me about is around scams and fraud. And with so much going online, the consistent message I hear from older people is that they're happy to be online and FaceTiming family and friends, they may shop online and do social events online, but they are very reluctant when it comes to health and personal finances because of that security and safety. So, how are we building that into our digital transformation, so that people trust the systems in terms of what their purpose is? Because that digital transformation shouldn't make accessing healthcare harder, slower or of a poorer quality for those who are digitally excluded.

Shav, you had a follow-up on that one.

Yes. I think, Rhian, you've made a really important point, and I think these point to the pandemic as well, where you said that one in five over-70s are digitally excluded. You also mentioned other people who, now, don't have children, and, 'What do we do?' In terms of building into the future, there is obviously the issue around current exclusion, but also, for those who then become included, if something goes wrong.

Absolutely.

So, what is our backstop? But it seems like we need a backstop for that situation, but, equally, for those who currently feel excluded anyway. And we saw this when banking—. You know, everything disappeared from the high street and everything became digital, and at that stage, we moved to a position where the hubs—. It was back to face to face, and once a week, you could actually go and see somebody, if you're lucky, in your area, in the local hub, to have a conversation about how you're going to be doing your banking.

We've seen in the news that large commercial entities are turning to AI-powered chats in an effort to save money, and those large language models that replace paid staff, of course, are then giving false, misleading and commercially damaging information to customers, and this very much leads into some of the comments, Rhian, that you've made. So, when we're talking about people's health, the result of a chatbot that either falsely advises you to rest up and that you'll be fine in the morning, or one that tells anyone that, if they've got a cold, for example, well, it's time to call an ambulance, and you're kind of going, 'I'm not sure which way I'm supposed to be going here', both of those can be, potentially, mentally really challenging for the individual, but can also be fatal and costly if you go in the wrong direction. So, what safeguards do you believe are then needed before any life-affecting decision is delegated to an automated AI-driven process?

I appreciate it's a big question, but you've pointed to the fact that there is genuine anxiety, people have that anxiety, because so many people get scammed on a daily basis, people are really embarrassed to talk about it. But when it comes to health, and if we are farming this out to elsewhere, what safeguards do we need to have in place?

I think some of the safeguards, the principles that we've already discussed, are there in terms of that co-production, that early involvement of individuals. It's at a very early stage in terms of the design, the testing, the evaluation, ensuring that any biases or stereotypes are not in-built within the systems that we're developing. In conversations that I've had with DHCW, I've not had that impression that that is a route that we are actively pursuing. Certainly, where we've had those discussions, I think they're very aware of the safeguards that would need to be in place, if that was a route that they were promoting.

I think there are opportunities at the moment. There's been a commitment to refreshing the digital strategy for health and care here in Wales. There is a commitment to a new digital strategy here in Wales. There is an opportunity to build a lot of the principles that we're talking about around accountability, around safeguards, around inclusion. Provide those, provide that structure at a national level, provide those expectations at a national level, and then hold organisations to account around them, because I think that's possible.

So, at the moment, we have the digital service standards for Wales, so lots of what Laura's spoken about are already within those digital standards that we have here in Wales, but they're not mandated; they're voluntary. So, it's up to individual organisations whether they are taking those on board. If we are really—

That seems really risky.

Yes.

The recent briefing paper that I published spoke about digital exclusion becoming far more spoken about within the policy arena and the programmes being funded, but, actually, how are we measuring the difference that that's making to everyday lives? There is a risk that if we only measure digital transformation from a systems perspective, and measure the efficiency from a systems perspective, the person gets lost, and the person's individual outcomes are lost within that system. We can think about that from leadership. If there are incentives around how many people are switching to online, where's the equal measure that's put against people's own experiences within that process? And we risk losing that, as we talk about digital transformation, because it will only work if everybody has the opportunity to access that.

And we've seen, when it comes to health records, for example, when things go wrong. If we are now completely switching to this alternative world, we create something, we don't have these safeguards in place, potentially, you could have a local GP, for example, that takes on this work. And if certain things are mandated, if they haven't got enough people within their team to have the human oversight, it could be, potentially, that they rely on the chatbot to do certain elements, and that could become problematic. I don't know, Hannah, if that is a concern.

Yes, absolutely, and I suppose we've spoken a little bit about how lots of blind and partially sighted people have very low digital literacy. So, there's also the side from—. We're talking there about AI and the tech itself, but, again, to echo what Rhian said, it's about the people. So, I think AI literacy is really low as well. So, it's not that AI is 100 per cent bad and we shouldn't use it, but it's, again, deciding what we use it for and making sure that our citizens know what's happening with that: when are they speaking with AI, how is it being used, what happens to their data, because they have to make an informed choice about that. That is probably something that, across society, we don't really have at the moment towards AI, let alone healthcare. So, again, there's not an easy answer, I don't think, but, yes, it's something that definitely needs more attention, more discussion, and, as you say, more safeguards to protect people.

Thank you.

Just from, again, a Digital Inclusion Wales perspective, to echo what Hannah said, it's not just the digital literacy, it's digital and health literacy and how those two things overlap, like you were saying. With the AI perspective, you can go on to AI chatbots and say, 'What's this rash?', and then, suddenly, you're met with completely unfiltered results for what you're looking at. So, I think that the risk lens needs to be broadened as far as digital transformation is concerned, and it will include everything that we've all talked about so far from a digital inclusion perspective: it's cost; it's literacy, both digital and health; connectivity; motivation; skills. All of those need to be included within risk registers when it comes to transformation, because then we can make sure that we are—. We can never completely avoid risk, but how are we making sure that we're considering it?

The other thing to look at as well—and Rhian's mentioned the review for the digital strategy—is making sure that there are digital inclusion principles that identify a meaningful minimum when it comes to people being able to access digital tools and that inclusivity agenda. It's not just about, 'Great, you've got a smartphone, and you can use it, and you can connect to the internet'; it's, 'How can you use it for your well-being? How are you monitoring? How are you critically evaluating sources online?' It's that whole package, rather than it just being, 'Here's a smartphone, off you go, you're free to use it.' So, I think that needs to be considered: how do we have some sort of established meaningful minimum that people can follow, whether that's patients, citizens or members of staff within the NHS workforce?

Great. Ben, is there anyone doing this well? Are there any examples?

On AI?

Yes.

Not that I know about in terms of patient engagement. Obviously, AI is used for diagnosis and those kinds of things, and I think we're seeing that the rate of innovation is going up. But I think the transparency of that's important to people, as you've touched on. I think large language models will change the relationship between patients and healthcare in the future, and we need to think about how, as all professionals in the space, we lean into that, and that we do that, as you say, with transparency, with some backstops and, ultimately, who's the human, who's the professional that's accountable for overseeing that.

Thank you.

