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Article Article July 26th, 2016

Reform reflections: Dame Una O'Brien on improving the NHS

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Any health and care delivery change needs to be sensitive to local needs

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Getting people who understand project leadership and management is crucial

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Anyone wanting to get on in the civil service should 'focus on improving their skills'

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One of the few women ever to lead a government department in London and the first to take the helm at the Department of Health (DH), Una O'Brien could not be more different from the traditional Sir Humphrey image of a senior British civil servant. Hailing from an Irish background, growing up in inner-city Birmingham and still with strong links to the city, she brings a refreshing perspective to the challenges facing today's public services.

And approachable, down to earth and determined to get things done, O'Brien is not one for accepting the status quo - anything but. “In government, change is just the norm,” she points out. “Public services in the UK are changing and the pace of change is only going to intensify.  These changes are driven by public expectations, the need to adopt and apply new technology and the underlying crunch for efficiency.”

Stepping down, not stepping back

Dame Una retired from the civil service in April - “I'm now taking a few months off to improve my health and fitness and take some time to think about what to do next” - but she remains fully engaged on the ever-changing mosaic that is the British political scene. Looking back at her time in Whitehall, she pinpoints unrealistic timetables and lack of engagement with the people who will be affected by the policy in practice as principal barriers to successful delivery.

“We all need to be more realistic at the outset about the time and effort it takes to implement a big policy change and to be open about this,” she reflects. “Policy announcements and legislation are important in shaping expectations, but they are just the start of what can be a lengthy process.” This resonates particularly strongly at DH, the department that she headed up for the five years prior to her retirement.

“When it comes to health policy, close engagement between people who will have to deliver the change and those who are the intended beneficiaries at an early stage in the policy process, invariably leads to a better outcome,” she points out. “But how do civil servants do this when they can be remote from the frontline? At the Department of Health we introduced a ‘connecting' programme, partnering civil servants with health organisations across the country. This proved very effective in building networks between civil servants and health care practitioners, helping to improve the quality of policy making and implementation.  And we helped to found National Voices, a coalition of health and social care charities in England, so that there would be a stronger patient and citizen voice at the policy table.

Such programmes were all the more important at an organisation as complex and vital as DH. Although it is a traditional ministerial department, it is supported by 28 agencies public bodies and scientific advisory groups as it seeks to improve and protect the National Health Service (NHS) in England and public health across the UK.

“All health and care delivery takes place in a local context and the needs of populations differ around the country, so it is essential that change is sensitive to local needs,” says O'Brien. “But at the same time there has to be clear direction with as few priorities as possible so that everyone can rally around a common cause.  I think we broadly have that within this Parliament from the work being led by NHS England and NHS Improvement.”

Certainly, you're not going to find her talking down the health service any time soon, although she is clear about the need for improvement.

“I will always be a passionate advocate for the NHS and for a better NHS,” she says. “I've never envied but have certainly admired health care systems in other countries - such as those in Singapore and Australia. In the USA, there is high variability, but it is intriguing to see how the healthcare insurers are driving innovation in out-of-hospital care. And you can't fail to be impressed by the system of care for veterans and by world-class institutions like the Virginia Mason Institute in Oregon and the Mayo Clinic in Minnesota.

“At the moment I'm particularly interested in the way low and middle-income countries are ‘leap-frogging' conventional modes of healthcare delivery by embracing digital and hand-held technology as the first mode of contact. One example I heard of recently was the adaptation of smart phone cameras to take photographs of the back of the eye that in turn could then be assessed remotely to speed up diagnosis and treatment of eye disease.

Such examples show that the NHS can never afford to rest on its laurels. In such a vast system, there is always room for improvement, with O'Brien citing personalisation as a key area to focus on.

“In the future our NHS will need to be more community based with a wider range of services delivered through modern local health care centres, enabling people to get support more quickly and as we age, helping us to stay healthy for as long as possible,” she says. “Our specialist hospitals will right up there with the best in the world and we will be seeing the impact of genetic sequencing on diagnosis and prescribing. But resources will continue to be a major issue and it will be interesting to see where the debate goes about its funding in the post-Brexit economy given our rising expectations.”

