Published: 20/03/2003, Volume II3, No. 5847 Page 18

Last Tuesday I was one of the few NHS managers in a large audience from a wide variety of organisations ranging from housing and childcare to education and leisure services.

'The mutual state' conference was organised by Mutuo, whose remit is to act as a think tank and policy consultant for 'mutuality' - the new ideological cornerstone of the NHS foundation and public sector reform movement.

As I listened to the views of the mutual societies and cooperative movement, it suddenly struck me how far removed this was from health service discussion on foundation trusts.

Instead, comment has centred on the potentially regressive nature of this aspect of reform and governance structure.

One session, chaired by Guardian economics editor Larry Elliott, sought to examine whether, in the words of a March 1999 Guardian leader, 'mutualisation [could] do for Labour what privatisation did for the Tories - give it a lasting legacy?'Mutuo director Peter Hunt, Ed Mayo of the New Economics Foundation, plus speakers from the Institute of Directors and elsewhere suggested that mutualisation offered 'a third way' of organising public services, according to a quote attributed to chancellor Gordon Brown, where 'mutuality provides a practical way of ensuring that citizens have rights to go with their responsibilities and are enabled to play an active role in the decisions that effect their lives'.

There was strong evidence during the conference that mutual organisations could make services more responsive to consumers and staff, more democratically accountable to communities and more flexible and efficient as supplier and provider organisations led by social entrepreneurs.

Our speakers invited us to think in a new way, which did not seek to replicate the sterile nationalised/privatised pseudopolarisation that has characterised much of the political hyperbole in recent months. Plenty of examples from continental Europe and Japan can be found to demonstrate that public sector values do not need to be confused with structure.

In its December report, Making Healthcare Mutual, Mutuo argued that the NHS has become the 'holy grail' of state provision in the UK. It argues, as has the Institute of Directors and others, that the NHS in its current monolithic state cannot place patients, citizens and communities at the centre of what it does as all roads lead back to Whitehall.Hospitals have always 'looked up' to government and Whitehall for direction and control and have little time, space or flexibility to act in a responsive and innovative way.

I suspect many HSJ readers - and an even larger number of chief executives - may recognise these causes and symptoms. I sometimes cannot help but remember some of the salutary lessons from film classic One Flew Over the Cuckoo's Nest when thinking about the NHS today with its vast army of inspection and monitoring agencies, colleges and modernisation movements: rules for rules' sake and the wrong lunatics running the asylum.

Past reforms and some of the new developments do not decentralise and empower.

Only more radical shifts proposed with the foundation movement might release innovation, truly focus on citizens and patients and empower professionals and leaders to set local direction for public and social benefit.

I left the conference with three thoughts.

We have become a product of the system we serve and we serve central government and the army of regulatory and inspectorial bodies. Can we, and the politicians who will shortly debate the bill in Parliament, really show some fresh thinking about responsive public service provision that is locally directed?

Second, despite myopic concerns, mutualisation might turn out to be the structural reform that unleashes social enterprise, talent and innovation and acts as the safeguard against the forces through which we have been socialised for the past six decades. Local governance could be our liberator not captor.

Third, we should guard against some of the comments made at the Mutuo conference, which saw mutualisation as an ideological end in itself rather than a means to an end.As managers, we need more governance and financial freedoms for ourselves as well as structural reform.Our end should be to serve patients better and make a much more active and responsive contribution to our citizens and communities. This includes regeneration, education, employment, and construction through new, exciting joint ventures and co-partnering arrangements with private, public and voluntary sectors alike.

In this way we can create more value and wealth and improve health by giving staff and patients better control of their hospitals.

Perhaps Jack Nicholson was right after all. l Mark Britnell is chief executive, University Hospital Birmingham trust.