Resetting Northern Ireland’s health and social care and lessons in leadership

 Matthew Taylor

Welcome to the latest edition of Health on the Line, produced by Health Comms Plus on behalf of the NHS Confederation. For those of you who are avid Health on the Line listeners, hello Mom. And yes, I know there are many of you out there. You'll know that I've recently been at Nikon Conference run by the Northern Ireland Confederation for Health and Social Care.

I had a great chat with its director, Heather Moorhead. Now, as part of that conference, I also had, actually, a fantastic conversation on the stage with Mike Farrah, permanent secretary for the Department of Health in Northern Ireland, and my predecessor as a chief executive, NHS Confederation. We, we talked about all sorts of stuff for how Northern Ireland might build a first-class health and care system, what the barriers and enablers to that might be. We had this conversation in front of 800 delegates. It's a good listen, but more of that in a few minutes. 

We've had milk lakes, we've had gutter mountains, postcode lotteries. But when it comes to teeth, we talk a lot about dentistry deserts. More than 13 million adults, around kind of one in four of us, are struggling to find NHS Dental care in England.

This is the result of chronic underfunding workforce shortages, and as we all know, a very flawed contractual model. 

Now Labour in England is committed to contract reform and the 10-Year Health Plan has specific initiatives to maximise the skills of dental care professionals. And equally in Wales, the government has announced contract reform focused on prevention, co-production and population health management.

No action at the moment in Northern Ireland, but I can tell you that stakeholders there are urging Stormont to take urgent action over what is a deteriorating position. 

So, the question is what do we do? This is a complex problem, which involves acting on a whole number of different fronts, from contracts to workforce, to embedding dentistry and neighbourhood working.

So what we've recently done at the Confed is we've brought together in partnership with NEC Software Solutions, a round table - it was just today actually, it felt a really kind of all-star cast of dental CIC, dental groups, primary care directors, commissioners, patient groups - we all came together to talk about the challenges that I've described, but particularly what might be the core components of a new national strategy, which then feeds down into local strategies. 

I chaired the event, but all the work was done by Rebecca Gale, assistant director of our primary care network, and I'm delighted that fresh from the event Rebecca is able to join me on Health on the Line. 

Welcome, Rebecca. 

Rebecca Gale

Hi Matthew. Thanks for having me. 

Matthew Taylor

Now, you did a brilliant presentation at the beginning of the day just on kind of how challenging the situation is, as it were, the burning platform.

I'm not going to ask you to go through all of that, but just pick out two or three of the kind of compelling reasons why we absolutely need a new approach to dentistry. 

Rebecca Gale

Thanks, Matthew. I mean, you introed with dental deserts. I think that's come a perfect place to start. We have a situation where we have vast ways of the country or regions that do not have adequate dental care provision.

I mean, 13 million adults alone, or people alone cannot access an NHS dentist. And that's not to say there are not dental practices or dentists operating in those areas, but we have a situation where the proportion of NHS dentists that want to provide NHS care is declining. And that's because of years of underfunding, insufficient remuneration, they are choosing to opt out NHS and move into the private sector. We have high rise in demand, high levels of unmet needs, and I think just a few key stats, tooth decay is the number one reason why children age five to nine are admitted to hospital. And in this day and age, that is shocking. 

We've got preventable disease. Oral cancer’s on the rise and people waiting for surgery and for treatments for cancer treatment, cardiac surgery, and for support with their long-term conditions that cannot access that care because they, they need their oral health needs to be met in the first instance. So this has far reaching consequences both for the individuals, for communities, but also the wider implication impact of system cost.

Matthew Taylor

Thanks, Rebecca. And, you know, we don't bring people together, busy people together, for conversations at the Confed, unless we've really thought about it and we're really interested in change and we think there's an opportunity for change. 

So just tell me what were the objectives of the session that you and I hosted today?

Rebecca Gale

To put into three key words to convene, to challenge, and to collaborate. Confed, as membership organisation for the entire NHS, we are in a unique position to join the dots, to describe what we think the opportunities are and to demonstrate where things are actually already happening. And I think it's important to say that there was a lot of innovation in relation to dentistry taking place up and down the country. 

