Until recently a stable factor in the background of our healthcare system, but operating in extremely turbulent conditions since the COVID-19 pandemic: the regional GGDs. Responding quickly to changes of great social importance, which call for effective cooperation with all parties and partners in the chain. Raymond Stijns, head of process and information management (PICA) at South Limburg Municipal Health Service (GGD Zuid-Limburg) on outsourcing IT: “Quality is very much about things that are not in writing.”
The GGDs in the Netherlands are responsible for implementing the Dutch Public Health Act. They do so according to a regional organisational model, with the GGD Accident and Disaster Medical Relief Team (GHOR) as the umbrella association. They are funded by groups of municipalities, mainly because most municipalities are too small to implement this act individually. Only The Hague and Amsterdam have their own‘urban GGD’. While most decision-making is takes place at the national level, it is also the policy that implementation is almost entirely decentralised. There are also major differences between GGDs, both in terms of geographical areas of operation and tasks.
Raymond Stijns, head of the PICA department at GGD Zuid-Limburg (GGD ZL), explains the impact of these regional characteristics and differences on the ICT of a GGD organisation. “Our organisation serves 610,000 residents in both rural and urban areas – the City of Maastricht is part of the operating area – and this is reflected in the diversity of our services.”
Firstly, a city calls for different services than rural areas, such as the GGD’s fallback role for people who do not ask for care or help themselves but need it. That issue is often more significant in cities than in rural municipalities. The differences are also reflected in the way vaccination centres were set up during the COVID-19 pandemic: small-scale and dense, or restricted and large-scale? Stijns: “In addition, GGD ZL is what is called a broad GGD, as it also performs tasks other than those associated with the Public Health Act. For example, we have our own ambulance service and the Veilig Thuis reporting centre for domestic violence and child abuse is also part of our work package, as is the Forensic Medicine service. The impact they have on our ICT landscape is huge.”
GGD ZL has approximately 110 applications under management. The entire system operates in accordance with the NEN 7510 standard for medical data security. But only a small percentage of all applications are generic or follow a national standard, resulting in significant fragmentation when it comes to providers and how applications are built. Furthermore, several chain partners, just like the GGDs, have their own national policies with decentralised customisation, e.g. Veilig Thuis Nederland determines policy, but local Veilig Thuis organisations opt for their own solutions.
Another specific example of this fragmentation: in the healthcare domain alone, GGD ZL has to deal with three different systems for secure e-mailing. Stijns: “We have to create integrations, so that those mail applications can be used with one another. If a supply chain partner decides to switch to a different tool, it remains to be seen how that fits in with the rest of our landscape.”
To what extent is this fragmentation an obstacle when formulating an in-house IT strategy? Stijns explains: “Strategic choices such as 'cloud first' or 'open source' are not so difficult. The devil is more in the details. The autonomy of local organisations mostly leads to problems if you want to collaborate or obtain information at national level.” Stijns gives the definition of a waiting list as an example. This is interpreted and processed differently in systems by various bodies. And GGDs use different tools to assess children’s mental health, for example. “Particularly at national level, you are impeded by the individual views of all these separate organisations.”
From implementation to governance
Local autonomy also has an advantage: This meant that GGD ZL was able to decide around 2011 to largely but gradually outsource IT. “Our IT department was looking for a way to ease pressure, as managing everything ourselves was becoming increasingly complicated. With a view to the future, IT was designated as a non-core activity”, according to Stijns. In 2012, a tender was put out for the data centre and infrastructure and the majority of the applications. GGD ZL opted for Open Line as its IT partner. In the second tender in 2018, the scope focused on increasing the SaaS character of applications, and outsourcing both connectivity and the first-line service desk.
In doing so, GGD ZL made the switch from implementation to management. According to Stijns, this involves the need to retain in-house expertise regarding architecture. “This is essential to understand what is happening with your IT landscape, so that you can play your management role to the full. You need to keep up with all developments – especially in the field of security and SaaS – in order to be a knowledgeable Open Line discussion partner.” Stijns therefore considers his own organisation to be a ‘critical client’.
