INTERVIEW – MIKE FARRAR
Clinical input and measuring outcomes
Why PBC needs a stimulus and why regulation needs to understand its limitations
Mike Farrar, chief executive, NHS North West
Interview by Andy Cowper
There’s a great photo of Mike Farrar from his semi-pro footballing days, getting punched in the face with both hands by a goalkeeper who, we must presume, is going for the clearance of a cross.
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It’s not just a great photo because of the punch - which must have stung a bit at the time. It’s a well-taken picture, which also encapsulates ambition, determination and guts.
NHS North West has been the test-bed for many recent reforms – leading work on commissioning for outcomes, and most recently, piloting the new PCT assurance system for world-class commissioning. Mike Farrar took some time out at the NHS Confederation conference to discuss progress in the north-west.
HPI: Your Healthier Horizons strategy document outlines a move from reformed systems (the home PC approach) to a transformed system (Web 2.0 internet approach). How does your SHA and health economy plan to ‘become the internet’ in practice?
MF: It’s incredibly ambitious, but dialogue about change in the abstract can get a bit grandiose, so it might be helpful to focus on a few practical examples of where and how we might go about making this change.
One way we hope to get things to change is to get commissioners to engage far more with their population about their own health and about their use of the NHS resources - maybe making registered populations membership associates, and sharing information so that people understand the real costs of treatment. You can increase accountability doing things like that, and also by creating more public-facing data. There’s a real ‘information drive’ at present with Bruce Keogh’s work on clinical outcomes, shifting the focus of producing data from a managerial purpose to a clinical one.
But the great challenge is getting the data over to the public in ways they can understand and use. That’s a touchstone issue for us, making health data for the public a living, breathing, moving thing. It’s the promise we’ve made in our regional vision. And the truth is that the traditional health information asymmetry between the professions and the public is inexorably coming to an end. As South Central SHA chief executive Jim Easton pointed out, “ in policy terms whilst we are busy liberalising provision, we must avoid trying to nationalise information”. The NHS can’t control information but maybe it can accredit it, or pick out and point out to good evidence.
We’ve got to tap in to the web 2.0 trend and understand how to work with it; not to try and control it. Information about health is already flowing to the public. Look at whats happening on the high street, with organisations like Boots actively informing the public and providing screening and other preventative interventions like vaccinations; look at 8-9 pages of health coverage in most daily newspapers – not just what’s happening to the NHS in news terms, but things about diet, exercise, participation, wellbeing. And I believe that this trend is in the public interest: so, we have to position ourselves properly to take advantage of it and get thinking about how to capitalise on it to improve the population’s health.
What role does clinical engagement play in your plans?
MF: We can point to structural things, like the North West’s Clinical Leaders Network (which predated Darzi); or the courses for clinical leaders to become senior clinical leaders and general managers. I’d also emphasise our push on practice-based commissioning as the vehicle for clinical engagement in commissioning, which I think the world-class commissioning competencies undervalue a bit.
We’re trying to show that we’re serious about clinicians being involved and making decisions, but you only achieve this if you move from talking about it, to genuinely living it out in practice it. When you measure organisations’ performance, if clinicians have no input, it’s unlikely to be good enough however good the aspirations of management may be. This is a real cultural shift and a different way of doing things: and it starts by tackling senior management attitudes to genuinely allowing clinicians to run services.
Did your Darzi review throw up much that you didn’t expect?
MF: It helped us to articulate our vision better, because we had to set it out for public consumption. We had actually been working on regional strategy prior to the Next Stage Review but Darzi helped us articulate it publicly much more effectively, and brought the clinical community into the same strategic space that we’d been trying to inhabit as the strategic body for the North West.
There weren’t a lot of surprises in what clinicians wanted to do, but it was a timely and helpful reminder to us when they asked us ‘are you going to implement what you’re saying?’ On one occasion a clinician raised the issue that the ‘Maternity Matters’ strategy looked good, but hadn’t been done yet: so could we do that before setting off another new strategy? It’s a fair point.
One down-side was that some of our clinicians were less ambitious and more short term in their outlook than I’d hoped.
Why do you think that was?
