Interview by Andy Cowper, editor,
Health Policy Insight

Michael Dixon is a man of many hats - GP, chair of NHS Alliance, medical politician, defender of alternative medicine, family man; but just as memorably, a man of many bow ties. The bow tie is not rare among medics - for infection control purposes, some say - but Dixon is almost unimaginable without his. It is literally impossible to imagine him in a T-shirt. Indeed, perhaps it’s where he acquired his ability to tie up loose ends in policy and point them back into the vital world of primary care.

On the eve of the NHS Alliance annual conference in Bournemouth, we met to talk about commissioning, provision and competition in primary care – and the developing ‘class divide’ in general practice between partners and non-partners. Healthcare in a recession, top-ups and private equity also feature.

HPI: What are the reasons commissioning is not advancing?
It’s partly due to its lowly starting point. World-class commissioning (WCC) is really the very first serious attempt to get the wagon going, and it will take time before creating ‘bite’ in the system.

Part of it is historical inertia, but other priorities like 18 weeks and (paradoxically) staying in budget have diffused the focus on commissioning. Even though commissioning is the answer to both. WCC is beginning to concentrate minds, but it won’t produce change for many months.

In terms of practice-based commissioning, I fear WCC may not achieve its best effects until the results of the PCT assurance framework are in the public domain in 2010, so we need other means to progress in the meantime.

Some parts of the DH seem pretty nonplussed about commissioning. But the WCC team, and some others like Chris Dowse, DH Head of Urgent Care, have recognised that there’s a disjunction between WCC and PBC. That’s symptomatic of a new honesty about where we’ve got to and what we need to do now, thanks to Mark Britnell and Gary Belfield and their team.

HPI: David Nicholson has famously said he wants the service to ‘look out, not up’.
I know what David means, but at the same time, it’d be nice for parts of the DH to look out, not in.

In the past, the DH has had an Emperor’s new clothes tendency towards self-congratulation and insularity. NHS Alliance were warning them three years ago about huge problems with clinical disengagement from commissioning, and we were told ‘clear off, it’s not an issue’. The rest is history, and now it’s accepted as a huge issue.

Unfortunately, we’ve seen some of the same with PBC. We were warning over a year ago about the lack of impetus in the system to get PBC up and running. It’s a credit to Mark and Gary that that message has now been accepted loud and clear. I’m pretty sure that the national increase in non-elective referrals is partly a symptom of the failure to get PBC up and running quickly and efficiently.

HPI: How can we make practice-based commissioning advance?
PBC is clearly a solution to various NHS problems. So it needs to be given added impetus in the minds of the boards of PCTs, SHAs and the DH. Without PBC, we’ll be trying to balance the NHS books without any realistic means - unless we want a return to big waits, or less access and choice.

To make PBC advance, we need various steps. It’s always helpful for the centre and ministers to reiterate that not only is PBC here to stay, it should be seen as the Number One priority, and not as a poor relation to 18 weeks, balancing the books or generally pleasing the SHA chief executive in other ways of their choice.

HPI: Do you see any ‘quick and dirty’ wins to get PBC moving?
Yes, I think there are some in progress, and there could be more. The DH’s survey of general practices was also a good beginning. It started a year ago, reports monthly, and still shows, sadly, that 25% of practices have no indicative budget; almost 50% have no commissioning plan; and less than 20% of GPs think that PBC has been delivered effectively so far. We’ve had those results, but no-one’s been ‘taken out and shot’ as a result. Why not?

We need to harden up a bit on exactly what each PCT and SHA is doing to ensure that PBC is moving. That means we should ‘take out and shoot’ anyone whose PBC consortia don’t all have indicative budgets and commissioning plans.

We also need to make sure there is a minimum amount of innovative redesign plans going through each commissioning round as a performance standard; and to ensure we get some money to pump-prime would-be innovators. The front line feel as if there’s no spare cash around.

In particular, we must ensure that the Darzi innovation funds go specifically to front-line innovation, and aren’t swallowed in acute trust innovations. We need the innovation funds to be unbureaucratic, and to ensure that their use is properly in line with the aspirations of front-line clinicians and managers; not given out by some remote body who don’t see front-line PBC needs.

HPI: What about management support from PCTs?
More, please! It’s high time to get effective PBC support.

