-NHS Confederation chief executive Stephen Thornton has called for the creation of a 'cadre of local leaders' to drive change in the health service.

Speaking at an Institute of Directors seminar at which the NHS came under sustained attack, he warned of pitfalls in speakers' demands for it to be abandoned in favour of 'core service funding', private payments and private provision. But he accepted that 'quite radical things' were being discussed for the NHS, including a shift from hospital to community and primary care and further integration of health and social services.

These changes would need leadership that had 'been missing from the NHS over its 50-year history' because of professional tribalism and the split between the service and a 'head office' staffed by civil servants.

Mr Thornton argued that 'top managers' could only create an 'environment' for change, while the 'missing leaders' running theatres or outpatient departments were 'uniquely placed' to achieve it. He said 'one of the things the NHS is likely to be calling for [through the modernisation programme] is an NHS leadership academy' to inculcate 'appropriate' management skills, teach clinicians about 'wider issues' and spread best practice.

The seminar followed the publication of an IoD policy paper arguing that the 'fundamental problem' with healthcare in the UK is 'triple nationalisation'- public sector monopoly of funding, decision-making and provision. It called for an NHS passport entitling holders to free 'core services' in NHS or private facilities and for less health promotion and screening and an expansion of private facilities.

At the seminar, IoD director general George Cox was unimpressed by the government's commitments to increase NHS funding and modernise the service.

He said increasing spending to European levels would require 6p to 8p on income tax 'which is not going to happen', and the NHS was a 'monolith' which 'nobody' knew how to make more efficient.

Dr David Green, director of the Institute for the Study of Civil Society, argued the NHS had been founded on the idea that the professions would determine need and the state provide the funds to meet it. This model was flawed because of potential conflicts of interest between the state, professions and patients that European systems eliminated with competition between providers and private, as well as public, funding.

Former British Medical Association chair Sir Alexander Macara strongly defended the UK's 'Beveridge' model against Europe's 'Bismarck' model, arguing it was cheaper and more equitable.

Dr Green said he was 'opposed to government campaigns to bring about social justice' since they encouraged the idea that 'nobody should get more than anybody else'. Competition, he argued, could also be a public good.

Audience member David Davies, chair of the Commons public accounts committee, asked how consumers could make informed decisions about such a 'complex' issue as healthcare.

Medical ethics, strong brands, competition between providers, advice from consumer bodies and some state regulation were put forward as safeguards.

Mr Thornton acidly remarked that Dr Harold Shipman was such a strong 'brand' that patients were reluctant to see his locums, was an independent contractor in competition with other practices and was loosely regulated by the state, yet still managed to murder at least 15 patients.