'The clinical engagement bit,' says Dr James Kingsland, 'has ultimately scuppered every attempt at NHS reform.'
Throughout his 25-year career as a GP in Wirral, Merseyside, the NHS clinical commissioning community lead says there has been scarcely a moment when the merry-go-round of reform has stopped.
Days ahead of a financial year in which yet another NHS overhaul takes effect, Dr Kingsland sits in a small, functional office in the Medical Society of London building in central London.
Fundholding, practice-based commissioning, even primary care groups - the predecessors to PCTs - achieved high levels of GP engagement at times, he argues. But each eventually came a cropper, bringing GP enthusiasm down with them as they toppled.
'Every time, we have lost clinical engagement, clinical thought processes, clinical leadership in how services are delivered, and we've ended up with inefficiencies,' he says.
A keen advocate of GP commissioning, Dr Kingsland has previously said that a 'GP with a budget is worth 10 on a committee'. So it's no surprise to hear him highlight the importance of clinical engagement in CCGs.
But what is striking is his argument that it isn't just CCGs that need GPs - the reverse is also true.
Dr Kingsland acknowledges the risk that GPs under pressure from rising workload could feel they have no choice but to withdraw from commissioning.
He accepts too that the jury is still out on whether CCGs will turn out dramatically different from PCTs.
But he is adamant that far from being a drain on GP resources, successful CCGs could be nothing less than the saviours of list-based, independent contractor general practice and a vital bulwark against ever-increasing workload.
Many GPs will take some convincing, believing the profession is simply being set up to take the flak for tough decisions at a time of severe belt-tightening. For Dr Kingsland, however, this is missing the point.
He points out that if a GP practice turns over something like £1m on average a year, a further £7m or so is spent on NHS care for patients registered with each practice.
'The inefficiency in how that £7m is deployed compared with the £1m is incredible,' he says. The Holy Grail for the NHS is tapping into the small business mindset that allows practices to make a profit from that £1m while delivering the services patients need, and exporting it to 'large organisations, at scale'.
Tough decisions will be an inevitable part of this, he admits.
Dr Kingsland is clear that rethinking NHS staffing and where services are delivered, then 'releasing money from estates', will be key.
'We have to close outpatients,' he says. Hospital wards may be downsized too if admissions and length of stays are cut, he adds. 'If we don't have that discussion at the very early stage of CCGs, all we will do is recreate the marginal attempts and notional release of resource that PCTs did.'
If practices can help unlock this funding, it could transform primary care built around GPs' registered lists, he says.
Where practices are struggling with workload, it is often the case that some of the work could be done by other professionals, says Dr Kingsland. CCGs can facilitate this.
'With a registered population, you can analyse how many people will come through your door each year. You can then profile the care needed and build a team to deliver it.
'You might say: "We need more healthcare assistants and nurses." You resource this by releasing money from other sectors, then the GP starts to say: "I used to see 20 patients for 10 minutes each, now I see 10 patients for 15 minutes each.".'
Dr Kingsland gives another example, explaining: 'You say to the practice, your patient is being reviewed three times a year in rheumatology by a junior doctor. That costs £1,000. If you do it in the practice, we'll spend the £1,000 on district nursing to be deployed around your registered list, so some of your work will be delivered by the district nursing team.'
Moving work into primary care may not translate into practice income, but into extra resources. This is where GPs must take a leap of faith.
Dr Kingsland wants the NHS Commissioning Board to make clear that 'investment in primary and community care' is part of CCGs' remit, even if it does not want rising GP profits.
As data becomes available, GPs will be able to track patients, drive up savings to redeploy and find it easier to monitor secondary care quality, he believes.
In year one, he says progress for CCGs will simply be having GPs on board. If they haven't done it by year two, a new government could come along and decide to crank up the merry-go-round all over again.