Disputes at opposite ends of the UK highlight the complexities of introducing democracy into the health service.

In Scotland, health secretary Nicola Sturgeon faces widespread opposition over her determination to introduce direct elections to NHS regional boards. Including local government representatives, there could be a majority of board members with a democratic mandate.

In London, meanwhile, Enfield council has won the right to judicially review a plan by Barnet, Enfield and Haringey primary care trusts which involves downgrading Chase Farm Hospital's accident and emergency unit and maternity services. This is despite backing from the Independent Reconfiguration Panel and health secretary.

Resistance in Scotland to direct elections is so entrenched that a third of the boards have publicly declared their opposition.

The democratic deficit in healthcare originated in Aneurin Bevan's decision to establish the NHS free of municipal control. Until then most of the country's hospitals had been run by councils.

Accountability moves

Under New Labour there have been tentative moves to introduce aspects of accountability - council scrutiny panels, foundation trust membership and local engagement as part of world class commissioning - while stopping well short of democratic control. Ms Sturgeon's plans break radical ground.

Apart from the cost, one of the main reasons for opposing direct elections is that boards could be paralysed by single issue politics of the "vote for me to save your A&E" variety. There are likely to be few candidates standing on a ticket of "vote for me to move your cancer services 30 miles up the road", even though that may be the most sensible clinical decision.

The role of councillors may be more complex. Many councils regard themselves as making their presence known in the health tent while standing outside it - as Enfield demonstrates. But councillors who support an element of democratic oversight remind you that local authorities are well used to taking tough decisions in the face of public outcry - closing schools, libraries and care homes.

And in many areas councils and PCTs have increasingly productive relationships.

Difficult balance

The NHS cannot be returned to local elected control as it is not a local service. It is a series of interlocking local, regional and national health economies which defy electoral boundaries.

But excluding the taxpayer from involvement is inherently difficult to defend. While Ms Sturgeon's plans risk democratic zealotry overriding clinical sense, the NHS could benefit from carefully constructed pilots which allow an element of democratic input.

If the Scottish government listens to boards' concerns and produces more sensible (and cheaper) plans, they could extend understanding of how best to enable the voice of the public to be heard in the NHS.