As one of HSJ's greatest fans, I would like to comment on your otherwise excellent leader, 'Aggrieved GPs take a back seat in the new NHS' (comment, 25 February).

You are right that many GPs will see the latest guidance on primary care groups as a government climb-down, but it is nothing of the sort. GP representation in a PCG responsible to the health authority as a sub-committee will be exactly the same as GP representation on a primary care trust executive answerable to the PCT board. The only difference is that the PCT board may be more locally accountable than the HA board. Your point is well made that there has to be a balance between clinician input and accountability to patients, the local population, the wider NHS and the taxpayer. The truth is that GPs never have been, and were never going to be, able to 'dictate the future direction of the NHS', but neither is it wise to keep clinicians at arm's length in decision making. If they are marginalised, the essential ingredients of the new system - ownership, mutual trust and inclusiveness - will be lost.

We will be back to 'them' and 'us' and the dysfunctional relationships between clinicians and managers that have been the hallmark of previous systems. Of course, there are islands of arrogance both among GPs and managers. None of us should be exposed to their whims.

As for a PCG proceeding to a PCT, GPs are being given something far closer to a veto than you suggest. No PCT will succeed without the support of most GPs or all the other stakeholders. There is no analogy with hospitals moving to trust status or practices entering fundholding. Partnership, not power-mongering, must be the order of the day, and the NHS PCG Alliance will be a fierce defender of any PCG that feels it is being bribed, bamboozled or steamrollered into becoming a PCT.

You clearly regard independent contractor status as a self-indulgent dinosaur. True, it does not work in some places - especially inner cities - but they will probably be the last to get PCT status. Independent contractor status probably makes GPs longer-serving and more involved advocates of their individual patients and local populations. The US experience suggests such autonomy is important if clinicians are to sign up to effective schemes for demand management, which will dominate PCG work over the next few years. It is also cost-effective, which may be why those in charge of the NHS seem to be reassuring us that PCTs pose no threat to it.

PCGs and PCTs will work because they represent different and often autonomous agencies. General practice will change if it is line-managed from the top.

GPs and managers have been polarised for too long. There is no room in the new NHS for the 'them and us' philosophy. Both need to change their mindsets. Where they have worked successfully together, they have been able to effect real change and maintain accountability both to patients and the NHS. The integration of primary care, however, does require outsiders to better understand what sort of animal they are dealing with.

Dr Michael Dixon


NHS PCG Alliance