Can I just make a final point there? When we talk about digital inclusion and digital exclusion, I think it's really important to recognise that individuals have the right to have that information in a non-digital means as well. So, whilst we're talking about digital transformation and digital exclusion, there will remain a group of our population who will not be online. Therefore, we have to ensure that there are alternative means for people to access the information, support and assistance that they require. Because this isn't about those who are digitally excluded now, but those who may be digitally excluded moving forward, because the pace of change within technology will exclude individuals. So, whilst we're talking about that digital transformation, we have to make that point that accessible, quality alternatives always remain options for individuals, for a number of reasons: connectivity, cost—the cost of being online is increasing. People are having to make those choices in cost of living not to be online any longer. So, I just want to make that point: digital transformation offers potential and opportunity, but we always have to maintain those offline options.

Thank you.

Thank you. Anna.

Thank you. I think you've probably answered a lot of the things that I was going to ask about as well, but just in case there was anything further you wanted to say about it, I was going to ask about service design, I suppose, and whether you feel that the diversity of citizens are sufficiently involved at the right time. And I suppose it's—. So, I think you've answered this really strongly and I'm thinking not so early enough, but also in the co-producing what the solutions are, and I would say throughout the system. Actually, when you talk about when this isn't working for people who are digital or people who are offline as well, who's picking that up and making sure, even if it's slow steps, that it's getting better all the time, constantly refining it? And it sounds like maybe there are issues you've raised already and accountabilities.

I don't know if there's anything—. I've got another question afterwards, but I don't know if there's anything else on that. I know you've spoken quite a lot about it already, so don't feel you have to re-say, but I don't know if there's anything else you wanted to add on that. 

I would just say that, as you touched upon, it's service design with digital as an enabler to that. But, as colleagues have said, if you look at the whole service and design that and involve people, you will have both options: you'll have non-digital routes and digital routes. And I think digital transformation, transformation of NHS care and the move closer to the community, that needs to be looked at through the same lens, and I think that would help. And like you say, I think it just needs to be done earlier and more consistently, so that people in communities, as Laura said, start to see their feedback coming back to them as well, so they can see that change. And then I think people will be more inclined to add their voice to the conversation going forward. 

Great. Okay, thank you. I'll go on to the second bit, then. Again, it builds on what you've said, that this is about—. It's not just about doing the services that you do now, but putting them online; the transformation element is that this should be driving a different type of leadership, looking at understanding new governance systems around it and organisational culture. So, to what extent do you feel that this should be about, really, starting with people, about working openly, being ready to test and learn and adapt, that continual improvement? Do you feel that this is something—well, as you've already answered, really—that is about transforming the whole services, and these different approaches and ways of working should be—? We need to be looking at those in digital services, but about the whole services.

I think Shav's touched on this, but actually—. I'm from a rural constituency. What are the implications, if we are doing this online, for people who can't get to those services, and what sort of—? Actually, we're going to need different types of hubs, potentially, for people to access healthcare physically as well as online. So, I don't know to what extent you feel that this is looking across our organisational culture, leadership, governance, and where you think maybe we need to do things differently.

From Llais's perspective, I'd touch upon the service change that's done by the health boards themselves. So, they obviously translate that direction into what's going to work well for the people living in their area. I think, as I've covered a little bit previously, that might be done separately to the digital transformation agenda and the strategies. I think, as Audit Wales highlighted in their report, the health boards are taking different approaches to that. Some have published strategies on digital transformation, others have woven it into frameworks. I think if they look at the whole and they think about the services they're providing, they will have options that work for people if they involve them early enough in that.

And as you say, what works in one rural area is not going to work in another rural area; what's going to work in urban won't work for rural. So, they need to continue to engage and consult and co-produce, but be honest about what can be changed and what can't. That's always something we hear about. They feel like they're being consulted on an already-made decision, rather than putting their voice to shaping the option that's actually going to work, be that down to location, age, digital literacy—it all changes. So, I think I'd just like to see that continued and strengthened, and more joined-up with the digital transformation in each of the health boards.

What I would say, I guess to echo what Ben's mentioned there, about especially digitally-excluded communities or organisations that represent them, is oftentimes they're asked the question, 'Great, how does this service work for you?' So, the service already exists. If we take things like the NHS Wales app or electronic prescriptions, the package is there, it's ready to go. Now we're going to ask you about what you think about it, rather than taking that tiny step back and saying, ‘What do you need?’ So, 'What can we provide to you as healthcare, social care?'—whatever it is—'What do you need?' Because that is a completely different question to this package of something that already exists—'How can we make that fit for you?' So we're trying to fit human beings into boxes rather than saying, ‘What do these communities—?’, whether it's rurality, whether it's Welsh language-speaking communities, or communities who have a real distrust in the system, whether that's healthcare or policing or whatever that looks like. I don't feel like, at the moment, when it comes to digital transformation in health, we're asking the right questions. Because we're saying, ‘Here's something that exists—how can we make it work?’ rather than, ‘What do you need as individuals?’

I've got—. Oh, sorry. I had a final follow-up. Can I just do a quick—? I don't want to cut across people who've got more they want to say, but, almost, if we do service design properly, hopefully, I would say—

Exactly.

—it would be the end of consultation. We don't need a consultation process that has, ‘Somebody else has done this already and we ask your opinion.’ If we do it properly, we just—. Yes.

I completely agree.

And I think—. You've made the point there. Digital transformation should be seen as a service redesign. It's not just digitising existing systems. And I think that's why digital inclusion should be a core component of any digital transformation programme. But then as part of that programme it needs clear accountability in terms of who's responsible for that digital inclusion, including who's responsible for those alternative options, who's responsible for responses to exclusion. But then, where's the assurance through that programme process? So, where does that programme report to? If it's a board, what assurance do the board have in terms of approaches to digital exclusion?

So, from a governance perspective and that leadership perspective and accountability, I think it goes back to something I said earlier: is the emphasis equally on patient experience and outcomes as it is on system and how many people are registering for an app and how many people are completing something online? Because I think the very first question said, actually, that doesn't capture those who can't complete that journey, who are excluded, who give up halfway through that process. I think Audit Wales has gone some way towards pointing out, from a governance and funding perspective, the findings from Wales, but how do we ensure that digital inclusion is part of that programme planning right from the start?

Thank you. 

Thank you. Carrie.

The joys of going last. [Laughter.]

That's me.

