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There had to come a time when the government gave up trying to manage the NHS directly. Its founder Nye Bevan may have wanted the sound of every falling bedpan to reverberate through Whitehall, but today they crash down so often and with such force that the noise is deafening and the effect counter-productive.

So this month the health secretary Alan Milburn gave a speech that may mark a turning point in Labour's thinking about the NHS. Having contrived to build a national framework of targets and indicators, he now wants to devolve power to hospitals and primary care trusts, with more patient choice and more "diversity".

Foundation hospitals, said Milburn, would "usher in a new era of public ownership". Modelled on co-ops and such like, they would be owned by local members including staff, patients and other "stakeholders" who would elect the governors. Before long, he signalled, they would be able to raise their own funds, perhaps by issuing bonds. Greater local control would inevitably mean greater diversity, but wouldn't that be a route to more rather than less inequality? Here, Milburn resorted to Richard Tawney's 1931 book Equality: "The more anxiously a society endeavours to secure equality of consideration for all its members, the greater will be the differentiation of treatment..."

These are murky waters. If you want to reduce inequalities you must understand the ways in which needs vary and address them in different ways. Treating everyone the same would certainly make matters worse. In that sense, "diversity" is essential. But a foundation hospital in a leafy suburb could become a lot richer than its counterpart in a deprived inner city, attracting higher quality staff and providing higher standards of service. In this sense, "diversity" will have the opposite effect to that imagined by Tawney.

I don't want to disparage Milburn's devolutionary ambitions. I share his conviction that Whitehall must step back and give more power to patients, managers and clinicians. But there is far too little clarity as yet about how to reconcile local empowerment with the goal of reducing health inequalities. Suggesting that diversity is simply a route to greater equality is disingenuous to say the least.

In fact, there is far too little clarity in the whole endeavour. The new effort to devolve power in the NHS is deliberately set in the context of the "new localism" - a radical campaign to gear local government towards "embracing community leadership", enriching local democracy and drawing on the "creativity and imagination of local people" to address local needs and problems.


Proponents of new localism want elected councils to develop ways of involving local residents in decisions and actions to achieve "community objectives". Here, too, is the prospect of a range of public, non-profit and private groups delivering a wider variety of services to different communities across the country.

So health and local government are apparently both in the throes of devolution, with power shifting from the centre to the locality, from monopoly to pluralism, from state to citizen, from service provider to community. Does this mean the two sectors are converging? Unlikely. They represent two very different, often opposing, cultures. The NHS jealously guards its distance from the messiness of representative democracy. Local government deeply resents the lofty corporatism of the NHS. Both sectors are already labouring under huge pressures. Each fears that closer contact with the other would compound its own difficulties.

But if they are not converging, how are they going to interact? What role will local government play in the newly devolved health system? Milburn did not say. If each sector is committed to finding new ways of engaging with communities, are they going to set up separate, perhaps competing, mechanisms? If so, won't they quickly exhaust the tolerance of local people? And, above all, what will happen to the public health agenda? Who will take responsibility for narrowing the "health gap" between rich and poor? Where will leadership be located and where will the driving force come from?

Foundation hospitals and semi-autonomous primary care trusts will be preoccupied with learning how to cope with their new powers and with providing health services. Perhaps now is the time to create a new kind of leadership for health (as opposed to health care) within a reinvigorated and empowered local government.

Anna Coote is director of public health, the King's Fund.