Paul Corrigan: foundations are the future

It is only five years since the creation of foundation trusts was seen as a threat to very existence of the NHS. While there are still a few who see them as the end of the health service road, most have joined the Conservative Party in admitting their opposition was a mistake.

This does not mean all is forgiven. One criticism of foundation trusts has proved correct. We now know that if you give the best public service organisations greater responsibility they will improve faster than others. This differential is what concerned some opponents. For them it is simply not fair that the best organisations tend to improve faster than the worst. It is here that the core politics of the NHS have shifted.

“For too long NHS improvement had operated at the speed of the slowest”

For too long health service improvement operated at the speed of the slowest. Most improvement assistance was aimed at the worst. It was more important that the worst caught up with the middling than that the best moved forward with pace, out on their own.

The creation of foundation trusts has successfully challenged this and shown that with greater responsibility and incentives the best improve in ambition. They set a standard which the rest aspire to.

There are still some in the Department of Health and in the NHS who find this unjust. They feel the improvements foundations have made, the surpluses they have accumulated and the world class status they aspire to are all the result of unfairness: their surpluses are somehow lost to the NHS and their world class status is hubris. They still see foundation trusts as somehow “outside the NHS”.

So foundations have not dealt with all the jealousies of guardians of the NHS. But their existence has moved the improvement debate on.

Obvious solution

The issue now is what practical interventions can the very best make to improve the worst. The next step must be to go beyond the decades of best practice clubs and improvement websites aimed at the worst. Foundation trusts have demonstrated they can run improving institutions and improve them faster. It is now the obvious solution for them to take over failing trusts.

For this to happen we will need to look at the law, which currently requires the board to dissolve before they can take over a failing trust. There also needs to be assistance with the developmental and financial costs of takeovers. And before there is a further storm about unfairness, across the country failing trusts cost the health service tens of millions in the varieties of bungs and readjustments they receive; repeating the failed economics of the past. Invest the same amount as an incentive to foundation trusts and you are investing in the economics of the future.

They could use a very small part of their collective surplus to create their own unit of expertise to manage and develop the necessary takeovers. This would relieve each single institution of the enormous financial and developmental expense of getting such a team together. Rather than facing the enormous expense for a single institution, a unit would over the next few years organise the 20 or so takeovers that are needed on a sequential basis, in batches.

They need incentives and collective organisation if they are to make these complex interventions to help the rest of the NHS. But there are other challenges they need to individually confront.

Aim higher

At the moment their ambition is good, but it is not aimed high enough and their boards are not taking enough risks. They are still saving for a rainy day when they need to start investing in a very different future now.

Medical science and technology is rapidly moving the traditional business of hospitals on. In 10 years’ time, when the post-operation length of stay has virtually disappeared, when 80 per cent of chemotherapy is done at home and when self management of depression and other long term conditions reduces emergency admissions, the foundation trust service and business model will have to look very different indeed.

The wise, innovative ones will start to invest heavily in that future now. If the development of new hospitals at home does not take place through foundations, their service and business base will disappear without a replacement in sight.

In this climate of step change in the meaning of institutions, risk taking foundations will thrive and survive. Conservative ones will falter as their services move elsewhere. Like all organisations, their future will depend on being adaptable to emerging environments.

So five years on it is “happy birthday” and congratulations on developing as organisations that have taken responsibility for their own and the NHS’s improvement. Before you are 15 you will all look very different.

Now for PCTs.