The important review by the Audit Commission and Healthcare Commission should lead to better recognition of the huge difficulties facing reform. There are very few people in the NHS who see choice and competition as key policies for improving services.

As Reform's recent report put it, they are a "national mantra not a local reality". They are seen as nuisance policies imposed from the top, even though on the few occasions where there has been full local involvement (such as with cardiac surgery in London), these programmes have been very successful.

We need to work out how to increase the local buy-in for competition and choice. As a first step this must mean separation of commissioning from provision and a stronger case for pluralism, including an increased role for voluntary and social enterprise organisations.

Nick Bosanquet, professor of health policy, Imperial College, and consultant director, Reform

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