Well, the areas I was going to ask questions on were about the app and about AI. So what I'll try and do is dig a little bit deeper, because I know we've covered some of this already. My original question was about how well the app is currently meeting patients' needs, particularly older people and disabled people, and I know you did cover a lot of that already in your response to Alun, and I know Hannah’s earlier concerns about lack of coproduction generally, and some concerns about engagement sometimes being tokenistic. So I think I might know the answer to this, but do you think that patients are currently sufficiently involved in developing the app, or have they been? And assuming the answer to that is ‘no’, have you got any examples where any feedback either from yourselves or from patients has resulted in an improvement to the app, or an example where you've raised concerns and they've not been addressed? Just picking up, I know, Ben, you mentioned—. You said that formal concerns are taken seriously in your experience. So I'd just like to understand a little bit better what exactly has prevented action up to now when concerns are raised, and I also appreciate the point Laura's literally just made in terms of earlier involvement being a key to solving some of the issues as well. So there are a few questions, but, hopefully, you can see what I'm getting at.

Do you want me to come in from the older person's perspective to start? Because I think some of the examples would be equally relevant. So, I think the app, some of the infrastructure requirements around the app—you need an e-mail to set up the app. So for an older person who may not have the skills, the confidence, the digital literacy, automatically they are looking for somebody else to rely upon to set up the app for them. I've had many conversations with individuals who've had to rely on a son, a daughter, family member or friend to help them establish the app. And they don't always want those individuals to have access to their health information, so there's a fundamental point there.

I think that in terms of—. I've had a number of contacts. The inquiries around digital exclusion to my advice and assistance line have increased by 400 per cent in a two-year period. So, this isn't a marginal issue; this is something that's impacting older people on a daily basis. They do raise concerns about being able to access the app for themselves, but they have concerns about other older people who don't have digital access. The repeat prescriptions is something that has been raised frequently with us, and I think that's about how it's communicated as well. The app isn't the only way that people can have repeat prescriptions, but that's what they're being told. Therefore, that creates that anxiety and that concern. As commissioner, I've written to chief executives of health boards and directly to GP practices to clarify and seek reassurance that that isn't the only way that patients can access. But, if that's what patients are being told, it's concerning for themselves, and they contact me to raise concerns about other people's access. The other inquiry that we've had is: when people have raised concerns about the app, where do they take it to? They've been passed from one organisation to another in terms of where they raise concerns about the app, without having any resolution. So those are some of the practical inquiries and concerns that are raised with me. But it is around privacy, it's about independence and it's around somebody's right to be able to access information and support in the way that works for them.

Thank you.

I agree. A lot of what we hear of frustrations with the app is around access and getting registered and not having support to do that. The other aspect is carers and family members having access to help do that. I know DHCW are working on that in the next release. I'll be happy to share this with the committee when we've had the response, but we've just written to all GPs across Wales to ask what functionality is switched on, what isn't and what are some of the barriers to doing that, so we can understand why they're not able to do that and why there isn't that consistency. Because the No. 1 thing we hear through complaints that we support is communication. It's always communication. So I really hope that the app would be used to—. Notwithstanding some of the barriers of registering, but when people are using it to have their hospital letters, their appointment letters and their test results coming through, for only about 10 per cent of that to be switched on across Wales is something we want to get underneath. So, I'm happy to share that afterwards when we've got the responses. 

To echo what Ben and Rhian have mentioned about the lack of consistency, when we've raised it before with things like proxy access for people who have children under the age of 16 or 18, or adults that they're also caring for, that's something that has been met with a little bit—. From a DHCW perspective, historically, when you ask how many GPs are switching on certain functionalities, it's, 'We don't know because we don't have authority to say switch everything on or switch certain things off.'

Personally speaking, I've moved from one health board to another, and the access that I was able to have within two GP practices is vastly different. I've also now got access to Patient Knows Best as a resident of Swansea, plus the NHS Wales app. Those two things aren't talking to each other, but they sort of do. It's very confusing, and I'm in the digital inclusion world. I understand that these things aren't linear and they can't always talk to each other, but I know that if I was a resident living in Swansea with less digital inclusion knowledge of this world, I think I'd be much more frustrated than I am with being like, 'Where do I go for what?' I think that that's a big one. That consistency message is definitely key.

I think I'd just echo what everyone has said, but also, specifically for blind and partially sighted people, I feel that the priorities of the NHS app and the features that are brought to the app are set by the NHS and by what the health service wants the app to do, rather than what people who are going to be using it would like the app to do, quite often. It's something that we've raised a number of times. We're really lucky to have within Digital Health and Care Wales some champions who are really keen to represent the issues we put forward to them, but they tend to get no further because it's on the shoulders of the champions rather than something that's embedded or has a strategic focus.

One thing that is of real note for blind and partially sighted people is the ability to access accessible healthcare information—so maybe the letters they receive through the post. We've talked a lot today about that balance between offline and online, and we're really missing that opportunity of being able to facilitate that really great offline service for people to receive their accessible health information in the way that they need to. We did some research, and one in three blind and partially sighted people told us that they'd missed a healthcare appointment or had their health affected because they couldn't read their health letter. That's huge. That's something that the NHS app and our systems could really help facilitate, in making sure that blind and partially sighted people have good health outcomes, are able to follow treatment plans, get early diagnosis and not miss their appointments. That's something that is of real importance. It's a patient safety issue, really. We should be able to feed that in as a priority for the NHS app, for Digital Health and Care Wales, but there isn't actually any mechanism there for us to do that and to feel like it's actually getting to a place where digital could facilitate that access for people and for them to receive information that they deserve. For myself, I started to lose my sight when I was eight, I'm now in my early 40s, and I've never had any healthcare information in a format that I could read myself. That's something, like I say, digital could really transform.

One of the things we've talked about is some of the barriers in digital literacy and access. We talked earlier about maybe creating more barriers in the future. I'm reminded of when we raised an issue about the app and the updates to the iOS software. If you're not able to afford a phone that has the latest software, and we know that some of them don't update after a certain time, you lose access to the app if you can't afford to have the internet in your home or a laptop. I think that's something we do need to keep remembering and thinking about. That just highlights, again, the importance of designing the service with other options, other than just the digital.

It also takes up space on the phone. If you've got so many other apps at the same time, it's like, 'Which one am I going to delete?'

That's it, yes.

Absolutely. And especially if you download it to be able to use it and then it doesn't do the basic functionality that you need it to—you can't order your prescriptions, you can't book an appointment—then you're just going to uninstall it. Then that's that trust already eroded with that transformation system or with that tool, which you've got to buy back again.

