Published: 08/12/2005 Volume 115 No. 5985 Page 33

While it is normally best for senior primary care trust managers to keep out of capital 'P' politics, in periods of great uncertainty and change it is appropriate for some of us who have been round the track before to push some thoughts up the food chain.

Perhaps it is time to raise people's eyes a bit, to recall the 'nobleness' of our calling to work in the NHS.

Sometimes we take this spirit for granted. It sounds too grand a phrase for hard-bitten practitioners on the ground; too airy-fairy a concept when faced with practical, everyday tasks in providing services and hitting targets.

But I make no apology for using it. It might even help us to remember why we are here in the first place.

We all know the three options that have been mooted for the provision of PCT services: back to the acute/ foundation trust's control; working even more closely with GPs; or a third option of handing over the entire child and adult service provision to other bodies, for example the independent sector.

What about a fourth way? A way that may be particularly relevant, especially bearing in mind that PCTs in some areas are already heavily involved in community development and regeneration above and beyond their normal roles.

This option is about keeping the NHS public service ethos alive, retaining that level of 'localness' in provision and in meaningful contact between provider and client.

Bigger is not always best. Private is not exclusively more efficient when we are talking about concepts such as care and community involvement. And distance of provision does not always make the local heart grow fonder.

Taking this concept further, some highly successful organisations deliver excellent service by being creative. We all know that cash savings are said to be the driving force of the latest health reform ideas.

All well and good, but many forwardthinking organisations know there are different ways of working and investing that bring a better overall result. It may not show immediately on the balance sheet, but it can pay off handsomely in the public's perception about the organisation involved. Ethical and moral considerations can help produce a more meaningful and long-term return on investment.

I am thinking of Merck's decision to provide cheaper drugs to developing nations; or Starbucks choosing to pay a premium for fair trade coffee.

In my patch we do business with the Eric Wright Group of builders, which is constructing our new health centres through our award-winning publicprivate local improvement finance trust initiative.

Apart from being a local firm with a local workforce, it also uses part of its profits to provide facilities in the Lake District for under-privileged children from Lancashire. Sound thinking, sound values.

When people know all this, they seem quite willing to value and embrace these organisations.

We like to think that our PCT's success story has led to equally high local esteem. So would the folk in East Lancashire be willing to see slightlyreduced savings to the public purse in return for keeping their strong PCT-led community health services intact? I strongly suspect they might.

Perhaps our political masters might take this on board when they consider bringing in changes in service provision.

David Peat is chief executive of Burnley, Pendle and Rossendale PCT, winner of the Secretary of State's Award at the 2004 HSJ Awards.

HSJ is organising a conference on practice-based commissioning on 13 December. For more information visit www. hsj-gpcommissioning. co. uk