Even for an old NHS hand such as Mike Farrar, the volatility of the political debate around the health service has come as a surprise. Barely a day goes by without the government’s radical blueprint for reform appearing in the news. Rocked by political tensions in the coalition, and facing opposition from health-service workers, the controversial proposals have exploded into a political crisis.
“We are in fairly unusual territory,” admits Farrar. “The NHS is always part of the political landscape. It’s a £110 billion industry so you expect it to be in the political domain. But in my career, I’ve never known it quite so ‘interesting’. It’s uncharted water for us.”
With Farrar lies the delicate job of navigating the crisis on behalf of the NHS “family” – the hospital trusts, health authorities and private health firms that make up the NHS Confederation, a kind of CBI for health services. The reforms are regarded as the biggest potential shake-up of the NHS since its inception, and come as the NHS embarks upon a challenging commitment to find £20bn in efficiency savings over three years, a combination the confederation is deeply worried about.
How exactly do you make it clear to leaders that, while you recognise and support the need for reform, you think the way they want to go about it is largely wrongheaded?
Farrar’s answer is well rehearsed, the by-product of a recent series of meetings with the prime minister David Cameron, deputy prime minister Nick Clegg, health secretary Andrew Lansley and many other key players. “We are saying we believe there is a case for reform,” says Farrar. “So we are not sat saying the status quo is perfect.”
Then come the not-inconsiderable caveats: the reforms as they stand are too broad and unfocused; they are poorly conceived and badly communicated and potentially destabilise key services and fail to build on NHS strengths. “We are trying to make sure this package of reforms adds up to a coherent whole,” says Farrar. “What we’ve said to the government is: focus the reforms on the things that matter. That means the real problems rather than the wide sweep of reforms that’s on the table at the moment.”
Farrar outlines three “real problems” facing the NHS: rising demographic demand for services; unacceptable variations in the quality of care between hospitals; and the need to integrate services provided by family doctors, hospitals and social care. These are perennial challenges, he accepts. Progress was made on tackling them in the past decade – waiting times came down, for example; some cancer outcomes improved – but this was eased by extra billions in taxpayer investment, a “luxury” he admits is no longer there.
The problem with Lansley’s reforms is not that they don’t recognise the challenges, but that they don’t address them forensically enough, Farrar reckons: “Our sense has been – and this is widely reflected on all sides of the health debate and by many stakeholders – that these reforms are throwing too many bits up into the air and are not focused enough on those three specific challenges.
“So, for example, the original health bill talked about a duty to promote choice and competition. We support choice and competition but we feel it has to be balanced with a duty to support collaboration. In some cases, more choice might be the right answer; in a lot of cases, if you want to get a higher quality of outcomes, you need to have collaboration and consolidation of services in centres of excellence.”
Farrar worries that untrammelled competition – the “any willing provider” clause in the reforms – could work against the interests of patients by financially destabilising hospitals and undermining the quality and safety of care. That, he says, is why there have to be limits to competition. “If you look at most markets outside health, the good get better market share, and the bad drop out of the market,” he says. “The problem with health is that the bottom end of the quality spectrum costs lives.
“People want improved care but what they don’t want is the things that they value destabilised in the process. That’s why we are saying, ‘get beneath the political rhetoric, have an intelligent discussion about what would make sense by opening up more competition but protecting the best of what we have now, rather than throwing it all back up in the air and losing some things that are highly valued.’”
Ultimately, the message to ministers is that change has to be evolutionary not revolutionary, and based on an acceptance that there is much in the NHS that is working well. “Evolution makes sense in terms of where we are financially, and in terms of building on what we know to be good,” says Farrar. “At the point where the reforms were introduced, public satisfaction with the NHS was at the highest it has ever been. That tells you something about evolution: a sensible strategy to build on strengths.”
Just days after our interview, Cameron made a speech in which he suggested he had been listening to some of the points made by the confederation and others: there would be limits to competition, and a regulatory duty to ensure integration of services in a geographical area. Waiting time targets would be retained, and there would be no “cherry-picking” of NHS services by private providers.
