The fast-moving changes in the NHS, particularly with respect to patients with chronic diseases, are a challenge and will have major financial and practical costs. For these changes to be successful the potential threat posed by PBR, PBC and CAB for smaller acute hospitals needs to be evaluated. Most importantly, bridging the primary and secondary care interface will be essential for the 'new' NHS to be successful. The shape of rheumatology in the future is also likely to depend on the national musculoskeletal strategy due to be published in the coming weeks.