Making NHS IT real

Another factor likely to play a huge part in shaping the future of the NHS is technology. But while medical advances continue to ricochet around the world, technology has also transformed the way the civil service as whole works and operates.

“Having been a civil servant for 25 years, I've seen more change than I care to remember,” smiles O'Brien. “The way civil servants work has been revolutionised by office based IT systems and nowadays we work in project groups, in open-plan offices and make wide use of digital media. But the real transformation is happening in interactions and transactions with us as citizens. I've been impressed, for example, with the continuous improvements made by HM Revenue and Customs (HMRC) in the electronic tax return.”

Government websites transformed markedly - particularly since the advent of the Government Digital Service headed by Mike Bracken. “Paying car tax has become dramatically easier as has renewing a passport,” she points out. “Government websites are better integrated and navigable thanks to recent changes. Of course there are big challenges ahead, not least the full implementation of Universal Credit that requires live interplay between HMRC and the Department for Work and Pensions systems.  And it is still early days in the use and deployment of big data, not least in ensuring that the public is on side.”

Asked whether she thinks government “gets” technology, she replies in the affirmative but adds that there remains more to do. “In my experience the civil service does understand intellectually and practically what technology can deliver, but its deployment in a public service context presents distinct challenges,” she says. “We are under much closer press and public scrutiny and that leads to low almost nil tolerance of mistakes and to risk aversion. Secondly, resources are tight, so we tend not to experiment but to wait until a technology is proven, meaning that it can feel we come late to the table.”

Onward and upward

As you'd expect, turning the page on her civil service career was not an easy decision - “it was just time to do something new” - but as O'Brien considers what will come next, she can reflect on a career in government that is by no means limited to health care. The lessons learned and experiences made will resonate in many a sector.

Take delivery and impact for example. “I learned that getting people with the right skills who understand project leadership, as well as project management, is crucial,” she says. “So, too, is identifying the necessary resources early - too often this only gets resolved when something goes wrong. And thirdly, maximising impact is about prioritising good quality risk management and using that perspective on managing people and the resources of the project.  But we are making good progress. The Major Project Leadership Academy - a joint project with the Saïd Business School in Oxford - aims to increase the calibre of our major project leaders and this focus on capability is bound to continue”.

Civil servants, she believes, as well as anyone considering a career in public service, should never stop learning. “With so much change, it can feel as though your career is out of control; my advice to any one wanting to get on in the civil service is do your current job really well and focus on improving your skills. That way you'll build the resilience and capability to take on the next challenge. “Changes will always be happening so this focus on doing well and never being satisfied with what you already know will mean that opportunities will open up for the future.”

And for those who may be thinking of applying to the civil service, her message is clear: go for it. “There is no finer way to use your time, skills and effort than serving your community and country,” she concludes. “I was very lucky working in DH because not only did I have the motivation of public service but also of improving people's health via the NHS. There are obviously many parts of the third sector and private sector that have a unifying purpose but I do think that the public sector has something very unique and powerful. It is a highly motivating and energising way to spend your working life.”


  • Googling better government. After helping rescue, Mikey Dickerson is now focusing on the US federal government's wider deployment of digital technology. He takes time out to tell Danny Werfel why it's no more business as usual
  • Cleared for take-off. When it comes to strengthening their health systems, emerging economies are not short of challenges, says BCG's Emre Ozcan. He explains why 'leapfrogging‘ represents the best way to deliver real change rapidly
  • City limits. How did a city mayor persuade his community to go on a diet? With the citizens of Oklahoma City now a million pounds lighter, Mick Cornett tells Adrian Brown about how he helped create a healthier future
  • Shaking up the UK's status quo. Few know more about the reality of life behind the UK's closed government doors than Francis Maude. Here, he tells us about the lessons gleaned from overseeing a radical programme of government reforms that continue to reverberate to this day
  • The God Revolution. Public impact is easier said than done, admits former UK Cabinet Secretary Lord Gus O'Donnell. Here, he tells Adrian Brown about his experiences as the UK's top public servant and why impact is rarely viewed as a key priority among policymakers.
  • Three golden rules on delivery. Ray Shostak has a crystal-clear understanding of how a government can increase its impact on delivery. Here, he sets out lessons gleaned from his stint leading the UK delivery unit, extensive experiences on the frontline, and working with governments across the globe

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