Published: 02/09/2004, Volume II4, No. 5921 Page 20

So foundation trust chief executives are unhappy (Feedback, 19 August).Well, happiness is relative, and in real life it waxes and wanes.

History tells us that reform is rarely achieved overnight, and those of us who introduced NHS trusts at the beginning of the past decade will recognise the symptoms of transition currently being displayed. The FT policy is not dissimilar - though many will argue differently.

Unfortunately, the NHS's record of learning from the past is mixed. The risk at the moment is that the different components of the NHS end up being managed in hierarchical silos, which is not only unsustainable but also bad for patients.

The most salutary lesson to come from the past decade is for organisations to learn to manage themselves independently, while working together when necessary.

However, I predict we will struggle again with the same concept. The national policy environment makes it impossible for individuals to work and strategically plan independently.

However, to work together in the local health systems of the future will require considerable maturity and understanding of interorganisational relationships.

I suspect that is unlikely to be achieved in these early days of new national and local organisations wanting to flex their new-found authority.

I have sympathy with my FT chief executive colleagues but let us not get current feelings out of perspective in the context of introducing change. If the same concerns are still being voiced one year from now, then I will genuinely share their concern.

Dr Neil Goodwin Chief executive Greater Manchester strategic health authority

I was reminded of an incident with my son as I read Mark Britnell's frustrations that foundation trusts do not have the autonomy they had expected (page 17, 19 August).

Having watched cyclists in the New Forest, he pestered me for a bike, which was promised for his third birthday.

However, excitement turned to tears when he realised his cycle had stabilisers and its use was restricted to the garden under supervision.Had he really expected to roam the forest alone?

Foundation hospitals have created expectations that a locally accountable and autonomous health service is a reality.

Nonetheless, NHS chief executive Sir Nigel Crisp admitted that he and Health Secretary John Reid had been 'discussing croutons into the small hours'.

Our political leaders have made a commitment to delivering improved healthcare, backed by billions of pounds in spending.

A test for a system of devolved power is the response to local failure - does the government say 'the buck stops locally, ' or does it put the stabilisers back on the bike in the form of increased targets, regulation and inspection, to demonstrate failure will never recur?

I take my hat off to Mr Britnell for being the first to express his frustration so publicly.

The centralised v decentralised debate is an old one. Recent work by the Harvard Business School concluded that either can work.

The key to success is to ensure that what is centralised and what is decentralised is clear to all parties.

The NHS seems to be going through a change where this is blurred. Perhaps now is the time for debate to determine the role and boundaries of the centre and of local NHS organisations, and how best to make the transition.

Hugh Risebrow Associate director Performance development team NHS Modernisation Agency