Introducing the seminar, participants were reminded of the fundamental tensions between ongoing efforts to reform the NHS through greater devolution of management and decision-making powers, and its potential impact on inequality. Previous seminars in the series had clearly indicated the need for health services to be tailored to local needs and circumstances if persistent inequalities in access and health outcomes are to be tackled. However results of a poll commissioned by the Fabian Society were reported indicating public concern over reforms that could lead to 'post code lotteries' in service provision.

The challenge, it was agreed, was to find the appropriate balance between centrally-set targets or minimum standards and local means of delivery. In the context of the diversification of healthcare provision to the voluntary and private sectors, and breadth of cross-government initiatives required to tackle the complex determinants of health inequalities, this would require a far better joining up of policy-makers and practitioners across government departments, public, private and voluntary sectors at all levels.

The advantage of this diversity, one participant suggested, was that it offered multiple entry points to tackling the problem. The concern was that continuity of care would suffer, particularly for minority groups, and that examples of best practice at local levels would not be communicated adequately and best practice shared throughout the system.

It was pointed out that serious attempts had been made to improve cross-departmental collaboration on health, notably with the establishment of the cross-governmental Public Service Agreement on health inequalities. Initiatives such as the joint Cabinet committee on obesity and the Departments of Transport's eight fold increase in spending on cycling, were presented as examples of the public health agenda starting to filter across government departments.

Several participants commented on the important role that employment and employers can play. Highlighting the evidence showing pathology indicators were substantially worse for people outside of the workforce, one participant suggested tackling worklessness as a priority in improving health amongst marginalised groups. The important role of employers (including the NHS) in promoting healthier lifestyles in the workplace, through provision of gyms, better food or information for example, was also discussed. This, it was cautioned, could be expected of bigger firms, but would be more difficult for SMEs.

At a local level, one participant suggested that imaginative public-private partnerships could greatly increase community resilience to health problems in areas of high socio-economic deprivation. The Eden Project was suggested as a particularly strong example, having had a transformative effect on a poor former mining area, providing an innovative non-health setting for health promotion initiatives. Another participant suggested that health policy-makers and practitioners needed to take community advocacy seriously if they were to confront the normalisation of conditions such as diabetes in certain areas. Local authorities and PCTs should be far braver than to date in pursuing such an agenda.

Participants agreed that a shift towards greater diversity in service provision at local levels would need to be accompanied by stronger accountability frameworks if public faith in the system was to be maintained. It was suggested that the latest NHS operating framework, outlining five overall objectives while offering PCTs a menu of fifty 'vital signs' from which to develop strategies appropriate to local needs, offered the right balance of central direction and local autonomy.

It was suggested that this devolution agenda had only gone half way; devolving power while not yet devolving responsibility and accountability. Indeed, the increasing diversity of provision had led to a fragmentation of accountability in the system. This was exacerbated by the tendency for government to want to take credit at the centre while health finances are good, and to want to pass blame to local areas when funding is tighter. Greater local accountability of health services were suggested as a major avenue of government interest over the coming year, and competing models of devolved accountability discussed.

One participant suggested that people were more likely to accept diversity if they had had the opportunity to express their views through a vote. Views were divided, however, over Liberal Democrat proposals to elect by PR members of PCTs. Some felt that this would tap into widespread interest in health issues, while others worried that it would reinforce or exacerbate health inequalities by giving voice to 'the usual suspects', rather than empowering marginalised groups. There were further concerns that direct elections would produce potentially naive 'save the local hospital' campaigns, rather than leading to hard decisions to close services that were effectively killing people.

Concerns were also expressed with the Foundation Trust model, it being suggested that people tend to develop affiliations with local hospitals rather than PCTs. A change of terminology, perhaps referring to a 'local health service', might help to increase public understanding. Greater involvement of local authorities was seen as an important avenue for further exploration – one participant echoing points raised in the series' launch seminar – suggested that local authorities tended to manage finances well, and unlike some PCTs, had little history of running deficits.

Many participants doubted whether citizens wanted a direct say in decisions over the institutional framework and grand direction of the NHS, expecting government either nationally or locally to make such big and difficult choices. However, the need to better communicate to citizens the decisions being taken was seen as crucial in maintaining the public legitimacy to act. After ten years of action to tackle notoriously stubborn health inequalities, the challenge would be to renew and extend what might be seen as a 'failing' policy that had not met its targets, over the next decade and beyond.

Several opportunities to engage citizens in debates over the future direction of NHS reform were noted. The 60th anniversary of the NHS, Darzi Review, debates around an NHS constitution and over local accountability all offered significant opportunities to engage citizens in codifying what they could expect from national and local parts of the NHS. It was suggested that such a codification would require far greater public engagement with citizens, though some participants questioned whether 'citizens juries' on the present model were the best forum for doing this. The fact that the Darzi Review interim report only makes two mentions of inequalities was seen as a cause for major concern to this agenda.

Despite one of the best departmental CSR settlements of 4% in real terms each year, health practitioners would increasingly be asked to do more with resources growing at a faster rate than in the last 10 years. In such an environment, NHS reforms would need to go wider and deeper if targets were to be met, not least in narrowing the gap in health inequalities. Winning the public permission to act would be crucial not only to keeping health inequalities on the agenda over the next decade and beyond, but to delivering more equal health outcomes across society.

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