If Farrar and his colleagues have succeeded in pulling the health reform agenda back into the realm of what the NHS considers possible, it will count as just the latest success in a formidable NHS managerial career. Farrar started as a gardener at Rochdale Infirmary in the late 1970s, at a time when he was also trying to make a career as a professional sportsman. He played semi-pro football for Rochdale and turned out alongside West Indian cricket legends Sir Garfield Sobers and Joel Garner in the Lancashire league, before a snapped cruciate ligament put paid to his dreams.
After a brief spell in the private sector, he joined the NHS, rising through the managerial ranks in the north of England before becoming director of primary care at the Department of Health. Top jobs in strategic health authorities followed and he became chief executive of the NHS for north-west England in 2006. From that job – the post is due to be abolished next year – he came to the confederation.
He has been carrying out his own listening exercise in the NHS, holding meetings with groups of managers around the country, taking the temperature at this most turbulent of times. Managers have been the butt of stinging political and media attacks about “bureaucrats” and “fat cats”. The imminent abolition of primary care trusts and the NHS-wide efficiency drive has cast uncertainty over the futures of many. But the outlook is not entirely gloomy, he insists.
“There is low morale: people are feeling a bit down. The first thing you hear is: ‘what is going on?’ But the second thing is: ‘We want to do the right thing.’ Everybody is trying to get through this phase so they can carry on doing the right thing for patients. There is enormous commitment to the NHS. It never ceases to amaze how committed NHS staff are, even when they don’t even know that their job is secure.”
Managers will be key to meeting the government’s objectives, and ending the uncertainty must be a ministerial priority, Farrar insists. “Every organisation in every sector – whatever job they’re doing – will tell you the keys to success are having a core, clear vision and common purpose people can identify with. We are asking the health service to undertake probably the greatest challenge in its history, with a lack of certainty about people’s roles and futures. That is not good management; nor the right way to achieve what will be a complicated process. So we are putting the need to get clarity in quite strong terms to government.”
Believing the dream
Farrar learned his own leadership skills “through experience”, he says. “I’m a person who enjoys the theory but likes to test it and see how it works. I got great experience before I came to the NHS: I tried to play professional sport – my background comes from sayings like: ‘You are only as good as your last game.’”
In the health service, however, the most prized senior management attributes involve being able to handle clinicians, especially doctors: often super-bright, highly individualistic characters who aren’t natural team players. Command and control, he says, rarely works. “I worked in the private sector in sales. I learned that if you want to get people to change, you have to appeal to them by demonstrating the benefits to them. Walk in their shoes. I need to get out there and talk and understand what the barriers are to them providing the greatest clinical care.
“There’s a lot of nonsense talked [about clinicians] – like ‘if you want o get a message to a doctor, write it on a cheque’ – but I’ve never found it to be the case. You get much further asking: ‘How do I help you achieve better quality and better outcomes?’ than you do if you say: ‘If I pay you a load more, will you do more for me?’”
The next big managerial challenge is likely to be public facing. As efficiency plans bite, services will be reconfigured and hospitals and units closed and merged, not least as it may make services safer. Managers have not always been at their best in explaining the idea behind hospital closures, Farrar admits, though they have not been helped by politicians.
“For the past five years, I have had numerous conversations with mainly backbench MPs about the case for change and – this is not a party political point – they will accept the case for change, including that you will get better clinical outcomes. But you will leave those meetings and they will say ‘But I still need to be at the front of the demonstration, as the public will not think I am doing my job locally if I am not opposing the change.’ The NHS maybe hasn’t articulated the case for change well enough to the public but we need political courage to say: ‘That is the right thing.’”
Farrar says he is “nervous” about the sheer scale of the NHS efficiency targets: “It’s the biggest ‘ask’ we’ve ever had, and while I think some of our organisations will get there, as a whole, it is going to be a real challenge. It’ll be a damn sight easier for us if we can get through the uncertainty and get reforms specifically designed to help us with the financial challenges. Focus, speed, clarity; all of these help us.”
So will the NHS survive? “Yes,” he says. “Because, as a nation, we want it to work. We believe the dream – that taxation is the route to comprehensiveness and fairness. So I think we’ll pull through because people want us to pull through.”
Mike Farrar is planning to harness the power of sport to boost NHS staff energies. Find out more here