Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome Dr Paul Rice, chief digital information officer at the Department of Health; and Dr Dermot Hughes, senior responsible owner for Encompass. For some of us, this is the second time that we have met today. I thank the staff and you for the very informative visit to the Ulster Hospital earlier. You are very welcome. I will allow you time for some brief opening remarks, and then we will go to questions.

Dr Dermot Hughes (Department of Health): Thanks very much for inviting us here. I will give you a quick, five-minute update so that you know where we are.

The "go live" in the Southern Health and Social Care Trust and the Western Health and Social Care Trust took place successfully on 8 May. In doing that, we have trained, in total, 82,000 staff, and we have 15,000 what we call "super users", who volunteered to train to a higher level in order to support their colleagues. The "go live" in the Southern and Western Trusts was very stable. We had no digital clinical incidents. We had only one issue that required us to reconvene the regional groups to look at a pathway. What that means is that, by the fourth implementation, the patient pathways are very stable, and it will mean that getting back to activity will be quicker and getting data will be quicker.

The Southern and Western Trusts are both going through a stabilisation process. There are no issues, so we are comfortable with that. The Northern Health and Social Care Trust is almost back to full activity. The Belfast Health and Social Care Trust and the South Eastern Health and Social Care Trust are back to full activity.

Given the sequential nature of the implementation, there is a rush to do more. Those in the South Eastern Trust have been waiting for 18 months to transform the service. Tomorrow, we will meet the directors of performance and planning to set out the first steps of transformation and look at how those align with the themes in the "big conversation" and the views of the permanent secretary. We will regroup at the end of July to see how we take that forward.

The programme has several ongoing pieces of work that are beyond trust work. We are building out mental health frameworks' outcomes. That will be built on the My Care app, and it will be completed by 30 June. It is a way of having standardised clinical templates that can be sent out to multiple patients so that they can get feedback on their mental health outcomes and outputs after treatment.

The other issues that we are managing include bringing in the independent medical examiner's role. That means that people can independently review information on death certification. That will be shared with the coronial officer, if required, and the General Register Office (GRO). There will be high-level governance of the whole system in Northern Ireland, and that will be done by September.

In November, we will go live with Healthcare in Prison. The prison population varies, but prisoners tend to be very vulnerable, with high levels of learning disability, addiction and mental health issues. It is an opportunity to make sure that all patients get the same quality of care, irrespective of where they happen to be at that time. We are working with Healthcare in Prison over three sites to do that, and the live trusts will help us go live.

We will also go live with the Northern Ireland Specialist Transport and Retrieval (NISTAR) service, which is an organ-support retrieval and repatriation process for the specialist transport of patients.

As well as that, we have to discuss transformation. The programme that is being implemented has another 11 years, and it is resourced for those 11 years, so the aim is to have an ongoing programme of transformation that will shape and change care to increase productivity; increase patient involvement; and improve the experience of patients. That is not an Encompass thing; it has to be a whole-system thing that we will help to enable.

We have had quite a successful goal; we have had a quick pause; and we are moving on to do the next pieces of work. That might be a lot to cover at once, and you may want to ask questions.

The Chairperson (Mr McGuigan): Thank you.

I had the privilege of being at the Ulster Hospital. I chatted with staff who use Encompass, and they are the important people, along with the patients. I was heartened by my visit this morning. We talked about some teething problems and issues, but everyone was extremely complimentary about the impact of Encompass on their work and on patient safety, which is very good.

I am going to ask some similar questions; apologies if I talked about them this morning. It is a very good and worthwhile system, but it has not been rolled out fully to all healthcare settings. When we engage with GPs, they tell us that they want to have full access to Encompass. As part of our inquiry into palliative care, we have heard from community pharmacists and those in hospice settings about their desire to have additional access to Encompass. We have heard that from social workers as well. Moving beyond secondary care settings, what level of access will other healthcare providers have to Encompass? When will they get greater access to it?

Dr Hughes: GPs provide most of the care in Northern Ireland, and we have to recognise that. GPs now have full access to a read-only aspect that is called EpicCare Link. It is an improvement on the Northern Ireland electronic care record (NIECR) that sent out information retrospectively. The GPs can see in live time what is happening to their patients, such as drug changes. The GPs can also place orders for radiology or bloods and receive messages. While the GPs cannot write on the system, they can do all those tasks.

Healthcare is much wider than Health and Social Care (HSCNI) and the Department of Health. We are doing some work as a result of the neurology inquiry, which required the independent sector to have access to electronic care records as a patient-safety tool. That work has started, and there will be information governance and contractual issues. The major providers of independent-sector care are care homes and residential homes, and that is an important piece for the system at present. When we looked at the data on the board today, it showed that the occupancy rate in the wards was 110%, 115% and 112%. At any time, 20% of the patients are medically fit for discharge but have nowhere to go. We can try to improve the system by having an expected date of discharge from the day of admission, so that the people in the independent sector will know the date up front. That still does not address the capacity issues, but it certainly will link into the system.

A lot of independent-sector work on waiting lists is commissioned by the Department of Health, and that should be on the same platform, because it offers the same quality of care. People do not necessarily choose to go down the independent route; it is a route that the health service chooses for them. That will take a bit of work.

The adult social care is working very well on the platform. We still do not have children's social care, because there is a desire for "family functionality". An electronic care record is your record; it is for one person. The vendor had to do some additional build to bring in the family dimension, and that will be ready by the third quarter of 2026. It will be a worldwide new functionality, which will have benefits for psychological therapies and mental health, because the family dynamic is often important in those areas. We also need to get financial functionality, which is slightly more tricky, because a lot of children's social work is tied up with time-urgent payments and their consequences for foster families. We are still working on that piece.

