Laura Donnelly on the spirit of debate

I was at an event recently discussing the perils of cerebral exclusivity. Well, that's not quite true. I gave one eyebrow a light workout while someone considerably more cerebral than me coined the phrase.

It came towards the end of a debate which had cantered around old favourites like clinical engagement and 'the need to create a compelling narrative to underpin the reforms', as well as more radical ideas on the table, such as new Conservative proposals to introduce competitive commissioning.

Now, forgive me if the translation got mangled via a cerebrally inclusive education, but I think the point being raised by one of my more learned colleagues was pretty simple. And not hard to agree with.

In short: there's not much point in policy makers, politicians and commentators indulging in highfalutin conceptual debate about policies of the future if the vast majority of the great British public, including NHS staff, are none the wiser about the intentions behind policies hitting them already, let alone signed up to them. Put another way, a choice of commissioner isn't much use to the average person, who doesn't know what commissioning is.

I was reminded of the point the next morning, when I found myself standing at the counter of a well-known pharmacist's, while a customer enquired what advice could be provided regarding his young child, who had a wheezing cough.

'Go to doctor,' replied the pharmacist, with a brevity I could only admire, and no lack of narrative thrust, even without the luxury of prepositions or eye contact. The customer left the shop fast, wearing an expression which looked rather like 'that's the last time I try to reduce demand on traditional models of healthcare' and yanking a poorly child whose arm was at risk of dislocation.

Perhaps it would be unfair to hazard a guess at exactly how engaged this one pharmacist was with the concept of a patient-led NHS on the basis of one encounter. But it got me pondering the size of the gulf between some of the worst excesses of policy and reality.

The risk is that the ever-increasing rhetoric about communication and engagement in the NHS is not only failing to bridge that gap, but is in danger of creating a third language, which only hinders honest debate and requires a whole new set of interpreters.

The Department of Health is currently planning a host of new arrangements on patient and public involvement. Out go patient forums, in come local improvement networks (LINks). Overview and scrutiny committees get a stronger role. And community petitions which allow local people to trigger changes in services and introduce new providers are under debate. How radical could this be?

That depends. In many senses, it ain't what you do it's the way that you do it. Bananarama's advice may have been aimed at the boudoir rather than the boardroom, but it could certainly be applied to organisations seeking to engage communities and staff in service change.

If an organisation wanted to embark on honest dialogue with its communities and get them involved in changes to services, there is nothing in the current regulations - or their predecessors, governing community health councils - to stop them. By the same token, we do not yet know whether the new proposals will be robust enough to force the hand of an NHS organisation that is determined to limit the public voice in decision-making. Much of the detailed proposals on LINks have yet to emerge - their budgets and powers, for a start.

Proposals being floated for community petitions sound tougher, and in many ways more interesting: these could see the weight of a percentage of the population being used as a trigger for changes to failing services, and the introduction of new providers. The detail on this will be key: in particular it will be interesting to see how far this works to stimulate an appetite for new providers in primary care.

The weakest link in the government's policies on choice has always been that when it comes to the gateway to the bulk of healthcare - the GP - choice is at its most restricted, and information supporting what choice there is, worse than useless. My own experience of 'choosing' my current GP was limited to Googling to check for reported scandals, asking health service contacts (who shook their head grimly at the name of the location), and finally asking my local patient advice and liaison service for the name of any local service that wasn't single-handed, and taking the only one which would take me.

But in primary care, marches, petitions and lobbies remain rare: it is hard to imagine people taking to the streets to fill inky petitions outlining their demand for nurse practitioners, early morning openings or access to community diagnostics. Nonetheless, the introduction of triggers to encourage changes is a start.

But experience in acute services suggests that the way consultation and engagement works often depends less on the mechanisms used and more on the spirit in which debate is entered: this means NHS planners must be able to demonstrate that they are flexible enough to respond to people's views, even if it is not what they want to hear. It is nearly a decade since I witnessed my first citizen's jury, then hailed as the answer to a reconfiguration planner's dreams.

But those particular plans haven't made that much progress in the years since, even if the fashions for discussion documents, people's panels, and pre-consultation consultations have come and gone.

South West strategic health authority chief executive Sir Ian Carruthers has embarked on what the DoH is describing as a 'sanity check' of reconfiguration proposals over the next six months. His experience will be vital in guiding managers who are facing some of the toughest and most high-profile decisions of their careers. But it is absolutely vital that local decisions remain in local hands.

Laura Donnellyis news editor ofHSJ.