So is general practice becoming a case of ‘them and us'? NHS Alliance chair Dr Michael Dixon warns we could be heading in that direction if clinical commissioning groups (CCGs) continue to place crude numerical limits on GP referral rates.
Certainly, the cases we uncover this week don't look good. Four referrals a week? One physio referral per condition per year?
These are the kind of mechanical, managerial restrictions you might expect to be set by one of the more dinosaur-like PCTs, rather than by GP on GP.
The GPC has been vocal about the developing situation within some CCGs, warning it is alarmed by the ‘micromanagement' and lack of democratic opportunity in certain areas.
Dr Richard Vautrey, GPC deputy chair and himself chair of a CCG, was uncharacteristically outspoken on the referral limits being employed by some GP commissioners this week, warning: ‘This type of simplistic idea of setting quotas at practice level is potentially very dangerous.'
Dr Vautrey is, of course, quite right.
A weekly, per GP, limit for referrals – even one calculated as an average, from an annual referrals budget for each practice – is almost the ultimate arbitrary control on GPs' clinical practice. It makes PCT schemes to cap overall levels of referrals or employ nurse-led referral management centres look almost enlightened.
But the profession, even so, must keep its anger in check, and be wary of sliding towards further division.
Dr Sarah Heyes, clinical director of Redbridge CCG and the GP at the centre of the latest storm over referrals, is hardly your archetypal penny-pinching bureaucrat.
She admits to having had ‘sleepless nights' over whether the new limit could be made to work without affecting patient care. That she pushed ahead regardless is indicative of the pressure GP commissioners are coming under to sort out the financial crisis facing the health service.
Even as they familiarise themselves with their new role, CCGs are having to take some exceptionally difficult decisions – and doing nothing is not an option.
GPs have always drawn strength from their unity. The Government's NHS reforms have already prised open divisions between primary and secondary care, and it would be tragic if they were now allowed to force open rifts in general practice too.
Grassroots GPs must be careful not to automatically cast CCGs as the successors of PCTs – as one GP commissioner writes in our letters section this week, if practices have chosen to sign up to a CCG, enthusiastically or not, they must share some responsibility for the decisions it makes.
But for this collective responsibility to work, CCGs across England must embrace democracy to a degree many have not so far.
A true democratic process will allow toughened discussion and peer review of referral rates, but in the long-term is unlikely to endorse crude referral limits.
Grassroots GPs must be given a democratic say as CCGs face up to brutal Government efficiencies – and they must speak up and make their voice heard to ensure we agree solutions the whole profession can support.