Audit Wales recently published a series of audits examining digital delivery across NHS Wales health boards and trusts.

Across health boards from Cardiff and Vale to Swansea Bay, and specialist trusts like Velindre and the Welsh Ambulance Service, the Auditor General reveals a clear, systemic pattern. Dedicated teams operating in high-stress clinical environments are trapped maintaining decaying infrastructure, navigating fragmented governance, and reporting on IT activity rather than healthcare outcomes.

Across NHS Wales, health boards spend a combined £216 million annually on technology. Yet over 80% of local budgets - around £170 million - is consumed simply keeping ageing legacy systems on life support. That leaves a meagre 20% for actual digital change.

With the Welsh Government drafting a new NHS Wales digital strategy, this audit series provides a reality check. We must stop treating digital as isolated IT projects and start treating it as a fundamental shift in healthcare delivery. We do not need another policy document filled with comfortable promises; we need a radical overhaul of how healthcare delivery is funded, led, and executed.

The invisible estate backlog in Welsh healthcare

Every public sector leader in Wales knows our physical estate backlog - the crumbling roofs and deferred maintenance that feature regularly in Senedd debates. Far less visible is the identical backlog in our digital estate.

Physical buildings and digital infrastructure pull from the exact same pool of capital funding. Because capital allocation across Welsh public services is short-term and unpredictable, health boards are forced into continuous operational triage.

For example, in Betsi Cadwaladr University Health Board, keeping basic IT infrastructure safe requires £10 million in capital funding each year. Yet its annual capital allocation is just £2.8 million - leaving a £7.6 million shortfall every year simply to maintain core systems.

This pattern repeats across Wales. In Cardiff and Vale, digital maturity remains exceptionally low. In Velindre, fragile legacy technology forces clinical teams into manual workarounds to track test results. When systems cannot talk to each other, clinicians spend hours re-keying patient data across screens. Wasted clinical time is a hidden tax on NHS capacity that never appears on a spreadsheet, but staff and patients pay for it daily.

The national delivery bottleneck and centralisation

This financial squeeze is compounded by a breakdown between national strategy and local execution. The standard policy assumption in Wales is that because we are a small nation, monolithic “Once for Wales” procurements are automatically the most efficient choice. In practice, this centralisation has become an anchor.

These centralised pipelines mean a bottleneck at the centre halts clinical progress everywhere else. Look at the Welsh Community Care Information System (WCCIS). Heralded as the single digital solution to bridge health and social care, years of implementation delays left health boards and councils stuck with a struggling platform. Today, organisations are actively abandoning WCCIS as it reaches end-of-life.

A similar inertia affects other clinical work. Digital Cellular Pathology was piloted in 2013, yet over a decade later, procurement processes drag on. Major national programmes managed by Digital Health and Care Wales (DHCW) - such as the Laboratory Information Management System (LIMS) and Radiology Informatics System Procurement (RISP) - face repeated slippages. In Betsi Cadwaladr, a local Electronic Health Record business case was halted waiting for a national solution, leaving staff relying on paper records and 400 fragmented systems.

Underpinning this is a major governance defect: blurred roles and accountabilities between the Welsh Government, DHCW, and health boards. Local chief executives remain legally accountable for patient safety while having zero control over national software delivery timelines.

Missing skills and the temptation to buy software

Technology is only ever as effective as the skills and governance behind it. Audit Wales shows that health boards face severe challenges recruiting specialist digital talent due to uncompetitive public sector pay structures. In Cwm Taf Morgannwg and Powys, stretched teams leave health boards dangerously reliant on contractors.

Lacking in-house digital capability, leadership defaults to buying off-the-shelf software packages that promise quick fixes. But no software package fixes a clinical pathway you do not fully understand. Buying software without basic foundational plumbing - like open data standards - simply automates bad practice and creates new silos.

Board oversight exacerbates this. Board updates focus on technical jargon and vendor reports rather than clinical outcomes. Multi-million-pound procurements are signed off without post-implementation evaluations to measure whether systems actually save clinical time.

What user-centred delivery looks like

This is not a story of inevitable failure. Across Wales, proof exists that a different approach works when teams are given space, skills, and permission to deliver.

The development of the NHS Wales App demonstrates this shift. Rather than treating it as a static software deployment, the team focused on user-centred design: mapping user journeys, conducting research with patients, and iteratively testing prototypes. By prioritising user needs and open standards, they proved that Wales can build modern digital tools people actually want to use. This must become the norm across every service, not an isolated exception.

What the new NHS Wales digital strategy must deliver

The upcoming NHS Wales Digital and Data Strategy offers a window to break this cycle. It must deliver five structural reforms:

  • Establish clear, bold and accountable leadership for digital transformation: Set a clear vision for service transformation in the NHS, and establish explicit boundaries between Welsh Government policy, DHCW central delivery, and health board execution.

  • Build reusable digital plumbing, not monolithic software: Move away from forcing health boards to wait years for massive, single-vendor “Once for Wales” applications. The centre should focus on building modular, shared digital plumbing—open data standards, common identity layers, shared components—allowing local health boards to build flexible services tailored to local clinical needs.

  • Fund long-lived product teams, not stop-start projects: Replace unpredictable capital bidding pots with sustained revenue funding for multidisciplinary teams that take continuous ownership of clinical outcomes and systematically dismantle technical debt.

  • Start with clinicians and patients: Shift from buying pre-packaged IT solutions to deeply understanding real user journeys across health and social care, co-designing tools directly with doctors, nurses, and patients to prevent digital exclusion.

  • Mandate radical transparency and post-implementation evaluation: Force health boards and national agencies like DHCW to work in the open, share learning, and routinely evaluate whether digital investments deliver measurable value to patient care.

Audit Wales has held up an uncomfortable mirror to healthcare technology in Wales. The Welsh Government now has a vital opportunity to shape a strategy that shifts focus from keeping legacy systems on life support to delivering modern, human-centred care.