One thing that I think was mentioned earlier in terms of workforce, when we think about workforce and digital transformation, we very often think about those IT specialists who would be needed to support digital transformation, but I think there's an opportunity to think about the workforce far wider and how the wider NHS workforce recognise digital exclusion, and how that is recorded so that that follows that patient's journey through, so that once it's identified, we don't try sending them text messages all the time or e-mails—it's recorded that they need that in paper form. And how does that go through that individual? It's about thinking about that workforce, giving them the confidence to acknowledge when somebody is excluded, giving them the confidence to signpost to alternative options, to look at where reasonable adjustments are needed, whether that's through visual impairment, whether that's through hearing loss. That's something else that's raised with us very often, where patients are given phone appointments when they've already said they have a hearing impairment and they require face-to-face or written information. So, there is something wider about how we think about workforce capability around digital transformation. And again, coming back to leadership, it's the way that alternative route is offered so that it's not seen as a poorer service or a failure in terms of digital transformation, and that that's seen as providing a good service to that individual who had those particular needs. So, again, it's putting the person at the heart of how we are measuring outcomes of digital transformation.

Thank you very much. We're coming very much to the end and we're sticking very much to time, so thank you to everyone for concise answers and questions. I've still got a couple of catch-all, end-all questions, so hopefully we should get these ones in. So, are there other issues that the witnesses wanted to raise? Is there anything that you've prepared or that you've brought to us that you have not yet actually been able to put across as evidence for us? I'll start with Hannah.

Yes, I'd really love to talk about the implementation of OpenEyes and OPERAi. There were a couple of questions there about rural healthcare. We're really supportive of the eye care reform, where people who need regular monitoring can now be seen in the community at local optometrists rather than having to go to a hospital, which is really fantastic for both the secondary healthcare system in freeing up appointments, but also for the patients.

We're told that the systems have been implemented, but that's a great word, isn't it, 'implemented'? What does that actually mean? It's quite a complex system where we have our electronic patient record for OpenEyes used in secondary, but then we have a system called Opera that is basically transferring the patient record from secondary to primary and back again if needed. So, that part of the system, we were told, would be implemented by the end of March, and we're told by Optometry Wales that it's actually only fully operational across all clinical pathways and in all primary settings in two health boards.

So, again, it's about, if we're looking at digital transformation, how we are defining how things are set up, how they are working properly. Again, it's about patient safety and transferring that patient's details so they can safely be cared for in primary care and monitored. We've also had a few incidents raised with us where the optometrist has needed to refer back to secondary care, and it's an emergency. So, an emergency means somebody needs to be seen within 24 hours or their eye health will be severely affected, and in that electronic referral process, it's actually gone into the urgent queue where the wait time is two weeks.

So, it's not just that it's been implemented, we need to have the transparency and the clarity over our digital systems about whether they're actually working end to end. At the end, we've got our patient who is the one whose patient outcomes will be affected if that digital system isn't operational correctly.

Thank you, Hannah. Of course, what they didn't say is which March. [Laughter.] Laura.

I was just going to mention the wider purpose for digital inclusion. I know we're here talking about digital transformation in health, but there are wider benefits that we can see as a society if we make sure that digital inclusion is fully embedded in what we do, from democracy to economy. We want to make sure that we're avoiding the digital inverse care law where people who are furthest away from what they need face the greatest barriers. So, that's one that I'd appreciate the committee keep in mind, just to consider that participation doesn't start and finish at the health of a person and accessing what they need to. It's much, much wider than that. It's housing, it's economy, it's jobs, it's across the board.

The other thing as well is to assess things before you make decisions. So, there are a lot of assumptions that happen. We've done a lot of work within different health boards, and we did a piece of work in Betsi where we surveyed 260 in the facilities and estates team to understand what their digital skills were. The people that were leading that project were like, 'Yes, it's absolutely fine, our staff can book holidays online and they're on social media and they can do these things.' And then, actually, when it came to them utilising the electronic staff record, remembering passwords and doing things on an actual desktop, potentially desktop, or laptop, there was a massive disconnect between the assumptions of leaders within organisations and then the staff who needed to do it. We did that work with the help of Unison.

So, yes, it's not making those assumptions, and that really beds into the culture and the leadership of organisations. It needs to be that inclusion isn't just, as I've said, one person's responsibility, but it's embedded from top to bottom, and the other way around.

Thank you, Laura. Ben.

Just briefly, I think we talked a lot today about how digital and the patient interact. We hear at Llais that the biggest thing for people as they go through their journey, their pathway, is person-centered care. Everyone can remember the nurse that took that extra bit of time to listen to them, to help with their health journey. So, any kind of digital transformation that helps people be more effective and frees up more of their time to give that person-centered care I think would be really welcome. And the message that people just see the NHS, they don't see the different groups across the NHS, different health boards, different professions—I think that's really important for us to think about as we move forward.

Thank you. And finally, Rhian.

Diolch. I think the work that has led to this inquiry by Audit Wales has shown that NHS Wales faces gaps in planning, workforce capability, funding, governance and benefits realisation. I think what you've heard from the evidence today is why that matters and how that translates and impacts on individuals across Wales. It can result in miscommunication, delayed access, unsafe dependencies and loss of choice that people should have. I think this inquiry is an opportunity to ensure that the next phase of digital transformation is inclusive by design and measures outcomes that are important to people. And I think there is an opportunity with the digital strategy for Wales and the review of the digital strategy for health and care to really look at how these principles can be embedded within these national expectations. The ambition should not be to move everybody online; it should be to use digital change to improve services for everyone whilst protecting access for those who remain offline.

Thank you very much and thank you to the panel. This brings the first session this afternoon to a close. Thank you to the panel for your attendance and your good answers and your contribution to this inquiry. As usual, there will be a copy of the transcript to check for any factual inaccuracy in due course. So, thank you very much.

We will now take a short break. We shall recommence at 14:55.

Good afternoon. Welcome back to the Members. I'd like to formally welcome our second panel to today's meeting for the second evidence session as part of our inquiry into NHS digital transformation. I'd like to invite the panel to introduce themselves for the record, please, and I'll start with Dr Shanti Karupiah.

Thank you, Chair. I'm Dr Shanti Karupiah. I'm the current vice-chair of policy and public affairs for the Royal College of General Practitioners Wales.

Okay, and Dr Meleri Evans.

Hello. Nice to meet you all from afar. I'm Dr Meleri Evans. I'm a member of the Welsh council for RCGP Wales and I'm established GP lead for the north Wales faculty. I'm also a GP on Anglesey.

Thank you very much. Okay, so let's get started. What's the single biggest way in which current NHS digital systems help general practice and the single biggest way in which they can obstruct it? And if I start with Dr Evans, please.

The most natural first instinct was to tell you how they can obstruct it, I'm afraid. That's the view from the ground, which is that there are still some seemingly quite basic things in terms of digital infrastructure that we don't have, believe it or not. One of the examples that I wanted to share was that I'm still in a position where I employ secretarial staff to receive paper copies of letters from hospitals and secondary care institutions, and they are then required to scan those onto our system into a format that our clinical system can recognise and that we can then interpret. So, it beggars belief, in all honesty, that we're still in a situation where things like this are still taking up our time. There are plenty of positive things, forgive me. So, generally speaking, the introduction of electronic prescribing has been well received and that, I think, is a view shared by a majority of my colleagues throughout the country.

