Published: 15/12/2005 Volume 115 No. 5986 Page 29

The NHS has bumbled along Micawber-like for decades, but this year the financial regime has changed utterly. The powerful combination of financial imbalance and structural reorganisation in the NHS is prompting some radical shifts in my local health economy.

Recently my consultant colleagues were invited to participate in a GP evening. Not only did they attend at short notice, but they engaged in constructive dialogue about services ranging from out-of-hours emergencies in paediatrics and adult medicine to cardiology and urology.

This was far more powerful in highlighting potential changes than my attempts to frighten the horses at hospital meetings by suggesting new primary care trusts might not want to commission some services at all.

We looked at data from practices which showed wide variations in referral rates - for elective and emergency services. It seemed that some practices, often those furthest from the hospital, were quite self-sufficient, with low referral rates, while others might refer three or four times as many patients relative to the population served.

With the rise in demand in some areas, the possibility of GPs with a special interest acting as a triage was welcomed by consultants.

Not only will we have to look closely at referral patterns. But we will have to define what a particular pathway looks like - from prior investigations, through new appointment to follow-up patterns.

Whatever your view on structural reorganisation, strengthening commissioning in the NHS must make sense. For me the added bonus is that it offers, through practicebased commissioning, an opportunity to engage clinicians across that unhelpful primarysecondary care divide.

The risk in having bigger organisations is that they engage fewer GPs, and those GPs are further away from their local base. For this reason the development of practicebased commissioning - and the clinician engagement that must accompany it - is essential.

New services, which are closer to the patient and more patient friendly, could be designed by consultants and GPs and may be more cost-effective.

New provider services led by nurses and other allied health professionals may also start to compete, which will help to keep all of us on our toes and provide a longoverdue challenge to some fossilised medical practice.

Working together it might be possible to agree the design principles of a service which can be run between the GP surgery and the hospital, involving a multidisciplinary team, as appropriate to the interventions required.

In specialties which are predominantly outpatient-based, clinics in the community might be an effective use of time if a GP with a special interest works alongside a consultant, developing their skills and reducing the numbers of referrals.

With GPs and consultants working together more regularly we will develop a better understanding of each others' contribution - and our limitations. Through that understanding we may just find that referrals are more appropriate and the experience yields a more satisfied patient. .

Professor Hilary Thomas is medical director of Royal Surrey County Hospital trust, winner of the patientcentred care category in this year's HSJ Awards.