Interview: Una O'Brien

When Una O’Brien (pictured above) joined the Department of Health in 1990, the NHS was about to undergo a major period of reforms. In her first couple of years with the department, GPs were given the option to control patient care budgets; hospitals and community service providers were allowed to become independent organisations; the hierarchy of NHS management was reformed and localised; and competition and choice were encouraged as the commissioning and provider sides of the service were split.

Now, as permanent secretary, O’Brien is overseeing another set of reforms (see below). GPs will join consortia and take control of much larger NHS budgets; all hospitals will become independent of the NHS structure; the hierarchy of NHS management will be overhauled and slimmed down; patient choice will be strengthened, and competition between providers encouraged. Health secretary Andrew Lansley has been keen to stress the evolutionary nature of current reforms, and although there are some notable new features – the role of local authorities, for example – they do seem to be the logical conclusion of those 1990s changes.

However, if this is an evolution, it’s amoeba to monkey rather than monkey to man. The Health and Social Care Bill is among the largest pieces of health legislation ever laid before Parliament – and its wholesale reforms come at a time when public services face unprecedented budget pressures. Well before the spending review, Sir David Nicholson – chief executive of the NHS – said that the health system would need to find £15-20bn in efficiency savings by April 2014.

The scale and speed of reform has attracted criticism, but for O’Brien the systemic and comprehensive nature of the reforms is a positive. One of the lessons she feels can be learnt from previous reform programmes – the NHS has undergone many, several of which she’s worked on – relates to the risks inherent in piecemeal change.

“Governments of the day have tended to reform one piece of the health landscape at a time,” she says. This means that “you’ve got some parts of the system that have changed and are working in a new way, and other parts are still working in an old way. That incompleteness leads to a less than optimal outcome. What this government’s aiming to do is to complete the reform programme, to see it through on each of the different dimensions.”

O’Brien has also learned that change takes time to bed in, and success is about remaining “true to our intention; persevering and retaining constancy of purpose”. She adds: “If I look back on those years in the mid 1990s, when the going got difficult, the reform programme was slowed – and on reflection, [success] really is about constancy of purpose and seeing things through.”

Aligning purposes
Reforming all parts of the NHS does present one challenge, Una acknowledges: that of ensuring that new organisations are part of a coherent whole. “As we’re changing a number of different organisations simultaneously there is the risk of discontinuities being introduced between organisations, so it really means that the relationships and the leadership comes to the fore more than ever.”

To help achieve this alignment, she says, leaders within the DH and the wider health system have agreed a set of principles and values which will guide decision-making about new organisations. Although there will be test and challenge between some of the new organisations, she is keen to ensure the reforms do not “create a set-up whereby these different national organisations are at loggerheads with each other or are caught up in territorial battles when, in fact, there’s a wider responsibility that we all carry for safe care of an increasing quality”.

Getting the leadership right across different organisations in the health system will be key to supporting this coherence, and the department is taking time to ensure its own non-executive board contains the right people. It currently has three non-execs, but has yet to appoint a lead non-exec – an unusual state of affairs, given that the lead is usually involved in appointing other board members. As the process of appointment is ongoing O’Brien can’t say much, but she mentions that she is also formulating other boards (such that of Monitor, whose new chair has just been appointed), and working to ensure the best skills mix of non-execs across the system.

O’Brien is working to effect these reforms – which the department estimates will cost £1.8bn – at a time when funding is stagnant; but when asked about this tension, she suggests that this sort of discussion is futile. The need for large savings was clear before the general election, she says, and “we would not have been able to reduce costs to that degree without reform of some sort, so I think the idea that we had an option for stasis versus reform is a false proposition. The key now is not to go back over that so much as to ask how the government’s agenda can best be deployed in aid of the efficiency savings that we have to make.”

Communicating purpose
The department must be persistent, she says, in communicating messages about the purpose of reforms. Public debate has so far focused largely on the structural changes; but these are, she emphasises, a means to an end rather than the final aim. The real goal is to empower patients, create a more flexible and responsive NHS, and introduce a system which is “as focused on health and maintaining people’s health in the community as it is on sickness”, she explains.