Challenge: You know, we are realistic. These are big issues. We say dentistry's on a burning platform, and we didn't expect to resolve or solve those challenges of that conundrum within a 90-minute round table. But the conversation was very much solutions focused. We did challenge the group to think beyond the status quo.

There were certain rules of engagement, that we couldn't just simply ask for more investment. And really thinking about in the context of a neighbourhood health service, what is the role that dentistry and oral health needs to play if the government's going to deliver on its ambitions? 

And then finally, you know, to collaborate. As you say, we had a great cast list, varying perspectives from across the country, and actually I should say three nations. We had Wales and Northern Ireland in attendance as well. So to really think about where is that point of consensus? Where can we come together and really build as collective voice to sort of think about what the narrative should be as we build our influencing work going forward?

Matthew Taylor

Yeah, I found it a fascinating session and it actually, I found it quite mouthwatering in terms as a policy wonk. You know, I can see the different components that need, I don't know how they should come together, that's the work we need to do, but I could see the components that will be needed for a fresh approach, a new strategy.

But tell me just now with it fresh in your mind, are there any particular points that surprised you that you, you, you thought, well, I've not heard that before. That's something to reflect on. 

Rebecca Gale

Yeah, I think perhaps not surprising, but comforting was the level of consensus in the room given the breadth of different organisations, viewpoints, people were coming to.

I think what really came out for me was the need for honesty and transparency and for that to come top down, and that is about honesty with the public about what is within our gift in terms of dental care provision, what can we afford. But also with the profession itself, you know, we need to make sure that we are targeting oral health provision to those that need it most.

And I think what was also surprising was - we talk a lot about digital and tech and where some of that, the opportunity to do more with it and for it to alleviate burden. I think what was interesting was the caution that came from the whole group about this cannot substitute some basic, fundamental need, and every child, for example, should be seeing a dentist. 

And it's just about making sure that any technological advances or digital advances, don't take away from that. Yes, there needs to be literacy. Yes, there needs to be better education and parents particularly need to be supported in that, but it doesn't take away from some of this fundamental rights. 

Matthew Taylor

Yes, absolutely.

And there were loads of things I found kind of really interesting. I thought there were recurrent theme that we are going to have to make choices. And in those choices we are going to have to prioritise two groups in particular, and that's children and the most disadvantaged. I thought how you do that most effectively whilst also having something to offer and something to say to everybody else, how you engage in the market.

You know, as I say, really fascinating kind of public policy change. 

One of the elements of the session that I really enjoyed Rebecca, was some people sharing the good practice they're managing to achieve even in these difficult circumstances. Give me, one or two maybe examples of what you heard today, which you were heartened by as good stuff that people are doing.

Rebecca Gale

Yeah, I think the examples we heard they're illustrative of commissioners that are prepared to be bold and doing what they can within the constraints of the current contract, but also providers that really do understand the need to their population, the need for local flexibility, and that one size absolutely does not fit all.

So we had examples of providers that have built partnerships with universities to tackle both the access and workforce challenges. 

But also, in terms of outreach initiatives, we have one example of a provider - a community dental provider - working with a general dental practitioner going out to a community, I mean, I can name it, Luton, to provide pop-up clinics and not just the sort of a standalone one-off event, but actually working with that general dental practitioner who can have then the capacity to register patients who perhaps don't have a regular dentist. They're right there on the spot using a QR code so that that risk or that need is captured and dealt with in a way that ensures that patient is not just identified but actually seen through.

And of 98 children seen that day, 97 per cent had never seen a dentist. 

Matthew Taylor

And they were different kind of ages. Some of them were, you know, nine or 10. 

Final question, one of the other things I kind of said at the beginning of the event and which came up again and again and again, was the scope for oral health and dentistry to be part of our neighbourhood offer, particularly in those most disadvantaged areas that Wes Streeting has talked about, he wants those areas to be the ones that lead in this neighbourhood environment. 

Just tell us a couple of things about what people were saying about this idea of dentistry as an inherent component of the neighbourhood offer. 

Rebecca Gale

I think fundamentally oral health needs to be embedded from the start and that it's not seen as an add-on.

