The gist of Polly Toynbee’s argument is obviously right (The NHS needs cooperation, not competition, to pull through, 19 February). She may not, however, know that here in Cornwall there is an effort being made to introduce an accountable care “system” (ie not “organisation”), which reassuringly does boil down to the sort of integrated care partnership that she and the King’s Fund promote. But there is still vociferous opposition to the plan from local activists and from some doctors, clearly because of the fear of privatisation. I can see that this unnerves local politicians, who fear that they will be stuck with doing their own NHS rationing if it goes through. You just can’t win.

All of us who have followed NHS policy and practice over recent decades must wake up to the fact that the NHS is now a monster: neither smart chief executives nor driven politicians have found it possible to manage as a single entity. It was actually impossible to do this when Aneurin Bevan said he wanted to hear the sound of a bed pan being dropped; and we are still stuck with that centralising mentality.

The secretary of state and his department should concentrate on preserving, supporting and regulating our basic entitlement to care, and empower the local NHS to develop. Those who will claim that this will lead to a postcode lottery of service provision should pay attention to the variations we already have all over the country. These have not been prevented by central control – and are at the expense of local innovation, and of enthusiastic patient engagement, which offer better prospects.

Peter Thistlethwaite

Saltash, Cornwall

• Integration within the NHS and between the NHS and local government is already happening in many areas and is bringing benefits to patients. NHS England’s decision to delay the use of the controversial ACO (accountable care organisation) contract provides an opportunity for them to explain what the contract adds to existing ways of integrating care, and indeed whether it is needed at all at this stage. In the meantime, NHS leaders at a local level are finding ways of using existing flexibilities to make progress.

Ultimately, amendments to the 2012 act will be needed to align current developments with the law, as the Conservative party’s 2017 election manifesto recognised.

Chris Ham

Chief executive, The King’s Fund

• Polly Toynbee warns us of the political pressure being exerted on the government by US healthcare providers and insurers, frustrated by the resilience of the NHS, which continues to perform despite underfunding, thanks to the dedication and ingenuity of staff.

But the government has another cunning plan coming down the track, aimed at forcing hospitals, starved of resources, to sell off their real estate, as the only remaining way for them to continue to fund their existence. This is set out in the 2017 Naylor review, NHS Property and Estates.

This quote from a King’s Fund review of the evidence on NHS estates, commissioned by the Department of Health to support Sir Robert Naylor’s review, has a familiar ring: “There should also be some room for ‘creativity’ when developing an estates strategy, for example, being prepared to consider options for delivering NHS services from non-NHS assets … and ensuring that as far as possible there are no ‘sacred cows’ when it comes to disinvestment or disposal.

“Potential approaches include: strategic management of estate, eg, public asset management, framework agreements, public-private partnerships.”

Perhaps drafted before the collapse of Carillion?

Kate Macintosh

Winchester, Hampshire

• Polly Toynbee’s call for an updated district model accurately identifies that it is structure not funding that is the central defect in the present health service. Yet any modern NHS requires a strong regional tier of management and planning. In 1990-91, as the health academic Calum Paton has pointed out, the old regional health authorities could feasibly have been given a wider remit to plan the distribution of community-GP services on the one hand and the specialist hospital sector on the other, as well as empowering them to address questions such as performance management, patient choice and clinical variations in care at the regional-district level. We got the internal market instead and the ensuing anarchy. Allyson Pollock’s NHS reinstatement bill signifies a good start, but even it omits the necessity of this element in a restructured NHS. A Corbyn-led government must make both the bill and a new regional dynamic the centrepiece of any future health strategy and policy.

Kailash Kutwaroo

London

• Nothing could enhance the public good and the health of the people more than creating community-led health cooperatives in and for the NHS.

The good news is we are doing this in Lambeth. The Lambeth GP Food Co-op is a community-led health co-operative of patients, nurses, doctors and local residents who have worked together over the past five years to develop a model that can be implemented across the NHS quickly and at low cost. Support from Lambeth council and NHS Lambeth clinical commissioning group reflects genuine interest in developing an alternative approach to managing the future of health and care in our local communities.

The 2017 independent report to the shadow chancellor of the exchequer, Alternative Models of Ownership, calls for more cooperatives across the sectors. We should look to Spain and Italy for examples to learn from.

Polly Toynbee calls for a new act. I disagree. All we need to do is extend the Co-operative and Community Benefit Societies Act 2014 into the NHS and monitor actions using the NHS constitution as a people-centred performance tool, and off we go.

Edward Rosen

Project director, Lambeth GP Food Co-op

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