Okay. Dr Karupiah.

I think I agree with Dr Evans. In terms of obstruction, I think it's the gap between national programme delivery and also the practical implementation in day-to-day general practices. And also I agree that, in this modern NHS, we are still using paper-based communication, because we worry about the information not getting to us appropriately. There may be a delay or loss of information, and also the workload. So, just to add on to the comments that Dr Evans made.

Okay, thank you. Iain McIntosh.

Thank you. Well, actually, I was going to ask—. I've got two questions, but I'll ask them a different way around, just based on one of the things you just said. In one of our earlier committee meetings, a concern was raised that physical patient notes may still be transported by taxi between NHS sites. Audit Wales has since clarified that this was not a finding from its work and it has not established whether or how frequently this happens. So, from members with front-line experience, are you aware of this practice continuing, and if so, in what circumstances, and what costs, delays or risks does it create?

Can I just clarify, was it a fax machine or paper based?

Paper based. These were physical patient notes still being transported by taxi.

Yes, absolutely. It varies from health board to health board and different GP practices, and it is a worry, really, because we have to open the mail, we have to scan the mail, we have to review it and manually process it. So, there's a high chance of it being misplaced or delays in getting it seen by the appropriate healthcare professional to deal with the issue. So, this is an ongoing thing. I mean, we were discussing amongst our RCGP members, and this is the case at the moment.

Okay. But more to the point, surely there's a more efficient way of scanning and e-mailing those notes, rather than actually putting them in a taxi to go from one site to another. 

Absolutely, absolutely. We just wish, when we are talking about digital transformation, that there could be a more seamless way of managing this. But we haven't reached there yet. 

So, what's the stumbling block to trying to achieve that, do you think?

I think it's the digital infrastructure. We spoke to some of my colleagues in Hywel Dda; they say that the digital infrastructure is not there to support this. Funding: there is not enough funding fenced for primary care to support this.

Right, okay. Thank you. Do you want me to go to my next one now as well? Okay.

Does NHS Wales measure how much clinical and administrative time is being lost through duplicate data entry, chasing information, and working around digital systems that do not communicate with each other? If there is no reliable baseline for those lost hours and cost, how can digital investment be prioritised, or its benefits demonstrated? And which single failure in the current system is wasting the most GP and practice staff time?

I think that that is such an important question. We don't have the data; we always ask the health board to support us to provide us with data. With administrative work, the workload is enormous. The repetitive procedure of doing things just eats away at the time that we can spend, and the quality time in which we could have a conversation with our patients. This is an area—the administrative tasks—where we could reduce that by having an automated system in place that would free up GPs to spend more time with patients. But that is happening everywhere.

Okay. But it's not effectively being measured then, by the sounds of it.

No, absolutely. When you talk about success measures, we don't have proper success measures in place. So, this is data we can collect. When we talk about digital transformation, we want to make sure that when we procure anything it's doing what it's supposed to do, that it's benefiting the patient in a safe way, in a timely way, with joined-up care, and also that it's being done in a safe way. None of this is in existence at the moment. 

Right, okay. Do you think we'll get to the point where it will be?

I hope so. We're talking about digital transformation. It's happening rapidly. What COVID taught us is that we can use digital technology to make our system work better. We did, somehow, when there was an urgent need, work well at that time. I think we need to capture that spirit and keep moving forward. Yes, the human connection is important. Trust is important. Digital transformation has its place. If used in a safe, fair way, and with proper clinician oversight, I think it can be quite successful in healthcare.

Okay, thank you.

Dr Evans, do you have anything to input into that?

I just wanted to add that—. The question was asked about where the inefficiencies are causing most frustration, and, in addition to what Dr Karupiah mentioned, I would add that the interface between primary care and secondary care is a source of inefficiency where digital transformation could be really quite effective in eradicating, potentially, a number of the things that cause those delays and inefficiencies on a day-to-day basis. 

So, on a bad day, I will see a number of patients who are coming to see me because of, I suppose, delays within secondary care. And there are a number of ways in which, potentially, we wouldn't need to get involved with that. So, for example, if there was a way that the patient could be informed of where they are on the waiting list, and how long it might be until they hear, the patient then wouldn't feel the need to come back to us in primary care to ask and to be given that information. The only way that I can get that information is to go directly to secondary care to do that. So, the interface between primary and secondary care would be a really good place to focus attention, I would say, in trying to improve efficiency.

Thank you. Alun Cox. 

I'm going to be asking my next question in Welsh.

Am I able to turn off the translation for myself? Because I don't think I'll be able to cope. Is that all right now? Okay.

Oh, I'm still being translated.

Is that okay?

Shanti, I don't know whether you wanted to add anything.

Yes, I will add to that. I agree with Dr Evans. I think, when we are looking at national strategies, there has to be clear accountability, realistic investment, and also meaningful clinical engagement with a front-line healthcare professional. Only then can we actually understand what needs to be measured so that we can capture the data and improve the system that's already in place, which needs improvement, before we roll out more new technology. Because we want to make sure our foundation is strong.

Okay. Thank you.

Thank you. Carrie Harper.

Diolch, Chair. I did just want to pick up quickly on Iain's earlier point about notes being transported by taxi as well; I think it's something I raised in an earlier committee. My understanding is that some of the reason behind that is because our health boards have information technology systems that don't talk to each other. Is that why some of those records are still transported the way they are?

I was actually interested in coming in on that as well, if that's okay? So, I think there are a couple of different questions here; one is contemporaneous notes or letters that are generated within hospitals, as an example. As I told you at the beginning of the meeting, we are very definitely seeing those things being transported by post and, potentially, by taxis or whatever other means if it's not Royal Mail. But that's not across the board, and it seems that there are some systems that can communicate well with our primary care systems, which are fairly uniform, in fact, in primary care in Wales; but for some reason, some don't. So, this question that you raise of interoperability, which is all of these different systems trying to communicate with each other, is really going to be key, I think. Because whilst lots of effort and money, presumably, is invested in making sure that each one of them works well on its own, it's not going to be effective or efficient until they can speak to each other and, therefore, avoid having to have paper copies of notes carried in taxis.

I don't know on that. I think most GPs want a reliable system. We have systems that don't communicate with each other. When we're talking about the interface that Dr Evans mentioned—secondary care to primary care—even when we're talking about social care, when we're talking about digital transformation, this should be right up there in terms of making sure all the systems are talking to each other. And also technology. We want to make sure we have the right technology to support the staff. Many a time, front-line staff, GPs, don't have access to information in a timely manner; we have to wait for weeks before we can actually get the information on the patient that we are needing to treat.