Historically it has felt siloed on the sidelines and it, you know, as one member said, we need to put the mouth back into healthcare. But it's more than healthcare. Matthew, you and I heard firsthand on a visit, didn't we, about a patient who, at the age of 27 had a mouth full of dentures. And aside from the physical impacts, you know, the wider consequences of that are huge. You know, their ability to socialise, their ability to work. 

So if we are to achieve the ambitions of a neighbourhood health service, then that preventative model needs to be at the forefront. And it’s almost less about teeth, and it's about that whole oral health and the interaction between oral health and the rest of the body, and also the rest of people's health and wellbeing.

Matthew Taylor

Yes, and also the other key idea that we've talked about always at the Confed when we talk about neighbourhoods, which is proactivity, not waiting for people to come to us, but going out, knocking on doors, engaging with people who don't read leaflets, don't read mainstream media, who may not even know how to access the health service, might come from other countries where primary care isn't the same as it is here.  We see over and over again that that reaching out into communities is absolutely critical to prevention and tackling health Intercourses. 

Now, I said, Rebecca, that I really enjoyed the session because, although it would take me a lot more time and thinking to understand how these bits stitch together, you could start to see the different components of this. 

You've got to take this next bit of work forward. What's your feeling - is this, as many people see it, and as I think government fears, it's simply intractable because of the financial problem. Or do you think that what we've heard today starts to take us towards what the components might be of a strategy that is both ambitious and credible? 

Rebecca Gale

I mean, as I said at the start, we are in a unique position. We represent those organisations and those commissioners that are charged with delivering transformational change. And today was, was the start of the conversation. You know, there were things that came up that we've heard before and have been said repeatedly over a decade.

But what feels different was there is this sense of the time is now. We are on the burning platform and with risk and times when certainty comes opportunity and there's the opportunity here to do something, do something differently. So yeah, I think we can demonstrate the art of the possible, I think we can draw on that group of experts going forward. As we said, there's consensus within the group. 

I came away feeling positive and optimistic that there were some tangible points. There are some ways round the perceived barriers that exist if we look beyond contractual constraints. And we know from the examples we have from today that some people are already doing this, and it's about how do we support them to scale it up.

There is obviously a real worry about the reduction in commissioning and cap capacity and expertise, which is why engaging and working with the sector and those delivering these services is ever more important. 

Matthew Taylor

That's right Rebecca. And, you know, it can sound very trite to say hope is important in the face of challenges, but actually it is relevant here because if politicians feel there is no hope of making progress, it's one of the reasons they don't engage with difficult issues.

So I think it's important that we say that there is hope, here.

 Well, all this talk of burning platforms and deserts, I'm going to say this is a hot topic and I'm sure we will return to dentistry on Health on the Line in the future. Thank you so much for joining me, Rebecca. 

And so from my sofa in York where I've been talking to Rebecca to a stage in Belfast where I had a fascinating conversation with Mike Farrow, the permanent secretary for the Northern Ireland health and care system.

I'm delighted to be here and in particular, delighted to be sitting down with a special guest. Mike Farrar, a man whose shoes I have metaphorically walked in as he's a previous CEO of the NHS Confederation. He's incredibly experienced, I think that just means ‘old’. But people say that about me as well. You know, we're veteran. That's what it is. 

Mike Farrar

No, it's all relative. Matthew, you're very young, really. 

Matthew Taylor

Mike, I just want to start, well first thing is, how do you say your surname 'cause there's Ferrah, Farrah, Ferrá. 

Mike Farrar

So I'm from Rochdale, so it's Farrah. It's a good northern…

Matthew Taylor

So, Mike, tell us, obviously you’re now here, permanent secretary for health and social care, doing really interesting work. But just tell us a little bit about your background. I mentioned the fact that you used to run Confed, but tell us your journey to, to get to here. 

Mike Farrar

Ok, well first of all, Matthew, can I just acknowledge before I start talking about myself, just what a brilliant job I think you are doing and the Confed has done and NICON [Northern Ireland Confederation for Health and Social Care] in Northern Ireland.

It really is impressive and it was what I was aspiring to do, but you managed to achieve it, so I just wanted to acknowledge that. 

My journey, I often start with this, but it is absolutely true, is that I am here as a failure 'cause my chosen career was to try and play professional sport and I wasn't even good enough to play for Rochdale first team when we were boss in the fourth division in 1982.

