A frank diagnosis

A frank diagnosis

Andre Snoxall, former general manager of HealthIntelligence, has gone back to England. Prior to his departure, he reflects on the challenges in creating and managing a shared services set-up in the politically and socially sensitive healthcare sector.

"The health sector has been through several changes since I have been here and it has survived. It is extremely hard on people," notes Andre Snoxall, who has held IT executive positions in the sector for the past seven years. "I have seen senior management employed to do one thing and then expected to refit into a new and completely different environment that suited neither their skills not their experience. I have seen others who have flourished because the new system was more suited to their talents," says the UK-born Snoxall, who has just left the position of general manager, HealthIntelligence, a shared services organisation of the district health boards of Capital & Coast and Taranaki.

Following, a largely Australian-based career stretching back almost 30 years, the 45-year-old says he is ready for the challenge of working for the first time in the country of his birth, a decision brought about because his wife wanted to study in England.

Now based in London, Snoxall can draw on a career that has taken him from being a computer operator with Telecom in rural Victoria, through a range of IT roles in New South Wales, the Gold Coast, Western Australian and Northern Territory mining towns, and then New Plymouth, before moving to Wellington a year ago.

Career highlights include being chief information officer with Dr Global, which for a time offered online health consultations, before moving into software that allowed such services. Snoxall also headed IT at both the Taranaki District Health Board and Capital and Coast DHB, before combining these roles as general manager of the DHB's outsourced IT provider HealthIntelligence.

Setting up HealthIntelligence, he believes, was probably his most difficult job in New Zealand.

"All industry sectors in New Zealand, and healthcare particularly, face significant challenges in attracting and retaining high quality ICT personnel. This was compounded at Capital" Coast DHB by several years of bad press around its IT systems and it was seen as one of the less desirable ICT environments to be a part of in the Wellington region," Snoxall explains.

This was very demoralising for staff, so in December 2001, Capital & Coast DHB began talks with the smaller Taranaki DHB, where Snoxall was its director of information management and planning (effectively its chief information officer/chief operating officer), an organisation known for its IT leadership and personnel.

"From these discussions came an operational plan for the two DHBs to share resources, to collaborate in developing solutions, and to leverage each other's skills and experience to move forward."

Taranaki DHB is located 400 kilometres from Wellington with a different culture and only a quarter the size of its partner organisation. Despite a different culture and patient base, the health sector was increasingly recognising the importance of breaking down silos and working with other organisations.

Constant management changes at the two DHBs, the need for Minister of Health approval, plus the need to create a limited liability company to run the organisation delayed its creation, but the business case was "solid and incontrovertible".

"HealthIntelligence was set up to be an alternate provider of ICT infrastructure to small and otherwise disadvantaged (government funded) healthcare providers who are unable to develop their own facilities at the same level and within the same cost constraints. In this sense, it has huge potential to address disparities in the health sector, but this will not occur until some additional investment is made to enable HIQ (HealthIntelligence) to develop such services," Snoxall explains.

However, he notes some CIOs wrongly expected such co-operation might subsume DHB ICT departments. He says this thinking could damage the case for collaboration, which the health sector could really benefit from.

"Those who will succeed in the future are the people who can communicate and collaborate most effectively, and those who are inclusive of different ideas, cultures, and opinions in developing their strategies," he points out.

Birth of HIQ

Thus, In July 2004, HIQ was born, with 83 staff (26 less than at the two DHBs combined) managing the IT of 5000 users across 23 sites and within existing annual budgets of $10 to 20 million.

IT projects have included developing an Integrated Computing Environment or ICE, which features a centrally managed and deployed grid computing environment. It uses Active Directory, Microsoft Office and a Citrix metaframe to deliver access to documents from anywhere there is internet access.

Gaining a centrally managed ICT infrastructure should help ICE reduce the real ICT operation budget by 20 per cent since 2001 while increasing end users by 85 per cent and the number of devices by 50 per cent.

A $12 million electronic health record and patient management system is expected to save the Capital & Coast DHB some $6.6 million and have a positive net present value over five years of $2.2 million. It will also reduce risks around duplicating clinical information.

A converged data network also offers fresh opportunities for collaboration by allowing free videoconferencing among 13 locations and a replacement telephone system should also be "30 per cent more cost effective" while offering more functionality.

Despite such technological progress and efficiencies, estimated to bring overall savings of at least $6 million in largely avoided costs in its first five years, HIQ has faced hurdles, particularly in the management set-up.

As he explains, HIQ is essentially an outsourced ICT service provider to the two DHBs with Snoxall as GM of the new entity while remaining CIO of the two DHBs, a situation that arose more through default than design. Snoxall was offered the GM job, which he said he did not want long-term, but HIQ has not yet filled the position.

"There is a fundamental conflict in this model of the provider also leading the change in the customer organisation and it was difficult to deal with, if for no other reason that the workload of setting up and managing a new company through the transition from an insourced department to an external provider was extremely high," he explains. "The organisation must not be seen as the leader of information management or healthcare initiatives within C&C DHB or Taranaki DHB and unless this clear accountability separation can be achieved, it will not succeed."

