Editor's blog Wednesday 6 July 2011: Text of Mike Farrar's speech to NHS Confederation Conference

(Video footage of the speech will be available through this link.)

I can tell you that I feel privileged to be speaking to you today as the new Chief Executive of the NHS Confederation.  For many, many years I have attended this event and sat in the audience as someone who is passionate about the NHS and committed to making one of humanity's greatest creations into the world’s finest health service.  Over the years I have been lucky to hold a number of important leadership positions in it, but I can't think of a more important role than the critical role I hold now.



That's because in all the years of my NHS career, I can't think of a more important NHS Confederation conference than this one.  It comes at a time of unprecedented financial challenge, unprecedented confusion over policy, unprecedented and unwarranted attacks on managers, and unprecedented nervousness about to deliver what’s being asked of NHS leaders.



And what that tells me – and indeed many of you who I’ve spoken to, or who have been kind enough to write to me since my appointment – is that there has never been a more important time for a strong and effective NHS Confederation than right now.



So that's what I intend to provide.  Clear leadership, a place for the whole of the industry to come together and take responsibility for it's own destiny, an impactful and influential force on Government and the emerging national bodies, an organisation close to and built on the strength of it's members, and an organisation that offers real value for your money – recognising that every penny counts.



Before I talk about how the NHS Confederation will support you over the coming year, I want to reflect on where the NHS is today and how we can move forward. Last week I was asked at the Bill Committee’s 'second' committee stage reading if the NHS wanted to move forward after the pause.  I said that – whilst few of us would have chosen 12 months ago to start from here – the NHS needs certainty, clarity, recognition of the enormous job that we face, and a desire to help us rather than hinder us in delivering it. I said that as far as the NHS is concerned, a organisations at a national level are trying to see the wood from the trees, whilst NHS leaders are watching the forest fire moving towards them!



And that's what you have just told us in our latest survey which shows, for the first time, the view from boardrooms around the country as the NHS sets out to save some £20billion over four years to keep pace with rising demand.

·         87 per cent of you are worried about finances: telling us that the financial situation facing your organisation is either “very serious” or "the worst you have ever experienced".



·         Half of you think that patient access, including the availability of care and waiting times, will get worse over the next 12 months.


·         And three quarters of you say that cuts in local authority spending on the NHS will definitely impact on the services your organisation provides.



People will overlook these worrying results at their peril. This is the view of those who run the service, who will implement the reforms, and on whom the immediate future of the NHS depends. They are unconcerned with the political knockabout and they don't have the luxury of the armchair commentators. The picture they paint is of pressure on money now and of pressure on money mounting down the line. It is getting harder to maintain the great progress we have made on the quality of care, and there is now real concern about the speed of access to services. The NHS also feels pressure as a consequence of the difficult financial settlement for social care.  This highlights that the NHS is not an island. The health and social care system has got to work together or it won't work at all.



Balancing the books, maintaining and improving the quality of services, and getting the relationship between health and social care right.  We know that these are the challenges you’re focused on.  And when we engage with the current health reforms, we’re focused on making sure that these reforms will make it easier, not harder, for you to meet these challenges and provide great services for patients and their families.



There are many things that are good in principle about the health reforms and we have consistently supported these.  They include the increasing role for clinicians in leading the NHS, the new relationship with local government on health improvement, and the desire to move towards measuring quality and outcomes.

I have no doubt that we are in better place as a result of 'the pause'. But, despite this progress, there is still much to worry about. We are concerned about excessive centralisation, bureaucratic restrictions on the freedom to act of local commissioning groups, the continued attack on management, and the lack of political courage when reconfiguration of services is justified on quality, safety, and – let's name it – on cost grounds.



But our figures, your views, should not be seen as a counsel of despair but a statement of reality and a huge wake up call. But they also need to be the beginning of a sentence that says this is what will happen unless we....



First, persuade the Government to stop attacking and start valuing management.  High quality management is essential if we are to achieve high quality care.   Great management, irrespective if you are from a clinical or an administrative background, creates the context for great clinical care.  We need a proper assessment of the resources needed to manage the NHS effectively, and this means moving away from a simplistic and crass management cost target with all the perverse incentives it entails.  No one disagrees with the need to find efficiencies.  But an organisation the size of the NHS, with £110billion of expenditure, needs a proper level of management to succeed.  Most comparable countries spend more on management than we do, without getting the outcomes and services. That's recognised by reputable bodies like the Commonwealth Fund.  The latest management reductions bring us dangerously close to undermining the advantages we have.  High quality management is the solution, not the problem.


