EM Forster famously gave democracy two cheers; the NHS seems rather less enthused.

EM Forster famously gave democracy two cheers; the NHS seems rather less enthused.

This week we examine one particularly contentious proposal from this month's commissioning framework: community action petitions which primary care trusts would be required to consider if the number of signatures went over a certain threshold.

Managers' nerves are understandable: politicians from the prime minister down have declared support for managers facing 'difficult decisions', but this pledge has yet to be tested.

The document focuses on community services, but how hard would it be for opponents of hospital closures to achieve substantial petitions? Would local people support disinvestment from acute provision to fund less visible services in the community? It seems unlikely.

For an NHS used to command and control, democracy is frightening. But the lack of local accountability in health services is one of its key weaknesses. Engagement with local populations is crucial to achieve not just structural reform and service improvement, but also to the health improvement agenda.

In their early days, formal petitions may exacerbate local tensions, but that process may well offer a more constructive forum for debate. Doing so depends on two decisions: where the threshold for petitions is set and what a 'response' to a petition entails.