Published: 09/05/2002, Volume II2, No. 5804 Page 4

Foundation hospitals will only work if the government has 'the courage of its convictions', the NHS Confederation has warned.

In a briefing paper due for release tomorrow, the confederation broadly welcomes the concept first outlined by health secretary Alan Milburn in January. But it raises a series of questions about how such hospitals should work and describes the association of short-term performance with long-term changes in legal status and freedoms as 'illogical' and 'bringing a number of significant problems'.

Confederation policy director Nigel Edwards said that if trusts were to be given foundation status on the basis of a three-star rating, then the way the stars are allocated needs to be improved, so ratings are based on 'a much more rounded view' of performance.

In discussions at the confederation workshop which resulted in the briefing paper, members insisted 'freedoms could not come and go with an annual assessment of performance' and called for further explanation on how the machinery for disestablishment and takeover of foundation trusts would work.

The paper calls for a new approach to performance management and the development of better strategy and commissioning. It says more attention needs to be paid to the aims of the hospitals and how they can unleash creativity, instead of to the legal and structural aspects of the new bodies.

'There is no point just changing the legal status without changing the performance management, ' Mr Edwards stressed.

He told HSJ the policy would only work if the government was able to resist the temptation to meddle in the running of foundation hospitals - even when events went awry. 'It depends if they [the government] have the courage of their convictions. They have to be able to bite their lips when something adverse happens.'

The paper highlights the tension between a primary-care led NHS, focused on local health communities where power lies with primary care trusts, and a more stand-alone role for foundation hospitals.

Mr Edwards asked: 'How does the governance management of PCTs fit in with foundation status? You have the professional executive committees of PCTs saying 'we thought we were the engine room, We are the owners of the health community'. It is an interesting tension.'

He said that since Mr Milburn's post-Budget speech put the spotlight back on the foundation concept, a divergence between a few 'gung-ho' acute trusts keen to act fast and a more cautious response from the rest of the health service had become apparent.

'A few want a huge amount of freedom, but the majority recognise that we have moved on since the internal market - however gung-ho you are about it, you want to be part of a health community in some way.'

Mr Edwards said the model seemed best suited to large tertiary hospitals which deal with large caseloads beyond the local population.

But he also questioned why foundation hospitals should be the only ones to win increased freedoms: 'If you accept the principle that we need a risk-taking entrepreneurial culture to achieve results, then why does it only apply to some hospitals?

Mr Edwards said he was not concerned that since Mr Milburn first mooted the foundation hospital concept little further information had been made available on how it might work, and was hopeful this meant there was still time to shape the policy.

He said: 'We already have a system of policy-making in which, perhaps, we make our stakes in the ground too early.'