Despite three years of London initiative zone funding, the needs of primary care patients in A&E are still not being met, argue Ross Lawrenson and Geraldine Leydon A survey of primary care initiatives in casualty departments in North Thames found confusion over aims and managerial accountability. Nurses and GPs staffing these projects often overrode the triage decisions made by casualty staff. The schemes lacked the information systems required for a full analysis of costs and benefits.