Una O'Brien interview: the Department of Health permanent secretary on NHS finances, pay, and public health
Una O’Brien feels proud of what she’s achieved in five tough years as the Department of Health’s top civil servant. But what does being permanent secretary at DH mean in 2015, and how is O’Brien tackling the most pressing issues facing the NHS today – including the critical state of its finances? Jess Bowie meets her
On the day CSW meets the Department of Health’s permanent secretary Dame Una O’Brien, her colleague Simon Stevens, the head of NHS England, has declared that the health service must “put its own house in order”. Out with junk food outlets in hospitals, in with Zumba classes for doctors and nurses.
But DH, it seems, is already one step ahead. The department boasts its own gym and in O’Brien’s office a press officer serves us glasses of invigorating, calorie-free tap water. The permanent secretary even has a standing desk, where she does all her emails and phone calls – although thankfully we’re allowed to sit around a table. Still, if O’Brien has one complaint about her job it is that it’s too sedentary: her great passions in life are walking (she owns a Fitbit), and being among greenery. She indulged both over the summer, squeezing in a walking holiday in the Alps and a trip to see family in Ireland (which was “very green and very wet”).
Now, though, it’s back to business. It’s been five years since O’Brien became perm sec of DH – one of the most high-pressured civil service jobs in any era, even without the biggest shakeup of the NHS for a generation. Unsurprisingly, her first three years in the role were dominated by delivering Andrew Lansley’s controversial reforms and, indeed, making sure they were delivered safely. “And we did deliver them safely,” she says with pride.
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A different, if equally taxing, set of issues relating to safety, quality, complaints and whistleblowing have characterised the second part of her tenure. “By the time we get to 2013, there’s a lot of controversy about the performance of the Care Quality Commission; we have the Mid-Staffordshire public inquiry report [into the disastrous collapse in standards of care at that NHS Trust], and some very hard lessons that need to be learnt in every organisation. For the department, there were very specific lessons about our culture,” she says.
These lessons led O’Brien to make two “really big changes”. The first was overhauling the way the department deals with incoming correspondence – despite the existence of a separate NHS complaints system, DH still receives around 30,000 items of correspondence a year. These days, she says, when a member of the public writes to say they’re seeing something going wrong, officials have a “very clear protocol” for making sure the complaint is being addressed. The other major initiative O’Brien developed alongside health secretary Jeremy Hunt in the wake of Mid-Staffs has been the Connecting Programme, which allows DH staff to spend time on the clinical frontline. O’Brien says this is “having a radical effect on the culture of the organisation”, which is now far more engaged with the realities of the health service.
After all of the organisational changes O’Brien has seen in the past few years – including the creation of NHS England as a semi-independent arm’s-length body – what exactly is the role of the perm sec of DH in 2015, and how does it fit in with that of other health leaders?
“There are many debates about the role of the perm sec and the Department of Health in the new system,” she says. “But what I like to focus on are practical things: I see the job very straightforwardly as to take the agenda of the government, and of our secretary of state and his ministerial team, and to turn it into change to improve people’s lives.”
As for all those relationships at the top – with Hunt and Simon Stevens, for example – O’Brien paints a picture of a set of leaders who come together with a shared vision, and who can, when necessary, have very frank conversations. “There’s no question of having to triangulate relationships, or of formalities getting in the way,” she says, emphasising her point by gesturing to a room across the corridor which is “open 24/7” for ministers and other senior health leaders to meet and discuss the most pressing issues of the day.
One of those issues, presumably, is the parlous state of NHS finances. According to figures from Anita Charlesworth, chief economist at the Health Foundation, the provider sector ended 2014-15 with an accumulated deficit of £822m, and around half of all providers in deficit. This was despite the Treasury having provided an extra £250m in the Autumn Statement, and also transferring £650m from capital budgets to revenue. Nor are forecasts for this financial year any better: the NHS is on track to end 2015/16 with a deficit of at least £2bn.
Is there a credible plan for tackling some of those terrifying numbers? And what is O’Brien’s role in that?
“Well, I think that paints a very bleak picture, the way you’ve described it, and I think the important thing is to put it in perspective. The NHS has managed its way through the last five years exceptionally well, having coped with a historically low rate of increase. I mean, all credit to the government through difficult times for maintaining real terms increase, but equally, that real terms increase was historically at its lowest point ever, while the needs and expectations of the population continue to grow. So the first thing is to see the outcome from 14/15 in a proper perspective, rather than necessarily to – how shall I put it – feel that everything’s falling apart. Because it isn’t.”
She goes on to acknowledge, however, that “there are genuine pressures in the system this year,” and says she and colleagues work daily with the provider sector and the commissioning side to challenge those numbers and also to “ensure that all these cautious finance directors up and down the system are not holding back pockets of cash to handle unexpected circumstances”. She adds: “There is a huge amount of money out there in the system and our job is to make sure that it is all deployed in year, and not held back until it’s too late to spend it effectively.”
