The report of your survey with Birmingham University of managers' attitudes to Shifting the Balance of Power made fascinating reading ('Cause and effect', pages 20-23, 11 October). It confirmed very clearly that the NHS Confederation had been right in raising three key issues in response to the Department of Health's consultation on this initiative.

First, as 78 per cent of respondents said, moving power to the front line - to primary care trusts and their clinicians - is the right thing to do and will improve decision-making for patients.

Second, as 45 per cent of respondents agreed, many PCTs will not have the capacity or capability to cope effectively with their new responsibilities.

We have argued that the government has missed an important opportunity to reinforce the need for more, better-quality managers, including clinical managers, to deliver the most ambitious change-management programme in NHS history.

But third, we believe that delivering the NHS plan crucially depends on changing the NHS's culture and behaviour. Shifting the Balance of Power makes numerous references to the importance of culture change, but does not define it or make any practical suggestions for what the Department of Health or local organisations should do to ensure it happens. Hardly surprising, then, that only 7 per cent of respondents thought the creation of a new NHS culture with a focus on leadership, openness and collaboration would be a result.

If we are not careful, we will spend valuable management time on a massive structural change, positively motivated by a desire to improve patient care, but will fail to achieve the very cultural change necessary if patients are to spot the difference.

Stephen Thornton Chief executive NHS Confederation