Published: 06/10/2005 Volume 115 No. 5976 Page 18

Yvonne Sawbridge, director of nursing, Burntwood, Lichfield and Tamworth primary care trust; vice-chair and nurse lead, NHS Alliance

The NHS will be different after the implementation of Commissioning a Patient-led NHS, but will it be better? In hospitals, services are geared towards dealing with disease. Many of us chose to work in the community as it appealed to our desire to care for people as individuals.

The problem will be getting new employers to understand these values. If they are ignored, the foundations of community services will be damaged.

The Department of Health is asking community clinical leaders to dismantle a service they are deeply committed to. These same leaders are then being asked to develop management buy-outs or hand their services over to a range of providers.

Former government health advisor Simon Stevens (Opinion, page 15, 11 August) outlines this range of future employers, but fails to recognise the negativity this will engender among community clinicians. Helen Bevan's description of the need for second order change (Good Management, page 19, 1 September) more accurately grasps the depth of the issue.

So what do we do? Community nurses are the major workforce affected. They have few political allies, but are big on passion, energy and social justice.

That is why the NHS Alliance, Queen's Nursing Institute, Association for Nurse Prescribing and Royal College of Nursing met recently to discuss ways of preserving the best aspects of community services and seek ways of using this policy to improve them for patients.

We will shortly be publishing a set of principles and facilitating workshops to help nurses grasp the opportunities this change could signify.

We have to act quickly and describe the opportunities in ways which give the community workforce meaning and purpose. No doubt entrepreneurs will emerge, but the majority of staff want a safe salary and pension - not unsustainable profits and an adrenaline high.

Rosemary Cook, director, Queen's Nursing Institute Your correspondents (Feedback, page 26, 22 September) are right to draw attention to the likely impact of Commissioning a Patient-led NHS on district nursing and health visiting, and to the importance of countering the adverse effect on recruitment and retention in these groups. The Queen's Nursing Institute believes it is also important to balance the focus on provision of services with attention to future service commissioning.

The services to be provided in the contested primary care market that may emerge from these reforms will be NHS services for NHS patients, whoever provides them. The responsibility for ensuring the quality and accessibility of these services will lie with the commissioners. Excellence in commissioning, and strong clinical leadership in commissioning groups is essential to achieving this.

We will be looking at ways of supporting nurses through the current changes, not only in maintaining innovative practice and developing business and strategic skills, but in engaging with, and contributing to, practice-based commissioning.

While individual nurses and therapists need employment advice and support through changes, it is important that the focus on this does not obscure the opportunity to have direct influence on the nature and quality of services.