The NHS is often painted as a monolithic giant; ruled from Whitehall with an iron fist. The reality is rather more subtle. Of course, local health services

often look upwards to the NHS headquarters for permission to act, and national targets and initiatives regularly cascade down the system. However, the NHS is better characterised by significant local variation.

Whether or not politicians would like to enforce their will throughout the NHS, the reality is that they cannot. The long arm of the Secretary of State may reach into local NHS boardrooms but it only rarely makes it onto the hospital ward or into the GP surgery.

Politicians and senior NHS management have recently emphasised the need for more local determination. This should be welcomed. And there are signs that this is more than rhetoric. Some serious devolution of decision-making power has taken place over the past few years, most notably foundation hospitals which are now accountable to an independent regulator and locally elected “governors” rather than to central government.

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Next in line are primary care trusts (PCTs), the commissioners of care. Those PCTs which prove their worth will, in future, be rewarded with greater freedom from central control and more discretion in setting targets.

But if Whitehall is to relinquish its control of PCTs, this must leave a democratic vacuum to be filled. The current accountability of ministers and senior NHS management may be imperfect, but it is accountability nonetheless. Simply transferring power from elected politicians to local managers and clinicians would smack of a “technocracy”.

In fact, there is a surprising political consensus. Liberal Democrats and Conservatives have both proposed new forms of local accountability. For his part, Gordon Brown recently committed to exploring ways to improve PCT accountability (currently the subject of Lord Darzi of Denham's review).

There is no shortage of options. Commissioners could become subject to direct democracy with PCT boards elected by local people alongside local councillors. “Foundation PCTs” could be created where local “members” elect governors to hold managers to account.

Alternatively, the NHS could piggyback on the existing local democratic architecture with responsibilities passed over to local authorities, or elected councillors invited to chair PCT boards.

PCT self-determination is also likely to raise a cheer from within the service. But will local NHS leaders feel so comfortable with an increase in local democratic control? Will that mean more, not less, inertia. Could decision-makers facing re-election make a tough call to close a much-loved but outdated facility? Will there be a stand-off between central and local government if local authorities have control?

But how great is the popular demand for more local control? An obvious risk is that new opportunities for democratic engagement will be spurned. Government should tread with care before launching any root and branch reform. A better, if cautious, strategy might be to pilot new approaches in those PCTs that will most enjoy early freedom from national control.

Richard Lewis is a director of Ernst & Young and a senior associate at the King's Fund.

Should Primary Care Trusts be Made More Locally Accountable? by Richard Lewis and Ruth Thorlby, can be downloaded from Thursday at www.kingsfund.org.uk

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