We have not mentioned that everybody in the room can have access to their medical records. At times, healthcare in Northern Ireland is patriarchal.

Patients need to be partners in care. We were talking about not going heavy on selling the app, because maybe two thirds of the population were not on it, but we have to go heavy now. We have limited functionality, so we are meeting the directors of performance and planning tomorrow to see how we can expand that functionality and make more facilities available so that people will be able to not just book their own appointments but upload their own data and results. It is not a portal; it is part of your record. If we want to do virtual wards or virtual outpatients, instead of bringing patients up and down, we can do those differently. In Northern Ireland, some services have two review patients for one you. The big problem in Northern Ireland is that there is not enough space for you, so how we move that dial and make more space available will be part of our discussion tomorrow.

The other issue in Northern Ireland is access to outpatients. "Did not attend" (DNA) rates are maybe be up to 8%. That is huge wastage. We can obviously have messaging, but we have analytics that can tell you who is most likely to DNA, and we can send targeted responses. However, that is probably not enough. We can also release something called "Fast Pass" that can be used if somebody signed up to turn up at short notice, allowing us to backfill the empty spaces. It is a problem that you have to address from both ends.

We have an aggressive plan, which we will share with the directors of performance and planning tomorrow. We would like to circulate it, but it will not work if we do not have enough people on the app. We will do some work on evangelising it to say, "It is your health; it is your record; it is your information". It really does empower people. To give a personal example, my son, who has learning difficulties, could use the app, go to a psychiatric appointment and put his own medication on it. It feels as though he is owning his own issues, which is really important for the future. This will become the front face of the health service. I know that we all say that it is successful because we have put it in, but that is only the start. It will be successful only when we transform what we are doing. That is the challenge to which we need to be held.

Dr Paul Rice (Department of Health): One of my colleagues whom we saw this morning made a very perceptive comment, saying, "We are at the end of the beginning". That is the nature of the situation. The five-trust deployment gives us a platform to continue to extend and develop in that context and venue of care. As Dermot outlined, there are whole sets and series of other venues of care — those are the ones that you are enquiring about — where progressively, over the life of the programme, the question of the connection, as a minimum, between the information that is held in those venues of care and the Epic tooling will be a challenge. That question has to be posed time and time again, as does the appropriateness over the life cycle of some of that information being fundamentally incorporated into the scope of the Epic product. However, each of those junctures will require questions about the requirements, questions about the fitness of products to meet those requirements, the cost profile and the benefits profile etc. That comment this morning was incredibly perceptive.

The Chairperson (Mr McGuigan): Dr Hughes, my next question was going to be on My Care, but you spoke about it in your previous answer. I am the Chair of the Health Committee, and I did not know that it existed. To be truthful, the last time that I was on the website was probably during COVID for the vaccination passport. I went on to it this morning between meeting you this morning and this Committee meeting. I had not realised that I had a couple of hospital appointments in the past couple of weeks, so I can give my fridge a break — I do not need to put the letters on the fridge. They are in the app, which is good. I should not divulge any personal information in the Committee meeting, but I am on medication that is not in the app, so I can upload that myself so that it will be available to see.

In the rest of the Committee's absence, Colin, the Clerk and I agreed that we will have an event in the Long Gallery in September, because it is important to publicise the app as a tool that we and the public can sign up for and use. Can you expand on what you previously said about how beneficial the app is to the individual and to the health system as a whole?

Dr Hughes: If we start with the health system as a whole, I will say that we brought this platform and implemented it here, but we are by no means the first people to do that. We are unique in that we are the only people who have covered community care, mental health, social care and acute care. We have partners who have helped us get to this place; there are people who are further on in the journey. We have good partners in Holland who use the app for lots of things, such as admission avoidance, healthcare at home, early discharge and changing how they deliver healthcare. We do not have to start from ground zero. We can take that work and their advice and turbocharge what we do as we go forward. If we went to anybody in Northern Ireland and said, "What are the top 10 things that you need sorted in the health service?", we would probably get the same answer from everybody. Those are not challenges that have not been seen elsewhere. The app has huge potential for people to upload their oxygen saturation levels, respiratory rates and blood pressure — that happens automatically with wearable technology. The way that that information is used elsewhere allows for the earlier discharge of those who need light-touch follow-up and when someone is not acutely ill. In essence, it is for people who come in often, so they can have the app as an admission avoidance. It is about decompressing the acute sector.

The real concern in the health service is not the 20% who are medically well but the people who are unknown, because they are on a waiting list or stuck in an ED trying to get in. Our big focus needs to be on how we make the system not only better for patients but more efficient. We have done that in the past. I used to be the medical director of the Cancer Network. It used to bring everyone up for a six-monthly review whether they needed it or not. A lot of people got frightened and concerned about it, and then we would say, "You're fine. Go away". We changed that and focused the review on those who needed it most, and the others maybe got virtual reviews or light-touch reviews and were told, "Go and live your life. That is part of your life; it is not taking over your life". I have been a beneficiary of that. We could roll that out with much more supported technology. Northern Ireland is quite a technologically enabled society. I do not think that we have any option — there is literally no option. Do we do the same again and expect something different? The interconnected nature of the implementation is that your social worker, community nurse, GP and hospital will know and can oversee it from a distance, and, if you have mental health issues, they can be on the one platform.