I know, just to follow on, this has been a frustration for a long, long time. In your view, who do you think should be held accountable for the lack of progress with this?

I think I'll just add that there's no clear accountability. Whenever we build any system or strategies, we always talk about we need to have a person that is allocated, where there is actually a person responsible to oversee all of this, for making sure the system works, making sure the results are seen, communication is communicated between services, and also follow-up is in place. Again, it's not just my opinion; it's talking to many GPs at the front line. We don't know who is the person who is responsible for it. But when something goes haywire, it comes back to us.

Meleri—sorry, I don't know if you had anything to add.

In terms of the responsibility?

Yes.

As I understand it, when the current systems have been investigated, general practice or primary care has, to an extent, been left out of the audit process or the investigation process, in some instances. We do exist out on a limb in a slightly isolated fashion. We can choose which phone systems we want to use, which phone systems we want to buy, which technology suits us best. But the problem is, when you have hundreds of practices doing that individually across Wales, with no oversight, the chance of interoperability is slim to none, I would say. So, I think better oversight is required if our systems are ever going to be able to work with those that are used elsewhere.

Diolch.

Thank you. Anna Nicholl.

Thank you. I've found it quite shocking what I'm hearing, in a way. I suppose I've seen it through my own experience of using GP services, but to have you outline it so clearly—. I'm glad we're doing this inquiry. I wanted to go into the design of services and digital systems, and to what extent you feel that you as GPs, staff and professionals are involved in that design of these systems, or digital services, right from the beginning, I suppose, and through to as they're being developed, and then, I guess, afterwards, when you're—. How is your feedback being picked up so those services are continually improving? It might be people coming down—. Do digital teams come and sit with your GP surgeries and see how things work for you and your patients and things? I don't know to what extent you feel involved in that service design.

Currently, when we are talking about the new agenda that's happening, we are very much consulted on, but not really involved in the designing process. I think that is important. If they capture the front-line experience, including patient voices, because we are building the service for our patients, which is being run by the front-line team, their first contact—. I think, if they can include us from the very start in designing the process, and not just come up with a plan and then just consult us, but then don't take on board the things that need to make changes, by which time everything has been done, and it's just left with us to run with it—. That's not really productive. I think, with much of this national strategy or delivery agenda, it's important we—. The RCGP always say we follow the patient journey approach, seeing through the patient's eye, how it will look when the system is being built—I think that is important.

Thank you. I don't know if there's anything to add, or I'll go on to my—.

It was just to echo that. Thus far, I'm not aware that, as GPs, we've ever been consulted from the beginning on any particular system—we're just made aware that it's coming down the line and then it happens.

I'll bring Shav in and then come back to you, Anna.

I have a question about AI and patient safety. We've seen examples in other sectors where AI-powered systems have provided inaccurate or misleading advice to users. In healthcare, the consequences, of course, could be really serious if things go wrong. What safeguards do you think need to be in place before any decision affecting a patient's care is delegated to an AI-automated or AI-driven process?

Shall I answer? I think, firstly, we need to find out whether we need that technology in the first place, whether it's going to bring value, whether it's safe for patients and whether patients are aware that we're going to use this AI technology. That's really key. We need to find out whether there's a value to it and also to make sure there is—. While we're implementing it, we have to measure the benefit of it as well. You just mentioned the problems—we want to make sure there's no transcription error, there's no omission of clinical information. Again, patient consent is key, and privacy—so here's where cyber security comes in. And also there always should be proper clinical oversight.

At the moment, in terms of the NHS app that we have, who is responsible for that oversight, in making sure that that is running in the way that it should be?

Dr Evans? 

I don't know the answer to that, sorry.

I'm not sure. But registering for the app and downloading the app does not mean it's equitable access. We don't know who's actually downloading, is it the whole population, how many patient numbers are actually using it, whether it's working as it should. So, we need to make sure we have proper measures. We spoke about the success measure. It's one thing to roll out and procure expensive technology, but when we don't measure the benefits, whether it's doing what it's supposed to do—.

Dr Evans, is there anything in terms of safeguards that we need to have in place before we hand everything over?

I think this is another example of where the governance is absolutely key here. Currently, we have a system where a surgery could go ahead and procure or make the case for, or decide that they want to use, a particular digital tool, and they can go ahead and do so. I think that there is an argument specifically in the case of AI that says that, more than ever, that procurement and that whole process needs to sit under a governance banner that is much higher up, and tested at at least a national level.

Do you think that we need to go down the route of maybe some digital sovereignty?

Explain what you mean by that, sorry.

So that Wales becomes in charge of our own data and what we're going to do with it, particularly in relation to health.

I'm not sure that I can answer that question for you. I think the question of data ownership specifically within primary care is not something that I'd be in a position to answer, I'm afraid. 

Thank you.

Thank you. Back to Anna Nicholl. 

Thank you. In a previous session, I was asking about leadership, governance, organisational culture, and that this isn't just about putting existing services online—it's about really shifting the way that we work. But it sounds to me, in this case, there's some benefit to just getting things online. But anyway, do you feel that you're seeing a shift in the NHS around the leadership and governance that enables these digital approaches—a culture, I suppose, that's listening, inclusive, that's adapting to where things are working or not? Do you feel that you're getting this? We've talked about accountability. Do you feel that the whole governance and leadership culture is shifting in a way that enables this?

I think it is worth talking about the potential for innovation, and there are things that are exciting, and quite rightly so. I've been involved recently with a programme that is developing a digital therapeutics app, and there's a growing body of evidence about the potential reach that we might have using these sorts of things, as compared to it being a face-to-face appointment with a GP every time you need to ask them something. So, there is exciting stuff going on, and I wouldn't want to leave people thinking that we're stuck in the dark ages, but I think there's so much to be done at a basic level, and I think that that does require a systematic governance approach, because at the moment it's up to individual practices what they're doing very often, and that doesn't benefit the system as a whole.

I'd just like a quick follow-up on that. I think you've made a case for some of this being done at the national level, and we need to have that oversight, which makes sense. But also with the innovation side of it as well, some of this can happen, I guess, because GPs' individual practices may see things happening and feel like, 'Okay, for our place or our patients, if we do X or Y—.' I don't know if you want to say anything about that local element. 

I do, because I think GPs up and down the country would be very angry with me if I said that there was one tidy approach that would suit every single practice across the country. There are products, for example, that allow you to run your surgeries completely by digital triage. I have peers and colleagues nearby who have instituted that sort of system within their practices, and it's really great for their practice demographic, it's great for the partners that are running it, but for some practices, some patients, it just wouldn't work. And so I do think it's unfortunately nuanced, which is more complex, in that one size doesn't fit all, because the requirements for delivering healthcare across Wales are very nuanced. But I think GPs, in general, and primary care, need to be better consulted at the beginning so that we can give what may be differing views.

