Published: 17/04/2003, Volume II3, No. 5851 Page 18

Our predecessors would have been astonished by the strength of the national agenda in today's NHS. The 'Lords of Trent' under whose influence I grew up - Ken Sumner of Sheffield, Martin Kennedy of Chesterfield, Howard Chubb of Derby - knew that they would not be troubled by outside influence unless they lost control of the money or took too close an interest in matron!

Today's national agenda has many benefits - consistency, coherence and delivery of improvement, to name just three.

However, it is essential that it is balanced by local focus.

Managers who give themselves unreservedly to the national agenda may serve themselves but will not serve their community.

The best balance to the national agenda is to develop our relationship with local government. In the past we went through a long and sometimes painful divorce.

In 1948, local authorities lost their municipal hospitals. In 1974, they lost their medical officers of health, ambulance and community nursing services.

In Conservative health minister Ken Clarke's reforms, they lost their rights to representation on health authorities.

This is the time to rebuild the historic interdependence. If we think carefully about the factors that affect health, we realise many of them are the responsibility of local authorities - social services, education, housing, air quality and other aspects of the environment. The public service agreements for the Department of Health and local government emphasise this.

How can we care adequately for children, older people, and those with mental illness and learning and physical disability unless we are committed to true joint working? Action on substance misuse and criminal justice depends absolutely on joint working in drug action teams, community safety and youth offending.

NHS managers have much to learn from best practice in local government, including working with elected members, community development and involvement and best value. The governance arrangements for foundation hospitals will not succeed unless NHS managers can break free from the appointments culture and learn to work with the democratic process - however limited.

The best primary care trusts are already showing the way, bringing the NHS and local government closer than at any time since 1948.

They are playing a lead role in local strategic partnerships, making joint appointments at senior levels, putting patients, clients, carers and community before organisational boundaries and rivalry.

The advent of some form of regionalism will also demand the closest possible relationships between health and local government. Chief medical officer Sir Liam Donaldson's shrewd move in placing regional directors of public health within the government offices for the regions builds the bridge to regional assemblies, regional development agencies and directly elected regional government in at least some parts of England.

We should not seek to undermine national accountability or delivery of the coherent national agenda we now have.However, we need to build local ownership and accountability.We also need to develop our own checklist:

Do we work well with all aspects of local government - not just with social services?

Are we fully involved in Sure Start?

Does joint working help or hinder community nurses, social workers, probation officers, police officers, teachers, housing agencies and voluntary sector workers?

Do we give the impression that we are part of some mighty edifice (Nye Bevan's description of the NHS in 1948) immune from local influence?

Have we understood the potential of PCTs, foundation hospitals and regional government to reverse decades of centralisation?

What about the implications of all this for the careers of NHS managers? Is it possible that, provided we are willing to learn with humility, we might be strong candidates for chief executive and other senior roles in local government?

From 1971-74, I worked for United Sheffield Hospitals - with a board of governors that reported directly to the Department of Health.Despite this apparent exclusivity, I felt very much part of the local community.Our members included senior members of Sheffield city council. I was a secretary of a constituency Labour Party, a member of the trades council. I felt as though I belonged with the people I served.

The best PCTs are already exceeding that experience.

Foundation hospitals, provided they welcome limited democracy rather than seek to avoid it, have a great opportunity.We should go back to our roots and leave behind the inappropriate managerialism which has separated us for too long from our partners in local service.

Ken Jarrold is chair and chief executive of County Durham and Tees Valley strategic health authority.