With 62 members, the foundation movement is coming of age. Monitor chair Bill Moyes offers a compelling picture of where foundation trusts are heading, and outlines his vision for the regulator's future
If one person is seen as being at the centre of NHS reforms in recent years it is Bill Moyes, executive chair of foundation trust regulator Monitor. After a difficult birth, the FT movement now stands at 62 trusts. The point is approaching at which the number of FTs will change not just what is asked of them, but what is asked of the organisation set up to bring them into the world.
Ambitions will grow all round the last year has seen the long-running consultation on regulation ask questions of all the bodies involved. For his part, Mr Moyes argues that no-one else in the system better understands finance than Monitor. In fact he says he is 'apprehensive about the number of FTs planning to merely break even because in this system that is not a good place to be.'
He says Monitor is now also picking up non-financial problems experienced by FTs, such as failure to deliver targets.
He sees this as the start of the regulator's long-term role of dealing with non-financial challenges. But is this appropriate? Mr Moyes believes so. 'It is important to be able to say to FTs that if you are in breach of your authorisation, here is what you must do to return to compliance and here are the consequences if you don't,' he says.
We discuss the criticism that there are too many inspection bodies. Mr Moyes counters this, saying that rather than critiquing the present arrangements it would be better to articulate how many intervention bodies there should be. 'I have never heard anyone describe what level of inspection and regulation is appropriate for a£100bn industry; an industry that at its worst can be very dangerous and which will consume£1m every five minutes by next year.'
Of course inspection is only half the story regulation means the power of intervention. Mr Moyes believes this should be vested in one body, if only to minimise chief executives being pulled in different directions by multiple regulators. It is an argument few FTs would contest.
Mr Moyes' experience of government and the commercial sector peppers our discussion. Listening, though, it is tempting to think there is not a lot more to him than the hard-nosed regulator. But this would be unfair. Mr Moyes comes from a poor family. He grew up as one of three generations living in two rooms in Dundee. There was no inside bathroom and the family paid a weekly visit to the public bathhouse.
It was not until he was 13 that they moved to five rooms with the luxury of an inside bathroom. A few years later his factory worker father suffered a series of strokes, which greatly affected the quality of his life. 'He became increasingly disabled and it was a miserable end to the last 20 years of his life,' Mr Moyes says.
During postgraduate career counselling at Cambridge, he role-played the Stock Exchange but realised he was not destined to make money. What he did discover was an affinity for public policy analysis and negotiation.
A career in the Civil Service beckoned: 10 years in Whitehall followed by a similar period in the Scottish Office. With subsequent experience in banking and retail to boot, why the move to Monitor? He found health the most interesting period of his civil service experience and, coupled with his time in the private sector, believed Monitor had exciting possibilities.
He says: 'I have got one of the best jobs for me. I can get involved in public policy and complex problems but I don't have to look over my shoulder all the time at ministers. I have to have some regard for them, but from an independent perspective.'
We discuss strategic development across the public and private sectors. Mr Moyes is not convinced by my argument that strategic life in the private sector is simpler because there are only a handful of realistic strategic options available.
He says that in the private sector there tend to be infrequent but intense periods of strategy formulation, which the organisation sticks to. Strategy is not as frequently revisited as it is in the public sector. The second difference, and this is where we do agree, is that implementation gets much more attention in the private sector. The public sector thinks too much about the what and less about the how.
For the NHS there is the relationship with government to consider, and Mr Moyes becomes animated when we discuss the missing pieces of the policy jigsaw. He bemoans the lack of competition, citing an urgent need to think through what it will look like and how it will work.
Is it the F-word that gets in the way? We agree that there cannot be a market system without failure, but he is clear this does not mean unplanned closures and whole organisations falling by the wayside.
Mr Moyes says we do ourselves no good by talking about insolvency: 'I cannot imagine any situation where a hospital does not have cash to pay bills, which is what insolvency means.' But he can imagine analysis showing that some services or buildings cannot continue in their current form and a planned approach to finding an alternative will be required. 'But it would be heavily planned and orchestrated. We risk exaggerating these challenges and turning them into political problems, which makes them even more difficult.'
He understands politics and the part it plays in big commissioning decisions. But what should not be a political decision is approving minor rationalisations of service such as closing a couple of wards.
This is the easy end of political involvement, he says. At this point I hear managers saying this is easier said than done, and has Mr Moyes actually experienced these issues for himself?
He has, in Scotland in the 1990s. It was not an easy time for the NHS and there was lots of debate about bed reductions in which he was heavily and publicly involved.
But the world has moved on, and the public sector is now the biggest employer in most parts of the country. So it is not surprising when politicians get upset about the possible impact of NHS changes on local jobs.
Mr Moyes counters this by drawing comparisons with other major industries where change has had to be addressed head on. Industries like mining, car manufacturing and steel are all referenced to underscore his view that we need to be honest with local people about the direction of healthcare and manage the transition rather than propping up services that make no sense. 'The worst thing we can do', he says, 'is to turn healthcare into an employment agency.'
Surely living successfully in Mr Moyes' world necessitates developing much more sophisticated leadership, perhaps more than has ever been seen before? Yes, but the answer is also for government and regulator to give people the freedom to get on with it, to resist introducing new priorities and micromanaging. He agrees that probably the biggest strategic challenge for hospitals is deciding what services they will have to give up in the future.
This is one reason Monitor is promoting service-line costing it provides chief executives and boards with analysis to confront and make decisions about services that are uneconomical, or patients are dissatisfied with, or the right clinical outcomes cannot be achieved.
This again mirrors other sectors such as private healthcare and retail. NHS reforms will drive boards to have more sophisticated systems, which in turn will help them appreciate what they can and cannot do organisationally.
Although Mr Moyes has been critical of the quality of boards in the past, he now meets people with a much more sophisticated understanding of the business. They have the skills and experience to run complex organisations and can see the bigger picture, no longer viewing hospitals in simplistic terms. 'They see FTs as attractive organisations, with non-executives now having the freedom and autonomy to help them grow, change and improve.'
He presents an articulate and compelling vision for the FT movement. It is clear from the way he has developed Monitor that he prefers order and structure (perhaps reflected in his love of gardening). By his own admission he likes frameworks, which he partly puts down to a fascination with mathematics and his PhD in quantum mechanics.
It provided, he says, a way of analysing phenomena that was beyond the empirical. Time will tell how this mantra will shape the future of FTs.
Neil Goodwin was chief executive of Greater Manchester strategic health authority until he left the NHS last year. He is now an independent consultant and writes a regular column for HSJ, which registered users can access in the opinion section of www.hsj.co.uk