Great. So, maybe learning without imposing across different GP practices, sometimes.

That would be great, yes. 

Alun Cox, you had a follow-up on this one. 

Yes, if possible. It follows on from some comments that you've made as an organisation suggesting that some practices are leading the way in terms of digital, while the majority are not using it to its full potential, and some outliers are barely using it at all. I'm trying to get a handle in terms of where you think the barriers are for those organisations. You said just then that it might not suit some practices. But are there barriers in terms of skills and understanding, or is it mainly around infrastructure?

Shall I answer, Dr Karupiah? In my practice, my organisation, as an example, we have about 30 staff, and so every time we're making a decision, for example, about whether we're going to use a new piece of software, that's quite a lot of brain space and effort for our team and for our practice manager. When we're talking about digital infrastructure in particular, we have a member of staff who has a particular role in IT, and it feels very often as though that's really inefficient. So, specifically in terms of procurement, there are people who are doing this day in, day out, certainly in our local health boards, and so I do think that overcoming the economies of scale, even in terms of brain space and planning these things, is a big barrier. I think that we should certainly look at increasing the scale while still maintaining our ability to judge what's best for our populations. I think that's the direction of travel.

Shav, have you got another question?

My question, I guess, is that we often hear, when it comes to AI, digitalisation and transformation—we've already talked about all of these things—about the challenge between front-line services and procuring new technology. When it comes to procuring new technology, it seems that everyone is able to decide on what they're going to invest in, and, clearly, there's no system or structure in place. My question, I guess, is: if we are going to be heavily investing in digitalisation, which it seems that we are, do we need to have a specialist role for somebody to oversee that for us in Wales in terms of the NHS? And second of all, does there need to be a balance between investing in front-line staff versus more digital tech? Because from the previous panel who came in, that was something that they were really pushing and emphasising, and it seems to be that we need to find our way. It seems like we're putting a lot—. Are we putting all our eggs into one basket? 

As I mentioned earlier, I think it's important to find out whether there's a benefit in this technology that we want to procure. That's really important: what's the benefit? I also want to bring your attention to a national commission on AI, led by NHS doctors in England. It came out in September 2026. The central message is that AI has enormous potential to improve healthcare, but they also said that it must be introduced gradually, fairly and with proper oversight. Yes, there needs to be an oversight by somebody who knows the system—not just the system, but the patient care as well. It should be somebody who's at the front line managing this, so we can design the system for the people that we want to care for.

When we're talking about technology, it's important that digital inclusion becomes part of patient safety. When we talk about digital exclusion, it basically means poor connectivity. There may be people who are not digital literate, they may have a language barrier or they may be disabled or have special needs. They are unable to use the digital technology or even the complexity of the digital service itself. So, we still have to maintain an alternative—face-to-face, telephone, digital access—for people who need to use the service. There's are many things we can do, but we have to make sure we do it appropriately with proper governance in place. Cyber security is important because we're dealing with patient information.

I think that's the second time you've used the words 'cyber security', which is telling me something.

I think safety is the key. We're dealing with patients at the end of the day. It's about their health. Any form of technology is welcomed as long as it's been assessed and tested properly, and it has to show there's benefit to it. AI should be supporting the decision making, but not actually taking away the professional judgment.

Yes, thank you.

We're nicely well ahead of schedule, so I've got a couple of questions from me. Regarding the workforce and training is where I'm going with this one. Are practices given protected time, training, and technical support when new systems come on board to adopt them, or are those costs effectively absorbed by already stretched practices?

Across the board, no. At the moment, we're bringing in electronic prescribing in our practice. There's quite a lot of work involved with that and, no, there's no time set aside. We can set aside time, but that's as business owners. We would need to do that, and we would need to make sure that that time is allowed for our staff as well. But as a general rule, no, that doesn't happen.

And of course, any time you need to take out of the day means fewer patient appointments available, presumably.

Potentially, yes.

Okay, that's fine. I don't know if Members have got any other questions they want to follow up on. Iain.

I'm glad we've got a bit of extra time, because one of the things I wanted to come in on, which has been discussed, is on the subject of AI and security. I understand, obviously, the need for cyber security to make sure we don't get hacked with viruses and all the rest of it. What I'm not sure about is where you are with any required regulation over which AI systems you're using. In other words, if you're putting a customer's data into AI—of course, when I'm talking about AI, I'm not just talking about ChatGPT; it's in everything nowadays—we need to make sure that that customer's data is secure and that it can't be leaked or used for other purposes. I think there needs to be a wider discussion about what regulation is introduced to make sure that that doesn't happen either, so that whatever AI system is being used, you use it specifically just for that one use. Are you with me? Is any consideration being given to that at the moment?

I think it's been discussed. I think it's important to have at least a minimum cyber security standard across the NHS, and also possibly appropriately adapted for independent contractors, because we are dealing with, again, sensitive information. Having a central cyber security assessment is key. Again, there needs to be oversight. This is all a new area to explore.

Okay. One more, if you'll allow me to indulge. Going back to this system we were talking about, where patients' notes have to be transported as data, I'm quite surprised that that's mostly down to the fact that we've got different NHS sites that are using incompatible systems that can't use that data. If we're at a point now where having to transport, literally, pieces of paper between sites is the only way, whose responsibility is it to make sure that we do get some sort of compatibility now between all the different sites? Because we obviously can't continue in this direction. It's unsustainable. I'm going back to the question of who's responsible for doing this, really, because it obviously needs to change.

I think that's the same question we ask all the time when we're having any sort of service design. Absolutely.

Well, exactly. The thing I'm worried about is that, if everybody goes away from here now and we don't answer that question, we'll still be sat here next year talking about the same thing.

Absolutely. There are new services being developed. At RCGP board meetings, we always say we want to make sure we know who's accountable and responsible for that service being deployed, all the time. Every time we go to a meeting, we say we want to make sure that we know who's in charge of something and who's responsible for it, because that's really key.

I think it's crucial. There's got to be some sort of guidance, so that if different doctors' surgeries or hospitals are starting to introduce new ways of doing things, the first thing that should be discussed is, 'Is whatever we're going to do compatible with what everybody else is doing?' Because if it's not, we're back to using taxis again. Sorry, I'm ranting on a bit, but you can see my point, anyway. Thank you.

Alun Cox.

Again, following that, we may well be belabouring the point, but I'd just like to get your views on the balance between central dictation and GPs' ability to make their own decisions and where do you fall on that, or is it a case-by-case issue? If there is more central dictation in terms of, 'This is the system that you will use', you lose some of your own autonomy in terms of making those decisions. And then the criticism maybe is, 'That doesn't suit my practice.' So, there is a balance there, isn't there? I'm guessing that what I'm hearing is that the balance isn't right, but I'm still struggling to see where the balance should lie.

