England's national director of improvement and efficiency, Jim Easton, has warned that the funding shortage of £15-20 billion over the next five years will require major changes in the way services are provided.

Mr Easton said his aim was to improve productivity through the relentless pursuit of highquality patient care.

He told a meeting at the RCGP: 'There are huge opportunities for primary care to grow and build in a way that delivers the overall quality and financial agenda for the NHS and strengthens primary care.'

This would involve moving care from expensive settings and providing more preventive and out-of-hospital services, he said.

'There is nothing new in that but we have not done it on a transformational scale. So across the whole range of levers that exist nationally, regionally and locally, we are trying to understand how we can pull all the levers at once.'

He said a new mindset was required to tackle the crisis: 'Whether you are running a hospital or a practice, over the past decade you did not have to exhibit massive hunger to do fantastic things and achieve a reasonable return for your business. So it's a profound mindshift for people to be able to say they are prepared to go for quality to sustain the current level of funding.'

Mr Easton said the QOF was a potential target: 'My prediction - which is not a precursor of a policy - is that if we wanted to keep QOF but really drive the standards harder, which on a personal level I can see a strong argument for, then what are the mechanisms that drive people? Is there enough hunger?'

He said that services could be transformed quickly with the appropriate action: 'If colleagues felt it was the right thing to do to transform diabetes services across their patch they could do it in a month and a half. But because there is a lack of energy and support, and the right incentives, it does not happen.'

RCGP chairman Professor Steve Field said many GPs did not understand the depth of the financial problems facing the NHS: 'People see the big figures, but I don't think that below that superficial skin level we actually have a clue about the scale of change needed and what we have to do as individual GPs.'

He said that GPs needed to show leadership and join together into federations of practices to improve quality, professional development and commissioning.

'There are great advantages in federations and I would strongly support their development and roll-out as quickly as possible,' he added.

GPC chairman Dr Laurence Buckman said: 'GPs are good at efficiency, and I think they have been obsessed with quality for a long time. I don't think there is a lot of slack, but you could be more creative, and GPs can help with that. Practice-based commissioning is an obvious target - it has not been as good as it could have been.'

• Hear the full interview with Professor Field in our podcast

Driving Efficiencies
More services to be moved from expensive settings. More preventive and out-of-hospital services. More energy and support for transforming services. GPs need to understand scale of change required at individual, practice and wider levels. Federations of practices to work together on improving quality, professional development and commissioning.