NHS reform requires the creation of significant parts of the NHS system that are independent of the Department of Health and the NHS mainstream hierarchy of the past.
Such organisations are essential for making the new system work, but they cause tension because they impinge on the power of the internal culture.
Independence in theory is a good thing; in practice, since it comes at you from outside, its impact is a bit of a surprise.
Every time a health service provider gains foundation trust status the DH and the NHS hierarchy loses some control of what is no longer their system
Over the summer there were signs of tussles between the DH and at least two independent organisations. The co-operation and competition panel was created to ensure NHS patients are provided with a set of clear choices between different providers. The geographical organisation of NHS services has not been created with these principles in mind, so there are some areas of service where geography makes competition difficult, and others where past mergers have made it impossible.
So the application of some straightforward anti-monopoly principles comes as a shock to the NHS: in the past the NHS did not have to ask anyone’s permission before it merged organisations together. Shock creates a reaction.
The struggle between the NHS/DH and Monitor has greater history. Every time a health service provider gains foundation trust status the DH and the NHS hierarchy loses some control of what is no longer their system. That was after all the idea behind the legislation. For as long as Monitor and foundation trusts act as if they still are under control of the past, then there is no conflict. But when they start operating as if they are as independent as in fact they are, then conflict emerges.
The reaction to this is that over the summer the DH has been consulting on changing the legal status of this architecture.
Creating independent organisations to build a new NHS is one thing, developing a culture that welcomes that independence is something completely different.