'It is not disagreeing but dissembling that really annoys doctors.'

Choose and book and challenging GP decisions do not tend to combine well to produce a happy clinical workforce. But the experience of Kingston primary care trust suggests that referral management can, if handled correctly, produce some good results for patients, doctors and managers.

Its clinical assessment service, working through and funded by a co-operative of local GPs, is in its first few months of operation but the results are interesting. Referrals to the main hospital provider fell by about a quarter in the first month of operation.

This is compelling when, as our new columnist and PCT chief executive Sophia Christie argues, the gatekeeper function of primary care is under growing pressure as some acute trusts attempt to leverage the new payment system to their advantage. As she says: 'consultant to consultant referrals are the largest growth area in the NHS' - exactly the area the Kingston programme is now moving on to tackle. As its medical director openly admits: 'The consultants are not happy: it's a change in behaviour and a change in culture.'

The lessons for others from Kingston's success so far? GPs haven't been 'engaged' after the fact; they have been central to driving the implementation both in form and goal. Although referral decisions are challenged (about one in six in the first month), responsibility ultimately remains with the GPs making them. And the programme has accepted the controversy associated with demand management and recognised that it is not disagreeing but dissembling that really annoys doctors.

Finally it has built-in obsolescence - it is hoped at least that it will change the pattern of referrals and then disappear.