Michael Calnan and colleagues' article adds to our understanding about the interrelationship between key players in the small general practice organisation.

The problems, particularly around the GP manager relationship, come to light in many action-learning programmes we run for practice managers, and regrettably they have been there for far too long.

The challenge for the NHS is in finding ways of doing something about the deficiencies. But the difficulty of doing so - as is so often the case - is in the independent contractor status.

To change what is happening needs first recognition within the 9,000 independent practice units that there is a problem, and then a wish to do something about it.

Nothing in the present NHS management or academic structure is geared to tackling this. Sadly, few practices recognise these problems, or even where they do, are willing or able to do anything about them.

In a cottage industry the concern is often more to do with keeping your own cottage going in your own way rather than taking part in the game run by the 'big house'.

Ray Wilcox Wilcox Penfold Partnership Norwich