Did NHS Confederation chief executive Stephen Thornton really say 'tough' to the NHS Alliance not being represented on the NHS modernisation action board (news focus, page 13, 26 October)?

If so, he is right. It is tough.

Tough on the 90 per cent of primary care organisations which are not represented but which were supposed to be the kingpin of the new NHS. (At our conference last month - attended by 700 delegates - 80 per cent said they felt disempowered in development to primary care trusts by outside forces. ) Tough on the primary care professionals, who were told they would be in the driving seat but are not represented collectively at the centre.

Tough on the health professionals, primary care managers and lay people who will be central to delivering the new agenda - but whose new multidisciplinary focus gains no recognition on the NHS's new central board.

And tough on the notion of working together, of resisting vested interests, of primary care leading the new NHS.

Indeed, primary care is not 'hermetically sealed'. But the centre will appear to be sealed in a timewarp as long as the board fails to deal positively with the new alliances within the NHS - and until it recognises restlessness among those expected to deliver the new agenda.

We must modernise at the top as well as at the grassroots. It does not help if those on the modernisation board carp at those who are not. What does matter is that professionals and managers support each other to deliver outcomes for patients.

Michael Dixon Chair NHS Alliance