My appointment as chief executive of the NHS Confederation in February 2002 came at a time of great expectation within the health service. Blair had recently unveiled his blueprint for NHS reform, as part of a much broader scheme to make public services twenty first century proof. The NHS Plan set out a clear and generally endorsed vision of how to make the NHS more responsive to patients, and was backed by substantial resources. This should have been a time of substantive and fantastic change.

A lot has happened within the service since those years. We should be pleased people no longer wait years in pain for hip and knee replacements, and the waiting list targets have contributed to this improvement. Yet the NHS as a collective system forgets the good change and does not take the time to celebrate. Sometimes it seems the service has lost its clarity of purpose.

The schism between clinicians and managers is symptomatic of this uncertainty of purpose. There are natural tensions between delivering the health system equitably and within budget, and the individual needs of each patient. However this tension often leads to entrenched positions locally and a lack of trust between managers and clinicians. The patient is always the loser when this happens.

This situation has led to negativity on both sides. There is too much time spent hectoring in newspapers instead of working together to improve outcomes and patient experience. Moving out of the NHS I feel sad about this as a doctor, manager and patient.

The current emphasis on closing the gap is right. The Royal College of Physicians' work on medical professionalism and the collaboration between the Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement on leadership are contributions to the solution.

But solving this problem requires more than rhetoric. We need local managers and doctors to sit down together, reaffirm their common purpose and talk about the things which matter to patients. We need a clear vision and statement about what the NHS is and how it will work. We need all groups working in the NHS to use logic rather than emotion in discussion how we move forward. Above all, we need maturity, tolerance and understanding.

We must all engage our brains and work together, for 'where there is no vision the people will perish.'