3. CONCLUSIONS
163. We agree with Dr Rutter that "there is
a richness and a focus and a clarity which comes with having patients
involved in this process at whatever level",[201]and
we endorse the Government's efforts to extend patient involvement
through the establishment of independent Boards of Governors elected
by patients. However, as Mark Sesnan pointed out, the concept
of Foundation Trusts is a new and very experimental idea:
In reality, this creature is going to be forced.
It is a forced birth, it is not going to be a natural birth, because
there is not out there necessarily even an understanding of what
we are trying to create here.[202]
164. We feel that the policy of Foundation Trusts
as presented in the Government's Guide needs changes in
several areas if it is to succeed. These include the rationalisation
of regulation arrangements, the introduction of clear national
standards for the membership and election of Boards of Governors,
additional assurances on the access of Foundation Trusts to the
NHS's limited budget, and clarification of the precise powers
available to both members of Foundation Trusts and their Boards
of Governors. We also think it is vital that PALS and ICAS are
maintained within Foundation Trusts, and that Foundation Trusts'
non-executive directors should be affiliated and accountable to
the CPPIH. We also recommend that the Government considers
a wider democratic option for trusts, including PCTs, to consider,
with or without the freedoms associated with the current Foundation
model.
165. Undoubtedly, as with any new system, more teething
problems such as these will emerge as implementation progresses.
It is vital that solutions to these problems are put in place
promptly so that they do not become more widespread and entrenched,
which is why we have recommended that the Government slows down
its implementation of these reforms to allow time for evaluation
and refinement.
166. As we have heard from the Secretary of State,
if Foundation Trust status is not introduced for all NHS organisations,
a two tier system may emerge. If it is rolled out across the NHS,
it will arguably constitute the most radical recasting of the
NHS since its inception. It is important that in any change the
principle of a primary care led NHS is retained. This makes it
all the more important that the overarching aims and principles
of this policy are clear and coherent, and do not contradict or
confuse other Government policy initiatives. In oral evidence
to us, the Secretary of State also spoke of the need explicitly
to codify the differences between Foundation Trusts and nonFoundation
Trusts in order to "make it clear both to Foundation Trusts
and NHS trusts that remain until they graduate to NHS Foundation
Trust status what the rules of the game are".[203]
We strongly support this aim.
167. However, confusion about this policy appears
to go beyond the complex mechanics of its implementation, to its
interaction with other policy areas. In our view, the Secretary
of State was right to question the value of "reductionist"
discussions which "pretend that all that is happening are
NHS Foundation Trusts or all that is happening is some element
of contestability or some element of patients exercising choice.
It is not any of these things by themselves which in my view will
result in improvements in services, it is how you get all of these
levers working in tandem that gets you the improvement".[204]
However, we have received much evidence from organisations and
individuals confused over the way in which the Government appears
to be "pursuing policies that are inconsistent and run counter
to one another" and "has made no attempt at producing
a coherent vision of how the various policies it is implementing
will fit together once they are all in place".[205]
The most fundamental inconsistency lies in this policy's renewed
focus on acute trusts. The Secretary of State told us that he
and his Department had not considered piloting Foundation Trusts
by geographical area "because in the end the incentive has
got to be on the individual organisation to improve".[206]
However, he seemed to recognise the paradox at the heart of this
problem, acknowledging that "the hospital is not a little
island, of course it is not, it has got to work alongside the
Primary Care Trusts, it has got to work alongside the community
trusts, it has got to work alongside the local authority and,
most importantly of all, it has got to engage its staff".[207]
168. We have addressed concerns about the possible
impact of this policy on patients, both in terms of its potential
to skew the balance of resources and power within local health
economies, and in terms of its potential to tip the balance against
nonFoundation Trusts. For these reasons, we have made a
number of recommendations concerned with strengthening local partnership
arrangements, and ensuring that nonFoundation Trusts are
not disadvantaged either in terms of resources or in terms of
staff. While we understand the Government's aim to use the prospect
of Foundation status as a lever to improve the performance of
poorer performing trusts, we feel that the proposals as they stand
are not entirely fair or consistent, and need to be rethought.
Equally, to ensure a genuine 'level playing field' across the
NHS, the needs of mental health trusts, ambulance trusts and Primary
Care Trusts must all be taken into account.
169. The Secretary of State told us in oral evidence
that Foundation status would not be introduced for PCTs in the
first instance. The justification he gave was that he did not
want to put PCTs "through a further period of organisational
upheaval" when "they have barely come on line and they
need to develop their ability to commission".[208]
However, as we have seen, NHS organisations are not isolated units
but need to work closely together in order to survive, which means
that reforms in one part of the health economy necessarily have
a significant impact on other parts. The introduction of PCTs
has been as much of an organisational upheaval for the trusts
they work with as for the PCTs themselves. Likewise, the introduction
of Foundation acute trusts will involve substantial reorganisation
and development for the trusts who apply, but will also present
huge challenges for the still new PCTs who have to commission
services from them.
170. As we have noted there has been some kind of
organisational upheaval in some part of the NHS almost every year
for the last twenty years,[209]
and the number of new initiatives the NHS is expected to implement
seems to grow daily: in the last 12 months alone, we have seen
a substantial proportion of NHS spending power devolved to brand
new organisations, the introduction of a farreaching patient
choice initiative, substantial reforms to commissioning, major
changes proposed to financial flows, the launch of an NHSwide
employment framework, and the introduction of a new national system
for patient and public involvement. We are seriously concerned
that the perpetual flux to which the NHS is subject does not permit
the climate of stability vitally needed in order to allow clinicians
and managers to concentrate on improving care for patients.
171. It is also vital to retain a clear focus on
how these proposals will benefit patients. At the close of our
first evidence session, Chris Willis, Chief Executive of North
Tees PCT, told us that "one of the biggest problems we have
in the acute sector is capacity. What you would be trying to do
as commissioners is develop high quality capacity in all providers,
not just Foundation Trusts, because they would not be able to
meet everybody's needs. It is in our shared interests as commissioners
to make sure that all of your local hospitals improve and meet
targets".[210]
However, the Royal College of Nursing expressed concern that "these
proposals do not indicate that capacity in the NHS will be expanded
by the introduction of Foundation Trusts - surely the problem
that most urgently needs addressing in the NHS".[211]
We support the Ministers' ongoing commitment to equity within
the NHS, and have recommended that the Government strengthens
mechanisms to tackle the concerns that capacity and equitable
distribution is not distorted by proposals for Foundation Trusts.
However we also feel that the complex tradeoffs between
the desire to free up local entrepreneurialism, and the desire
to ensure uniformly excellent standards of care, need to be better
argued and more fully explored. Achieving the delicate balance
between these two aims is central to delivering real improvements
to NHS patients over the coming years. We hope that the issues
we have raised in this report will inform a wider debate on democracy,
accountability and devolution in the NHS.
201 Q158 Back
202
Q328 Back
203
Q482 Back
204
Q454 Back
205
Ev 122 Back
206
Q363 Back
207
Q363 Back
208
Q372 Back
209
"Foundation Hospitals - a new direction for NHS reform?'
Kieran Walsh, Journal of the Royal Society of Medicine
2003; 96, 106-110 Back
210
Q70 Back
211
Ev 112 Back
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