Former Department of Health permanent secretary Dame Una O’Brien and the DH's current deputy director of legislation and policy reflect on the lessons from a series of seminars drawing on insights from past healthcare leaders and those working on the innovations of the future
“Those who do not remember the past are destined to repeat it.” This aphorism from the philosopher and poet George Santayana was the inspiration for a series of seminars marking the end of Una O’Brien’s tenure as permanent secretary at the Department of Health.
Santayana’s words, later paraphrased by Winston Churchill, are especially true of NHS reorganisations – repeated attempts to find a perfect configuration which does not exist. Yet while policy can be cyclical, we also wanted to look forward to some of the exciting innovations likely in the health arena over the next decade.
New developments such as genomic sequencing, wearable sensors and big data are transforming healthcare possibilities. But how can civil servants make future-proof policy if they are unaware of the latest technological developments in their area of expertise?
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The seminars, held in March and April, were attended by a wide range of civil servants from DH and across Whitehall. Speakers emphasised that some seemingly new phenomena have been around for many years.
Twenty-four-hour news cycles were in place in 1997 when Alan Milburn (pictured below), health secretary from 1999 to 2003, first learned of his appointment to be a junior health minister via Ceefax. Stephen Dorrell, health secretary from 1995 to 1997, pointed out that as early as 1955 the Guillebaud Report had set out the impacts of ageing, technology and rising expectations on the NHS. On the other hand, some occurrences that were commonplace in the past now seem inconceivable, such as Ken Clarke, health secretary from 1988 to 1990, smoking in meetings with the chief medical officer.
The growth of measurement was an enduring theme. Sir Hugh Taylor, permanent secretary at the Department of Health from 2006 to 2010, remarked how in 1998 almost nothing in the NHS was measured, just money and the size of waiting lists. Under Alan Milburn, the Labour administration realised that the size of the waiting list was meaningless, what actually mattered was waiting times – how long it took patients to get treatment.
Duncan Selbie, director general of programmes and performance for the NHS from 2003 to 2007 and Paul Corrigan, a special adviser to Alan Milburn, recalled how a powerful political pledge was made to reduce waiting times from over 18 months to six months. The rigorous use of data established where change was needed, and created a competitive environment where hospitals did not want to lose “their” patients, so sweated their assets. Six months was achieved and then waiting times were reduced to a maximum of 18 weeks, effectively ending waiting for treatment as a political topic.
We have gone from being data poor to data rich, which is only going to increase as genomic sequencing gives us vast amounts of information on how individuals will react to specific treatments, while wearable technology will provide real-time data on people’s health.
Geoff Mulgan, chief executive of the innovation charity Nesta, emphasised that the challenge is to overcome concerns about individual patient information to allow pseudonymised data to be organised as a “health knowledge commons”, namely an open and accessible system of information. Innovators can then bring data together in new ways to create insight and discover patterns. This might allow disruptive innovators in health comparable to the effect of Uber in the taxi industry and Airbnb in the hotel sector.
"In the 1980s, it was very difficult for the department to get a slot in the legislative programme"
There is also the potential to tap into multidisciplinary care teams of engineers, computer scientists, clinicians and, crucially, patients. For it is patients who are most expert in their own care and should, wherever possible, take the lead supported by the complementary skills of professionals. This would be a truly personalised medicine.
The prominence of health was much discussed. In 1962, as a new Fast Streamer Sir Graham Hart asked to be placed at the Department of Health – where he would eventually serve as perm sec from 1992 to 1997. He was rung up by an incredulous HR official, to check he had not made an error. No one at the time ever asked to go to Health, then a political backwater.
In the 1980s, it was very difficult for the department to get a slot in the legislative programme to create the NHS Management Board, the first attempt to make the running of the NHS less political. Now, after the tortuous progress of the 2012 Health and Social Care Act – the most recent attempt to set the NHS free from political control – legislation on the structure of the NHS is once again viewed with concern by government, not because it is considered insignificant, but because it is politically controversial.
It wasn’t until the 1990s that health really shot to the top of the political agenda. Participants disagreed whether it was 1992 or 1997 when health was first really significant at general election time, but since the 1990s it has rarely been out of the spotlight. This suggests that successive post-holders have found it difficult to keep health out of the news, despite that being, according to Stephen Dorrell, the PM’s top requirement of the secretary of state for health.
"Alan Milburn described how, rather than getting a hose to douse the fire of a struggling NHS, he got a flamethrower"
Obviously some, such as Milburn, have not tried. He described how, rather than getting a hose to douse the fire of a struggling NHS, he got a flamethrower. He used articles such as that by Lord Winston suggesting the NHS was worse than Poland’s healthcare system to create a consensus that change was needed and more money had to be found. This enabled him to get usually critical stakeholders such as Unison and the British Medical Association to sign up to the NHS Plan, which set out significant improvements in staffing; increased use of the private sector; reductions in waiting times; and the establishment of national standards.
In the context of difficult financial times and with the backdrop of the junior doctors’ strike, the seminars struck a note of optimism. Lord Darzi, director of the Institute of Global Health Innovation at Imperial College London, and Dame Sally Davies, chief medical officer for England, highlighted the fantastic health research going on in the UK, supported by the effective funding and governance of the National Institute for Healthcare Research.
World-leading institutions like Moorfields Eye Hospital are using stem cells to treat blindness, while the project to map 100,000 genomes will provide new insight into causes of cancer and rare diseases. Mulgan contrasted this evidence-based clinical innovation with the relative lack of rigorous policy experimentation. Current initiatives such as the New Care Models programme are addressing this, but ultimately more of a start-up risk-taking mindset will be needed in healthcare to produce truly innovative solutions.
"Sometimes 'top-down' can work. The progress on tackling waiting times showed how it is possible to mobilise the NHS to achieve something remarkable"
Sometimes “top-down” can work. The progress on tackling waiting times showed how it is possible to mobilise the NHS (described by John Reid, health secretary from 2003 to 2005, as “the world’s biggest army for good”) to achieve something remarkable. Public servants came to work to make a difference, and with clear direction, backed up by a strong moral case, great changes happened.
Other policy successes identified were the National Service Frameworks, establishing clear best practice approaches for health problems like cancer and stroke, and the creation of the National Institute for Health and Clinical Excellence (NICE), making rigorous decisions on the funding of new health treatments. There was a sense that the department could celebrate some real achievements over the last 20 years.
And what of the Department of Health of the future? Politicians and former officials were united in highlighting the department’s people as its greatest asset. Taylor spoke of the need to “protect, guard and nurture talent.” Milburn emphasised the importance of social mobility and ensuring that talent came from all backgrounds, something to which he saw real commitment from minister for the Cabinet Office Matt Hancock and cabinet secretary Sir Jeremy Heywood.
Maintaining morale and helping talent flourish will be a challenge in the midst of significant reductions in administrative budgets, but with health firmly established as a top governmental responsibility, it will be vital that the department has the best possible civil servants to meet challenges and exploit opportunities. Hopefully this seminar series has played a small part in providing useful context and raising capability.