Improving people’s health; diagnosing illness sooner; giving patients greater control over their treatment; preventing unplanned admissions to hospital – all of these are positive end goals, but O’Brien acknowledges that it’s hard to focus on them when changing structures are endangering people’s jobs. “I absolutely understand that,” she says, “I think we’ve just got to be very clear, consistent and persistent in explaining the bigger purpose and also the need to reform the [health] system so that it can be [financially] sustainable.”

The NHS faces the twin pressures of demographic change – more people living for longer, but often with chronic health problems – and the rising cost of treatments. It must also adapt, she suggests, to take advantage of technologies which would improve care and help support the preventative, proactive elements of the NHS’s work.
“We need a more flexible, responsive, preventative NHS to be able to cope with that [agenda],” she says; one that can move quickly to adopt and spread innovation. “We know that the current system is slow at [spreading innovation] and part of the potential opportunity of these reforms is to be able to move to better for less more quickly. I think we need that dynamism.”

O’Brien must also communicate these end-goals to her own department – where engagement levels have dropped by five per cent since last year, according to the recently published People Survey results. She acknowledges this is a concern; though she says she does not rely solely on the survey results to gauge the mood of her team, also taking the time to meet staff face to face. “It’s very important to me that I have direct access to people and I’m picking up the mood, which is changing all the time,” she says.

“Those results tell a story of October [when the survey was conducted]: a story of uncertainty. I absolutely understand that and I know that in this series of complex changes, which affect all the people in health, what I need to do with David Nicholson throughout 2011 is progressively close down the uncertainty as we make more decisions about where an organisation’s going to be, what functions transfer, and what jobs are available to people. I am totally committed to doing that.” She adds that she is determined to show “that line of sight through to a better and a different future” for the department’s staff.

Public health
A large part of that future will be in protecting and promoting public health through a new organisation – Public Health England – which will be responsible for distributing around £4bn of funding through a ring-fenced grant to local authorities. It will also, she says, focus on providing evidence and analysis on “how to support people, as individuals and communities, to stay as well as possible”.

But better public health cannot be something the department drives alone, and collaboration is an important part of O’Brien’s vision. “Our ambition is that every department needs to be a department for the public’s health,” she says, adding that on the flipside she wants her department to become “a better neighbour in Whitehall”, bringing the agendas of other departments into its work more systematically.

She mentions three ways in which the department can promote its public health agenda. The first will be through spreading evidence “about what affects people’s health and what drives illness in a population” – for example, through the evidence supplement published last year alongside the white paper on public health. Secondly, via the public health cabinet sub-committee, which Lansley chairs and which O’Brien describes as “a very vibrant and positive committee, both at official level and ministerial level”.

Finally, she is working closely with other perm secs. She has, for example, held a seminar with business perm sec Martin Donnelly for SCS in their two departments, focusing on key areas where the departments have a common agenda: developing skills for health, for example, or the role which the health department can play in contributing to economic growth. The department could be more “upfront” about these cross-cutting aspects of its work, says O’Brien, adding that she is excited about the department thinking more purposefully and working more systematically across Whitehall to support wider government agendas.

O’Brien is also building common agendas with the education and culture perm secs, but she points out that these aren’t the only departments with which the DH can work fruitfully. Rather, these relationships are about leading by example, with permanent secretaries modelling collaboration for their staff “and saying: ‘It’s good to form joint teams, it’s good to share expertise, it’s good to be clear about our common goals, so that we can make the best use of the resources where our departments intersect’.”

Skills and analysis
This vision of a more collaborative department, a more prominent Whitehall player, will require DH staff to develop new skills. O’Brien is “a great believer in building the skills of the people we’ve got”, calling it “fantasy” that outside the civil service there is “another set of people who can come in and do this work. We’ve got fantastically talented civil servants and one of the great things about the civil service is the capacity to learn, grow, and develop skills and flexibility”.

Two particular skills requirements she mentions are an improved ability to work more effectively with others – to listen and engage with other people’s agendas – and a strengthening of the “analytical base of our policymaking” by the application of academic disciplines such as behavioural psychology and social anthropology. These, she says, can “help us to understand where government can be most effective.”

