The concerns raised by the Hutton commission on the NHS are central to the agenda of the Socialist Health Association. The government's plans to improve the quality and quantity of the services delivered by the NHS are necessary, but not sufficient to deliver the benefits which the NHS is capable of delivering.

The NHS is now probably the largest organisation in Europe isolated - to some extent - from the pressures of the market. But it suffers from some of the same problems which plagued other nationalised industries.

It is a centralised command economy. There is no genuine democratic involvement or participation. All those who participate in decision-making bodies as non-executive members, lay representatives and the like are in the pay of the secretary of state, just as much as the paid staff over whom they supposedly exercise some sort of democratic control, and even more liable than the staff are to be dismissed if they dissent. Despite the many expensive local consultation exercises, all important decisionmaking actually happens in Whitehall.

As junior health minister Gisela Stuart said: 'Working effectively in partnership with patients can. . . be of great benefit to the NHS. It delivers better results for individual patients and better health for the population.'

But partnership will not work if one partner holds all the power. It is time this government considered ways in which genuine power and decision-making can be brought down to a local level.

The Hutton commission's proposals to set up a written constitution for the NHS may not be the best way forward, but it is time that these issues were given serious consideration. The Labour Party should go into the next election with some clear ideas of how local decision-making in the NHS can be given legitimacy. The SHA is inclined to favour greater involvement from elected local authorities, but we will certainly be looking to contribute to this debate.

Martin Rathfelder Development director Socialist Health Association London E1