Staff have been asked around Europe to present on the service. You heard the South Eastern Trust staff today. They are a credit to the health service. We have something unique that other people want to do. When the two trusts went live most recently, we had the province of Quebec, New South Wales, the Republic of Ireland and several trusts from the UK shadowing us. It would be a complete shame if we got to this stage and did not take it further.

Mrs Dillon: You have covered quite a lot of what I wanted to ask, Chair. One of the most important things, and you said it, is that GPs have read-only access to the app and cannot write on it. I am concerned about that, because that is a big gap. Others talked about the hospice, Community Pharmacy and others. Those are important, and I would love to see us get there if we can, but the first stop should be our GPs, and I do not think that that responsibility should be put on to them. I have been asking the Department about this since long before Encompass was anywhere near any of our trusts, and, to be honest, I do not think that I have got a satisfactory answer. It has always been pushed back a wee bit with, "Yes, hopefully, GPs will be able to do that some day". That sounds to me like, "The GPs will have to do that if they want to do that". That is not fair. The Department made a decision to go with Encompass with a big investment — that was the right thing to do; I am in favour of Encompass — but if we want to get the best out of it, the people who deliver most of the healthcare to all our citizens and to all of us should have more access. To get the best out of it, should we not be working to get GPs access, however that is done or whatever kind of software is needed? Is there a way to do that?

Dr Hughes: Some 90% of healthcare is delivered by GPs. The business case was ambitious to a degree, but when areas in the rest of the Province are on the Epic platform for all their care, those that are not are at greater risk.

We have a few places that are not on it, so the risk becomes greater. There are complex problems with monopoly suppliers and procurement. I know that the trusts that own GP practices by default are asking us the same question and want to know whether they can be on the platform as well. I do not know the answer to that yet. There is some willingness, but that is going into areas of procurement that are beyond my pay grade.

Mrs Dillon: I get that. The Department needs to take the responsibility for it. I am going to keep asking about that and pushing it. It is important, and I do not think that the responsibility should be put on to the GPs. The Department absolutely needs to work out a way to do that work. You said that there is an 11-year lifespan for the system, so it is no good if we get it in six years' time for five years. I am flagging that up. I do not expect all the answers today, but I am going to keep coming back to the point. I expect the answers at some point.

I raised a number of other issues yesterday at the all-party group (APG) on carers. There are some good things in Encompass that can make people aware of where they will have the capacity to put flags on to say that somebody is a carer. It is just about how we make sure that they identify as a carer, that that is flagged and that there is the potential to put further flags into the system. All that is really good stuff, and, given our current focus on palliative care, flagging when somebody is a palliative care or end-of-life patient could resolve some of the issues that we have with some of the challenges for those individuals and their care. I think that that is all positive. At the APG on carers, I raised whether we can get a list of what can be flagged on Encompass so that we know whether there is something that could be added that would be really beneficial to you and others, particularly given what we are hearing from the people who have come to the Committee and the APGs.

Finally, Encompass is a great opportunity for information, data and statistics, but we need to get those. There cannot be a blockage through the strategic planning and performance group (SPPG) where the data goes to it and then we hear, "Let's not give to anybody else because it might actually direct money to where the services are required". That is not on you, by the way, but we need to get that information.

Dr Hughes: I will talk about the care-of-the-dying pathway. The recommended summary plan for the emergency care and treatment (ReSPECT) pathway is built in to the system, but we do not have it turned on, because we still need to work through it in the Department of Health so that it can be released. Hopefully, that will be soon. People go through the ReSPECT process or a similar process, and, once they are discharged, that drops off, so they have to go through the process again and again. We have it built in so that that does not have to happen, but we cannot turn it on until we get the policy and other issues.

Can you remind me of the other issue that you were asking about?

Mrs Dillon: The list of flags that are on Encompass.

Dr Hughes: We certainly will give you that. A lot of that is with social care, and we have flags and a break-glass provision. That is often used in social care, but it can be used for other issues in sensitive care. We have proactive audit so that we know who is looking at information. Are they a member of the carer team? Do they have the same name as the person? Do they have the same address? It is a very sensitive tool. In the past, we had information governance that was based on paper, and, to be honest, it was impossible to audit. We can now audit all this stuff, so we are developing a framework to tell staff how to behave and the consequences of not adhering to expected professional behaviour.

I will take that point away. Part of the issue is that this has been developed from our point of view, which is a healthcare point of view. We have a 32-person patient engagement council, but it is very difficult for that to understand the system until it is up and running. I think that it is really important that we have a vector to say, "Why don't you do this? Why don't you have that?", because we cannot talk about engagement and not actually take it on board.

Dr Rice: I will make a brief comment about the flag-and-alert point. I absolutely understand your point about, first, understanding what is there and, secondly, understanding what the capacity will be. One of the things that we need to mindful of from the international research to date is alert fatigue and the extent to which that can have an adverse impact on clinicians in that they get an element of snow blindness. It absolutely is an important conversation, but it is also a conversation that highlights the fact that it is a management of change programme and a set of conversations about cultural change. None of the switches will go on and off without the depth of the dialogue that Dermot talked about with the professional and patient audiences.

Mrs Dillon: I really appreciate that. This is a point, not a question. One of the issues that came up was that some results will not go on to Encompass, and rightly so. I understand the reasons for that; they could be very sensitive results. That is not something that you want to put on to a system to be shared with a patient without a conversation. Is there some way of putting something up to say, "Contact the consultant", "Contact the secretary", or "Contact your GP"? If nothing goes up, that could be frightening too, and people might think, "Why is that result not up?".

