If public services really were owned by the public, accountability would always be at the core of their business. But since this is not the case, all public services must continuously review how they are held accountable.
In carrying out such reviews, we must keep in mind how the public experiences and expects accountability, rather than how the political class thinks it should happen.
The political class feels the ultimate arbiter of accountability is the election of local or national representatives. Understandably, if you spend your life running for public elections, you come to believe voting is the ultimate method of ensuring accountability.
If there are questions of public accountability for primary care trusts, then the natural reaction of the political class is to reach for the local electoral register and start working out a voting system. But this is not the sort of accountability the public is asking for. What they really want is for their leaders to get on with the job after communicating much better with the public.
Having elections to decide the crucial issues of the day is really important for our society. However, given that only 20 per cent of people believe national politicians tell the truth and only 33 per cent think local politicians do, voting is not the answer to improving the public's actual experience of PCT accountability.
Increasing political interest in restructuring PCT accountability through some form of relationship with local democracy raises more problems than it solves. The very act of bringing party political contests into the day-to-day management of the local NHS would also use large quantities of resources and create conflict between political and clinical decisions without necessarily improving the public experience of accountability. As far as the public is concerned, the problems of the NHS are not about accountability - rather they are about speed of access and quality of care.
We are not going to rehearse the arguments about local versus national democracy here, although there is something intrinsically problematic about giving democratic legitimacy to the local delivery of services that the public expects to be uniform across the nation.
What we need is a different public experience of accountability through direct communications. For the last 10 years, it has been clear that local authorities with good communications strategies have a much better public experience of accountability. Councils that are better at explaining what they provide and communicating what they are trying to achieve are always better regarded and trusted than those that are poor communicators.
All councils have elected members, yet some are perceived as better run than others. This is because they focus on what matters to local residents and ensure that local residents are kept informed. Rather than structural changes, the public really just wants to know what is going on, which services are available and how to access them. They tend to think all a PCT does is co-ordinate GPs - they are unaware of the diverse range of services most PCTs commission.
Research shows that the most popular documents local public services can produce are simple guides to what is available and how to access it. In local government, the cross-party Local Government Association is asking all councils to send out such a document to all residents every year - not just because it is the right thing to do, and valued by residents, but because it helps highlight where money is being spent and boosts confidence and satisfaction.
To increase accountability, PCTs need to become much better at communicating about things that matter to their residents, and not think that new structures will do this for them, however democratic.