cover art for Episode 17. Backstage with: Dame Barbara Hakin

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Episode 17. Backstage with: Dame Barbara Hakin

Dame Barbara Hakin’s immense personal contribution to the NHS has spanned four decades – as a clinician, manager and national leader.

During her long career she has worked as a GP for 20 years before taking up her first management role in the NHS, first as a Primary Care Trust Chief Executive in Bradford and then as a Strategic Health Authority Chief Executive in the East Midlands. 

She went on to become National Director of Commissioning Operations and Deputy Chief Executive at NHS England, where she helped oversee the establishment of CCGs. Described as Sir David Nicholson’s right-hand woman and a forthright and skilled operator, she has often been depicted as the most influential woman in the NHS during her time there.

In this conversation Barbara provides a fascinating overview of how primary care has evolved over time, as well as advice on leading effectively as the shortest person in most rooms, whether clinical credibility matters, and influencing politicians.

Side note: Given the number of three letter acronyms mentioned, you might find this historical overview and this one useful to look at alongside the conversation. The King's Fund also has some great animations and explainers which might help. Please see a summary of the terms she mentions below too in case it's helpful.


  • Her early journey (3 mins)
  • Work life balance (6 mins)
  • Remaining a doctor and being in management roles (10 mins)
  • Her first experiences of NHS management (16 mins)
  • Being an influencer (21 mins)
  • Having presence and making your voice heard (24 mins)
  • Journey to helping to set up NHS England (28 mins)
  • Imposter syndrome (33 mins)
  • The Health and Social Care Act, and Andrew Lansley (34 mins)
  • Advice on working with politicians (38 mins)
  • Her favourite health minister (41 mins)
  • Her view on integrated care systems and the trajectory of primary care (42.5 mins)
  • Future challenges for primary care post-Covid (48 mins)
  • Final 3 questions - a leader, a book, and top tips (51 mins)

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Here are some explanations of the terms Dame Hakin uses:

Commissioning: the process by which health and care services are planned, purchased and monitored.

Fundholding: In 1991, the Conservatives introduced the purchaser/provider split. Health authorities began to commission (buy) care, and GP fundholding was introduced. Under GP fundholding, GPs held real budgets with which they purchased primarily non-urgent elective and community care for patients; they had the right to keep any savings and had the freedom to deliver new services. Fundholding was not compulsory and applicants initially had to meet a number of criteria to enter into the scheme. Smaller practices could group together to form fundholding consortia. 

PCGs and PCTs: Fundholding and family health authorities were replaced in 1999 with 481 primary care groups (PCGs). In 2000 the government announced that PCGs would become primary care trusts (PCTs).  PCTs were managed by a team of executive directors headed by a chief executive.

PEC: Other board members of the PCT included the chair of the professional executive committee (PEC). This was elected from local GPs, community nurses, pharmacists. Broadly speaking, PECs provided a clinical viewpoint on the strategy and operations of the PCT. 

SHA: In 2002, groups of health authorities were formed called Strategic Health Authorities (SHAs). These were responsible for developing and improving health services in their local area, ensuring quality, measuring performance, and making sure that national priorities were integrated into local plans.

2012 Health and Social Care Act: In 2012, the 10 SHAs and the 152 Primary Care Trusts which looked after services at a local level, were replaced by NHS England and more than 200 Clinical Commissioning Groups. The proposals were primarily the result of policies of the then Secretary of State for Health, Andrew Lansley

ICS: These Integrated care systems (ICSs) are a key part of the NHS long-term plan, and are intended to bring about major changes in how health and care services are planned, paid for and delivered. 

ICSs are partnerships that bring together providers and commissioners of NHS services across a geographical area with local authorities and other local partners, to collectively plan and integrate care to meet the needs of their population. In November 2020, NHS England and NHS Improvement published Integrating care: next steps to building strong and effective integrated care systems across England, which Barbara references towards the end of the podcast.

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