Separating the NHS’s purchaser and provider functions more clearly would help everyone who works in the service focus unambiguously on their purpose

I enjoyed Anna Donald’s poignant final column for HSJ. Anna became a friend last year when she provided sage advice and support when I was diagnosed with breast cancer. One of her beliefs that I hold dear is that investing in quality is ultimately cheaper. I suspect she is right and hope to prove it one day.

I recently had to organise a talk on the NHS and its history for colleagues without a background in the ‘Nash’, as we cognos affectionately term it. My research has been fascinating as it reinforces Anna’s message about the need for clarity of the insurer-provider split. In her home country of Australia, the split is so effective that choice is facilitated at the interface with primary and secondary care. No ‘you’ll get what you’re given’ paternalism for the Aussies.

Here, we began by talking about purchaser and provider, then about shifting the balance of power, and now we aspire to world class commissioning, but we seem powerless to separate the functions, preferring instead the ‘blancmange’ solution.

But perhaps the clearest message from my reading was the accelerated frequency of reorganisation. A paper by Wolstenholme and Wolstenholme entitled A Systems View of NHS Reorganisations - the pain and cost of boldly going where we have gone before,illustrates how little impact structural reorganisation has on outcomes, instead serving as a distraction that undermines the loyalty, commitment and focus of good staff. Not only does this approach risk that disillusionment will take them to pastures new but it also comes with a significant financial burden.

But perhaps there is one innovation that has arisen from all this change that will stand the test of time and illustrate some learning from the process. The foundation trust.

I had the privilege to visit a foundation trust for a meeting. In the spacious glass atrium, I was greeted at a business-like reception by friendly, helpful staff and laminated cards explaining how to find my destination. Looking back to my vulnerable and disoriented patient experience finding a department in another FT 18 months ago, this was a welcome innovation. The hospital was clean and had an air of competence and high-quality care a far cry from the low-morale, crumbling edifices that some have become.

It rekindled my excitement about the great cathedrals of health that hospitals can be, exhilarating places when they work well. Cathedral is the correct analogy here and not parish church, which equates more to the 1962 model district general hospital.

This was further reinforced by an enjoyable discussion with the chief executive, who has to be one of the most grounded in the service. His visions of service sustainability and development all put the patient at the centre. He even had the poise to suggest that the private sector would raise the bar and create challenges to which his organisation would have to respond, seeing that as positive and beneficial.

So perhaps in foundation trusts, which appear to go from strength to strength with their model of greater autonomy, localism and self-determination, the NHS has its closest analogy to the publicly listed company, something that can differentiate and thrive and thereby foster progress.

Where reorganisation is directed at freeing up existing components in the system, such as hospitals, it can work. Where it tinkers with the size and scope of organisations or their interrelationships, it is doomed to confuse and disguise. To turn Anna’s argument on its head - world class commissioning is the goal for the NHS, but to get there we need clear separation so that the pawns in the system can focus unambiguously on their purpose.