Una O’Brien, permanent secretary, UK Department of Health: Exclusive Interview
All healthcare is local, says Una O’Brien – but we need international collaboration to realise the potential of digital technologies, and to tackle the growing host of global health challenges
In some parts of the world, says Una O’Brien, digital technologies are offering completely new health services – radically improving outcomes in areas where traditional healthcare systems are sparse or ageing. In East Africa, she notes, “new developments enable people to take a picture of their eye [on a smartphone] and email it, and then they can diagnose diseases like glaucoma much earlier”. On a recent trip to India, she learned how “apps are being used for diagnosis and to bypass some of the institutions, improving access to healthcare”. And there are similar opportunities in the developed world, she believes: in the UK, the Department of Health’s (DH’s) permanent secretary argues, “we’ve got to leapfrog a generation of technologies, and really get the NHS and our health and care system to go digital.”
As O’Brien suggests, much of Britain’s healthcare system has so far missed these opportunities: it has excellent medical equipment, but its communications and digital technologies lag far behind those of the general population. “I was very struck by the fact that 84% of people in our country use the internet, and about 60% own a smartphone – but currently only 2% are able to use the internet for digital interactions with the health service,” she comments. “That’s really ripe for change.”
Previous efforts to modernise the NHS’s ICT haven’t always worked out. The Blair government’s dysfunctional National Programme for IT (NPfIT) was eventually scrapped – and much of its £10bn cost written off – by the coalition government elected in 2010. Consequently, many NHS communications – both between staff, and with patients – are stuck in a slow, costly and pre-digital age. “But there’s a public expectation that people see more accessible services that are up to speed with the sorts of changes happening in other parts of their lives,” says O’Brien. “We’ve got one of the highest levels of internet shopping in the world, and very high use of mobile devices – people are saying: ‘Why can’t my healthcare work for me in that way?’”
The NPfIT had great ambitions, but most people acknowledge that it also had two major weaknesses: it was pushing at the boundaries of current technologies; and it involved a vast, top-down project intended to get everyone plugged into a common system. Today’s approach, O’Brien explains, simply sets out “the essential standards about how data is packaged and recognised, enabling it to move as appropriate [around the NHS]; and linked to that – and fundamentally important – are up-to-date, trustworthy protocols around data security.” When data can be easily and safely shared, individual organisations may choose their own paths towards the common goals: digital access to health data for medics and patients; and the use of anonymised data in medical and public health research.
This security point is key – for as O’Brien acknowledges, people are concerned about how their medical data might be used. “We have to bring the public with us, and people have to see the benefits of their data being held electronically – not just for them personally, but for the population in general,” she says, pointing out that the health secretary has just asked psychiatrist and data expert Dame Fiona Caldicott to help design a solution. “People own their health data, and we’ve asked Dame Fiona to look at the choice architecture that people should have.”
Staff across the health service, she adds, “come to work every day with their own handheld devices and are looking for a better offer in their workplaces. So I don’t think there’s an issue with persuading people [to adopt digital technologies]: the challenge is to get organised sufficiently to deliver these changes and to direct the investment.”
O’Brien has spent the last 25 years helping Britain’s healthcare systems to get organised and direct investment, having joined DH as a policy manager back in 1990. “I’ve always had an interest in politics and government,” she recalls. “And in my late 20s I developed an interest in health and health policy.” The prompt was a very personal experience: “I had meningitis, and as I was recovering I thought to myself: ‘I don’t really like the career path I’m on.’ I got the chance to apply to join the civil service in my early 30s, and I’ve never looked back.”
Working in private offices, the Prime Minister’s Efficiency Unit, senior DH jobs and NHS management, O’Brien built up her expertise in healthcare. But to manage the DH, she says, “the most important thing is leadership skills, rather than deep knowledge of the sector.” Her experience in NHS delivery is really valuable, she adds, but “the industry of healthcare is vast, and a lifetime isn’t long enough to know it all. So you have to marshal the skills and experience of everyone, and not try to know it all yourself.”
The permanent secretary will need all those skills and experience to handle the three big challenges facing the UK’s healthcare systems.
The first is to improve prevention and early intervention: “To expand capacity outside hospitals and improve access to primary care, to community care, so we can stop people from getting ill in the first place.” The second is “to improve the quality of healthcare when you need it, so that wherever you are in the country you get the best available care, and so that performance is transparent”. And the third is to improve efficiency across the system – both helping NHS bodies to enjoy good management whilst minimising administrative costs, and enabling the DH to manage a protected healthcare budget effectively with a shrinking administrative budget.
As well as pursuing opportunities such as sharing back office services, “we have to look at ways of organising work that take down boundaries and interfaces, both between teams in an organisation, and between organisations,” O’Brien comments. “A huge amount of work is nugatory and tied up with people coordinating across boundaries.”