Dr Hughes: We have time frames for when things go up, but, if they do not go up, patients know that it could be bad news. We are very clear that the app does not replace proper medical or nursing care. If somebody has bad news to hear, that is given face to face in a supported way, and the information can follow. However, very limited functionality has been turned on. I think that we will go down that pathway and expand what we do, but we will do it with our patient engagement council, most of whose members are there for a specific reason. We will test it with the council to see whether it thinks that it is appropriate. Its members will say to us, "You're far too conservative. This is my information". I think that they have a point. The health service provides healthcare, but it does not own people's information. It is a wee bit patronising.

Mrs Dillon: Everybody is different. I would think, "Just give it to me. I want to know", but not everybody is like that, so I totally understand that you have to be conscious of that.

Mr McGrath: It is good to see you again today. We had a good visit this morning. We had a good look around the system to see how it works. I think that I was the first MLA, certainly in this parish, to have CaseWorker. I think that almost every MLA has CaseWorker now. I have had it for nearly nine years. I just see the benefit of being able to use and streamline information and receive flags as opposed to having lots of paperwork, folders and files. I often wonder how elected representatives managed before it came along.

This is in no way to disparage our tour today — it was great, and I thank the staff for organising it — but, of course, you get brought to the good parts, where you are told, "Here are our brilliant people who love it and think that it is class". During the transition period, a number of staff said to me, "It's a flipping nightmare" and, "I absolutely hate it". Are there still really good, robust opportunities for people to flag up instances in which they cannot get it, it just does not work or it does not do what it is meant to do? You showed us a slide this morning about there being almost no apology for saying, "This just isn't working" or, "This isn't right", but there is definitely still an opportunity for people to be able to flag up where they feel that the system is not working for them rather than just being told to get on with it. Is that still there?

Dr Hughes: The slide did not say, "No apology"; it said, "The power of apology".

Mr McGrath: OK. [Laughter.]

I am sorry about that. [Laughter.]

Dr Hughes: Some people are zealots about that stuff, and others just do not want it; they just want to treat patients or be a nurse. We have to modify our training to do that. I am not talking about the programme; I am talking about the trusts. We had very standardised American training all day in a room at a computer. It was mind-numbing. The trusts did not think that that was good enough, so they set up what they called user labs. They took scenarios in the ward, such as putting up drips or giving medication, and worked through them. The Belfast Trust did a bit, but the Northern Trust did 14,000 seats, the Southern Trust did 14,000 and the Western Trust did 12,000. We have changed the training to say, "We'll train you with your colleagues just as you work in the ward, rather than having you sit at a computer". For the consultants, we have done a thing called personalisation, which shows them all the tricks and how to take away the drudgery. We tried to do that in advance of going live. In the Southern Trust, 85% of the consultants were trained to that level before going live. In the Western Trust, it was 88%. Nobody across the rest of the world has those levels of training.

That is a testament to the staff who want to do it and want to do it well, but it is a radical change. We do not have digital dictation or voice recognition. We would have liked that, but that is maybe a good thing, because the technology has moved on. We are doing a pilot of ambient technology, whereby you and I come into a room and have a conversation, which is automatically fed into the platform as itemised data. It is pretty standardised technology elsewhere, but we will obviously have to take it through information governance on a pilot process. There are lots of opportunities, and our Dutch friends are much further ahead of us using large language models (LLMs) and automated scribing so that nurses, doctors and allied health professionals (AHPs) can focus their time on the patients and the data goes into the system. That makes those staff more efficient and effective, but it also gives a better quality of outcome for patients.

I will share an anecdote. There was a Dutch publication in 'The Lancet' in which consultant-level summaries were compared with those at AI level. It was found that they were of equal quality, but the patients thought that the AI ones were more empathetic, which, from working in a stressed environment, I can sort of understand. Those are the tools that are there. Our colleagues in England are doing ambient technology with outpatients on the basis that they will use it, but one extra patient will be seen. That is maybe an 8% increase in productivity at outpatients. That is the kind of conversation that we are going to have, because there is not any more money, but we are asking whether we can work smarter and get better outcomes.

Mr McGrath: Is there a capacity for staff to feed in if they feel that something is not working?

Dr Hughes: Yes.

Dr Rice: You are also highlighting the fact that there is the concept of work as imagined and work as done. Whatever you are doing through that design stage and however you are adopting the practices of others, until you have the living and breathing experience of running that system, there will always be changes that you will want to incorporate. There is a very elaborate governance process to establish the value of that change. Some of those changes might actually be a training deficit, going back to your earlier point, or they could be people saying, "We were really well intentioned. We thought that this was the right way to do it, but, actually, there is a tweak or a twist that we need to incorporate."

Mr McGrath: Finally, and again, this is not a criticism of the system; it is a slight frustration, maybe up at this side of the process, about waiting list figures. We are being told, "We cannot give you figures for this period or that period because of Encompass. We cannot tell you the number of people who are accessing the service because of Encompass." I will blame the Minister on this one, but it felt as though the Department was maybe just being used as an excuse not to tell us. I know that it was not, but it felt like that. If there are data gaps because of Encompass, can they be retrospectively filled? In other words, in a year, will we be able to look back and see that, where we were being told at the time, "We cannot tell you what the waiting list is because of Encompass", a gap has been retrospectively filled, or is that information lost and gone forever?

Dr Hughes: That is a very salient point. We would have to put our hands up and say that the due diligence in what Epic delivers through NHS data is not good enough. We have had that conversation formally, and I have written formally to trusts, but they did not tell us, and other trusts have also had that experience. When we go live, we have to look at all the data and then go back to the staff, who are exhausted, and ask, "What does that look like, and can you validate all that stuff?" Traditionally, the data just came out of the system, and our staff were not involved in that process. That has been a struggle.