MF: I don’t think it was unique to the clinical community. In many cases, we general managers, are the same, especially when the status quo feels pretty reasonable if you enjoy what you’re doing and you’re hitting your national targets. On reflection, it’s quite hard for NHS managers and clinicians to think 10 years ahead.
Looking at a lot of the regional strategies, they feel quite like traditional plans with few surprises. In the North West we tried hard to go for a regional vision rather than a plan, and to add in some tangible first steps, but time will tell if we have succeeded in trying to be more ambitious
How is the progress of commissioning for outcomes changing things?
MF: My speculation is that the final Darzi report will set in train, across the country, the work on payment for quality that we thought it would be good to do and started implementing in NHS North West 18 months ago. Real clinical quality measures tell you about clinical performance, and should lead to significant rewards for organisations who achieve good care. We know it works from our trials in the seven North West pilot sites. So far, it’s been revealing to see real data on clinical performance in five big areas of acute care, and it’s telling us interesting things about the state of NHS clinical care.
When this outcome measurement scheme started in the US, using 31 clinical standards in five big acute conditions, if every appropriate standard was achieved it was classed as ‘perfect care’. In the USA, at the start of the programme, US hospitals were achieving perfect care on only about 50% of occasions. We’ve done preliminary audits in the North West on one of the three cardiac interventions, and found that perfect care was only achieved in 30% of cases. In other words, if people think the national tariff pays for ‘perfect care’, our audit suggests it’s delivered on only about 30% of occasions.
When we have our first full set of national data, I expect the NHS to be below where US hospitals were 3 years ago at the start of the US programme. But it’ll be interesting to see where we do start and how quickly we can catch up.
Will you publish your findings?
MF: We’ve not yet agreed with our trusts about what we publish, other than to say that we do see this becoming publishable data. And it will support our drive for public dialogue and better information on services. We get our first set of results at the end this month, and the first potentially publishable full set at the end of October.
Is practice-based commissioning having a real impact?
MF: No, not yet. Its impact is incredibly variable. I’ve recently met a lot of movers and shakers in practice based commissioning consortia across the region, and found considerably varying levels of engagement.
Nationally, I’ve heard that some PCTs believe practice-based commissioning (PBC) is dead due to the arrival of PCT world-class commissioning. But I think the Darzi review will restate the need to put PBC at the heart of world-class commissioning. There are still some practical technical issues for the Department to address, but PBC is a key vehicle and recently it’s had insufficient attention and focus.
What technical areas of PBC need work?
MF: The big issue is about the conflict of interest between PBC as providers and commissioners. It’s not about restricting consortia’ provision, but about creating a regulatory framework to avoid conflicts of interest and allow demand management initiatives to flourish without unnecessary bureaucracy.
Do we see the world-class commissioning competencies as something to support PBC’s development? Is PBC written large enough in current policy to make it be taken seriously? In my view, PBC could be given a stronger push.
And revealingly when there’s national discussion about the new roles and issues in terms of system management, a lot of people just seem to think ‘park PBC for now and we’ll consider it later’.
Answering Peter Mount’s question on over-regulation, Alan Johnson said it might need to be “boiled down”. Do things feel over-regulated to you?
MF: It clearly feels like that for Peter. The question about regulation is really about how government protects the population. Regulation’s role is to deal with failure in a market environment where we can’t afford to lose the social good of a hospital or practice. I see regulation as having a specific role protecting equity and minimum standards but, I don’t believe that regulation is the right vehicle to stimulate excellence. If it tries to regulate for higher quality than acceptable minimum standards, it can create inappropriate bureaucracy without much value in return.
Regulation should occupy a more appropriate and important space – licensing, minimum standards and dealing with failure - and let the people who are performing have greater freedom to fly .
How is the whole thing feeling at the moment?
MF: It feels like we are all waiting - for Darzi . But waiting around for change or edicts nationally is wrong: we should get on with it.
There is likely to be two years till the next general election and that’s a long time to be speculating on the outcome. Two years is a long time to be inert. The Darzi report and the regional visions give us all a great challenge to deliver. In two years, SHAs need to ensure and demonstrate delivery of health systems that are aligned and delivering our visions.