Memorandum by Dr Mark Exworthy (FTM 03)
NHS FOUNDATION TRUSTS
1. SUMMARY
Foundation Trusts (FTs) represent a significant
phase in the decentralisation of the NHS. Allied to other reforms,
FT status offers (high performing) Trusts the opportunity for
greater autonomy in various functions from the Department of Health
(DH)/centre. Here, autonomy can be seen (i) as "freedom from"
the centre as well as "freedom to" be innovative and
responsive, and (ii) as a key factor with incentives in promoting
further improved performance (crudely, autonomy+incentives=higher
performance).
The willingness and ability of FTs to exercise
their autonomy will determine the impact they have both within
their organisations and the wider NHS. Currently, the evidence
suggests that they have yet to exercise fully this autonomy but
have the potential to do (given their current evolutionary path
and supporting policy developments).
2. LACK OF
EVIDENCE
In general, there is a lack of (research) evidence
on the work and impact of FTs, given their significance to English
health policy. The reports by the Health Select Committee (2003),
Day and Klein (2005), Healthcare Commission (2005) and the Audit
Commission (2008) are the major sources of evidence. Some studies
have been conducted into specific aspects which relate to FTs,
such as Payment by Results (PbR). Anecdotal evidence is much more
prevalent.
3. SYNTHESIS
OF EVIDENCE
This synthesis is informed by the provisional
findings from our research (see 4).
2a. Macro-level: Autonomy from the Centre:
Recent reforms have transformed by the role of
the "centre" in that the DH is no longer the sole agency.
For example, the Secretary of State no longer retains residual
powers. Instead, Monitor (as regulator) has a key role in ensuring
performance standards of FTs and acting as a buffer between DH
and FTs. Generally, Monitor is well regarded by FTs. The role
of the Strategic Health Authorities (SHAs) in relation to FTs
has also changed given the removal of performance management function.
The number of FTs by SHA area varies considerably and may imply
a key role for SHAs in fostering FT development. However, the
DH and SHA also require a change in attitude and behaviour to
reflect the changed landscape of FTs and their activities.
2b. Meso-level: FTs in the local health
economy:
Despite autonomy, FTs' actions are constrained
to varying degrees by the context of the local health economy
(or community). For example, PCT deficits or "competition"
from other providers might constrain service developments of or
related to FTs. Provisional evidence suggests that FTs are "picking
and choosing" the issues on which they are cooperating (especially
if it is in their self-interest). There are some perceptions that
FTs have secured an unfair advantage in the LHE (for example,
as a result transitional relief arrangements associated with PbR).
PCTs still remain generally weak (in capability and intelligence)
compared to FTs, comprising the strategic perspective of PCTs.
2b. Micro-level: FT attitudes and behaviour:
FTs have been the "high performing Trusts";
this was the criteria for their approval. This biased sample indicates
that their performance might also be strong as FTs but initial
evidence suggests no significant improvements as a result of FT
status. The willingness and ability of FTs to exercise their autonomy
is debatable. Generally, they are able to exercise autonomy (under
their new status as public benefit corporations) although FT status
demands that senior staff change their skills and attitudes. Equally,
FTs appear less willing to exercise autonomy to a great extent,
as they are still acquiring legitimacy as organizations in their
LHE and internally. This unwillingness might reflect their view
of risk (aversion to it) given their greater degree of financial
exposure, the uncertainty associated with the new policy environment
(including on-going features of centralisation) and the impact
that their decisions might have upon other local organizations.
New governance arrangements are seen as an important development
but have yet to translate into meaningful change. The relationship
between the FT Governors and the Board still require further development.
4. FUNDING
Our current research is funded by the National
Institute of Health Research (Service, Delivery and Organisation
R&D programme): "Decentralisation and performance: autonomy
and incentives in local health economies" (2006-09) http://www.sdo.nihr.ac.uk/sdo1252006.html
(Lay and scientific summaries are available on this web address).
The research project involves a collaboration
between Dr Mark Exworthy (Royal Holloway, University of London
(principal investigator), Francesca Frosini (RHUL), Lorelei Jones
(London School of Hygiene and Tropical Medicine), Stephen Peckham
(LSHTM), Prof Martin Powell (Birmingham University), Dr Ian Greener
(Durham University), Dr Jacky Holloway (Open University) and Dr
Paul Anand (Open University).
June 2008
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