It’s been a quiet few days for health policy, with the exception of the news that Imperial College plan to experiment with payment for performance, about which more tomorrow.

The main event of the morning was an online discussion between Alan Johnson, the Secretary of State for Health, and Labour members who logged on for a discussion. The questions set out some of the issues that Labour loyalists worry about in relation to health policy.

A member from Rochdale asked Alan Johnson where he stood on the possibility of top-up payments being introduced to the NHS. The questioner explained that he was personally against the idea, as he feared it would lead to a two-tier NHS.

Alan Johnson said he could "completely understand" the questioner's position. Whether the Secretary of State was indulging in a bit of triangulation, leaning left to a Labour questioner, it is difficult to know - but Johnson began by defending the current position, "which dates back to at least 1983". He said the problem was that the guidance contained "esoteric terminology such as episodes of care, which the public find difficult to understand".

Johnson knows, however, that resolving the top-up issue is more than just clarifying the language. He adds that there was ‘a great deal of concern around several tragic cases, mainly involving cancer drugs where the patients concerned were not given a clear indication of whether or not they would have to pay for their NHS treatment if they purchased drugs unavailable to NHS patients'. Johnson said that the review would make it clear that the founding principles of the NHS are maintained.

AJ was playing with a pretty straight bat thus far.

Next up a member from the greater Manchester area shared his view that the NHS "is being seriously wounded by privatisation". He said the core Labour voter wants reassurance that the NHS will continue to be the core provider of NHS services.

Alan Johnson disagreed with the comment about the NHS: the private sector as yet only provide a small amount of care, and have helped to cut waiting lists. The Labour Government has also sought to ensure that private firms provide value for money. Johnson denied there was any predisposition towards the private sector. "Our decisions are based on who will provide the necessary capacity and quality of treatments that patients deserve". Of course, he pointed out that GPs are essentially private businesses and he added that pharmacists are too. "There is no socialist principle being abrogated here".

As if on cue, up popped a question from Martin Rathfelder, director of the Socialist Health Association: "you have announced some good initiatives to screen people for conditions - do you think we are putting enough emphasis on measures which will stop people getting ill in the first place?"

Alan Johnson wrote: "Martin, the simple answer is no, which is why the Prime Minister set such store on prevention in his Kings College speech on health in January. Nye Bevan always envisaged that the health service would be as much about preventing poor health as diagnosing and treating illness. We have done an awful lot already particularly on smoking, school food, and high quality exercise and sport in our schools but the recent Darzi report and the regional bottom-up visions for health upon which it was based envisage a whole series of initiatives to incentivise, motivate and encourage the system towards what one regional report called "prevention on an industrial scale. Alcohol is a big part of this agenda and we will be making announcements shortly".

The final question was from a member of the Wycombe branch. "Alan, we need to make PCTs more accountable to the public. Non-exec directors are a start, but not the answer. In Buckinghamshire, we feel that there is no way that we can influence the PCT board. We attend their board meetings as observers and can ask questions but have no influence. A petition of over 40,000 signatories carried no weight. The local CLPs seem to be siding with the Tories now, saying that mechanisms are urgently required to address this. The Labour Government has done so much to try to increase participation, but PCTs are not answerable. What is the way forward?"

Alan Johnson, said that the NHS constitution "clarifies and makes transparent the principles and process of decision making in the NHS and points out the good work being done in a number of PCT areas to improve accountability". He suspects the consultation will raise more ideas, but says that the world-class commissioning agenda and the new LINks initiatives mean we are moving in the right direction’.

Will Labour loyalists feel reassured by Alan Johnson’s words? He says reassuring things, but there are some really difficult problems down the line. Take accountability, for example. The NHS constitution says little that is new on accountability. Instead, it takes market mechanisms (such as choice) and employs the theoretical feedback mechanisms (like exit or complaints) to suggest that there is a coherent mechanism for local accountability, when there really is no such thing in place.

LINks schemes may be effective, but they are not even in their infancy. The official website told me earlier that there were no details available for my area, Camden, in London.

The problem for Labour, as the member from Wycombe points out, is that many people know believe that policy and its implementation is over-centralised, but it is the Conservatives that are taking credit for this diagnosis. More than Labour, they have become the champions of localism.

Another problem for Labour is that their twin approach to accountability – more information for people to make choices and a vague idea of linking together lots of different community perspectives – may actually be pursued with more vigour and passion by the Conservatives. They are openly Blairite about punishing poor producers by empowering consumers to make alternative choices. Their ideas for local health watchdogs are clearer than the LINks concept.

Labour needs a distinctive idea to improve local accountability, and it needs to be more engaging to Labour members than giving consumers greater choice – though this is a good thing in itself. Its approach to accountability needs to involve a political element, in the sense of being able to engage in the way that social relationships are shaped and how ideas can be contested.

Alan Johnson did not mention the CLG White Paper which suggests that local authorities will represent political views from within the local community. This could create a more adversarial relationship between health and local authority.

During the consultation on the NHS constitution, it will be interesting to see whether the NHS will step forward and embrace a political relationship with local communities.