The government has raised the question of the health service's democratic deficit.

Health minister Ben Bradshaw has called for primary care trusts to be subject to more accountability to local people.

At present, there are three mechanisms bringing a measure of democracy to local primary health services. The PCT boards use non-executive directors to bring a wide range of views and expertise to bear, councils operate health scrutiny committees, and PCTs use consultation and user involvement to embrace patient views in decision-making.

In recent years scrutiny and patient involvement have grown in scope and sophistication, but the national picture is very patchy.

While relationships between many councils and PCTs have evolved to the point where joint working and co-operation are the norm, health scrutiny is too often under-resourced or ineffectual.

Similarly, the degree to which PCTs involve the public and patients fluctuates wildly across the country, with far too few examples of it being embedded in culture and practice.

So is the government right to raise the spectre of democratic reforms? The cries for stability from PCT staff shell-shocked from continual organisational bombardment are understandable, but that cannot be the end of the argument.

The growing culture of patient empowerment must extend to the governance of primary care.

The underlying principle must surely be that giving patients a voice plays an important role in improving health outcomes.

And strengthening local accountability helps to shift the balance of power away from the centre. Local managers should aspire for public accountability to replace central control, not their own.