Regarding managers facing the axe at failing trusts, franchising has been tried before in the NHS, but what might work better is a more selective approach.

The Healthcare Commission's ratings show clearly that, as judged by patients, the best NHS services are provided by specialist, not generalist, organisations.

Identifying which services are "failing" and then franchising their management to best-of-breed specialist providers, whether NHS or independent sector, is likely to deliver focused improvement with less disruption, opposition and "heat without light" than franchising an entire trust.

Too many football club chairs sack managers instead of allowing them to replace two or three players. A rash of unproductive manager-bashing and sacking might be avoided if trusts were similarly simply encouraged to franchise the two or three services that might be better provided by specialist organisations.

Steven Wrigley-Howe, Care Consulting