Use it or lose it: freedom from Whitehall is a two-way street

In an exchange over the long-running saga of whether PCTs should keep their provider arms, Mr Nicholson revealed that he was under repeated pressure from local health services to issue a diktat to clarify the issue.

"But I'm not going to - stop asking," he pleaded, insisting he was serious about promoting local control.

So what was the response? Thunderous applause? Bouquets of flowers thrown on stage? Palm fronds placed on the ground to carpet his route from the auditorium? Er, no. He was asked yet again to tell everyone what to do.

One of the best pieces of advice I have heard to public service managers on their dealings with Whitehall is: "Stop asking them questions, because they will keep giving you answers."

Getting government to relinquish line management control of any public service is only half the battle.

The exchange with David Nicholson betrays the fact that it is not just in ministerial speeches or the operating framework where change needs to take place; managers need to demonstrate to the DH and their strategic health authority that they are able to take more responsibility and are willing to be held accountable for it.

For many managers, a reduction in central control releases untapped reservoirs of creativity, leadership and entrepreneurial skill; the way acute trusts have seized the opportunities offered by foundation status is testament to that.

But as the boundaries of centralism move back millimetre by millimetre they expose a small but dangerous minority of managers whose powers of independent action and risk-taking have atrophied under years of central control.

Failing to exploit every opportunity offered by new freedoms, however slender, is not only a missed chance for a trust. It also gives ammunition to those who want to rein back local autonomy and reimpose central control.