You do not need to be a student of Machiavelli to realise that anyone who seeks to lead a large-scale enterprise must rely on able and committed lieutenants on the ground to bring their plans to fruition. Fostering a sense of well-being among them is crucial to success. And integral to that sense of well-being is the opportunity to debate and influence the plan of action in an atmosphere of mutual trust.

This elementary lesson is one which ministers still have to learn. One of the most important professional groups in the NHS - arguably the most important - feels excluded from policy-making and patronised by the extent to which the very minutiae of its actions are dictated from the centre, crushing all scope for initiative. Trust and health authority chief executives, meeting at their annual forum last week (see News Focus, pages 14-15), reflected on the irony of their situation: though most of them support this government's values and aspirations for the health service, far more than they ever did those of the last, ministers seem blithely impermeable to the fact. Chief executives have the distinct impression that because - as public servants - they served the Conservatives loyally, Labour sees them as secret agents of the old regime, sullenly intent on frustrating its reforms unless they are stringently policed.

Contrast this with the warm reception perceived to greet the doctors' and nurses' representatives on their visits to Richmond House. Chief executives despair that the organisations which might convey their views to ministers are compromised and ineffectual. And of course, not only does the lobbying might of the British Medical Association and Royal College of Nursing outweigh that of the NHS Confederation and Institute of Health Services Management combined, but their members' public image is such that ministers have to listen to them or risk a backlash. No such worry attends their treatment of managers.

But herein lies another irony. For whatever problems they may suffer with public opinion, the real power in the NHS lies with its chief executives. Without their commitment, neither primary care groups, clinical governance, collaboration with social services, cutting waiting lists, nor the IT and human resources strategies will ever be more than words. It is time for ministers to show them more goodwill. Practical politics demands it. And if they don't, the NHS may find its recruitment and retention problems begin to infect yet another pivotal group of staff.

The London Initiative Zone has made progress in its five-year existence, with many innovations and some outstanding successes to its credit - all achieved against a turbulent background of NHS reorganisation (see pages 24-27). But no one would claim LIZ has solved the capital's dire primary care problems.

Perhaps it is unreasonable to expect it could have done so in five chaotic years - except that it did have a great deal of money at its disposal, freedom from many irksome regulations, and political and managerial determination in spades. Some observers might conclude that, given all this, its returns are rather modest.

The LIZ experience holds important lessons for the rest of the country, especially for health action zones. It is a reminder that high hopes and relentless rhetoric - even backed with cash and the best will in the world - are seldom fulfilled in reality. Landscapes are never transformed; with luck the glacier may shift half an inch. But that is never a reason for not trying.