The trouble with troubleshooters supporting foundation trusts is that they could end up imposing direct management on the organisation, writes Sue Slipman.

The passing of the Health and Social Care Act signals a new beginning. One of the biggest tasks facing public providers of NHS services – NHS trusts and foundation trusts – is to work towards creating and sustaining a whole foundation trust economy.

NHS trusts need support to become FTs as quickly as possible, as this will give us a more effective healthcare sector; delivering greater efficiency, quality improvement and local accountability.

However, we also recognise that not all trusts will be ready for FT status within the short (albeit flexible) timeframe imposed by the legislation. And, as the sector grows, more FTs are also likely to need support.

Against this backdrop it is understandable that Monitor will want to implement a resilient system to ensure that FTs avoid failure.

Previously, when an FT has fallen into difficulty, Monitor’s role has been robust but at arm’s length: the trust develops a detailed action plan, which the regulator monitors closely until it is satisfied that the FT is back on track. Delivering the plan might mean board resignations and changes at the top.

However, as times get tougher Monitor has been working on alternative ways to tackle the problem head-on.

One of its suggestions is “chief restructuring officers” or “troubleshooters”. The idea is that a troubleshooter would be parachuted into a struggling FT to advise the board on turning the organisation around. From Monitor’s perspective this could simply be seen as a difference of degree in terms of how it intervenes, as it already requires FTs to provide regular reports on governance, finance and quality.

However, at the same time as advising the FT chief executive and supposedly supporting the board, troubleshooters would be directly accountable to Monitor and reporting back on the competence of the management team.

While the idea of introducing external assurances is understandable, having them as a board member would ultimately remove one of the underlining principles and success factors of FTs – their independence and autonomy.

The approach would raise questions as to whether the regulator was, in effect, imposing direct performance management on the FT, treating it as part of Monitor.

And as any organisation will tell you, an environment in which there is trust among the board members is integral to its success. In governance terms there is a further, more important issue. An FT board is a unitary board with individual, joint and several liability. If one of its members is responsible to the regulator this undermines the central tenet of the governance structure.

A troubleshooter’s role in supporting the board while simultaneously reporting back to Monitor will make board members naturally cautious. Failings at this very basic level could create real problems, such as resignations, or destabilising and undermining the chair, chief executive and the board.

Troubleshooters also raise the bigger question of Monitor’s role in regulating FTs. For Monitor to make appointments at board level that are directly accountable to them surely causes a conflict of interest. Moreover, having a Monitor representative as part of the board means they lose their ability to offer an ‘outsider’s’ perspective - something which FTs find invaluable. 

In short, the introduction of troubleshooters would undermine the FT model. It strays into the realms of direct performance management and moves away from the principle of proportionate risk regulation.

Clearly this is just one of a number of ideas it is considering. However, if Monitor takes this forward, the roles individuals would play would need to be made crystal clear.

While we do not believe troubleshooters are the answer, we do believe the question Monitor is asking is absolutely right: as the FT sector grows and diversifies, how do we ensure organisations are sustainable and that quality is never compromised?

The best improvements come from within. But that does pose a practical challenge for Monitor in terms of how to locate interim talent, and put a solution in place that does not destabilise an organisation.

There is certainly a place for external support, but there has to be a clear line between management and leadership, and regulation. Any solutions need to respect the governance, independence and integrity of the FT model.