One flagship scheme to improve cross-boundary working – the £5.3bn Better Care Fund, designed to improve coordination between health and social care services – recently came under fire from the parliamentary Public Accounts Committee, which argued that the DH’s desire to extract short-term cash savings from the reforms had caused delays and damaged the project. “Inevitably you’re always trying to do two things simultaneously: to make the best use of the money you’ve got, and to invest for a better future,” O’Brien responds. “It’s inevitable that there are tensions between those two things, and we just have to face them as they come our way and remain absolutely focused on our medium- to long-term purpose. That’s what gives you your true North”.
A few years ago, there was little consensus among politicians and health professionals about where that true North lay; but today there is “an alignment of purpose across the leadership of the system and in what the government wants to achieve,” O’Brien argues. “For the first time I can remember for a very long time, we’ve got a synergy of ambition across the political and managerial leadership”.
Beyond the desire to improve prevention and service quality, there’s a consensus that “the focus is not on changing structures or organisations: it’s on what steps need to be taken to improve the pathway of care for patients,” she says. As former NHS chief executive David Nicholson told GGF recently, the NHS certainly needs a period of organisational stability: under the coalition government, it underwent a major structural reform designed to pass the main responsibility for commissioning health services from the regional and sub-regional levels to local collectives of GPs. “Over the last 20 years, we’ve tried different steps to pool problems regionally or nationally to sort them out at that level, and then give the work back to the locality,” comments O’Brien. “What we have now is another chapter in that story.” Inevitably, the reforms “disrupted pre-existing relationships, which now need to be re-formed” – but “everyone now understands that the only way to get sustainable change is for all partners in a healthcare system to work together in collaboration.”
The truth is, says O’Brien, every health system struggles to ensure that decisions are made at the appropriate level, so “let’s not reach for a once and for all answer”. Ultimately, “all healthcare is local: a highly personal encounter between a person in need and a health professional.” The task of the centre is to identify those issues which need national or regional action, and get things moving: for example, “right now, antimicrobial resistance [AMR] is a long-term problem that we’ll only deal with if we handle it nationally and internationally.”
AMR is “a huge issue”, says O’Brien: “There is a risk that my generation will all end up dying of horrible infections because we won’t have effective antibiotics.” The economist Jim O’Neil examined the issue for the government, she adds, and “warned that we could see an extra 10 million additional deaths per year by 2050 unless something is done – so he’s certainly painted a doomsday scenario associated with inaction.”
Coordinating international action, she explains, “will not be easy, because the way in which antibiotics are made and distributed varies from one country to the next.” The DH is examining “the new models of investment that would mobilise the pharma companies internationally to invest in new developments, and I think that’s going to be the next stage.”
O’Brien is “thrilled” that the World Health Organisation (WHO) recently passed a resolution on AMR; equally important is an international “determination to learn the lessons from what turns out to have been quite a slow identification of the scale of the Ebola outbreak [in West Africa], and to make sure we get organised internationally for that not to happen again”.
Involving troop deployments and NHS volunteers, the UK’s response to Ebola was “really well organised once we were clear how we were going to get on with it,” O’Brien believes. “But across the world, we recognise that we need a better early warning system”. DH has been working with WHO on how to “improve surveillance of infections as they enter the population”. Meanwhile, the UK is supporting the Fleming Fund to build labs and disease-surveillance systems in low-income countries, and establishing a “rapid response team made up of epidemiologists and infectious disease experts that can be deployed anywhere in the world within 48 hours, to help lead the response to a new disease outbreak.”
O’Brien clearly believes the WHO needs reform. “That organisation will be wanting to learn the lessons from Ebola; they’ve said that themselves,” she comments. “And we’re pleased that the UK chief medical officer, Dame Sally Davies, is now on its executive committee: she’ll bring our contribution to bear in supporting that organisation in its endeavours. It’s wonderful that we have an organisation bringing people together from all over the world to debate these issues, so we want to support it and help it improve in the way that it itself has set out as necessary.”
Whatever the WHO does, though, new communications technologies and forums are facilitating a global conversation between healthcare professionals. “The borders are coming down,” O’Brien comments. “The ubiquity of knowledge over the internet means that we can share information much more quickly – and we are absolutely in the market for ideas.”
The world’s medics and health managers certainly need that interchange – not only to learn about emerging medical techniques and technologies, but also to collaborate on tackling the many challenges shared by healthcare systems around the world. These days, says O’Brien, type 2 diabetes is becoming as serious a worry for China and Mexico as for the UK. All healthcare may be local, but the inspiration for how best to deliver it is as likely to be found in New York as in York; in Kerala as in Cambridge. “Sitting down with healthcare colleagues from different parts of the world can really help you understand what might be possible,” concludes O’Brien. “We’re all stealing each others’ ideas with pride, and making the most of them!”