Seeking the legislative power to direct foundation trusts, both NHS Improvement and England want to move back to more centralisation and control, notes Andy Cowper

Ever fallen in love with someone you shouldn’t have fallen in love with?

Of course you have. We’ve almost all been there: in love with someone who isn’t good for us. People can fall in love with ideas, too, and the NHS might be about to fall in love with A Very Bad Idea Indeed.

This week, HSJ was leaked the news that NHS Improveland is looking to get the legislative power to direct foundation trusts.

And let us be quite clear: if the legislation is passed to enable this, that will mean abolishing foundation trust status.

What’s the problem to which abolishing FTs is the solution?

This does feel a bit like it’s our dear old friend “The Politician’s Syllogism” at work:

  1. Something must be done;

  2. Abolishing FT status is something;

  3. Therefore abolishing FT status must be done.

What is very unclear from the story briefed to HSJ is what NHS Improveland believe the problem to be. But I have a worrying feeling that it might be a question of taking back control, which is working so tremendously well in the bonfire of the sanities that is Brexit.

Control as in totals?

If it’s a question of the central bureaucracies of NHS EngImproveland taking back control, let’s just have a look at how well their efforts at control have gone with financial control totals.

Oh yes. That is not actually going very well, is it?

The NHS needs more centralisation: discuss

I have written in this column many times about the incentivising of financial lying in the NHS being a thoroughly bad idea.

I have also written similarly often about the NHS’s toxic culture of concealment, and about my view that “a service created to deliver the right answers to the centre is likely to face a range of perverse incentives. I suspect it is also likely to develop problematic cultural traits, including bullying, an over reliance on lawyers and a candour deficit”.

Now there are good arguments to getting the NHS to work in a more system like way. There are probably occasions on which FTs’ semi independence has made this more complicated.

Yet we must beware of trying to use a sledgehammer to crack a nut here. As I wrote previously, “the integration the NHS really needs… is not an integration of organisational forms: it is an integration of genuine teamworking, and real mutual acknowledgement of role legitimacy”.

My view has not changed. And if people really think that more organisational consolidation and centralised direction will get to the really tricky issues, then I’d like an ounce or two of what they’ve been smoking, please. 

A much ignored part of both the 2003 and 2006 Health and Social Care Acts is that FTs have an explicit duty to cooperate with the rest of the NHS. This has not been much tested legally, which seems strange if we are proposing that the only tool available is ending FT status.

New power to force mergers

Mergers in the NHS have not always got a golden history, as this round-table I programmed and wrote for HSJ back in 2013 confirms.

In the first place, we get into legislation that would go far beyond the NHS. The Enterprise Act would probably need to be amended, as Lord Lansley’s former special adviser Bill Morgan has often noted, and then there is the small matter of the resulting role of the Competition and Markets Authority in NHS mergers.

It is not obvious to me that the philosophical, practical and political problems with moving back to more centralisation and control in the NHS can all be overcome, and only arose because we didn’t have Simon Stevens and Ian Dalton running NHS Mission Control in the past.