Dr Jenny Harries became UKHSA's first chief executive, after being an integral part of the government’s response to Covid-19 as deputy chief medical officer. She shares the experience

When Jenny Harries became England’s deputy chief medical officer in 2019, she expected it to be less dramatic than her previous jobs. As deputy medical director of Public Health England, she had worked on the government’s response to the West African Ebola outbreak, Zika and the Novichok poisonings in Salisbury. Her new role was to focus on tobacco control, health promotion and physical activity.

“I did say to somebody, just before I moved into the role, ‘Well, you can have too much excitement on this health protection stuff. I think perhaps I’m going to do something on a wider public health basis,’” she recalls. 

She was soon at the centre of the response to Covid-19, alongside chief medical officer Chris Whitty and deputy Jonathan Van Tam – becoming instantly recognisable as she sought to inform the nation about the pandemic’s development. “When I came into the Department of Health, I knew some people, but I wasn’t part of the system. And as soon as I appeared on the No.10 platform for one media briefing, everybody knew me. No longer was I a stranger anywhere in the nation,” she says. “And people just welcomed me. In many ways, it’s been personally and professionally really valuable. I just feel very privileged.”

“I did say, ‘Well, you can have too much excitement on this health protection stuff. I think I’m going to do something on a wider public health basis'"

She notes that with her experience as a former public health director, Whitty’s expertise in infectious diseases and Van Tam’s in emerging viruses and immunisation, “if you’d planned to put a senior professional team together, you probably couldn’t have done much better”.

Her experience in that role was so profound that she has since decided to leave that expert unit for the UK Health Security Agency – formed in April out of Public Health England and NHS Test and Trace – where she is continuing to tackle the threat of coronavirus.

Reflecting on her time as DCMO, Harries says: “It wasn’t always smooth. And it’s been very tiring. But it has really reinforced to me something about the civil service.” Joining the civil service quite late in her career, she “found it a really exciting place to be, you have very bright people... just moving mountains at national and local level to get things done.”

CSW asks if it was ever difficult to advise ministers on the Covid response but never to get the final say about how best to protect the public. “Life can be frustrating in general at times and I’m a born optimist, so I tend not to let that bother me,” she says. “What bothers me is if I haven’t done my job properly. I don’t mind if somebody else makes a different decision if I’ve communicated the risk or the opportunity as well as I can, based on evidence and good science.”

Being a director of public health was good training for that, she says, describing local authorities as a “microcosm” of the national system. “When I moved into the deputy chief medical officer role, one of my old director of public health colleagues said ‘you’re going to the dark side’, as if I couldn’t hold my own professional opinion and draw a line. I personally have never had to step over my line... there will always be different views. And that’s good. I’d rather live in a democracy and have my voice heard and for somebody to make a decision that may not be quite the one I would have made. One of the privileges of the job is to sit around the very top tables and provide that input – and almost invariably, it is accepted and acknowledged and acted upon. I haven’t felt through the pandemic that that has been problematic.”

Nevertheless, with the benefit of hindsight, is there anything Harries wishes had been done differently – even in those areas that have attracted the most intense criticism, such as care homes and the seemingly haphazard approach to enforcing lockdown measures?

Harries says next year’s public inquiry will answer those questions. “I think people have made their very best endeavours, using the information that they had at the time,” she adds. “We now know of growing evidence about this particular virus, for example, about the importance of aerosol transmission, or the proportion of cases which are asymptomatic – these are quite critical. But they weren’t evident at the start.”

'Extremely different cultures'

In bringing together PHE and NHS Test and Trace – and with it the Joint Biosecurity Centre – under UKHSA, Harries has the challenge of marrying two organisations with “extremely different cultures and different skill sets”, she says.

“We have Public Health England, who have very specialised individuals in health protection, based on science – and quite a small organisation comparatively, in pandemic terms,” she says. PHE brings with it expertise in immunisation, vaccination, virology and rare infectious diseases and genomics, among many other things.

“Then there is test and trace, which has been set up very rapidly to deliver on a single topic – on Covid... so we have one [organisation] which principally started and framed in the public sector with civil servants; the other one, of necessity, bringing in a large number of individuals with different skill sets which the civil service doesn’t tend to have.”

She says when she became chief exec, she spent time on the test and trace side to familiarise herself with all of its components. “I realised that you needed a dictionary to translate between the two systems. ‘End-to-end customer services’ would be an entirely appropriate thing to say in test and trace. And it has a ‘required business direction’ to its ‘product delivery’. If you’re sitting in public health, talking about ‘customers’ can be quite a challenging concept, because for public health physicians and professionals, the population is their patient, effectively, and you wouldn’t normally talk to your patient as a customer.”

