Foundation independence is on a knife edge
Foundation trusts are undermining their autonomy through poor governance and accountability.
Two weeks ago, in an interview with HSJ, health secretary Andy Burnham highlighted the failure of FTs to balance their looser national accountability with more effective local oversight.
NHS chief executive Sir David Nicholson rammed the point home on Tuesday, telling board chairs local accountability had often been lost.
Now the Francis inquiry into the Mid Staffordshire scandal, which was published today, has exposed the precipice awaiting an FT whose board fails to get a grip on operational performance.
Combine poor local accountability and patchy board performance with contracting finances, the risk of trusts falling into deficit, and several FTs emerging from scandals, and it becomes clear there are near perfect conditions for the incoming government to drastically curtail FTs’ independence.
It is not a question of whether someone will take action on FT governance, but who, when and what.
FTs need to do it to themselves before the new ministerial team does it to them. Proposals accepting the weaknesses of current arrangements backed with hard-edged commitments to deliver rapid improvements are the best hope for avoiding an unravelling of the FT experiment.
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Terence Lewis | 25-Feb-2010 11:31 am
Good governance ensures an organisation secures sound performance in those areas that will affect its standing in the assessment of stakeholders. A key part of this process, in both public and private sectors, is satisfying regulators in the field. The NED has a pivitol role in this, but in my view boards for foundation trusts have been constructed with a strong business and financial bias at the expense of patients. This model has been relicated in many PCTs with, in my view, the consequences we are now seeing more generally and tragically in the Francis Report,
In my view, it is an imperative that NHS boards contain NEDs who 'know that business' through the patient's eyes and understand, value and espouse the public service ethos. This is not to undermine the effecient running of the service, but to ensure all stakeholders are given equal value in the decisions made and services provided.
My interest is primarily in the field of mental health but I believe my experience there and the conclusions I have reached, hold true in other parts of the system.
It has long been my belief that the DH more often than not writes good policy that reflects the priorities of the government that has won the right to act in our name. However, that is not the end of the story. Good policy before being implemented is often interpreted by key stakeholders - usually a process from which patients are excluded. The interpretation of these policies, and the timescale for their implementation, will take place within and between the Department of Health, the NHS Executive, regulators and organisations representing other stakeholders, and they will take place in fora from which service users and carers are excluded or have a token presence.
If this situation persists, not only will users of services continue to be discriminated against, but will once again see policy ‘watered down’ and remain unable to do anything about it. As serious, will be the neutering of dynamic policy, intended to increase the status of service users in the commissioning and provision of services; and to enable them to influence and hold to account – the role of the ‘customer’ in all parts of the private sector.
To address this key issue, an organisation to represent users and carers needs to be funded and established at national level. Such an organisation would replicate for patients and families the ability to establish a full time professional team to represent their interests, equal to that at the disposal of other stakeholders in advocating for their constituencies, and receiving funds from the service to do so.
This institutional exclusion – and it is exclusion, even if unintentional – enables the potential for policy such as WCC and HQCfA to improve services and re-align the prioritisation of stakeholders to be diluted. Instead a ‘company solutions’ is put in place. These solutions often require less ‘stretch’ for organisations in terms of ways of working, innovation, identifying new providers, being absolutely clear about VFM and ensuring the quality of the patient's experience is at the heart of governance and is a measure by which organisations will stand or fall.
In the private sector solutions to meet the need for change and the challenges this presents, must have the interest of the ‘customer’ at their heart. In the process, a significant degree of impact on the interests of other stakeholders may have to be accepted. In the public sector, the absence on share holders, holding the customers’ proxy, is the missing element which recent policy is intended to address by giving patients dynamis direct influence.
Regulation has a significant role to play on behalf of the patient, but cannot substitute for the real-time response of patients and families to the quality of services and their experience of them. The roll-out of Patient Choices and the potential it has to develop new relationships between the service and patients is welcomed and considerable.
The situation revealed in the Francis report make clear that dynamic and informed patient participation must be secured at every level where decisions regarding the development or delivery of services are being considered. This will be especially true in a period of reduced resources such as we are now moving into. The alternative is that the stakeholders at the table will secure a ‘company solution’ and the wider system is likely to accept this. This is not surprising since, in the main, those in senior positions across the system have at some time been ‘company’ men or women themselves.
To touch on the ‘how’ question, in addition to the reconfiguration of boards, another action required is clear, but may be beyond the will of the Department or the Service. It requires the establishment of a national independent body to represent the interests of patients, particularly at the highest level. The organisation would perhaps replicate features of the NHS Confederation in funding and with a professional headquarters, able to contribute equally at the highest level to the development, interpretation and implementation of policy
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