Matthew Taylor

And what position did you play, Mike?

Mike Farrar

Well, you might imagine with a nose like this, I was a centre half. I was a bit of a donkey and I was too soft really 'cause you had to be a bit of a slug to play centre half in those days. And I can assure you that I have none of my own front teeth 'cause they've all been knocked out.

But I came into the health service as a health promotion officer. And I have this kind of view that helping kids on council estates, it speaks to Michael's points completely about getting kids more active in sport, would be what being a health promotion officer was. It turned out that I was effectively taking breastfeeding films round for the midwives and health visitors to community clinics, and so it wasn't quite what I imagined it to be.

But I then sort of moved from there into drug and alcohol addiction services and mental health services. And I was the chief exec in the NHS, very privileged to be so, for around 15 years. And I also had six years on to comment to the Department of Health negotiated the GMS contract from fee for service to population. So I had an extraordinary amount of really great opportunities, lucky opportunities, and hopefully I was able to meet those.

And then really when Simon Stevens got the NHS [England] chief exec job around 2013, I'd had a bit of aspiration for, that wasn't therefore successful, but thought I'll think about other things. And that went into consulting and for 13 years was consulting and one of the great pieces of work that I had was working with the chief execs in Northern Ireland and that bridged into doing some work with the top team of the Department of Health around, interestingly, resetting their culture.

And when Peter Mandelson, my predecessor,  said he was standing down, I said, well, I've got lots of ideas about how you might reorganise this because I've worked for split systems, dual responsibility systems at the top. He hadn’t really prepared for anything and he said, it's fantastic, we really like it, would you do it?

And I ended up sort of hoisted by my own ideas, but I have to say, what a wonderful privilege it has been to be in Northern Ireland. And I was just thinking when I was listening to Michael, that actually one of the things about my sporting background and I've continued in sport, haven't actually governed Park Run, but a lot of things like UK Active, Swim England, EFL football trusts and things like that, is that sport has a great way of, when it confronts challenge, it gets inspired.

So it doesn't get daunted. We tend to be a bit stoical with challenge and sometimes a bit daunted, but sporting people, people like Jonathan Edwards when he was the World's record holder, you would say to him, Jonathan, we're going to put sand in the sandpit that you're going to jump into, he would say, that's fantastic 'cause I've got to jump over it to avoid being cut.

You know, there is nothing, sometimes nauseating to be frank, how positive people are about sport, about we just lost eight nil, but we're going to take the positives. But the truth is that when you hear about what Michael sets out there by way of a challenge to us in Northern Ireland, what a fantastic privilege it is to have the opportunity to rise to that challenge. And so that's a real inspiration. 

And if I bring one thing into this role, Matthew, getting into this role, is that this is the most amazing opportunity we have as a group of leaders to do something incredibly important and special for everybody in Northern Ireland. And so I'm driven by experience and I'm driven by ambition and that aspiration to, you know, work with colleagues in this room to make something great.

Matthew Taylor

I just saw something really interesting in your answer in terms of a kind of consistent theme for us at this conference, which is around the relationship between the service and people and patients, and we're publishing a report today that I was handed to refer to, and I've left it on my chair, so Heather's going to bring it up to me in a second so I can wave it around.

But just two examples I thought, really interesting examples. Park Run, which hundreds of thousands of people run every Saturday morning, all entirely organised by volunteers. It's fantastic and there are some GPs who prescribe Park Run for people, as you know, part of their kind of Coach to 5k. 

You also mentioned breastfeeding where the evidence of the health benefits of breastfeeding has gone up whilst the levels of breastfeeding in the in the UK have gone down.

And in both examples that both areas where working with the public as partners, as individuals, and as communities is vital to achieving change, but they're also examples of health inequalities because breastfeeding rates are lowest amongst the most disadvantaged. And whilst I love Park Run, it is achingly middle class.

So two really interesting things for us to pick up - partnership with people and health inequalities. But let me return to the question I warned you of, which is, what is the kind of one biggest thing or thing you've changed your mind about in that illustrious career? 

Mike Farrah

Can I pick up first on, on your points there? Because right at the heart of the reset, and it's the first thing we say is that we have to change the relationship that we have with citizens about their own health, and that is a massive sort of cultural shift for the service. And most people come into healthcare because they'd like to do good for other people, but that can sometimes get in the way of ourselves feeling that we're empowered and so right at the heart of the reset, we should come back to that Matthew, about what are we trying to do differently to engage people? 

