Dame Barbara Hakin is the ultimate poacher turned gamekeeper. A GP for 20 years, she then became the NHS Employers lead negotiator for the new GP contract until 2008. But this year could be a landmark in her wide-ranging career.
On 1 April, CCGs – led by GPs – will take control of budgets worth £63bn in the biggest shake-up of the NHS since its birth in 1948. Dame Barbara, in her role as managing director of commissioning development at the NHS Commissioning Board, will be the person overseeing it.
Dame Barbara has a tough job ahead of her amid signs that GPs are losing their enthusiasm for participating in the reforms.
The GPC warns the Government’s imposition of the GP contract in April will drain the energy and will of GPs to lead CCGs and the test-case of Lewisham A&E is highlighting the powerlessness that some CCG leaders feel in the face of large-scale hospital reconfigurations.
A Pulse survey of 226 GPs showed last year that 52% were willing to boycott commissioning in response to contract changes while the BMA annual conference last year called on GPC to consider a boycott in response to the Government’s pensions reform.
Sitting in the monolithic mothership that is the Board’s headquarters within Quarry House in Leeds, Dame Barbara is sanguine. Any commissioning boycott over the contract changes ‘would be a concern’, but she is confident that GPs still have the heart to lead CCGs.
She says: ‘As I get out and about, I find that the majority of CCGs and practices still want to be involved in commissioning and have an influence on making changes for their patients,’ she says. ‘Some of them have more time for commissioning than others.’
Dame Barbara is equally unperturbed by the controversy caused by the revelation that member practices would be bound by their constitutions, whether they signed them or not. She says that as long as the CCG is supported by the ‘broad church of general practice’ then the Board is happy to authorise it.
She says: ‘In any system, you will have enthusiasts, a large group of people who are happy to go along with things, but perhaps don’t want to lead the charge, and a small number who have a problem with what the majority want to do.
‘It would have been quite wrong for us to say CCGs should have every member practice signing the constitution. That was one way in which a CCG could show it had every practice engaged, but we did do a range of other things to make sure they had strong clinical engagement, such as the 360 degree feedback, for example. So the judgement was much more about “is this a true membership organisation?”’
Despite this, in some cases CCGs struggled to get literal sign up from GPs, with practices refusing to put their names to their constitutions. But Dame Barbara is clear those practices have ‘real concerns’ must seek change from within: ‘It is difficult to influence something from the outside.
‘Every practice has to identify an individual who will relate to the CCG so I think the practices who have concerns should engage through these mechanisms.’
Conflicts of interest
Dame Barbara emphasises that it will be the whole of the NHS that will benefit from GPs being involved in the commissioning process: ‘It is important to remember that GPs are amongst the most trusted people in a community,’ she says – a plus for CCGs looking to make sometimes controversial changes to services.
But there are potential dangers that could erode this trust. A Pulse investigation in December revealed one in five CCG board members has a financial interest in potential NHS providers, which could lead to perceptions of conflict of interest.
‘GPs have earned the public trust but it takes hard work and CCG boards need to continue to earn that trust by making sure that their processes are transparent and open,’ Dame Barbara says.
‘If they do have a conflict of interest, they have to demonstrate how they are not taking part in that particular aspect of decision making.’
Another potential weakening of this trust could come when GPs are forced to refuse patients treatment because of rationing. The case in Slough, where a couple are suing health secretary Jeremy Hunt over their PCT’s to refuse IVF treatment because of the woman’s age, could prove a template for cases against CCGs.
‘All of us who work for the NHS really want to make sure we have equal services in the right circumstances for patients,’ Dame Barbara says. ‘There are times when decisions are based on local needs and circumstances. But we will be working with CCGs to ensure there is a consistent approach for patients.’
No GP ‘bonuses’
Dame Barbara is very clear that one potential public relations problem – the quality premium – is going to be strictly administered to make sure it is not seen as a ‘bonus’ for GPs.
She says the Board has recommended that CCGs should be blocked from simply handing the payment, made to CCGs for meeting their targets, to GP practices.
She says: ‘The final definition of the regulations will be put before Parliament. But we are recommending that the quality premium can only be used to improve services for patients.’
If the Board’s recommendations are approved by Parliament, CCGs will be able to develop improvement programmes from the premium payments that include financial incentives paid to practices who meet improvement targets in a specific area, such as diabetes.
One of the major items in Dame Barbara’s in box is ensuring that nascent CCGs get through authorisation. So far she has been successful, with all of the first and second wave of CCGs – bar one CCG that asked for a delay – have been declared fit.
But, of the 101 CCGs authorised in waves one and two, only 27 have been authorised without any conditions. For the rest, the majority have been given conditions that consist of extra guidance, but some have been given higher-level conditions that involve troubleshooters being forced on CCGs.
Despite fears these harsh conditions would erode the concept of clinical commissioning. Dame Barbara says CCGs have been ‘comfortable with their conditions’.
‘The whole of the authorisation process has been designed to be developmental but also designed to make sure that the commissioning of services are safe,’ Dame Barbara says.
‘The responsibilities of these organisations are massive. They are going to be responsible for a huge amount of money we all pay to make sure we have this NHS delivers services free at the point of need.’