This is partly about making sure PCTs and PBCers are doing business properly over access to the right data and support systems, but partly about non-techie stuff – ensuring peer leadership within each SHA to light the fires among PBCers and PCTs, and ensure PBCers aren’t being repressed and PCTs aren’t being bamboozled. Through peer pressure and nothing else, we could support, flag up and celebrate good practice.

But we need hands-on stuff, not more announcements or bits of central help that may not be relevant to PBCers or PCTs.

HPI: The current vogue seems to be for a redefinition of PBC’s place in and relationship with world-class commissioning?
We need to definitively enunciate what PBC is. Nationally, it ranges widely in practice, from places where the PCT does 100% of commissioning with some advice from local GPs and practices, through to where PBCers set themselves up as almost-entirely independent enterprises to the PCT, expecting the PCT to listen - who may feel, in turn, that their PBCers don’t understand national and local priorities.

Those are extreme examples: we need to articulate a happy medium. We also need to set out the added value of PBC in getting primary care clinicians talking to secondary care colleagues to work out appropriate care pathways, which is still not happening on the whole. Practices remain remote from the secondary care process, which is not a good thing.

We also need to think about PBCers being fully involved in forming PCT local development plans (LDPs) and getting away from some of the rhetoric that PCTs are for strategy and PBC is for implementation. You can’t divide the two: if PBCers are not signed up to the plan, they won’t carry it out.

HPI: WCC director general Mark Britnell told the 2007 Alliance conference “We’re building the (commissioning) system with you, not doing it to you”. Does that seem true?
That’s an accurate description. This iteration of commissioning has been more done with the front line than ‘at’ us, unlike previous attempts.

My concern is that it all seems so laboriously slow. Mark mentioned the support package for PBC in that speech, but the tenders are only just being requested now, one year on. Why has it taken so long?

HPI: You’ve warned in the past about the risks of ‘macho’ commissioning. Is it still a worry? The recent HSJ poll of PCTs, which found two-thirds of respondents hadn’t yet decommissioned a service, suggests otherwise.
It remains a big concern, because if you go back to the late 1990s and the heyday of locality commissioning, and the pilots of primary care groups (PCGs), we brought about change by leaning on a provider with whom we had a close relationship. If that was not coming up trumps, then we used to fish around elsewhere, and if the provider was still not listening, then we went elsewhere. I still see that as the best mechanism to effect change. With secondary care, it’s the only mechanism, and we’ve not yet seen acute trust contracts put out to tender.

For some reason, primary care has opted for a different system – it’s about looking for multiple providers and putting out tenders, which take up lots of energy, NHS money and take staff away from the day job of providing better services. If you have an already adequate provider, why should you fund mending an unbroken machine? There’s a risk the NHS becomes a giant auction house, and we end up employing people who are good at business proposals, tenders and PR men, and that means less money for those doing the real business of patient care.

HPI: Should PCT decisions on polyclinics be referred to the new NHS Co-operation and Competition panel?
I think that’s entirely appropriate. NHS Alliance says that polyclinics (or GP-led 8-8 health centres, if we prefer!) should ideally be brought about in consultation with local people and front-line practitioners. Ideally, they should be created organically, and be integrated - but primarily primary care – organisations, rather than offshoots of primary care.

If a local practice or PBC consortia think a polyclinic has been foisted on them, but fails to serve best use of local resources, then I think there would be a good challenge for a few test cases to get a few core principles out in the open.

At one extreme of this debate, we have some inner-city practices passing from parent to child, where there are issues of closed shops, quality and access. Those probably can be improved by semi-imposition of a polyclinic, which may get local clinical opposition - and patient opposition too, as patients still tend to be faithful to their GPs.

Equally, there are opposite scenarios where a PCT may not listen to front-line practitioners, who give good, locally appropriate and sensitive services closer to patients’ homes, and foist a polyclinic on the locality to fill the quota of one per PCT, to be seen to be in line with the DH and the SHAS, when it’s not what the local population needs. It will be helpful to have someone who discriminates between these scenarios. At the moment, the waters are muddy, and the debate’s ridiculously polarised between those who say the front-line are all always right and never act in self-interest and polyclinics are always a bureaucratic imposition; and those who think polyclinics are the bests use of resources and should be the general model for primary care willy-nilly.

