With its use of selective stories, partial facts and opinion from a restricted range of experts presenting only a narrow range of insights, the current dialogue on priority setting resembles propaganda more than it does debate.

Counterbalancing voices, such as those of primary care trusts and the public health community, are largely absent. Yet it is they who have responsibility for the health of the communities they serve and it is they who face the dilemma of meeting diverse needs fairly.

As a public health consultant working in commissioning, I believe we have only ourselves to blame for this sorry state. I frequently hear expressions of resignation such as "it is impossible" and "we just have to accept political realities" when priority setting is being discussed. If we convince ourselves that clinicians, politicians and the public will never positively engage in issues of scarcity, we risk not fully committing ourselves to changing the situation.

Try harder

While the constant reorganisations have not helped commissioners to tackle priority setting effectively, the real reason we have not succeeded in creating a healthy public debate is that we have not yet properly tried. This is not to diminish the courageous efforts of some individual primary care trusts and people - and I do not use the word courageous idly, because another feature of propaganda is to demonise those who deliver unpleasant messages - but such efforts have been sporadic. There is no co-ordination of message or action among PCTs. In short, there is no collective plan.

PCTs already have the skills needed. Transforming priority setting should be like any other public health programme, aiming to increase knowledge and understanding and change attitudes and behaviours.

The North Karelia project in Finland, which resulted in a dramatic turnaround in health outcomes relating to cardiovascular disease, demonstrates many of the requirements for success: planning and playing a long game, investing time and resources in the change process, adopting a programme approach to making change happen, securing strong leadership and, finally, adopting multifaceted strategies co-ordinated to optimise effect nationally and locally.

Strategic planning

But where do we start? The Primary Care Trust Network could be crucial in providing leadership, co-ordination and a central communications function. Locally, PCTs should increase investment in resources to develop and deliver a long-term priority setting strategy. Such a strategy would include improving local decision making, implementing programme based decision making across all services and promoting professional and public engagement as well as proactive communication with the population served by the PCT on the process and outcomes of priority setting.

So let us engage in good old-fashioned public health activism with a view to securing a balanced debate and creating an environment in which health economies can make decisions in full knowledge of the consequences of the choices they make.