The phrase 'so near yet so far' has never more closely applied to the medical relationship between GPs and hospital consultants. Simply put, most conditions can be managed in primary care but, in more serious instances, we require an expert opinion and refer our patients to consultant colleagues. As little as three years ago, this simple arrangement summed up healthcare, give or take a bit of private practice.
Things have undoubtedly changed. GP-to-consultant contact has become much curtailed. Patient care remains very familiar but the political gulf between our two tribes has widened.
First came the two sets of contract negotiations, which have been exposed to close scrutiny. GPs took a pummelling for over-delivery against targets and the consultant contract has been criticised for failing to influence productivity against greater expense.
Money for old rope on both sides, yet the first gulf came with GPs dropping out-of-hours responsibility. It was not even on the British Medical Association GPs committee's negotiation shortlist until then health secretary Alan Milburn placed it on the table in a bid to get GPs to back the plan.
GPs voted with glee to drop the responsibility, arguably resulting in huge influxes of emergency care patients into accident and emergency and acute assessment areas. This decision alone must account more for regional overspends and acute admission trends than any other individual factor.
The second follows from this and the crazy new hobby of a few business-minded GPs who lead practice-based commissioning clusters. The core remit for this has left little room for anything other than recovering local financial balance and contributing to primary care trusts' local delivery plan targets. Lead doctors have rapidly become embroiled in pseudo-corporate roles establishing a 'them and us' culture with acute trusts.
Consultant disbelief must surely come from the assertions that work - and money - should be pulled from their institutions in the interests of patient care pathways, broadly along the themes of the white paper. If 15 per cent of care is more easily provided in the community as a short-term goal, why hasn't this always been the case? At the same time, we have seen increased capacity in local sectors demolishing waiting times, private practice, a training culture and governance issues in equal measure.
Third, we have spawned the much-criticised referral management centres. I'm sure these frustrate patients, GPs, consultants and private industry in equal measure. Frustration may not be the key issue but it adds to the referral gulf, writing to an anonymous specialist at an uncertain department and location. Without peer-reviewed economic analysis supporting such facilities, it seems churlish to build fences between surgeries and hospitals.
The key to all of this must be in the claims for clinical engagement. The premise on which this is founded must be the perception that most doctors have little interest in the corporate roles of the NHS and reform agenda. A lack of understanding on either side only contributes to ludicrous meetings where the only obvious collective truth is self-preservation.
The emergence of combined working arrangements will be the only way for PCTs and acute trusts to resolve financial dilemmas - and doctors who are united would be far better leading at the front than fighting rearguard.