HPI: Why do you think the Government chose to pick a fight with the profession over polyclinics?
I think polyclinics are an answer to an essentially urban and maybe suburban question. There’s a perfectly rational idea that in urban areas with large concentrations of population, to maximise services in the community and devolve provide some devolved secondary care services in primary care, polyclinics have a centralised logic, be it all on one site or in a hub-and-spoke arrangement with existing practices (the predominant model at the moment).

But somehow, that issue became superimposed on the Government and the DH’s thinking that the new GP contract was too generous, and somehow blaming the BMA for it. Unfortunately, the shrapnel means that most GPs feel individually blamed for the very contract that the Government strongly suggested GPs should accept.

There’s been a lot of bad feeling – some at the centre see GPs having had it too good and so think we should be brought to order on improving access and service configuration. GPs too often now feel alienated, and so are sometimes being unreasonable in terms of working to rule about access for extended hours and putting the businesses before their vocation as doctors.

For me, the sadness in this is that I think the large majority of GPs are vocational doctors and don’t want the position or image as businessmen, but if they feel undervalued and viewed as hostile by Government and the DH, it becomes a self-fulfilling prophecy.

The biggest single issue in primary care is how to bring back the sense of community, duty and vocation which have meant that the NHS has always got more than it paid for and especially in GPs’ gatekeeping ensuring best use of money and resource. Look at the increase in non-elective referrals: people seem to be saying ‘if no-one values what we do, why should we bother?’

HPI: Is there a ‘first-class, second-class’ divide in primary care between principals and partners and salaried GPs? If so, what will polyclinics do to that?
I’m afraid, sadly, that there is, - much to the discredit of some of my GP colleagues. A pragmatist would argue that this is simply market forces. There were 164 applicants for my job when I entered general practice as a partner – in the past six or seven years, there have been hardly any partner vacancies. So it took three years for me to come up to parity, but in recent years, people are asking for parity right away.

Now there’s an over-supply of doctors. Not only does that mean there’s no lead-up to parity, some have decided to recruit no new partners but instead have taken on salaried GPs to increase the profits of all remaining partners. Those are the GPs with the mega-salaries. It gives general practice a bad name; demotivates those who can’t get partnerships; and is entirely the wrong direction.

If you create a cadre of alienated GP registrars and locums who find themselves locked out of conventional general practices, then you immediately provide a cheaper workforce for people who want to set up polyclinics

It’s really important that my fellow GPs see that only recruiting salaried employees is writing the death warrant for traditional general practice and for the GP as independent contractor.

HPI: What do you think are the real reasons behind the increase in outpatient referrals?
There are two important aspects. One that’s unvoiced yet, and I have the stats to prove it, is that lower waiting lists lead to greater demand. Looking at own practice referrals, part of increased demand is from people going NHS rather than private – we’ve had a 10% increase in orthopaedic referrals this year.

More generally, if the waiting time to see an orthopaedic consultant is less than to see an in-house community specialist, that leads to GPs lowering the threshold to refer. This means that there may be a minimum waiting time that we don’t want to go below. In NHS South-West, the aim for 8 weeks referral to treatment may be misguided, as it will overheat the system.

With bankrupt banks, falling growth and NHS cash becoming scare, the future problem will be not lack of choice but overheated system and we’ll have to re-learn how to limit demand.

Other aspects such as NICE guidelines are inflating the system. I used to operate on Basel cell carcinoma patients – NICE now makes me refer these patients. With QOF, I must now ensure all patients with heart failure have ECGs, but a few years ago none did. This pursuit of secondary care standards of quality, rather than more pragmatic primary care standards of quality, drives up referrals and makes new demands on the NHS budget.

That's OK when the system's cash-rich; when the system's not, you have to ask yourself if the easily available primary care standard will do, or is it the long wait for the hospital consultant?

I think this will lead to interesting debate over the next few years about risk management. I was brought up as a GP to tolerate uncertainty. Secondary care don’t tend to tolerate uncertainty, each patient has a full range of investigations. We’re tilting to a secondary care perspective (which I think is being led by secondary care thinking, and dare I say it sometimes, a secondary care closed shop thinking in ensuring demand steady), and I think it’s wrong.