We have out-of-the-box tools that are working really well, and I think that you saw that today. At the same time as going in for the regulatory report on the standard essential patents (SEPs), they have now changed to strategic outcome measures and strategic outcomes frameworks — SOMs and SOFs. As well as managing the validation of that data, we are changing to a new thing. It is very similar but is often slightly different. The data is not where it should be or where we would like it to be. We will retrospectively put the data up. We have agreed remedial work with the vendor, Epic, and we have an enhanced team resolving that. I think that the south and west will be in a better place, which just shows that, if we were told, we could have learned and would not have to be in this place. It is not good for us, but it is certainly not good for a vendor, because when people come to us and ask, "How did you do that and what were your problems?", I will have a list of things that the vendor did not tell us.

Mr McGrath: It is really important, because data drives nearly everything. If we do not know how many people have cancer in a particular place, we cannot tailor the resources that go to that, or if we do not know the number of people who are waiting somewhere, we do not know how to tweak the services. It is good to know that it has been flagged up as an issue and that you are trying to resolve it.

Dr Hughes: For cancer, we have the all the local multidisciplinary teams (MDTs) and regional MDTs up and running on the platform, and everybody can see the information. It is one record, so information is not in silos. Every professional who is providing multidisciplinary care has access to the information, which represents a big governance enhancement.

Miss McAllister: Thank you very much for your presentation. I will focus on performance post "go-live". Encompass is a great system. We have to move with the times, however, and update it as we go along. Hopefully, every time that Encompass needs to be updated, not much money will be required to do that, meaning that we do not fall years behind. If it is not updated, we could find ourselves having to catch up and then having to do the same again in 10 years' time.

I understand the difficulties with technology. I also hope that the ambient technology understands all the different Northern Irish accents. [Laughter.]

That will be interesting to see from the pilot.

On performance, specifically in the South Eastern Trust, the report states that general surgery, breast services, obstetrics and gynaecology, and neurology:

and are described as "underperforming". The report talks about plans, performance and improvement. It does not mention anything specific, but I ask why those services have struggled to return to full capacity. It is important to highlight that. We think of Encompass as a computer system, but does it mean that these services struggled with face-to-face consultations, waiting lists or surgeries? Which is it?

Dr Hughes: The trusts that initially had Encompass struggled because often people would write short notes, but, once care is standardised, there is a minimum standard of information that has to be put in, and that is probably more than some services did in the past. In breast services, for example, it became a linear system. People came in and perhaps saw a breast nurse, after which they had radiology etc, so everything was done in a linear fashion. In previous days, people were doing asynchronous work and working at many tracks at the one go. The underlying learning from that was that we did not plan for the upturn properly, and, again, we had deep discussions with the providers. When we went live in the Belfast Trust, we had written what we called a playbook: a back to green activity playbook. We were very directive about what we had to do.

When people struggle with the platform, it is often because they are not putting in information correctly, and that slows them down. The resolution to that is to get professional leads in straightaway to help teach people. They are dealing with psychology more than IT, because people who are experts in what they do are floundering a bit. They sometimes do not ask for help. As soon as we see a downturn, however, that just means that people are struggling with getting the activity down in the system. We improved that with the Belfast Trust. With the Northern Trust, it was better still. With the Southern Trust and Western Trust, it was much better. The downturn will therefore be markedly less.

Miss McAllister: You talk about "downturn" and "upturn". Do you mean physically seeing and treating patients, the use of data or the use of the system?

Dr Hughes: I am talking about the activity on the system.

Miss McAllister: OK. The report states that those services:

and described them as "underperforming". Is that "full capacity" in meeting and treating patients, or full capacity in using the system?

Dr Hughes: It means activity. For example, if they had seen 15 outpatients, it might mean that they struggled to get past that figure. The South Eastern Trust is now back to activity, but one area that it did struggle with was antenatal clinics, because consultants in Northern Ireland do their own ultrasound scans, which is unique to Northern Ireland. That is an extra task that they were doing, which added complexity. Sometimes, when an implementation is being done, Northern Ireland variants are found, and we will probably have to address in the long term. We will have to ask why that is, and why what we are doing is not similar to what is done everywhere else.

Miss McAllister: Do the consultants who do operations and treat patients usually have people to assist them with their notes? Are we talking about everyone in a consultant's team having access to Encompass to do that? As elected representatives, we often contact consultants' secretaries for information and other stuff. Do secretaries also have access to Encompass to enable the consultant to get on with treating the patient?

Dr Hughes: There is role-based access, so people should access information only if they have the right to. The secretaries may have those rights if they are assigned to them by the consultant under a proper information governance structure. Encompass is one platform, and it is a platform that people can access, but it can only be accessed appropriately.

Dr Rice: You have highlighted the fact that there is a huge amount of administration behind the clinical processes.

Miss McAllister: Yes.

Dr Rice: The work has to be factored into all the preparatory work. Colleagues who visited this morning saw the full spectrum of access to the system and how it is used. They met the converts and the reluctant converts, so there is a spectrum. It is important to focus on the clinical relationships and roles, but, if we look at systems globally, what does not get expressed to the same extent is the volume of administrative work involved. Dermot's experience reflects that of others, and that should be captured and included in the system's next deployment.

Dr Hughes: We manage the data and information about patients in work queues. When the South Eastern Trust went live, it suddenly had 3,000 work queues. The Belfast Trust had over 4,000 work queues. It is therefore very complex work. The staff had to learn a new way of working. It is a new type of working.