O’Brien and her colleagues have “a set of actions that relate to 15/16 which will be unrelenting”, including clamping down on the use of agency nurses (of whom more shortly) and introducing controls on executive pay. She also talks about the “really, really exciting work” being led by Lord Carter, who in June published his interim report into efficiency in NHS hospitals. Carter’s research has involved gathering comparative data of how money is spent by hospitals, and according to O’Brien enables DH “to challenge individual organisations to say: ‘Why is your nurse rostering system less comprehensive and fully utilised than the one in the hospital up the road, and why aren’t you doing something about that?’”
“For the first time ever, it’s not theoretical data, it’s real data, based on what people are actually doing. And we’re finding that rather than us trying to issue orders from the centre about what people need to do, trusts want to join this project,” she says, adding that Lord Carter’s work is a good example of the department’s coordinating role. “We create a framework where we do something that no one trust could do on its own, and therefore we enable them, through that comparative data, to improve their performance.”
Over the summer, Jeremy Hunt announced a crackdown on medical staffing agencies which, he said, were “quite simply ripping off the NHS”. Not long after, George Osborne gave us his Summer Budget, which promised to cap public sector pay rises at 1% for the next four years. Meanwhile, private sector pay is expected to climb by 3-4% by the end of the decade. Won’t this discrepancy provide a huge incentive for doctors and nurses to move out of the NHS and into agencies, thereby adding to the problem of hospitals having to pay over the odds for staff?
“I don’t think so,” O’Brien replies. “I think this is a wider question about the NHS. This is about the affordability of the public sector that we want to see, and judgements have to be made at a macro level in government about the scale of pay – whether it’s the civil service, schools, the NHS – as to what is affordable. And there is a genuine trade-off between pay increases and jobs.”
O’Brien adds that while she “cannot deny the challenge of the time we’re in”, the fact that employers are able to plan ahead and have that “line of sight” provided by the recent announcements on pay “does give them more flexibility than simply a harsh environment where you don’t know from one year to the next what’s coming.”
Prevention is better than cure, the old adage goes – and NHS leaders agree. In his Five Year Forward View last October, Simon Stevens even went so far as to say that “the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health”. Yet just nine months later, again during Osborne’s Summer Budget, it emerged that £200m had been cut from local authorities’ public health budgets – a move that the health think tank The King’s Fund condemned as the “falsest of false economies”. Did O’Brien and Hunt know these cuts were coming? Did they come to blows with the Treasury over them?
The DH perm sec’s reply is characteristically diplomatic.
“Look, the thing is, the ring-fenced public health grant to local authorities was a very significant innovation of the 2013 reforms and it’s true to say that after the election every department had to find a way to contribute towards the immediate savings. And while I think that that was difficult – and things done at short notice are always awkward to deal with – if you look at the bigger picture, actually we’ve made real strides in local authorities taking a leadership role on population health.
“We’ve moved directors of public health into local authorities, given local authorities dedicated responsibilities. And, by the way, that reduction did not affect any of the mandated core services that local authorities have to provide. So all of these things are difficult, and I wouldn’t deny that. At the same time, it’s important that we have a balanced view of things and I would like to spend at least as much time talking about what we do spend money on as what we’re having to reduce money on. And I think local authorities have done a fantastic job taking on that public health responsibility, and they’re being very innovative in their approach.”
Any conversation about public health must, of course, include obesity. O’Brien says work is “very well advanced” on the new cross-government obesity strategy, that the prime minister is personally committed to it, and that she expects it to be published “this financial year”. She also describes plans to set up a cross-government obesity unit, which she hopes will be located in her department.
When the last major document on obesity came out in 2011, many in the health sector were surprised to find that it made no mention of the potential role of tax and price in helping tackle the crisis. With the former Conservative health secretary Stephen Dorrell – and even leader writers in the Telegraph – now adding their voices to the clamour of health organisations calling for a sugar tax, can O’Brien hint whether discussions about tax and price will appear in any form in the next strategy?
“Well you know I’m going to say that fiscal policy is a matter for the chancellor, so I’m not going to comment on that at all,” she says with a smile. “But what I think is really exciting now is that we have got far more people engaged in thinking about what we need to do to change the obesogenic environment. I was only in Tesco yesterday evening and, interestingly, as you’re queueing to pay, there is now no chocolate, there’s no confectionery, it’s all health-related things. That visible change is absolutely fantastic, because wherever you go now, people are starting to realise that it’s bad for industry to have people die young and for people to be unhealthy. And I think there’s a broader social change underway.”