I think the best way to think about this is to go back to basics and look at the patient journey as a whole. So, we in primary care undertake the greatest number of contacts for sure, from day to day, but we're only the beginning of the patient journey. So, we have to accept that our systems need to be able to communicate well with the secondary care systems. But, actually, over and above that, it gets so big and complicated that we can't have any more to say about that, I suppose.

As far as basic clinical digital system computer systems are in the question, in Wales, we are in a position now where I think that we all have the same clinical system and that's only been relatively recently that that has happened. So, it's the other systems around us that have to communicate better with us. But then I would say that because I'm a GP.

Could I just ask a further question then on that? So, that single clinical system, is that making a difference, or will it make a difference?

I'm just going to check: Dr Karupiah, that's your impression as well, right? We've all got the same clinical system now.

Well, they're rolling out the e-mail system at the moment.

Yes. So, yes, it does make a difference. An example is that, previously, if I had a patient moving to my surgery from another surgery where they were using a different clinical system, their notes would not automatically migrate. I can't believe that I'm saying this in reality because it was happening up until a couple of years ago. But then you would be waiting for their paper notes to come, depending on where they came from. In some instances, if you wanted particular information, you would have to sit and go through the paper notes. And then we would have clinical coders going through the paper notes and working out what was pertinent in the medical history to log on our new computer notes. So, yes, it has been noticeable that that doesn't happen to the same extent any more.

Of course, we have patients moving into our area from other countries and the same cannot be said for that. So, if we have patients moving in from England and they have a different clinical system, then the electronic notes don't migrate. It can make things clinically very difficult, especially if you're starting to see the patient when they're in the middle of an episode of care for something in particular. But, yes, that's one example where things have improved and we did notice a difference.

Anna.

Thank you. It's good to have an example of where things have improved and, I guess, you can see how that beds down and, hopefully, continues to improve. I wanted to come back to accountability. So, there's something here that might be about digital and it being new, and perhaps there are roles that should be there that aren't at the moment, and we need to create those. Also, to what extent might it be a reflection of the NHS generally and the complexity of the NHS? I hear we're doing stuff around rural healthcare, and also there are calls for one person needing to be accountable for everything in the NHS. And I guess, to an extent, you know, there's the Minister stuff, but is it something about looking at to what extent one person or one position can be accountable for all of this, or to what extent might we need to be clear about accountability throughout the system? There's going to be different layers of the NHS, and rather than looking for kind of one simple line of accountability, we need to know that it's complicated or complex, and so we need to understand at each layer who's responsible for what, I suppose. I don't know if that makes sense as a question.

No, you are right. When it comes to accountability, it's very complex, because the NHS has so much layering, as you just mentioned, and sometimes we just need it on paper. Who's exactly accountable for which services, which system, and the person's care? It all comes down to it having to be written black and white, otherwise we can just assume and the wrong person may be taking the blame for it.

Thank you.

And talking of blame, I guess this is where, potentially, it goes wrong, and if fingers are pointed at different people, you never get to the bottom of it, and potentially, in the process, the wrong people's names gets put in the press. That's years and years of reputation just flushed down the toilet overnight. And I guess my question is that you mentioned England and what was happening in England and that there was this group that had been set up recently, and is it time for us to have something similar here? Do we have something similar here? Are there lessons that we can learn? Because they must be looking for something specific, maybe we need to be doing the same thing here as well.

I think definitely.

Okay.

Even that commission, the information on it, they said that there is an enormous benefit in having this new technology. But, in Wales, I think the challenge is to make sure when we're designing anything, we include the right people. Again, I'm talking about having front-line people, the secondary care—we want everybody at the table, along with patient voice. We want to make sure we capture what will benefit, what will work, and how the users' experience will be. They're going to kind of inform us what they would also like to see. So, as a patient myself, I would also want the same. I want to know that whatever system is in place is benefiting me, and I want the same for my patients. So, I think, when we're building anything, we need to invite everybody who's involved in the service provision from the start, not just once everything is done you just go and consult. And always continuously measure the technology, not just before approval—continuously measure whether it's doing what it's supposed to do, so the intention at the start is the same at whatever position we are in with the technology. That's really important.

We had the older people's commissioner in the previous panel. They were saying that one in five people who are age 70 and over are definitely digitally excluded, and there was a good panel discussion about patient care and the need to involve people from the get-go rather than bringing them in once the app has already been created, for example, and how fixing things once they've already been built becomes much more costly. Do you think that that is the case?

Absolutely. That's why we need to include all patient population, irrespective of age. And the technology is such, they also have something called ambient voice system. You can include in so many ways technology to help people who are not digitally savvy.

Can you explain that a bit more for us?

It's voice recognition. So, if you've got a system and if they're not digitally able to use it, probably if the system is built as such, it recognises the information that they're asking and it brings out the information to that person. If they have a question, they're going to answer them, 'Oh, this is how you have to do it. This is the person you have to contact. This is the number you're going to dial out.' So, if we're building a system, let's build it really well and look long-term, including the whole population, not excluding anybody.

Yes. And are there any other countries that are doing this well? Are there any examples?

I don't have an example in my mind at the moment, but this is the discussion that the private sector is having at the moment—at the very moment. 

Okay. 

Okay. Just a couple more from me before we finish. It looks like we might get you away a bit early today—give you the gift of time. Does the RCGP see any sign of DHCW heeding your previous call for it to focus its efforts in some part on encouraging consistency across health boards and across primary care providers?

Sorry, could you repeat that?

Sorry, yes. Have you seen any signs of DHCW heeding your call for it to focus its efforts on encouraging consistency across health boards and across primary care providers?

Dr Evans, is it okay if I just answer this briefly?

Please do.

There are discussions with DHCW about primary care, and I know, when I've spoken to a number of officers there, they're always having an active discussion. Just like we talk about systems needing to talk to each other, I think organisations need to talk to each other. That's the best way that we can work together for better healthcare.

Okay. And finally from me, is there anything that you want to bring to the attention of this committee that you've not had an opportunity to do so yet?

I can't think of anything at the moment. If I do, I will write to you.

Yes. Dr Evans.

No, I don't think so. My main message is that I think the potential to work at the interface is one of the biggest potentials for gain across all sectors within health.

Okay. Thank you very much. Thank you very much for your time this afternoon. This brings this particular session to a close, and I thank Dr Evans and Dr Karupiah for their time and answers to this committee today and the evidence given. There will be a copy of the transcript made available to check for factual accuracy in due course. So, thank you very much for your attendance. 

Thank you.

I'm now moving to item 5. I propose, in accordance with Standing Order 17.42(ix), that the committee resolves to exclude the public from the remainder of this meeting. Are the Members content? We are content. We will now proceed in private.