In terms of a change over my lifetime, I got to be chief exec when I was 39, which was great in Tees Health Authority in Middlesborough, which, you know, I've always worked in a significant deprivation, which is maybe says something about me in terms of that kind of sense of challenge in what I was trying to do and belief in social justice. 

But I think I came in as a leader, and so this is a leadership point, feeling that it was my job to have all the answers to set that sort of direction to give confidence. And in part it is, but what I learned increasingly, and I'm six foot four, well, six three now I've shrunk a bit, and what I realised was that when I spoke and made statements, then the more certain I was, the more difficult it was for colleagues around me to contribute to that debate. And I started to realise that the more vulnerable and open to say I'm, you know, what should we do? And ask more questions rather than make more statements is that I started to realise that I was getting fantastic response. People were wading in to help. People loved the direction, but had ideas. And so the one thing that I've learned, which I've tried to convert to people I've talked about leadership, is if you have that ability to be vulnerable and express vulnerability in a constructive way, you will absolutely create a momentum for support and engagement that sometimes when you're a youngish leader or maybe sometimes an arrogant leader, then you miss all that perspective and diversity and rich contribution. 

And that would be the thing that I’ve learned most about how to lead really.

Matthew Taylor

Really interesting. And my leadership lesson, I realised the other day. Well, there's two points. The first is we have to believe in the health service that improving the way we care for patients is also the path to financial sustainability. If we don't believe that, if we believe the path to financial sustainability and the path to better care for our patients, take us in opposite directions, we're doomed.

And I want to ask you to kind of reflect on that in the context of reset. But the other thing I've come to believe is this, as a leader, wanting to enjoy your work and wanting your life to be good is aligned with being the best leader you can be. 

There is a big, kind  of heroic leadership complex in the NHS, which is if you're not getting up at six in the morning and you're not stressed out of your head and you're not in a constant state of personal turmoil, you’re not really being a leader, and I want to say that’s nonsense. Actually, the most effective leaders are enjoying their jobs because they've created around them a team of people who are doing fantastic stuff. They know that they are adding value, and not second guessing. They trust the people who work for them. So that’s the thing…, maybe it's just an excuse 'cause I'm old and I want to be lazy. But that's my insight. 

Let's go to reset and then think about particularly this question of how do we get recovery, getting back to standards, getting shorter waiting lists, getting the finances under control. How do we reconcile that with transformation? Because so often in history, these two things, have felt like they kind of push against each other.

Mike Farrah

I think we try to take a pretty broad brush approach to this and a lot of what we're actually proposing to do is not unknown to the rest of the world, and in many cases has been done better and first in in other parts of the world. 

The key for me was trying to establish right from the word go, why do we need to reset? The why question was the big one around what's going on, and the minister referenced it before about the, the amount of the public, the block allocation that Northern Ireland has that was going towards healthcare expenditure, just being kind of exponential the last couple of years it's flatlined, but actually it has been heading up inextricably and really we were facing a prospect by 2050 that you'd be spending to like 70 to 80 per cent of your budget on health and care.

And as I often point out to people, when you look at how we spend that money, most of that is with people at their latter stage of life. So we would've been choosing to spend money in Northern Ireland on the latter stages of people's lives in healthcare delivery at the expense of starting life for young people, tackling inequalities, [the] environment, education or job opportunities, transport, leisure, et cetera.

So really getting the why question sorted as to why we had to change. And it's a weird thing because pretty much every permanent secretary, we've got a few in the audience, gets judged by their own sector on how much money can you get for us? And I'm saying, actually, it's not my job to get more money, what I want to do is see how we can spend the money we've got better. Because we should see, and you referenced this, certainly Michael did, in in my mindset, health is a horizontal budget. It supports education attainment by supporting young people's mental health. It creates job opportunities by investment in commercial clinical trials life, life sciences, investment. It reduces re-offending rates because we deal with mental health to people who are in chaotic lives. All those areas; health is a horizontal budget, not just a vertical one.