As GM of HIQ, Snoxall reported directly to the HIQ board, composed of board members of the two DHBs. He is also part of the executive management teams for both the DHBs, reporting to the CEOs of both.

"This was the role I was employed for and working with peers at this level to define strategy and operational plans for improving management capability is my first love," he says.

Combining roles difficult

Combining the GM role of HIQ, which is one of nurturing and developing a specialist outsourced ICT service provider with being CIO of two DHBs, is simply too big. Snoxall also doubts the effectivity of having the same person as CIO of both DHBs.

"I think a CIO's role is to work closely with colleagues within their own business to assist them in identifying how information might best be used to enhance the value of the business for the stakeholders," he says.

"A CIO operating in absentia from the site for 95 per cent of the time just doesn't make sense to me. I have always found difficulty with leading information management initiatives at Taranaki when located at Wellington and what seems not clearly understood by people is just how advanced the user base at Taranaki DHB is. They have had an ICE-type environment since 1999. They expect as standard fare all the features that are still being deployed in Wellington."

Consequently, such isolation from New Plymouth means that HIQ has made little difference to Taranaki DHB, with C&C being its main beneficiary.

What "probably was the worst thing that could have happened" at Taranaki, he says, was the disestablishment of the CIO role there in 2000 before HIQ was even conceived as this removed strategic IT leadership from the DHB.

"At Capital & Coast I have seen the benefit that could be derived from effectively working with a CIO eroded by the time I had to put into driving and managing the joint venture. However, it is not too late for both DHBs to step back, realise how HIQ can be enabled to work effectively (as an outsourced ICT service provider) and how they can both address the issue of a CIO that drives information management and ICT initiatives," he says.

As this issue went to press, a replacement has not been found for Snoxall.

Any successor, he says, would need excellent general management and people management skills and the ability of running a sophisticated ICT services provider. Any combined CIO for both DHBs would also need sufficient capacity to understand the fundamental political, social, demographic differences between the two DHBs. They would also need to work in both centres but they should be spared operational accountability for delivering ICT support services.

While this might sound like an advocacy for more change, Snoxall feels the health sector has had enough change, and Labour's switch from the health funding authority (HFA) and health service (HHS) model to the district health board, planning and funding model is interesting and should be given a chance to succeed.

"(However), I don't think there was enough support given for the incumbent management teams in the transition phase nor a realisation of how the organisations could be restructured to work properly," he says.

"As a result, service departments that were once expected to provide support services to hospitals are now expected to provide a new set of services to a much wider spectrum of customers and to operate at a different level.

The chief operating officers who run the provider arms in most DHBs have lost some of the control they had of these functions and the competition for scarce funding is tight," he continues.

However, Snoxall believes the biggest issue facing the health sector is its ability to innovate, not necessarily about technology, but using resources to change how a business operates. Health seems more concerned about how much funding it has, rather than what it can do with it.

"The DHB model may offer opportunities to innovate that weren't offered by other models but I am not convinced. I suspect that significant innovation can only come when ownership and accountability are clarified," he says.

The DHBs should lead innovation on a regional or sub-regional basis, but never national. However, the Ministry of Health should also be able to support the development of standards such as the Health Information Standards Organisation (<a href="http://www.hiso.govt">www.hiso.govt</a>), which have the ability to lead healthcare through developments of appropriate frameworks that will enable systems and technologies to integrate.

With HISO providing standards in terms of leadership, systems and infrastructure, Snoxall further advises, "The Ministry of Health should stay right out of implementation and delivery of any other services. I don't want to skim over this too quickly. HISO has more potential to reform and deliver real value to the health care sector than any other initiative ever undertaken by the New Zealand government."

No impact on policy

Now, before we wonder if one government might run health better than another, Snoxall underscores CIOs have no impact on government policies and there is little gained by its politicians spending much time with the IT executives.

He says he has enjoyed his interaction with the Ministry of Health, pointing out the ministry is not a management body, but rather one that "clearly tries to achieve change through leadership, advice and example, rather than being autocratic in its methods and this is as it should be".

Snoxall, however, has met current Health Minister Annette King, other government ministers and former PM Jenny Shipley, who also once had the health portfolio. "I was impressed by the dedication and commitment of both these people, although on different sides of the political fence, to making change and [I] empathise with the difficulty of doing that through bureaucracy. [However] the minister of the day has always made their wishes, aims and ambitions for state health care fairly clear and these are conveyed reasonably well by the Ministry of Health.

"My overall impression is that political parties and individuals can have some strong and fundamentally good ideas but their ability to influence the sector except in the most fundamental ways is limited".

The health system does not need any more upheaval at the moment.

Many DHBs need support to continue the direction they are going and that support should be visible and vocal from the government and the Ministry and the Minister."

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