At the Northern Ireland NHS Confederation conference in October, former health secretary Alan Milburn opened his keynote speech with a tribute to Mike Farrar.

‘As you probably know, you’re extremely lucky to have him. He’s an agent for change. And if anyone can reset the health service in Northern Ireland, it’s Mike Farrar.’

Mr Milburn might be a bit biased – he and Mr Farrar (pictured above) are old friends and have worked together for many years – but it is a commonly held view. Mr Farrar’s career (mostly in England) has included high-profile roles as chief executive of the NHS Confederation, chief executive of health authorities in the north-west, Yorkshire and Tees and head of primary care at the Department of Health in London.

In 2013 he set up his own consultancy – but then voluntarily returned to the NHS at the start of the pandemic to work pro bono as deputy CEO at King’s College Hospital, London.

So why, in his 60s – when anyone might think he deserved the chance to wind down a bit – did he agree to be interim permanent secretary of the Northern Ireland Department of Health? The dual role also makes him head of the health and social care service in the worst performing system in the UK.

‘The point about age is a good one,’ he says, ‘I always said that at the point I felt I wasn’t adding value, that would be the point where I would stop. What I was getting back from the consulting work I was doing, more and more widely across the world, was that I was still adding some value. So, when the opportunity came up to come to a whole country like Northern Ireland, where you can really get your arms around it, and really bring some ideas to bear, I felt that Northern Ireland was offering me an opportunity and a privilege to bring some thoughts into play.’

Many of the challenges facing the Northern Ireland health and social care system are global; Mr Farrar points to a worldwide excess of demand over supply in health systems and countries’ inability to meet the health and social care needs of their populations. But – while this isn’t his analysis – few would deny Northern Ireland has its own problems. Its waiting times are notoriously bad, with some languishing seven years or more for treatment from first referral.

The legacy of the Troubles still looms large and has had a major effect on mental health and wellbeing in particular. Structure-wise, high-profile reviews and working groups have made the case that Northern Ireland simply has too many acute hospitals for its size – but very little has changed. And, of course, there’s been a lack of political leadership – since devolution began, the Northern Ireland Assembly has been suspended several times, sometimes for years, generally owing to political disagreements.

Mr Farrar is optimistic, however, that the current direction of travel – underpinned by the latest Reset plan – has been well-received.

‘Others might tell you different, but it feels like there’s been a hugely positive response to these ideas. My belief that we have a great opportunity is borne out by hundreds of people now in Northern Ireland that we could be doing something really special.’

The Reset Plan, published in July, essentially aims to establish a neighbourhood-centred system of health and social care, bringing more services closer to communities.

In other words, very much the same direction as other health systems in the UK and beyond. It’s also pretty honest about the financial pressures facing the health system – something that will be more than familiar to the healthcare workers yet to receive this year’s pay rise (although the money has now been directed) and to GPs who are in dispute with the health department.

Mr Farrar led the team that brought forward the ideas for the plan – a process that also involved a lot of consultation and collaboration with others in the health and social care service, and they are determined it won’t just sit on a shelf.

‘It’s the minister’s plan and obviously the minister is accountable,’ he says. ‘But if anybody’s been around the last two days [at the Northern Ireland NHS Confederation conference] you’ve had 700 people saying, “we’re right behind this”, and it won’t be for want of effort. Put it this way, there’s a real commitment to the plan.

‘And what’s really interesting is that the things we’re proposing aren’t rocket science. You can see them in Sweden, Spain, Australia – all over the world, people are trying to do prevention, earlier intervention, place-based health, standardisation, life sciences investment. The thing for us is getting the culture and the ways of working right to support that because the culture we had was aligned for a different way of working than the one we’ve got now.’

From his many years of experience of working in health services – specifically when leading systems in the north of England – he is only too aware that setting out plans is the easy bit. It’s much harder to implement them, and even harder to ensure they have the intended effect. He is exceptionally honest about that.

‘I’ve done things where I’ve committed, and it’s not quite worked out, and that’s a real warning for me. I’ve been saying for 20-odd years I want to change and reduce health inequalities, and yet, probably apart from a period in South Yorkshire where we did something really impressive around cancer and coronary heart disease that really demonstrably changed health inequalities and life expectancy, most of the other things I’ve done haven’t translated.

‘So, what I would hope is that, first of all, people are behind the reset. But secondly, if we are serious about some of the outcomes we want to see, we can focus on that, because to tackle inequalities you have to move resource – you have to put the resource to people who wouldn’t ordinarily get it, and that means it’s at the expense of people who are currently getting it. You’ve got to be brave, you’ve got to be committed, and you’ve got to work across government and influence.’

That’s the part he feels is the real challenge, he concedes, but he’s determined to make it happen. ‘Like I say, I’ve been saying some of these things for a while and we’ve not quite managed to get there. But maybe this is the last hurrah for me, and I’m determined to do that.’

He loves the job and Northern Ireland, he says. But he stresses that, although there is a real determination in the health services to transform, and in particular to cut waiting times, there are also real challenges. ‘I’ve come in at a time when we’re probably in our most difficult financial situation, and that just takes away some of the things we could do to make really rapid improvement.’

Having said that, he welcomes the progress that’s been made already. For example, between April and September this year, according to the department’s statistics, the number of people waiting more than four years for an outpatient appointment fell by 24 per cent, equivalent to 24,811 fewer patients, and the number of patients waiting more than four years for treatment fell by a third, a fall of 6,683 patients. Over the same period, the service has also ramped up its treatment of red flag or critical patients.

‘The truth is that they [waiting lists] were going in the wrong direction and now they’re starting to come back,’ he says. ‘I’m delighted at the progress but we’re not fools, we know it’s hard. But we get a three-year [funding] allocation next year, so there’s a great opportunity to plan forward and try to get down by the end of these three years to the kind of waiting times that are not damaging people’s health.’

Mr Farrar signed up as interim permanent secretary having committed to staying at least a year, which would take him to April 2026. But he might not be heading home then.

‘There have been some conversations, which are very flattering, about if I want to extend that. I’ve said, “well let’s get a bit closer and see if the proof of the pudding is in the eating”. And if it is, I’m more than prepared to think about staying and that’s in part because I think the job I really want to do is not done. I don’t want to leave a job half-finished. I owe it to the people who are now wanting me to do this to see that to the next stage.’

• Prevention and seeing the citizen as an asset in that task
• Investing in primary care, community care and social care; delivering mental, physical and social healthcare in a joined-up way
• Being as effective and efficient as we can with the resources we have
• Adopting a whole systems approach; to optimise the whole of Northern Ireland’s health and care workforce and estate, and to reduce the level of unwarranted clinical variation
• Maximising digital investment and the strategic use of data
• Exploiting opportunities for research, supporting early adoption of new medical procedures and treatments; with the opportunity to attract the inward investment this brings
• Creating the system and structure that supports collaborative working and decision making.

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