When asked if fear of a nanny-state has gone too far, and whether conversations are going on in the department about a more radical, less nudge-based approach, O’Brien replies that “we’re looking at every option in terms of what can be done”, adding: “We’ve already made big progress on voluntary labelling on front of packs”.
But obesity projections for Britain over the next 30 years still look dire. Are those traffic light systems – which some food suppliers haven’t even adopted – really having the required impact?
“I think they are having an impact. Nobody thought we would make as much progress with the Responsibility Deal [with industry] as we did, and I think these are broader political choices. Our job, and the job of Public Health England, is to put all the evidence in front of ministers. That’s then their job to make that choice between setting a rule – whether it’s around the amount of fat or sugar in food – or allowing consumers to make a choice for themselves. And I think that’s ultimately where the partnership between the civil service and politicians is at its best.”
O’Brien has always been vocal about the barriers facing women who want to progress in the civil service. At last year’s Women Into Leadership event – run by CSW’s parent company Dods – she spoke about a less-discussed social norm that can hamper equality of opportunity: the fact that caring for elderly parents with long-term illnesses often falls on middle-aged women, not their male counterparts.
“Well, I think we’re doing something, but we could do more,” she says, when asked what Whitehall is doing to support women in this situation. “What’s happened in society in general, and the civil service as well, is we’ve got better and better at supporting people who are caring for very young children. We’ve extended the formal offer for male employees as well, and we’ve actually got a number of male employees who’ve gone part time or taken parental leave, which is great. What we’re not so good at is a constructed offer for people caring for elderly relatives. I think the civil service is better than a lot of employers, but this will be a need all of us are going to have to address in the future.”
Unfortunately, the issue is very close to home for O’Brien.
“Very sadly my own mother passed away this June. She was 93. I had incredible support, and we try in the Department of Health, where people are facing an end of life situation in their family, or they’re caring for someone whose health is declining, to be as adaptable as possible. So all of these options around job-sharing, part-time working, unpaid leave – we try to make available to people who are facing those situations, too.”
The discovery of O’Brien’s recent bereavement casts a new light on an earlier part of our conversation about her favourite authors: she said she was currently reading Clive James – much of whose recent work focuses on illness and mortality.
“It’s an incredibly poignant journey that he’s on, because he’s aware that he’s got a terminal illness and he’s writing about it. I’m very touched by the experience that he’s going through, and I think there’s something universal that he’s expressing through that experience which is very meaningful to all of us.”
It’s hard to think of many people who could handle such reading matter having just lost a parent. But perhaps O’Brien’s reading habits are unsurprising for someone whose professional life demands both grit and compassion – not to mention the ability to think philosophically about matters of life and death every day. At one point during the interview, O’Brien says that when she and CSW’s other cover star, the chief medical officer Dame Sally Davies, arrived in their current roles in 2010, they decided they weren’t going to “make a thing” about the fact that they were both women. And indeed, they have hardly spoken about it.
“But here we are five years later, and I think now is the time to speak about it, because now we actually stand on our record,” she says. “And it’s a record of delivery and it’s a record of leadership. I think what we’ve shown is that women are not a soft touch at the top of an organisation. They can do massive, difficult things and remain calm, focused and resilient.”
Social care and the new minimum wage
“Well, I mean the announcement [of a mandatory £9 National Living Wage by 2020] is still relatively recent, and I think that different players in that industry are working through the implications. We’re hearing the retail sector, for example, are currently considering the implications for them, and I think it’s too early to say really what the consequences will be. What I do want to say, though, is that anything we can do that will raise the incentive for good people to come forward and work in the care sector will only be a good thing for us as a society. It’s really important that that work is given a higher status and greater value. These are really, really difficult jobs and I think if we can find a way to ensure that that policy is delivered in the care sector, it will be to our social benefit. But it’s really early days and I don’t think we fully understand yet – across a number of different parts of our economy – how that policy will be delivered in practice.”
Dame Sally Davies
“The reason it works between us is we have a good understanding of, and respect for, what the other can do. Our roles are quite distinct: mine is running the department, supporting ministers across the entirety of their agenda and liaising across the arm’s-length bodies; Sally’s is a leadership role in the medical profession and the chief health adviser to the government. We’ve tried always to look for the synergies between our roles, and I’ve done my best to back Sally and give her the freedom to take the issues forward as she’s discovered them. The complementarity is that Sally supports me in the running of the department. I think over the last five years we’ve brought a set of values to bear about how you lead which isn’t competitive but is mutually supportive and collaborative. If we’ve got differences, we’ll have a conversation – we don’t run agendas behind the scenes. We’ve both come up through quite tough environments, Sally’s has been clinical, NHS, research; mine’s been management of the civil service. We’ve both learnt that those competitive behaviours cause a lot of toxic relationships at work which are not health enhancing. So I think all of that is behind the way we’ve set out to do things.”