HPI: With Darzi plans, do the SHAs simply become the new centre?
Yes. I see SHAs as devolved centralism. Though I applaud the ideas of decentralisation and clinical involvement in Darzi, and it's a great start, there's no cause for complacency. Front-line clinicians remain virgin territory for knowing about Darzi, let alone implementing. have to go futther and better

HPI: What do you think of the arrival of private equity firms like Merrill Lynch (who bought Integrated Dental Holdings) coming in via APMS? Or ECI Partners who own Harmoni, one of whose care home businesses for highly vulnerable children went into administration, leaving a struggle to resettle the kids and returning £20 million to investors? It’s reported that half the bids for polyclinics are from the private sector.
I do have concerns because I would like to see provision in future predicated on what we have now, which is pretty good, rather than turned on its head to large corporates fighting it out -with patients losing out as a result.

My preferred provider is not a large private equity-funded type, but something led by front-line clinicians and managers (specifically a social enterprise), keeping faith with the local population and avoiding profiteering from the NHS. More than anything , this strengthens the idea of NHS as being about patients, the population and clinicians working together as a ‘mutual investco’, improving local community health and services.

Co-ownership is important at every level, whether to individual patient health, or to the clinician trying to improve local services, or to the local community trying to use resources. Too much private equity-type involvement will lead to demand inflation, profit inflation and loss of the mutual good-will factor between patient GPs, managers and the NHS

HPI: You’re a senior fellow of the Kings Fund. How do you feel about its FESC partnership with Ernst and Young and UnitedHealth?
What is the problem if they’re not doing provision? As a commissioner for my PCT and PBC, I just want to go to people who can best satisfy my commissioning needs. Compromises start occurring when those who are advising on commissioning also want to be providers within a health economy.

One NHS Alliance principle is that while we work with a number of private industry colleagues, in our commissioning support work, we only partner with those who want commissioning involvement. We don’t work with people who want to do provision.

HPI: What are the knock-on effects of a recession on general practice?
In the short term, a lack of general growth in NHS and general practice in particular. A problem about how to curtail referrals to secondary care. Referral management Centres (RMCs) are already coming back in a big way – the issue here is whether RMCs are co-owned by local practitioners, or are part of rationing demand from above. Hopefully, the former.

I think oddly, less available finance will enhance the GP role in long term, as our cost remains very low compared to any others service in the NHS and to other countries.

GPs are uniquely able to demand-manage the system to get patients what they need, and to give those less need access to other services. Only a GP can balance looking after the patients they see as their best advocate, but also make their decisions on resource use with proper concern for all their patients.

Any answer to resource shortage is always in general practice, as it’s infinitely expandable. GPs always had to meet demand coming in the door, by hook or crook, even if they were not always desperately accessible. For the last 60 years in the NHS we’ve continued to meet demand, be it flu epidemic, ill partners or rain leaking in – we’ve always managed.

As an elastic part of the system, I think it’s particularly evident to GPs when demand outstrips supply.

HPI: Are you comfortable with the arrival of top-ups in the NHS?
Yes, I think they are quite inevitable. It’s interesting, we had a large internal Alliance debate, polarised between public health people being very opposed due to their population approach, and front-line clinicians being generally in favour and unclear why an individual who could afford a top-up has to lose out.

The very rich never lose out, but the middling rich could only have a top-up if they’re otherwise looked after by the NHS. In general, I accept it’s the way things are going. Patients used to have to pay for fertility treatment, and have for over 50 years paid prescription charges. However, our submission to the Richards review specifies that we must not allow NHS to become a sump service, and not provide less because there are top-ups - and NHS patients who can’t afford top-ups should not bear any associated costs of those who can. We also feel there should be some contingency fund for those who can’t afford top-ups, with contributions by the pharma industry, to allow help for the indigent.

HPI: Doesn’t that just mean the return of the 'panel patient'?
Possibly.

HPI: Would you say that medical self-regulation is any more fixed than when we did an interview in 2007, when you admitted doctors don’t really like regulating each other?
Things have been moving very fast since them. We’ve got GMC revalidation and some hardening of yearly appraisals, and with Darzi, the national licensing system practice accreditation for general practice, which will vastly increase the ante in general practice, and assure patients that every practise and every GP is of a certain minimum quality standard.