“I realised that you needed a dictionary to translate between the two systems. In public health, talking about ‘customers’ can be quite a challenging concept”

With the new agency expected to be fully up and running and staffed by October, Harries is integrating the two on an incredibly tight timeline – the transition schedule, which includes formal consultations, leaves just four days spare if everything goes to plan. “So it’s very challenging – a very tight timescale, different cultures, different languages, but it’s all on track.”

While the organisation’s initial emphasis is on getting through the pandemic, Harries says its long-term focus will be much broader. UKHSA will use the same skills needed to respond to Covid, on a smaller scale, to respond to the “10,000 or so other health protection incidents that go on each year”.

“So I think we will go back gradually to what you might call bread-and-butter health protection, but with different modes and models to be able to step up really quickly with better and clearer connections to key partners,” she says. Those partners will include NHS bodies, business and local authorities – who were angered early in the pandemic by poor data sharing and communication about the pandemic response.

Getting “the right level of national regional and local engagement” is important, Harries says. Her own CV includes stints as a director of public health in both Wales and England, and she says she often puts herself back in those shoes: “What would this look like? What would I want central government to do? How would I want all of the different parts of the civil service to work to help me tackle the problem for my population?”

An important facet of what Harries calls “bread-and-butter health protection” is addressing inequalities. She has appointed a director of inequalities to challenge the executive team to look at all of its data to ensure its decisions consider their impact on potentially disadvantaged groups.

“People tend to think it doesn’t fit with health protection and health security anymore – that bit goes to health promotion,” she says. “For me, it is actually a critical component.”

UKHSA’s work will also include addressing the threat of antimicrobial resistance – which has led to the development of multi-drug-resistant diseases like TB – and the global One Health agenda, which links up policy, legislation and research to address challenges such as food safety and zoonotic diseases that spread between animals and humans.

“Before the pandemic, I don’t think people quite understood how an infectious disease could cause such turmoil in communities and in the economics of the nation and the globe. But now it is very evident”

Through tackling these threats, UKHSA will form part of the UK’s critical security infrastructure. “I think people understand that now,” Harries says. “Before the pandemic, I don’t think people quite understood how an infectious disease could cause such turmoil in communities and in the economics of the nation and the globe. But now it is very evident to them.”

The pandemic transformed people’s attitudes towards infectious diseases in several ways, she says. “Nowadays, it’s not unexpected if a test swab kit pops through your letterbox – you put it back in the post box and you have a message come up on your mobile phone. That sort of skill set was not part of PHE before, and yet it potentially has huge opportunities for other infectious diseases – particularly flu, for example.”

Does that mean the UK could one day have a test and trace operation for flu outbreaks? She says there is certainly an opportunity to build on existing surveillance systems that instruct the health service to start using antivirals each year when flu cases rise.

“What we have learned through the pandemic is a very different way to do that – potentially helping keep patients away from primary care if they don’t need to be there,” Harries says. “[It could even have] positive impacts on reducing the use of antibiotics when we don’t need them because people understand what the infection is that they have and how to manage it.”

She points out that there have been many smaller-scale operations to track and control outbreaks of diseases that have appeared in the UK, such as monkeypox and MERS. “We haven’t had large outbreaks [of those diseases] because they’ve had a good amount of health protection control. But I think what we’ve got now is a different mindset as well as a different potential opportunity in terms of infrastructure,” she says. “And there is a lot of work currently considering how we can best utilise the testing capacity that we have in different ways to get better outcomes and more focused interventions.”

A remit letter sent to Harries by innovation minister Lord Bethell in July, setting out the new agency’s priorities, said it must “continue and further develop surveillance and modelling capabilities and research-led, evidence-gathering activities to inform action at national and local level”. It is also expected to use “world-class data and analytical techniques” to underpin its work on disease prevention and response.

The Joint Biosecurity Centre, which was set up last year, is the “beating data heart of the new organisation”, Harries says. “There are very few sources of data which actually can’t be useful,” she says, adding that the new organisation gives health officials the opportunity to “think differently and really broadly”. Part of that means moving towards more open data – working closely with academia and making research public.

Harries adds that the UKHSA will “absolutely” continue using partnerships to enhance its work. Last year, for example, the JBC worked with The Alan Turing Institute and the Royal Statistical Society, and drew on mobile phone data from a telecoms company tracking footfall and social distancing at shopping hotspots.