Miss McAllister: The aim is to create efficiency, to update the data and technology and to improve patient access. Is one of the aims to see more patients? Can we see that happening anywhere? You said that the South Eastern Trust is now at the performance level post "go-live".

Dr Hughes: That happened some time ago.

Miss McAllister: The report said that it was not, so it is good to hear that it is.

Dr Hughes: I will give you some examples. We are starting to do that work, because we had focused on going into trusts. For example, the medical, clinical and digital lead in the Northern Trust is a child and adult psychiatrist, and he was very concerned about the autism backlog. He is building the autism assessment on the My Care app so that when patients and parents come in for their assessment, all the information is available, and they can have a meaningful conversation. There are lots of examples. If you have ever been to a fracture clinic, it is a bit like a war zone. There can be 30 people at a clinic. We wondered how we would cover that on the platform. The question was this: why would we do it the same way when there is an alternative? The X-rays can be reviewed, and patient-reported outcome measures can be sent out on the app, and we can ask people to come to the hospital. In that way, we can stream the work instead of its being a case of one-size-fits-all. Our productivity will therefore not just mean more of the same. Rather, we are thinking of doing things in ways that patients will accept.

Miss McAllister: Thank you.

Mr Chambers: You have answered a lot of my questions already. I like the phrase from your colleague — "We are at the end of the beginning" — because it helps me appreciate that it made so much sense for a lot of the energy and effort to be directed towards the roll-out of the system and to sorting out the glitches. The My Care app is a critical part of helping the system provide benefits. It will help reduce the unacceptable number of missed appointments and the number of phone calls that patients make to consultants' secretaries or GPs to get blood results etc. The app is therefore a critical part of the platform. You said at the start that a light-touch approach was taken to advertising the app, because you did not want to be swamped. You wanted all the energy to go into rolling out Encompass, but we are now at the point at which there will be renewed energy and a push to get people to register with the app.

I also appreciate that, in order to protect patient security and system integrity, you have to ask people a lot of questions when they register, but I found the registration process to be challenging. I was probably not helped by the fact that I did not have any of my primary-school-age grandchildren beside me. [Laughter.]

They would have helped me greatly. If my memory serves me well, the registration process got a bit frustrating when — I do not know whether it was a quarter or a third of the way through, or halfway through — it started to ask me for information that I had to search the house to find. It therefore would have been better if I had known that I would need my patient number and all that other stuff. Date of birth is easy. Perhaps you did this, and I missed it, but if you are making a push to get people to register, a message saying, "Before you start, here is what you need" would be helpful. That would make the process easier. As I said, you really need to get patients on board. You may not have the figure with you, but what is the uptake of the app?

Dr Hughes: It is 167,000.

Dr Rice: And two.

Dr Hughes: It is 167,002. I apologise, because what you have just described is 100% correct. It is the nidirect pathway. We just assume that people know how to deal with that, because they did it during COVID four years ago, which is kind of stupid. People need to go on to the app and verify whom they are: they need their passport details. It is a secure way of registering, but it is difficult to do. Not everybody in the UK uses that methodology, but we thought that it would be a secure method, especially if people want proxy access and to get information that way.

We need to do that better. There is no point in our asking you, "Would you champion this?". We need to champion it. We ask some staff, perhaps when they change jobs, to be My Care app champions at, for example outpatient clinics. Usually, people go on to the system when they are there for an appointment. They should be guided through the registration process. Perhaps we should tell them, "If you are interested in getting the app, make sure that you have photo ID and stuff like that, and we will help you with registering".

It will not happen by osmosis. We have to have a programme plan in place, with staff and the infrastructure to drive it. If we are hoping to change care by using the app, we do not want a disadvantaged group of people to be left out and not able to be part of the change because they may not be digitally literate or because we have not given them enough help and support. I always think about whether people would prefer to have some of their appointments virtually instead of having to drive to Belfast and wait a couple of hours to get into a car park? I am not saying that that is how care will be for everybody, but there are lots of opportunity to improve it.

Mr Chambers: We probably all missed saying this to you, but congratulations on what you have achieved so far. It is a superb effort. Thank you.

Dr Hughes: It was not us. It was 80,000 staff, and I keep saying this, 15,000 of whom were super-users, who volunteered to do extra work for no pay. One in five members of staff was a super-user, which meant that, if people had a bit of difficulty, there was somebody at their elbow. That was incredible to see, because everybody was incredibly busy. I have been in the health service for a long time, so it was amazing to see.

Mr Chambers: Well done, everybody.

The Chairperson (Mr McGuigan): I can remember going through what you talked about at the time of signing up for nidirect, but, this morning, my device had all that stored, so I was able to get on to My Care within 30 seconds with no difficulty. It had therefore —

Mr Chambers: No grandchildren to hand? [Laughter.]

The Chairperson (Mr McGuigan): — stored that information really well. The nidirect sign-up process will be slow and cumbersome, but I imagine that a lot of people's details are already stored on their phone.

Dr Hughes: I helped my son get on to the My Care app on Saturday, and, between us, there was a bit of bad language used. [Laughter.]

The Chairperson (Mr McGuigan): OK. Two members still have to ask questions. We are beyond our time limit for the session, so I ask for quick questions and quick answers.

Mr Donnelly: I declare an interest as an Encompass user. I was previously a nurse. When I started nursing, many years ago, everything was on paper, and we have slowly moved towards digitisation.

