Hakin rejects 'disappointing' reform criticisms

Dame Barbara Hakin has 20 years of experience as a GP. She has also been a primary care trust and strategic health authority chief executive. All good preparation for the role as the Department of Health’s national managing director for commissioning development.

But perhaps she was not prepared for the seemingly endless rows besetting the reforms she is responsible for implementing. Certainly, during her interview with HSJ she grew increasingly irritated with the string of confusions, concerns and controversies dogging the government’s plans.

The latest, highlighted by academics in the past few days, are clauses in the Health Bill which apparently allow consortia to “define entitlement to NHS provision” at their own discretion – potentially limiting the extent of services provided – and to extend patient charges to services they consider non-essential. Dame Barbara appears genuinely incredulous anyone would suggest the prospect.

She says: “Writing a bill is extremely complicated and it has been a privilege for me seeing the amount of work that goes into it.

“[Government] lawyers have spent hours and hours trying to get the right words for the intent [of the policy].

“I find it disappointing that hordes of commentators out there then try and look for where one word might possibly allow for something that nobody intended in the first place.

“Quite frankly if that happened [commissioners attempting to reduce or charge for services] I’m sure the system would intervene.”

Such controversies cause confusion even among the keenest clinical commissioners, and exacerbate everyone else’s doubts. The approach taken by Dame Barbara to tackling such ambiguities is to quash them without hesitation.

Concerns over the reforms already confronted include providers competing on price, and the suggestion that commissioning consortia will not always be public bodies (they will be). But others persist.

GP mini-market

One contentious suggestion currently circulating is that the changes could result in high performing consortia attempting to grow by attracting new patients or practices. It appears to be a potential outcome of the bill, and suggests a dynamic pseudo-market in commissioning that some would like to see.

But Dame Barbara is clear: “I really don’t believe we’re in the era where patients [will] choose practices on the basis of the commissioning of their consortium. My experience is patients are reticent to move even when the provision is awful. It is a leap to think they will do it because of commissioning.”

Practices themselves are also unlikely to shift much between consortia, although she believes that “over time” two or more consortia might decide that it would be “better” if they “pooled their resources”.

And what about the prospect of high performing like-minded GPs grouping together – leaving others within the region who would drag them down excluded, along with their patients? The bill appears permissive but Dame Barbara is adamant, saying it is “very clear a consortium must cover a geographic area”, to account for unregistered populations, making it “almost impossible for consortia to pick and choose” practices.

“It’s almost part of the deal of being a consortium that as a community of practices you help everybody to get better,” she says.

The most persistent of the knotty topics bedevilling the reorganisation is competition, particularly Monitor’s new powers as an economic regulator, and the likely extension of any willing provider rules beyond elective hospital care.

Dame Barbara maintains it is unlikely Monitor’s role will substantively affect how consortia work. Monitor’s focus will be as an “appeal mechanism”, allegedly against anti-competitive behaviour. However, she adds: “We need to make this much more clear.”

Her comments contrast with Monitor’s declarations that it will apply the same approach to NHS services that is taken to the regulation of privatised utilities.

Vision on

Dame Barbara is expected to play an important role in Sir David Nicholson’s emergent NHS Commissioning Board. She is well placed to see the benefits of health secretary Andrew Lansley’s vision – to elevate clinical decision making – but also recognises the need to build a better all round commissioning system as part of the reforms.

She emphasises the changes are “not about undermining all the great things management have done”. Managers are “absolutely critical to improving patient care”, but: “We have just got to get a lot more clinical leadership.”

The picture emerging is for consortia to focus quite narrowly on the clinical fundamentals. The authorisation process for each consortium to begin commissioning will focus specifically on “clinical added value”, Dame Barbara says. “[That] has to be the main thing we see from consortia.”

Meanwhile routine management – contracting, for example, will almost all be farmed out.

It is these day-to-day tasks which were detailed in the wide ranging competencies of the now defunct world class commissioning assurance scheme. Commissioning support units, which will develop from PCT cluster groups, will, at least initially, be the main suppliers of this service to consortia. Dame Barbara reveals support units themselves face an authorisation process similar to the world class commissioning process.

She says the expectation from emerging consortia is they will “buy in a considerable amount of support” from the units. “We need to be comfortable the commissioning support is as fully competent as the consortia themselves.” For support units, assurance will be “focusing on those broader aspects of commissioning which were heavily featured in world class commissioning”.

Plenty of time

One of the many enormous barriers to the success of the reforms is the almost complete lack of preparedness of GPs in some areas to take on commissioning. Dame Barbara does not dispute the regional variation. But does it matter?

“We’ve got quite a long time,” she says. “We would like to see all consortia fully authorised by April 2013 but we have contingencies if they aren’t. We have two years to go. I would rather these organisations were right than they were rushed.”

It is an approach supported by many GP leaders, who are keen not to be pressured by PCTs into fixing, for example, the size and governance arrangements of consortia before they are ready.

However, a second somewhat conflicting demon confronting delivery of the reforms is the risk that the current holders of power – the national NHS management, PCT leaders and strategic health authorities – will not “let go”. Enthusiasts for the reforms have warned GPs could “walk away” if they don’t see things changing.

In particular they have warned that some of the newly formed PCT clusters are threatening good relationships between GPs and individual PCTs, and prioritising grip on short term performance over liberating GP commissioners.

Dame Barbara’s team have been talking directly to GPs “as much as we can to overcome” such problems.

Her answer is to stress PCT clusters are “incubators” for future organisations, but that their own life is strictly time limited. She states firmly: “This is not the creation of a new intermediate tier that goes on forever. These are transition vehicles which will deliver for today and the next 18 months, but then are completely changed out of all recognition – they do not prevail.”

Turning PCTs into clusters was not mentioned in the government’s white paper proposals, and is the classic decision taken on the hop to try to make policy work.

Dame Barbara’s approach suggests that, if the implementation is to succeed, there will need to be more such decisions.