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Limited resources in the NHS is nothing new, but the recent changes and drives from the Department of Health have had a significant impact on the relationships between doctors in primary and secondary care, as well as the roles and services provided. With great change brings great opportunity.
Large egos need to be placed aside as we as a profession take this opportunity to work closely together as a unified team. Most would agree that good teamwork is essential for success, and that respect for all members of the team is paramount. One of us still remember the first clinical attachment at medical school when the Professor of Medicine spoke of the importance of dignity, not only in relation to the patients we treat, but also to those with whom we work. Do not underestimate anyone in the team, he said, not even the cleaners, for without them our workplace would not be safe enough to see patients, and
without patients we would be without a job!

This is easier said than done. Most secondary care colleagues have been affected by the governments drive to move health care into the community. Many hospital Trusts are struggling, and District Hospitals become increasingly under threat as acute care is centralised. GPs appear to be best
placed to inf luence commissioning of health care locally, and many Consultant colleagues have felt powerless to affect any change themselves, having been excluded from the initial discussions.

In this 4th issue of Clinical Focus Primary Care, Dr David Rout, GPwSI in ENT in Bradford, tackles accreditation, calling for a robust process, either at a local or national level, with co-operation from the Primary Care Trusts, local GPs and Consultants. This article is followed by Niki Cartwright and Dr
Chris Monella writing about implementing a GPwSI service, further illustrating the need for all parties involved to work closely and supportively together.

There is a GP with a special interest in Dermatology, who has recently set up a private skin clinic, having promoted himself impressively through the local papers and magazines. How long will it be before others follow suit? And how long will it be before medical insurance companies approach GPwSIs to carry out private work currently done by consultants, but at a lower cost? Do you want to practice in a dog-eats-dog world? Perhaps we already do. Stick your head in the sand at your own peril. The competition out there is everincreasing.