Day surgery for cataracts.

based upon this confusion of roles would not be equipped to handle the complex managerial and contractual issues that the new system of matching resources to performance will demand."'2It remains to be seen whether the expansion of the new management role of DHAs to include being champions of the people will restore this confusion of roles.Members report that health authority meetings since the 1991 changes have been more comfortable and friendly and that decision making is easier,'3 especially since they are increasingly held in private.'4But there has been little debate on the impact of membership on the new reforms or on the effect of large purchasing consortia and district mergers, which remove health authority members still further from their communities.'4The model of direct ministerial management of health care, with its focus on individual consultation, is a long way from the 1944 green paper, which originally intended that local authorities should run health services and special professional and technical guidance would be provided by local health services councils."'Then, in rejecting the suggestion that experts should be included in local authority administration ofhealth services, the government felt, "The risk of impairing the principle of public responsibility (accountability) -that effective decisions on policy must lie entirely with elected representatives answerable to the people for the decisions that they take-outweighs any advantages likely to accrue."Recent research shows that local democracy does count.16 17 Regardless of their political opinions, people identify with and value the role oftheir local authorities in decision making.Many of the debates throughout the 1980s indicate that there is no reason to believe that they would not support a more democratic health service.1819If the NHS Management Executive is having second thoughts about whether the new district health authorities and their members can fulfil their management role and be champions of the people then it has to realise that market research models can never be a substitute for a democratic process and local accountability.Otherwise community consultation, consumerism, and participation in needs assess- ment, priority setting, and developing and monitoring service specifications are meaningless.