I was in the South Eastern Trust, where the training was all classroom-based, as you described. It was hard for a lot of nurses who were not very computer-savvy. It was incredibly digital. Every aspect of the job therefore changed overnight. There were even new steps involved in taking bloods. Staff were given new pieces of equipment. There are huge benefits, however. Using a Rover device now means that a drug cannot be given to a patient by mistake, which is fantastic for patient safety. A lot of the patient safety elements are therefore very good as a result digitisation.

I have seen a huge uptake in staff using Encompass. I go in for bank shifts, and I noticed a big change initially. Everybody was adapting to it following their training. Now they are absolutely flying, and there are moments when I wish that it had always been that way, as there are huge benefits. The job has changed, but that change has brought huge benefits. A lot of people would think that.

I apologise for not attending the visit this morning. Unfortunately, I had another engagement, but I would like to have gone, even though everything would have been very familiar.

One thing struck me when you spoke about the due diligence around NHS data not being good enough. I think that that was the term that you used. Is Epic doing what it promised it would do? Are we getting the data that we expected from it?

Dr Hughes: The out-of-the-box tools to manage the day-to-day work well. Part of the deficit came from the need to train and educate everybody. The assumption that people would somehow magically be able to do everything was erroneous. That was a shortcoming. There is other data — regulatory reporting and service delivery plans — that we then have to take out and validate. The frailty is that that assumes that people are putting the data on to the platform in the correct way, but it is unlikely that people will do it 100% correctly in the first instance, so validation has be done alongside the digital teams checking that people are doing it correctly. It is therefore a lengthy process. We have what we call "sprints" for the out-of-the-box tools. We think that that has been done and that it has been well received. We are, however, still working on the validation. We are doing returns, so we are taking steps. It is the same everywhere, however, so if we do it in one area, we can lift it for another area, meaning that there is a benefit. At the same time, we are redefining what I call the new measures: the SOF and the SOMs. We are working with the data teams in the trusts and with the SPPG and the information groups in the Department of Health. It is a complex piece of work and not something that we have done as well as we could have.

Mr Donnelly: OK.

Dr Rice: There is a basic constraint with a lot of the US-based systems. There is almost a sense their being a left-hand-drive model. We are having to shape some of the data to serve purposes that would not inherently be the demands that are made in a US-based model. For example, we are not focusing on price, because people are not given a bill for their treatment. Some of those elements are intrinsic to the way in which this product and competing products are built. Some of our expectations of concepts such as queueing are not necessarily as fundamental in the US, because queuing is not expected there to the extent that it is here. For some of the stuff that you are talking about and that Dermot has highlighted, we progressively shape the outputs with the right people — the people who understand what we are looking for — in order to make sure that that is what the system does routinely and automatically.

Mr Donnelly: When will we —?

Dr Rice: It is a progressive process.

Dr Hughes: We are aiming for the end of August. The vendor has produced an NHS data framework, but that is for NHS England. Although we are similar, we are not identical. It may not be possible just to lift that framework.

Mr Donnelly: OK. I have one other question, Chair, if you do not mind. It relates to the cost of Encompass. The estimate was £300 million. That is the cost of three maternity hospitals, for example, so there is quite a big price tag involved.

Dr Rice: Not how we build them. [Laughter.]

Give me the name of that builder.

Mr Donnelly: We are now told that the cost is £360 million, so that an extra £60 million, and it will cost an extra £11·5 million a year from now on. Is that the correct pricing?

Dr Hughes: Yes.

Mr Donnelly: What was the extra £60 million for? Why has the price increased so much?

Dr Hughes: I will fess up to that. I take responsibility, but not in totality. [Laughter.]

When the programme started, there were approximately 50 staff in trusts to deliver the work. If you divide that number among the trusts, that is about eight staff in each trust, with perhaps twice that number in Belfast. The Belfast Trust alone has 24,000 staff, so the work would not have been successful. At that stage, in 2021, we had a discussion with the Department for the Economy, the Department of Health and the Department of Finance to see whether we could expand that number. We therefore expanded it to about 250 clinical staff, so we had extra nurses, doctors, AHP staff and social workers to lead the clinical transformation, and it is clinical transformation. It is not really an IT transformation. We are doing one thing: standardising care. We are changing the pathways for everybody, and we are putting them on to a digital system. For a period, the additional resource was in the form of staff.

The programme has a lifespan of 13 years, so it is not a case of "plug in, play and decay". Rather, we will plug it in, and it be with us, with the resource, for the next 13 years. The resource is almost 200 people. That means that, as there is a need for services to be changed, shaped or transformed, we have the build teams, the training teams, the business change teams and the clinical expertise in place to allow us to do that.

It is not a case of, "We are here now, and we are going to do one thing". Encompass represents generational change, with investment over a long period. It will, however, be worth the money spent on it only if we do that change. It will be worth the money only if people say that it was a good investment. I will be honest: if the £360 million delivers what it needs to, that is better than £300 million spent that does not deliver.

Mr Donnelly: So that I am clear, are you saying that the extra £60 million was for additional staff time?

Dr Hughes: It was for additional staff numbers.

Mr Donnelly: Additional staff numbers?

Dr Hughes: Yes. We were implementing in the context of a system that was running hot. We needed to get people out of jobs in order to give them roles. In each trust, we had digital leaders in social work, digital leaders in nursing and digital safety nurses. That is a range of staff recruited to make sure that we could do the implementation effectively, efficiently and safely. Those roles are for three and a half years to get Encompass over the build stage and the delivery stage. Some of those roles will therefore end.