And so what I've been trying to do in Northern Ireland is try and explain that we're not just a drain on people's overall budgets, we're trying to think carefully about how you could use our resources better. And there's something for something dealing there, by the way, which is if you think that what keeps us well, it's something to do, someone to love, somewhere to live. And none of those are really what we do. We need others to do it.

So the something for, something deal is with other government departments, is that, let's see this in a joined-up way. 

But coming back to this idea of reset, we were absolutely saying we're looking at the way we spend money from the wrong end of the telescope, which is, and I think most health systems have suffered from this, is you get forced sometimes politically, Matthew, and you would understand this, to put your resources into the supply-side solution to a demand-side problem. It's an easier dialogue around we'll build, we'll increase the workforce, et cetera, than it is to say, we'll try and talk to people about how the social conditions of their life impacts on their health and what we should do, as Michael was saying, around economic policy and poverty, et cetera.

So what we try to do in the reset is look at this from the other end of the telescope and start with the people and the citizen and say, what could we do to help you be the best person you can be in terms your own health? And because I'm a health promotion officer, I'll go into this some degree of trepidation, but I would argue that our public health messaging has been rather poor 'cause it's focused almost entirely on giving information. And when you give information, you widen inequalities because the people who latch onto that information fastest tend to be the highest socioeconomic groups. 

What you've got to do is talk to people about not what they just know about health, but what do they feel about health and what do they think others, either normative bit is normal about health and getting to those areas.

So we're trying to use a bit of behavioural science and I, you've got a lot of expertise around this area and the nudge kind of concepts and moving people. But instead of preaching more at people about what they know about health is to try and understand what they feel and find ways to help them feel differently and take steps.

And we are looking to do something for something deal where. The example I give is you probably won't be able to see on screen, but I have some hearing aids now, and as a finely honed athlete of previous years, not doing Park Run, you'll imagine it was quite challenging for me to accept that I was going to wear hearing aids.

It was something I associated with my granddad. The point that moved me was when I realised that between 6 and 8 per cent of dementia in older men in particular is due to untreated hearing loss, and I thought, right, that moves me. Now, what would happen,  me getting myself some hearing aids is fairly significant in my life, but in the great scheme of things, but what would happen if the HSE wrote to me and said, thank you for doing that, because that's going to really help us. 

And so one of the things that we're trying to get is how do we have a different dialogue with the public about how they use services, but how do we sort of try and encourage and think very different to public health messages saying, these are your five-a-day.

So using behavioural science is starting to get people to think differently, more positively about what they can do to make a contribution. And there's a long way to go culturally for the service to accept that. I'll give you one example. I was talking to some young GPs who were saying, and it was rather depressing at one level because they were saying, if someone walks into my office, again in my consultation room, and brings a bit of paper in that I've seen this latest treatment, could I have it for the condition I've got, I'm going to kick 'em straight out. 

And I thought how opposite that is to the way we should manage somebody or try and work with somebody who's taken an interest in their own condition that's trying to find a way to solve it. To see that as a challenge to us and our authority and our expertise.

This is why people as partners is so different to the way we try to do before and that's where the reset starts. We can go into the other bits, but that's where we're fundamentally starting this really. 

Matthew Taylor

So Mike, the other thing that has really struck me about your leadership. And it is, I'm afraid a difficult contrast with England is that in England it really, things do feel very hierarchical. There's a strong kind of culture of control from the centre. You see it in kind of performance management rhetoric in league tables and all of that. And of course there has to be accountability, but it's very clear there are some people at the top in charge and there are people in the service trying to deliver. And if you don't deliver, blame is not far behind. 

You've adopted a much more collegiate approach to how it is, you can work with the cheap executives of the health and care system here. Why have you made that choice, and what do you hope will come from that model of sharing responsibility? 

Mike Farrah

I think it starts with the fact I've defined the role that I think I have in a slightly different way, perhaps to the one that's the way which leaders in England has defined them. 

I see my job and indeed the, the job of my colleagues who work at the centre, if you like, in terms of the policy to create the right context that people out there can lead and deliver services brilliantly, not to tell them how to do their jobs and blame them if they don't. And if we don't get it right on the front line, the first question is, well, what did I do wrong that didn't allow those individuals to do the best job they could do? 

