With his traditional bow tie and emollient manner, Dr Michael Dixon is the ultimate gentleman GP. But today he is visibly furious.
‘It is scandalously unfair and dictatorial,’ he says. ‘We still have all the old barons in place telling us what to do. Yet there is no recognition that CCGs are meant to be statutory organisations.’
He has just learned that those CCGs who have failed to agree contracts with their local hospitals will be hauled up to explain themselves in front of NHS England and – of all people – the representative body of hospital trusts.
It’s a very specific example, of most immediate concern to GPs heavily involved in commissioning. But as he dissects the impact of the NHS reforms, it’s a theme that comes up again and again. A year after GPs in England took the commissioning reins from PCTs, Dr Dixon is clearly very frustrated that the centre is still throwing its weight around and CCGs have not been given the freedom to enact real change.
He says: ‘For heaven’s sakes, they are statutory organisations. Let them lead and their leaders lead – don’t constrain them and make up a whole set of rules that stop them doing what they are designed to do.’
Friend of the Prince of Wales and one of the most prominent cheerleaders for the Government’s NHS reforms, Dr Dixon is sometimes seen as an establishment figure. But today, he is very much seeking to tear down a system he believes is stacked against GPs.
‘Constrained by the system’
He cites payment by results, competition regulations and the power of secondary care as major barriers to CCGs exerting their power.
‘It has been a good year in that CCGs have been achieving within the limits they have been given,’ he says. ‘However, have they been given their wings properly? The answer is no, as they are still constrained by the system that was designed for a centralist grip and which is secondary-care dominated and on the whole does not take account of general practice at all.
‘Hence the continued underfunding and general practice being in many ways bottom of the pile. That’s really got to end.’
Dr Dixon warns that there is a real risk that NHS England’s heavy-handed approach to managing GP practices and the continued underfunding of the profession will undermine GPs’ will to take part in commissioning.
‘NHS England is not getting it, because it is not sufficiently connected with the hind brain, if you like, of your average GP or nurse,’ he says.
‘The vested interests of centralism and secondary care are the two things that threaten to destroy all we are trying to
do with primary care commissioning.’
Is the situation worse than it was under PCTs? ‘I think it is in danger of getting worse,’ he replies. ‘All we have seen in the first year of NHS England commissioning is them paying the bills – or sometimes not paying the bills. What we have not seen is inventive commissioning.’
In many cases, says Dr Dixon, local area teams have been acting like the ‘old bully boys’ rather than working with local GPs. But he sees hope in the agreements made in some areas to ditch QOF reporting for the last part of 2013/14 to allow GPs time to look at redesigning primary care.
He says: ‘I do see a silent revolution among local offices, who are beginning to get the plot of primary care-focused, local, clinically led commissioning. They are beginning to work with their CCGs and to have a productive local discussion, rather than being the lackeys of the centre, which they weren’t meant to be in the first place.’
Dr Dixon offers a compelling vision of how GPs can shift more care outside hospital, managing intermediate care beds and forging closer links with district nurses, mental health teams and social care. But he describes the current situation as ‘fighting with treacle’ and warns that more funding for practices is essential.
He says: ‘I witness every day the pressure that we are under. Yesterday I was the emergency doctor in our practice and having finished morning surgery and done two visits, I had 45 calls, a further 10 consultations, one emergency visit and had to organise one patient’s terminal care and the admission of two others.
‘General practice is in danger of becoming a sweatshop where we are simply fire-fighting. If we are going to become good proactive commissioners, we have got to have more GPs and headroom in terms of resources.’
He has no truck with all the warnings over privatisation, saying simply that markets are ‘inevitable’. But he warns GPs to be wary of muscular foundation trusts using their vast resources to gobble up primary care contracts and move towards a salaried GP service.
‘I think that there are some people in Whitehall who possibly see the future as being foundation trusts employing GPs,’ he warns darkly.
He is enthusiastic about NHS England’s move towards joint commissioning of GP practices with CCGs, batting away BMA concerns that it will lead to accusations of conflict of interest.
He says: ‘We want the contract to stay with NHS England, but when it comes to how you improve and resource primary care then I think the CCGs should be in a commanding position. Because the CCG understands primary care, because GPs are running them, whereas the local office is often fairly under-resourced in terms of people and local knowledge.’
As we reach the end of the interview, Dr Dixon begins to sound more upbeat again. He says CCGs have proved themselves capable of making sensible changes in difficult financial times – despite often being the ‘fall guy’ for overspends or other legacy debts from elsewhere in the NHS – and have ‘run it better than the previous lot’.
But even allowing for the positives from the past year, Dr Dixon’s message is clear: ‘Commissioning can work and it can have leverage, but it cannot be straight-jacketed by all sorts of competition and other rules from NHS England. It must be allowed to make up its own rules.
‘Either the commissioner is in charge, as the statutory body, or it won’t work.’