The Urban Trust Network's enthusiasm for the creation of primary care trusts - coupled with its warning this week that a proliferation of small PCTS could destabilise community health services - is a welcome intervention in a debate which, to date, has been dominated by GPs (see news, page 6-7).

There is, of course, little evidence either way on the 'best' size for a PCT, and the guidance due out later this month from the Department of Health will offer no definitive answers. But at least now there is a counterweight to the GP lobby, a substantial part of which has been uneasy at working in primary care groups for fear of losing its independence, and which would appear to find the idea of being subsumed into a still-larger organisation anathema.

The 'small is beautiful' viewpoint has much in its favour, but those who have despaired down the years at the fragmentation of primary care are understandably anxious to ensure that it is not exported to the wider health service.

Not that events of the past week or so will make debate, still less progress, easy. Even leaving aside prime minister Tony Blair's inept generalisations about public sector workers as a whole, the specific relationship between the doctors and the government has sunk to a nadir.

British Medical Association chair Dr Ian Bogle made clear last week that he and his colleagues feel excluded from policy-making and believe themselves to be regarded with suspicion in Whitehall (see news focus, page 12-13). But then, given the catalogue of issues on which the BMA's conference decided to condemn and vilify the government, it should come as little surprise when its leaders are not exactly welcomed with open arms.

It is not a good base on which to construct a reformed NHS. But it does rather look as if ministers are aware that every reform of the past 51 years has come despite the leadership of the medical profession and are fully intent on doing something about it this time round.

GPs believe rightly that NHS Direct and the advent of walk-in primary care centres threaten their gatekeeper role; doctors may also have fears about the implications of consultant nurses and other aspects of the nursing strategy (see news, pages 2-3). The strategy might be intrinsically the good thing that many in the nursing profession believe it to be, but it also plays its part in DoH-doctor realpolitik - and in this instance serves as a warning shot across the medical profession's bows.

The challenge for managers is to keep the GPs on board as the health service changes all around them.