And what that means is that all the brilliant people, and we have some fantastic people in this room, Matthew, some of the best people I've ever worked with, and I kind of see my job to create the context that they can be absolutely brilliant.

So I think it's a definitional point about how do I see my role. And the great news from my perspective, having said that's my mindset, has been the response has been phenomenal in terms of the chief execs, the chairs, you know, as many of the frontline clinicians and the voluntary sector. And the people I've tried to talk to have responded really positively for that because for years I think there was a sense in which they weren't enabled to be the best that they could be, and we weren't getting the right decisions - I mentioned in our breakfast session, that when you look at the way we take decisions at the moment in Northern Ireland, we've got the wrong decisions in the wrong place. We are too centralised. We're not delegating decisions to the right level, to our trusts, to our trust boards, to our communities. The only way you can do that is to lead in a way that supports that delegation of authority and responsibility. And with responsibility comes accountability. It's not an easy gig, but the truth is that that I believe is the only way in a complex system you get the outcomes.

And I think Michael's bit about places and the things that gave him hope. They were things where delegation of responsibility and, and the policy base creating context. You know, I feel I'm as accountable to our front line, and that's the way that I see that job. I'm not always sure that's the way it feels sometimes in England. 

Matthew Taylor

You talked about accountability, so let's talk a little bit about challenge. When I come to Northern Ireland, what is really wonderful is the sense of common purpose, the sense of proximity to things, mutual appreciation, camaraderie. The danger with all of that was a culture which people so often say, well, everybody knows everybody else, is a certain amount of complacency, a lack of kind of rigor, a lack of challenge, you know, you don't want to take on your mates that you might see in the pub or whatever it might be. 

Where do you think this group of people, fantastic people doing amazing work, but where do you want to challenge them? 

Mike Farrah

I think implicitly we're already in that space because what I've said is that this country could have one of the best health systems in the world. That was a thing where people would say, not everybody in this room, because I think people understand some of that, but people would say, you're kidding me. We've got four year waits. Scotland's a two years, England's one year. What on Earth would make you believe that with that is possible. 

And the truth is that we have a lot of fantastic assets that if we brought them together, but ambition and belief, and this goes back to my sporting world, is that you don't start your season thinking, we’ll end mid table. You know, we're at the bottom of the league now; we'll end mid table. You are always pitching for, we are going to be the great, and the challenge has been in Northern Ireland that there's been a little bit of learned helplessness, that our culture's been a bit parent childish. That we've not liberated and empowered and enabled our front line. And so that culture change is really fundamental. The pieces of our reset plan, when you read them, you can read in the ten-year vision, you can read in Spain's plan, you can read in, you know, a lot of the countries' plans around what they propose to do. The difference is do you have a culture and alignment of your kind of ways of working that support it?

And that's the challenge. The challenge in the room is. Can we look at ourselves differently? Minister said it. Can we look at ourselves differently in the way that we've always worked? And it's disruption and it's noisy and it's uncomfortable. And my challenge in the room is that we're always asking ourselves that question, not when I'm in the room, but when everybody's in the room. Is there a better way of doing it? Why we doing it this way? And what can we do differently that's better? And who can we learn from? So the challenge is that, but we have to be ambitious. 

You came to the Confed wanting it to be the best it could be. We've got to believe that we can be the best we can be and there's a bit of belief. I'll never stop asking us to be better. Never stop because there's always work that we can do to be better. And we've got to quantify that, by the way. And we've got to set ourselves those standards and judge ourselves if we can't and look at ourselves if we're not deliberate. That's the great challenge in the room. 

Matthew Taylor

So that brings me a mind of a point that’s got two elements to it, and these are the last two questions I'll be asking you. 

So the two things I wanted to say is, firstly, neighbourhoods. Now, the minister spoke eloquently about neighbourhoods. It's a big part of reset. My view is we will not do neighbourhoods right unless we understand it involves a fundamentally different relationship with patients, a fundamentally different relationship with other public services, and a fundamentally different relationship with communities.

And I kind of want to challenge you by saying, do you get how different things would have to be to make this neighbourhood stuff actually work? 

And then my second question after that will be, as I said, these moments of learning have been moments of pain. And sometimes I think we worry about people's resilience and we feel we can't lead them to those moments of deep learning because it's kind of unfair on them. But I don't think we're doing people favours if we don't. So what's your message about resilience to colleagues?