Second, we need to convince politicians to support NHS leaders when we make tough decisions on service reconfiguration.   When I talked to MPs on the Bill Committee about the health reforms I was asked whether the Bill would speed up or slow down service reconfiguration.  I said I didn’t think it would make a difference, as the major barrier to reconfiguring local services is the lack of political support for change.  I talked about MPs who fully acknowledge the case for change in private, but say that that they will be at the front of the protest march when it comes to change in their local hospital.  At this point in the Committee hearing there was a shuffling in their seats, then a number of MPs pointed at each other saying... he means you!  We need to engage the public in a more sophisticated conversation about moving care into bigger specialist centres or out of hospitals into local communities so that we have their backing, and this will take strong leadership and significant courage from politicians as well as NHS managers.

Third, we need to find intelligent solutions to complex problems.  We need clarity soon, with practical solutions to the outstanding questions posed by the health reforms.  We need an intelligent framework that helps us deal with the complexity of competition and collaboration not a political fix, that balances the need for national consistency and local flexibility, and that balances proper governance with the freedom to act swiftly without burdensome bureaucracy.  In each of these areas we need to make sure there is ongoing dialogue between policy makers and NHS leaders on the front line whose experience and expertise can help them to get the balance right.



Fourth, we need to focus on today as much as tomorrow.  Many of the proposed reforms kick in from 2013, but the decisions and support provided in the next 18 months will determine whether the NHS is a going concern for future leaders to inherit.  We have to act now and that means sheer hard work, an ability to deal with the ambiguity yet take brave decisions, and to do today's day job while safely bringing the new system into place.  I have seen throughout the country people leading and taking responsibility even when uncertain about their personal future.  I fear that we may have lost considerable time over the past 12 months as a consequence of the policy uncertainty and the drain of senior management we have also seen around us.



And that leads me to my fifth point, we need to take our destiny back into our own hands by delivering long term transformation not more short term fixes.   We need the confidence to shape our own destiny, to innovate from within, not to wait for others to do it, and to challenge our own outdated business models.  Many examples exist across the country where NHS organisations have developed new approaches to tackling major service and financial challenges instead of waiting for the solution from above.  We should be more confident in finding these local solutions and promoting those that work to others.  A great example of this is the need to help patients and the public to engage differently with their own health, and change the way they use NHS resources.  We cannot expect the taxpayer in days of tighter economic growth to fund greater and greater injections of funding, although we can and will lobby for sensible and appropriate settlements for the NHS and social care – especially at a time when we are now going backwards against the spending levels of similar economies.  There are crucial elements of the health reforms that help us to improve our public health system and we must not regard them as fluffy add-ons. It is our actions in promoting better public health at a local level which will transform the health system in the long term.



So that’s my five points but I also know that if I canvassed this audience today we would add at least another five, and another five if we asked staff in local hospitals and so on and so on...  And that's what the Confederation needs to do.... To start asking more, getting itself better attuned to your views, and being more effective when it comes to making them stick in all the right places.  A strong voice at the Confederation is an asset to Government not a problem to it.  As I said to the HSJ, speaking truth to power is the only way to have a sustainable lifespan and we, not just the Confed have lost some of our edge in this regards.



The new NHS Confederation will build on the strengths of the thinking that people like Nigel have offered so magnificently (and more about him later...), but we will move the focus of our policy work from blue sky policy thinking to applied policy where we use the excellent work of the think tanks like Kings Fund, the Nuffield Trust and the Health Foundation: we will test it out, learn if it's applicable and help secure it's value by turning it into action. The NHS Confederation will not be a think tank but a do tank.



And that will also help us to provide a clearer focus for innovation and spread of best practice where our suppliers have struggled to get adoption and spread.  We will help our members sort out the wheat from the chaff and take the opportunity to pick up on new technologies, devices and pharmaceutical breakthroughs earlier.



The new NHS Confederation will enhance its role as the place for employers to interact with the service, building on NHS Employers to create a superb organisation capable of dealing with the industry-wide industrial relations context we will all face, supporting and building strong partnerships with employers, staff and the Government under Dean Royles excellent leadership.