‘Increasing the SaaS character’
When the SaaS character of applications is increased, conditions are imposed on management and security – the security aspect has also been entrusted to Open Line in the form of prevention, management and recovery. However, other factors also play a role. “In the case of some applications, for example, support from the provider is poorly organised. That may be a reason to part ways rather moving towards increasing the SaaS character. We work closely with Open Line in making such decisions, but we ourselves take the lead.” In many cases, Stijns’ team also needs to get everyone on the same page internally. In the past, for example, managers have sometimes developed their own Excel lists or have commissioned applications. “These days, different requirements apply”, says Stijns. “Professionals should renew their applications in a timely manner, but preferably in consultation with ICT.”
In the case of COVID-19-related applications such as CoronIT and Coronamelder, GGD ZL is dealing primarily with national policy, which can also lead to local bottlenecks. Possibly because solutions do not align properly, or need to be rolled out at a very fast pace. Or because it has been decided to print out data while continuing to work digitally. “Then you simply have to adapt”, Stijns explains, “and that also demanded a lot from Open Line, particularly with regard to fighting COVID-19. The pandemic arrived and Open Line responded perfectly. We depend on national policies and national guidelines, both of which are not always predictable. In week 40, an additional location was needed, in week 42 it turned out there had to be six including 300 people, 300 accounts and quite a bit of infrastructure.” Stijns thinks it might have helped that Open Line is strongly embedded in the GGD ZL region, and that fact may be quite important in any case for a regional public service.
The dynamic surrounding COVID-19 has of course been felt by many organisations in the recent period. However, GGDs were permanently under the microscope during the COVID-19 pandemic. How significant was that dynamic? Most GGDs are not the only agency vaccinating. GGDs work closely with, for example, healthcare parties that carry out vaccinations: such as the nursing homes, care homes and domestic care (VVT) sector, GPs or mental health (GGZ) professionals. At policy level, instructions are issued by the National Institute for Public Health and the Environment (RIVM), the Dutch Ministry of Health, Welfare and Sport and the umbrella organisation of the 24 GGDs: GGD GHOR. As the GGDs were given a huge work package in a short time, each local organisation had to scale up across the board. Example: the separately established COVID-19 organisation of GGD Hollands Noorden grew by 700 new employees in less than a year; GGD ZL had an additional 1,200 employees on its books at the height of the pandemic. This is only possible if IT and HR work very closely together and if new tools such as a workforce management application can be rolled out quickly.
Open Line and GGD ZL already collaborated prior to the pandemic. What has this collaboration achieved so far? It's clear that there's a huge difference compared with the baseline situation some nine years ago. Stijns explains: “At that time, we had four system administrators each managing a rack of servers. If something failed somewhere, it often led to problems in the other three racks. Outsourcing has brought us uniformity and quality assurance and we see that reflected in a huge reduction in the number of Priority 1 incidents and far more stability. This ensures calm among the IT team and less hassle in operations. In addition, the details of security – prevention, management and recovery – have been structured together with Open Line. It is simply no longer possible to arrange security just on the basis of prevention. Monitoring is the responsibility of Open Line; recovery is also an essential component.”
A suitable partner
Stijns explains that GGD ZL deliberately opted for an IT service provider that was not unduly large. “This ensures you don’t have to deal with excessive differences between the levels of the organisation. In other words, in the event of escalation, you quickly arrive at the right level. That aspect is very well organised at Open Line. The service provision outside the formally specified service levels is also remarkable. Just referring them back to a contract is not what GGD ZL is looking for and they understand that. And we in turn do not then abuse the flexibility that is offered when required. We operate 24×7, so you benefit from formal arrangements, but the quality lies precisely in what is not in writing.”
About GGD Zuid-Limburg
The GGDs in the Netherlands are responsible for implementing the Dutch Public Health Act. They do so according to a regional organisational model, with the GGD Accident and Disaster Medical Relief Team (GHOR) as the umbrella association. They are funded by groups of municipalities, mainly because most municipalities are too small to implement this act individually. Only The Hague and Amsterdam have their own ‘urban GGD’. While most decision-making is takes place at the national level, it is also the policy that implementation is almost entirely decentralised. There are also major differences between GGDs, both in terms of geographical areas of operation and tasks.