Published: 19/08/2004, Volume II4, No. 5919 Page 17

Promises on foundation freedoms are being broken - and It is not the politicians who are to blame Alan Milburn arrived at the conclusion after careful thought and John Reid grasped it instinctively: shifting the balance of power was not only managerially necessary but politically sensible in the light of system reform.

The reform movement is based on greater patient choice, supplyside capacity, devolved decisionmaking to frontline clinicians and, in the vanguard, independently run organisations in the form of foundation trusts.

Shifting the balance was supposed to transfer power to GP surgeries, community centres and hospitals.

This would make services more responsive, cost effective and flexible. It would also reduce bureaucracy in organisations that supposedly sat in the 'centre' but, in fact, occupied the periphery of healthcare delivery.

However, over the past three months I have noticed an increasing lack of coherence between national inspection and regulation bodies and, more alarmingly, a desire to control.

It would appear that some new players and old characters are quietly at work to keep control of power and, perhaps inadvertently, maintain the status quo.

There is a lack of clarity in the roles and responsibilities of the Healthcare Commission, Monitor (formerly the independent regulator for foundation trusts) and the Department of Health.

Who, for example, controls and manages the consequences of payment by results, MRSA (methicillin-resistant Staphylococcus aureus) or choice?

Foundation trusts tend to get asked about the same subject by several different organisations.

The European working-time directive and MRSA are the two most recent examples. Panics and reforms associated with both issues mean that foundation trusts have to keep commissioners, their strategic health authority, Monitor and the DoH informed.

Even our local council's overview and scrutiny committee has established its own sub-group on MRSA and infection control.

Instead of bureaucracy being reduced, more questions are being asked of the front line.

Look, too, at new guidance on the complaints procedure from the Healthcare Commission. If a complainant remains dissatisfied with local resolution, they can request review by the commission.

How can the commission handle all second-stage procedures? Should they even be involved in a local issue?

A further worrying sign came on the day the 2004 star-ratings were published.Monitor issued a press release that declared: 'The regulator has written to four foundation trusts asking each to explain the reasons for the loss of a star and to give information on the proposed action plan, for the regulator to review. If a foundation trust is significantly breaching its terms of authorisation, the regulator has powers to require the foundation trust to do, or not do, certain things, and to remove directors or governors.'

I realise that Monitor was trying to explain a complicated situation, but can you imagine even an old regional office threatening directors who had moved from three stars to two in so public a fashion?

Yet more confusion is illustrated by a DoH letter to chief executives dated 3 August, which, in the same breath as mentioning 'earned autonomy freedoms', goes on to take away the£1m bonus non-foundation trusts received for gaining three stars. The decision was taken on the basis that foundation trusts are subject to a different financial regime and that, by inference, they will do well from payment by results. This makes no sense.

Even though foundation trusts do not report to government, ministers and civil servants have been very keen to show they are still part of the NHS and will receive equitable treatment with non-foundations trusts.

We deeply resent the confused and simplistic thinking that equates foundation trusts with financial prosperity. Payment by results was designed to ensure competition, choice and balanced control over supply and demand between commissioners and providers.We are helping to refine this monumental and progressive system - not exploit it.

System reform is a massive and complex movement that will take time. Naturally at this stage, there is a mixture of old and new systems-thinking going on.

The politicians have stayed true to their word - they have attempted to devolve power by creating new independent authorities. But these new bodies seem to be displaying a natural temptation to hold and wield this power in a centralised fashion.

The irony is that it is not only politicians who like holding power; it is also those who work in national authorities.

Politicians have demonstrated through legislation that they are willing to let go. Can others think and do the same?

Those who believe in system reform must keep pointing out that the emperor has no clothes until such a time as we can create a less centralised and inflexible healthcare system that gives patients more control.

Mark Britnell is chief executive of University Hospital Birmingham trust.He has written this column in a personal capacity.