Mr Donnelly: Was it not foreseen that that would happen from looking at any of the previous roll-outs in other places?

Dr Hughes: It was not in the initial business case. I will ask Paul to come in on this, but that is not unusual for IT business cases. They often focus on the IT bit, not on healthcare change and transformation. That formed part of my discussion. A lot of people come to see us to ask how we did Encompass. We have pretty standard talks about clinically-led and digitally-enabled transformation. That clinical leadership is needed. Any member who was at the event this morning may have met David Wilson and Angela, who are senior leaders. People will not deliver Encompass unless they own it in the trusts. That is what has made it safe. Everybody says that implementations were very successful, but they were successful because healthcare staff were doing them.

Mr Donnelly: Did we not also do that? Did we not look at other places where such a system had been implemented?

Dr Hughes: Yes, and some of them did not implement it so well. If you go back to the very first one, which was in Cambridge and was implemented by Epic, it is fair to say that there is a natural tension, with a vendor saying that is costs £x, so an honest assessment has to be made. I think that we made a more honest assessment.

Dr Rice: My experience is from outside Northern Ireland. I have been here for three and a half weeks. The reality is that the "If you build it, they will come" model is an old-school approach to IT, particularly in the context of clinical systems that require the change of practice that you mentioned when talking about your time in nursing, a change of practice amongst doctors etc.

There is now less risk of somebody undercooking things and not understanding that this is a transformation programme than there is of people thinking that it is an IT programme. If we leave only one impression today, let it be this: forget about the word "IT" and embrace the word "digital", and when you think about the word "digital", think cultural change, leadership, transformation and those sorts of qualities. To do that in a health and care system, you need the expertise and talent of the people to whom Dermot is referring. We can afford those people due to the extra buffer.

Mr Donnelly: I absolutely appreciate that this is a huge generational change towards digital healthcare. That is to be welcomed, and it has huge potential benefits. My question was about an extra £60 million worth of costs in a context in which budgets are very tight and we are cutting other services.

Dr Rice: I appreciate that.

Mr Donnelly: It is an extra £60 million of public money.

Dr Rice: Sure.

Dr Hughes: I understand that. That spend is over a long period. The business case is for £512 million of non-cash releasing benefits and a smaller amount of cash-releasing benefits. However, we think that those figures are low. We would like to think that we will surpass them.

Mr Donnelly: Time will tell. Maybe in 11 years. No problem. Thank you very much for that.

Mr Robinson: Thanks, gentlemen. My personal experience of the My Care app has been nothing but positive. I say that as someone who is dumb when it comes to technology and devices. I struggle to navigate my way through them, and I do not even know what they do half the time. In my experience, My Care was easy to navigate, and I was able to access scan results rapidly. That saved me going through the Monday morning mayhem of ringing the GP surgery and trying to access results. That was a big positive for me, and I hope that it reflects the experience of others.

With the roll-out of any large programme of digital technology, there will be hiccups along the way. When a staff member encounters a hiccup, how timely is the support? I talk about how difficult I find it to navigate the equipment that I have in here, but I have people upstairs whom I can phone and get timely support from to deal with my problem. Given how critical technology is nowadays, how quickly can staff access support?

Dr Hughes: If somebody has an issue, they raise what we call a "v fire", and it is triaged on a range of P1 to P5. If it is deemed to be P1 or P2, it is addressed immediately, as it is life-threatening or urgent. There is a digital safety team in each trust, which should be able to help staff and sort them out on the spot. A lot of issues can be resolved locally, because we have those funded, digital teams in the trusts.

We have had unexpected downtime for about 20 minutes on one occasion. We have planned downtime every three months. There used to be a four-hour window for that, but we reduced that to an hour and a half. That is done at 4.00 am to minimise disruption. As we have had four implementations, the patient pathways are now very stable. There were glitches as we went through each go live. When we go live, we have a huge enhanced team: we have a team of 200, as I mentioned, but we augment that to maybe 400, with people coming from Europe and America. Therefore, when we go live and know that there are risks, we have a huge team so that we can fix them immediately. As we went through that process for the Southern and Western Trusts, we set up regional meetings to discuss any changes that we needed to make. We did not need to use the enhanced team on those occasions because there were no regional issues. The pathway is now much more stable and the number of issues has reduced.

That is not to say that there are no issues — there is always something — but we have ongoing support and 24/7 cover.

Dr Rice: I am going to contradict something that I said earlier. I do not want you to think about this as being an IT programme. Part of your question is about the basic level of anxiety that someone feels when they turn on the machine and it does not do what they want it to do. Dermot has given you a comprehensive overview of the system's workflows and pathways etc. There are IT teams in the trusts — they are ubiquitous across all the organisations — that are there to address the first-order complaint of, "This machine doesn't seem to be responding in the way that I want it to". There are training teams available to augment the response. It is a case of having cover for everything, in that, if someone has a concern with IT, somebody will be there to help them with the IT side, and if their concern is the clinical workflow on the pathway, the process and the mechanisms that Dermot highlighted are in place.

Mr Robinson: In the grand scheme of things, 20 minutes of unexpected downtime is very good.

Dr Hughes: Yes. I should have said that we have a "business as usual" system, whereby all the information is downloaded to free-standing computers. That means that you still have access to the information, so you can still treat patients. You would still need to be connected to the system, however. The downtime has been vanishingly small.

The Chairperson (Mr McGuigan): That is fair enough. Gentlemen, thank you very much. We really appreciate your time. We went way over time, which shows members' interest. We will be in touch about the event in September.

Dr Hughes: Great. Thank you very much.