Mike Farrah

I honestly do believe that the neighbourhood model, I understand the neighbourhood model, and that's in part because I've worked on small pieces of the neighbourhood model that I think we can bring together in different parts of the country and indeed across the world that exhibit exactly what you described. 

So the Wigan can deal. A something for something deal with a population, an unhealthy population, about how can we keep your council tax down if we fund the voluntary sector and yourselves to try and stay healthier. And they saw things like underspending of social care budget, et cetera. Using the resources, using your data to identify where the drivers were coming from in terms of cost pressures.

Focusing in on who those families trusted and your point about a different relationship with the statutory sector. Just as magnified in that particular example where families were having visits from 70, 80 people a fortnight coming into their house, different people asking them different questions. These are troubled, complex families, and they asked those families, who do you actually value who comes into your house? And they ended up with two or three rather than 70, and then they empowered those two or three to be able to be behave holistically.

All things changed as a matter of that because there was a trusting relationship between what the state was offering, whether it's criminal justice, education, help or whatever, and what those families value.

And so those elements we need to build in there. Right at this moment in time, Matthew, we're doing a big consultation exercise, if you like, with people about what do you believe the neighbourhood should be. What some of those fundamentals are hopefully going to come out of that, baked into the way that we do.

So I think we do have a sense of what it is. It's not structural, it's cultural, as well as devolving power, responsibility, and decision making into those communities and joining up some of the public services offer and seeing ourselves as horizontal side. I think we get it. But we'll see whether we can execute it.

In terms of resilience, we're asking a huge amount of people now. I don't know 'cause I can't answer everybody in this room whether or not, as we start to look at the reset, people are thinking, my goodness, this is a fundamental question for me about how I've led in the past, what I believe in the past.

The people who I see most and I'll, I'll talk about 'em 'cause most are in room and they're a fantastic group of our chief execs. And the one thing I've said to our chief execs is if we're changing our culture, it starts, if you like, with you. 'cause being in a parent-child relationship, being the child is quite nice sometimes. You get told what to do and if you don't do okay, you might, but you could, you know, we're asking our chief execs to say, we are going to take responsibility for this whole system along with ourselves and change their mindsets. And we're asking a lot of people, and then that cascade goes through their organisations.

The one thing that I know from my experience today, and I live in Belfast now, and it's one of the most welcoming places in the world. It's just fantastic to live here. And people don’t appreciate what you've got actually, in terms of the warmth and quality, the stunning beauty of the country. I mean, it's just a fantastic place to be. But as people are really determined, when they get a bit between their teeth in Northern Ireland, they're going to do it. And that level of resilience. 

What I need to be mindful of, and if you'd have asked me, my learning journey around my leadership style is. I'm very ambitious. Million miles an hour, right? We go for it and then I look behind and I realise that half the people are out of breath and struggling and not with me.

I've got to recognise that we've got to go at the pace that people can manage, but we've got to be ambitious to get that additional sort of I'm asking people to do extra, but people should need to call out if it's going too fast and they can't. And we need to support people in that journey.

And that matters 'cause we, we haven't invested for the last ten, 15 years in a lot of succession planning, a lot of leadership development. So there's some really key roles that are coming up in senior positions in all our areas of healthcare where we need to be encouraging people to come forward. If they see the leaders falling over, that's not going to be very helpful in terms of encouraging that next generation.

So it really matters alongside the ambition. 

Matthew Taylor

And Louise Casey, who worked on that Trouble Families programme, one of the things that she also said to me was that when families had started to kind of get their act together and get a better support, one of the first things that they did was they asked that family to help another family.

And that was utterly transformative because those people had never been asked to help anybody else, never been trusted to help anybody else, and they took immense pride in being able to help other families go on the journey they've gone on. It reminded me of Richard Titmuss’ judgment of the Labour government, of the post-war era, which is, he said, it's not that we didn't give enough, it's that we didn't ask for enough.

So taking the public on this journey with us is absolutely critical, I think, Mike. 

So, thank you so much for joining me on Health on the Line. 

Mike Farrah

Absolute pleasure. Thank you.

[Audience applause]