Harries admits that people are wary of how their data is being used, and trust is “quite difficult to establish”. She says people have welcomed the visibility of government’s top scientists and public health professionals – among them Whitty, herself and chief scientific adviser Sir Patrick Vallance – during the pandemic, and the health security agency aims to “continue those conversations with the public, and try and maintain a trusted relationship”.

The organisation must also be mindful about which data it collects, to ensure it gets a “true picture” of what’s going on, Harries adds. If people can’t access websites to report test results in a disease outbreak, for example, there is a risk they will be overlooked.

But the public’s perception of an organisation is not only affected by how it acts. When Hancock scrapped PHE last year, the public health body appeared to make a convenient scapegoat for the coronavirus response’s failings. Does Harries have any concerns that similar criticism could undermine UKHSA’s authority? She replies by saying the prime minister himself provided the remit for the new organisation, showing the “level of support behind it”.

“I don’t think that needs debate,” she says, adding that the agency is already a “key component of discussions” with government departments about policy and other decisions. She adds that the public has recognised “just how much critical work has been done by Public Health England through the pandemic”. On test and trace, vaccine effectiveness and genomics, “there are huge areas where Public Health England expertise has been included”.

“And that is recognised by many other government departments, whether it be the Department for Business, Energy and Industrial Strategy, whether it be the Department for Education – right across government... I think there is a strong recognition of skill sets which are in very short supply. And one of the critical components when we build a new organisation is to strengthen those and create very strong succession planning, so that the country has a cadre of specialists going forward.”

Her comments echo those of civil service leaders who have stressed the need to bolster skills internally and decrease the need for external consultants.

UKHSA can expect to come under scrutiny in this area – in January, the National Audit Office described NHS Test and Trace as “heavily reliant” on consultants, and its then-head Dido Harding said it had around 900 Deloitte consultants earning at least £1,000.

Harries says her agency is “not looking to be reliant on consultants in any shape or form where it doesn’t need to be”, and has a plan to “very rapidly ramp down” its use of consulting firms. “Most colleagues across the civil service would recognise that there is a time and place for using consultants in most parts of the public sector, but that’s not how you normally run your organisation,” she says.

But she notes that Harding was building “very, very rapidly – literally on a day-by-day basis – a huge startup organisation from scratch”. She adds: “There are a number of things which we have learned from this that will be good for the civil service to think through. One is about the speed of onboarding individuals... I think that’s important for preparedness for emergency response going forward. We do it well, but at this scale it’s quite challenging.”

Meanwhile, UKHSA must work to address particular skills gaps in data science and data infrastructure, she says. That means not just recruiting talented experts in their fields, but training them up: “It should be, in my mind, that you should pass through the doors of the health security agency in the UK to earn your stripes to work wherever you are... that might be in data science, virology, communications, public and health protection issues or health behaviours.”

Harries also wants to beef up areas of health protection expertise where she says the UK has “fairly minimal capacity at the moment”: entomology, including mosquito-borne disease; climate change; chemical response; radiation; nuclear response. She says while health-protection bodies have some capacity to respond to those threats, “they’ve been the poor cousin, almost, to infectious disease”. 

'A degree of horror'

Perhaps the colleague who Harries once told she could have too much excitement in a public health job might wonder what convinced her to take on such a huge challenge.

Again, she insists working on the pandemic response was a “privilege”. And there’s no doubt her career has prepared her for some of the crises she will face. Asked what it’s like to be suddenly faced with the news that a rare disease has broken out in the UK, Harries admits there are some that “fill you with a degree of horror”.

“One of the interesting ones was monkeypox. We had the first cases a few years ago, we’d never had it in the UK before so it meant that we didn’t have any guidance.” Experts were called and it was a “learning curve, right across government, across some of our health protection teams as well”.

“I always look calm. I don’t necessarily feel that way. I’m just as human underneath"

“I think that the most challenging one was Novichok. It’s one which I think none of us would have anticipated happening in a small market town in the south of England – and with such significant consequences for the individuals involved, and the communities. Also because it required extremely close working with colleagues from security forces, which is another good reason why the health security agency will be part of that structure as we go forward.”

CSW wonders if being a physician has given her practice at remaining calm in fraught circumstances. She laughs. “I always look calm. I don’t necessarily feel that way. I’m just as human underneath. And I think one of the issues for managing incidents or responding is knowing your own resilience levels – I’ve had quite a lot of practice on that.” 

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