The new Confederation will provide a better international offer, helping us to learn and share problems and solutions with other health leaders in different systems.



We will be a place where clinicians in leadership roles will feel equally at home to leaders from administrative backgrounds. Clinical engagement and involvement is not just a matter of rhetoric, everywhere inside the NHS we are seeing clinicians seek to more involved in leadership, bringing with them the solutions that they see from their vantage point, and the NHS Confederation must be no different from this. We will be saying more about this over the coming months.



The NHS Confederation will also be a place that offers the chance for communities of interest to meet to discuss and resolve common problems across the industry such as new models of urgent care, managing choice, commissioning for quality and outcomes, and measuring social value.



We will be a place built on strong networks, whether they are in house or independent – I believe we can achieve more by working together than we can by working in isolation.  What do I mean by that?  I mean there is a huge value in a strong network voice that has an in-depth understanding of members concerns on key issues, but that voice can be and should be amplified when relevant by a strong industry-wide voice.



If the mental health network argues for more money to be spent on mental health, this could be seen as self-interest, but if the Confed says it too?  If the foundation trust network say that small shifts in revenue destabilise services, that's provider interest, but if the Confed says it too?  If the partners network says there are non-NHS suppliers who could offer better ophthalmology interventions, they may have conflicts of interest, but if the Confed says it too?  And if the ambulance trust network says that they may struggle with extra demand to achieve the 75 per cent target, but they compete and beat the rest of the world on overall performance, my absolute agreement at the Confed and our promotion of that truth can fundamentally change perceptions.   The networks and the NHS confederation must work on the added value of an 'and-both' relationship rather than 'either- or' basis.

I guess you get the picture and that's important because it's essential in my view that we stick together as an industry. We need a strong voice and you don't get that by pulling apart. And it is that strong voice that will always be the acid test of the NHS Confederation. It’s great that we are determined to continue to provide good membership services, and that we are equally determined to add value to our services for you going forward, but we need to ensure that we are impacting on the things that matter to you, when you need Government, policy makers and the new national bodies to listen.



I have been around Government and the top of the NHS for many years now, and I have seen both successful and unsuccessful attempts to influence policy makers and politicians. Sometimes it is by being constructive and support of their efforts that you can get to be the loudest and most trusted voice. Sometimes, as is the case with the attack on management, we must come back fighting stronger and harder.  Sometimes the centre has no solution, and we can shape policy by identifying and drawing attention to find solutions already being used at a local level in the NHS.  There are many ways to do influence effectively on your behalf, but let me assure you that we will use them to make ourselves the force to be reckoned with that you want us all to be.



I often say that the trick of my job to is to know when to be inside the tent and when to be outside it.  The trouble over the last year is that it’s not been easy to find the bloody tent!



So as we now begin to meet in Manchester this year at this most important events, let me summarise my key messages and then close by doing three things.



To sum up, this is a hugely important time and one that requires strong leadership in the NHS and in the NHS Confederation. There are a number of issues still to be faced, despite progress during the pause. My prescription is: value managers; support reconfiguration; focus on today as much as tomorrow; find intelligent solutions to complex problems; and finally take our destiny back into our own hands by delivering the long term transformation not short term fixes.



And finally to my last 3 comments:



One – thank you for your support, and for the generosity many of you have shown in giving me a steer about what the NHS Confederation needs to do to serve you well.  I’ll be talking to more of you throughout conference to hear your views.



Two – thank you to my immediate predecessor, Nigel.  He has been fantastic for ever and is one of the NHS’s greatest ever thinkers, and he has helped me to navigate my way into the new job so well.



And, finally, three – to look sideways for one moment to another industry with their toughest challenge of a lifetime ahead of them..... to those Olympians facing their own personal mountains next year.  I have said on a number of occasions that we, like them, should be at our fittest and strongest for our challenge ahead – and later this week you’ll hear about the wonderful opportunity we have for NHS staff involved in the 2012 challenge to carry the Olympic torch.  But the point I want to make is about the attitude Olympians have to their challenge.  Like them, we have two choices –  to be daunted by the scale of our challenge or to be inspired by it.   And, like them,  it is the latter we must choose – to use the motivation of the toughest year in our careers to excel, to achieve our own personal bests, and to sit down calmy afterwards in the glory of our achievements and think, we did that, and we did that for our friends and our families, and we did that for the NHS.