'Formal public meetings only ever engage the sort of people who like attending formal public meetings'

'NHS trusts in England, both weak and strong, will have to come to terms with a reconfiguration of key services that will reduce the number of hospitals offering a full accident and emergency department, paediatrics and maternity services,' wrote John Carvel in The Guardianafter his interview with NHS chief executive David Nicholson. Thank you, David.

It was his first interview as NHS chief executive and it placed the aspiration for reconfiguration and change at the forefront of service policy, rather than trying to pretend nothing is happening.

The NHS does not have a proud history of telling our own story. Our most likely reason to engage with local people is when we have to do a consultation. Most are initiated as statutory requirements once a decision has been reached. We seek to minimise the scope of consultation and the constant claim is that nothing much is changing and local people will notice no difference, which generally begs the question 'Why bother?'

We are obviously hiding something, but get irritated and dismissive when local people assume we must be up to something.

A consultation is one of the rare occasions when an NHS organisation has to take part in public meetings. I vividly remember being sent out after two weeks in a new job to tell the deprived population of west Newcastle that after great deliberation we, the good suits of the health authority, had come to the conclusion we should shut the most active A&E in the city to concentrate resources on the university site. I probably didn't do a great selling job.

Most of the time our other main contact with the public is through debates conducted in the media. Typically, an individual is seeking a particular treatment, we have refused and our appearance is always already on the defensive, having been exposed as failing a member of the local population.

The aspirant patient can choose to share as much personal information and ill-informed perspective as they choose; we have to be wary of confidentiality and of not demonising an individual. The finer points of technical effectiveness tend to be missed from the debate. This is how Herceptin became a life-saving drug rather than something which had some impact on limiting the return of cancer in 17 women from a control group of 2,000 for a two-year period.

This poverty of approach has led to increasingly desperate attempts to create national systems to drive better engagement with patients and local people. The major problem is that there is little attempt to recognise that these two groups do not necessarily share the same interests. The public, as taxpayers, may be looking for a range of local services that do not place additional burdens on the family budget. Individual patients understandably want to maximise their personal share of the common good.

Ever since the NHS Plan, ministers and the service have been searching for an alternative to community health councils that put local people in a formal scrutiny and challenge role, without having to rely on 'the wrong sort of local people'. These are those who have the personal and social capital to engage with local health policy and services, to meet for several hours a month in formal settings and to be able to track, analyse and articulate challenge to the highly paid, highly educated professionals who run local services. This is a group largely unrepresentative of the majority of the most vulnerable service users.

Patient advice and liaison services may have largely worked well to support people through complaints, but patient forums have struggled to attract as many members as predecessor CHCs. In primary care trusts at least, it does not seem uncommon for a population of 250,000 to be 'represented' by two or three individuals, generally with a specific personal area of interest. Given the choice between reading my kids a bedtime story and attending my local ward committee, I would rather leave the councillors to it.

Formal regular meetings of the public will only ever engage the sort of people who like attending formal regular meetings of the public. I remember the poor boy fielded as the youth representative on a neighbourhood board. He wore an anorak. He didn't look like the sort of boy other boys would talk to.

We don't need to invite people to meetings; we could go to where they are. We can tell local radio listeners that we have every intention of changing local services, not because they are not good but because they need to be better.

We could send out press releases saying what we are prioritising for investment and what we cannot afford this year because medical science has been so successful and so many people are now living longer that as taxpayers we need to seek best value for our investment. We can go to ward committees, oversight and scrutiny committees, lunch clubs and playgroups to tell people about our vision for local services.

We also need to remember what a large employer we are and that many members of the public form their views of what is happening in the NHS by what their friends and relatives say. If we don't keep our workforce engaged and positive, no wonder we lose the public.

If we were less defensive we might avoid some of the emerging suggestions about how to make us more accountable. The proposal for a right to petition has the potential to tie up PCTs in Heathrow-like planning rows for years to come. The Exocet option is to transfer the NHS to local government, addressing the democratic deficit by passing responsibility from those usually elected by at least a 60 per cent turnout to those who may have been lucky to have 30 per cent democratic participation.

Given the alternatives, a lively evening discussion with a group of engaged and challenging local residents is an attractive option. We have a good story to tell about the changing NHS, but if we don't go out there and tell it no-one else will.

Sophia Christie is chief executive of Birmingham East and North PCT.