This links back to the public health agenda, where the department will increasingly be working to change behaviour rather than deliver services. The topic was the subject of the Cabinet Office’s Behavioural Insights Team’s first report; and the department already has experience of trying to change behaviour through, for example, its Change4Life campaign. What have they learnt? That there’s a lot more to learn. “The evidence base for sustained behaviour change is patchy,” says O’Brien, adding that the department is keen to help build up that evidence base and, as with public health more generally, to “get better at evaluating evidence ourselves and sharing evidence across Whitehall”.

Accountability
Another challenge raised by the health reforms is the more complex nature of accountability in the remodelled NHS. The DH will retain ultimate financial accountability to Parliament for money voted to the health system, and the secretary of state will be accountable for the strategic direction of the NHS – but the bill gives many powers directly to the new organisations, which will then be accountable for their spending and progress against an outcomes framework developed by the department.
On paper the lines of accountability to Parliament are clearly planned. In practice, is it a concern to O’Brien that she retains ultimate responsibility for spending and achievement in a system over which she will have much less control?

“I think this is a more honest and realistic assessment of what the accountability is,” she says. “I believe – and my own experience of working in the NHS completely reinforces this – that accountability needs to be as close as possible to the patient and to the population that the health service serves.” Placing responsibility inside provider organisations gets it “into the place where it actually bites”, she says, and is a journey which the previous government began in 2002 when it introduced foundation trusts – which are already individually accountable to Parliament. “It’s not about politics,” says O’Brien. “It’s about the reality of how care is delivered.”

This does not absolve the permanent secretary, of course, of all accountability for the health system. She shares “with the government of the day” a clear accountability for “the overall design and architecture of the system” and “whether that system is sufficiently well-designed, well-implemented and capable of doing its job; and that we have a process of checking that it does its job”.

On O’Brien’s desk the day we meet is an ombudsman’s report into care of the elderly. It has clearly affected her emotionally as well as professionally: when she mentions it, one senses just how deeply she feels the responsibility to do a good job of designing and overseeing a reformed NHS – a system that must care for and protect people at some of their most vulnerable moments. O’Brien argues that wholesale reform offers an opportunity to rethink many organisations within the NHS, introducing the right governance and structures to improve healthcare for the long term. Whether these improvements materialise remains to be seen, but one cannot doubt O’Brien’s commitment to achieving them.

All change: reforms in a nutshell
The DH and ten strategic health authorities currently oversee both the commissioning of healthcare – through primary care trusts (PCTs) – and its provision through hospitals and some parts of PCTs. In the new system, commissioning will be delivered largely by GP consortia – which will have control of care budgets in their area – and overseen by the NHS Commissioning Board, to be established as a non-departmental public body by April 2012. All GPs will be required to join these consortia, though their size and governance arrangements will vary across the country.

Local authorities will appoint directors of public health, responsible for coordinating public health activities in the area. Health and Wellbeing Boards will be established in upper-tier local authorities to produce needs assessments and joint strategies for their communities, and to encourage partnership working. GP consortia will be expected to work closely with these boards to prepare commissioning plans each year. They will be able to commission care from ‘any willing provider’, and competition between all providers will be encouraged.

All hospital trusts will become foundation trusts by 2014, with financial and operational freedom from the NHS. Two regulators will oversee provider organisations: the Care Quality Commission, which licenses and monitors health and adult social care services in England; and Monitor, currently regulator of foundation trusts, which will become an economic regulator, setting prices and enforcing competition in the health service.

CV Highlights
1980    Graduates with a BA in Modern History from St Anne’s College, Oxford
1983    Wins a Kennedy Scholarship to Harvard University. O’Brien then spends her twenties doing a number of jobs which “effectively covered the ground that a fast-streamer might have covered”, she says – including working as a policy researcher for two frontbench MPs, undertaking postgraduate research in international relations, and spending three years working for London Lighthouse, a centre for people with AIDS and HIV
1990    Joins the Department of Health as a policy manager
1993    Becomes private secretary to the Minister of State for Health
1994    Principal private secretary to Brian Mawhinney as Secretary of State for Transport
1998    Moves to the Prime Minister’s Efficiency Unit as deputy director
1998    Serves as secretary to the inquiry into paediatric cardiac surgery in Bristol
2002    Seconded to the NHS as director of development and clinical governance, University College, London NHS Foundation Trust
2006    Returns to DH as director of supply-side reform
2007    Made director-general of policy and strategy directorate
2010    Becomes permanent secretary