'I'd like us to look back on a time when people came to a big shed and had 10 minutes with the expert'

What will this year bring for an organisation like mine, King's College Hospital foundation trust? King's was licensed as a foundation from 1 December so we are bedding down the governance arrangements. And although we have long since changed our board processes to meet foundation trust compliance requirements, and although we have had a shadow board of governors for over two years, crossing the start line has released tremendous energies.Our board committees are becoming crisper about their purpose. The performance committee is working out how precisely it can add value to care group and corporate development. This moves us away from a procession of reports received and comments offered. The finance committee is moving towards profit and loss analysis as opposed to guessing what makes or loses money. If we don't get to this position across the acute sector we risk getting into serious trouble without knowing it. Thankfully, through our Agnentis IT project we are growing the necessary understanding of income and expenditure. Our new investment committee has a set of priorities about what we can offer to the rest of the NHS without the need for consultancy at commercial rates - and what we can offer beyond the NHS without getting out of our comfort zone or into markets we don't understand. While that sounds very business-like the board of governors is a revelation. As other foundation trusts have found, patient and public governors are direct with their concerns as well as their praise. This will clearly extend beyond cleaning, catering and attitudes to the behaviour of professionals, lack of clear process, and poor use of patients' and carers' time.

A big opportunity

This is a chance to understand where our types of organisation transfer much of the hassle of getting services to our consumers. This contrasts with the best of the service industry, where competitiveness has impelled banking, insurance, travel and the like to take that hassle back to themselves.

I'd like us to look back in a few years on a time when we put people to the trouble of coming to a big shed, passing through a series of queues, and having 10 minutes with the expert, as a thing which we will have abolished. As the tariff is progressively unbundled, and if we could be rewarded for knowledge and support to other professionals (and patients themselves) rather than bringing people into the big shed, we have a growing chance of getting there. Meanwhile, like all acute trusts we grapple away with system requirements for the 18-week target, attempt to reconcile that with PCT intentions (which we support) on demand management, provide opportunities in growth areas, and manage all the other compliance and improvement requirements. Just pulling patient safety issues out of the improvement agenda, barely a day goes by when we are not reviewing strategies on infection control, both within our clinical governance processes and corporately. And all this needs doing without overheating costs against income and undermining our target surplus. We also need to take our people with us at every stage. There may be a tendency at this point to become daunted or even depressed by the range of requirements. I remember a speaker once describing chief executive conferences as 'an opportunity to come out of the trenches and exchange war stories'.

Positive outlook

But I see grounds for optimism. The fear of unobtainable diagnostic requirements to deliver the 18-week target looks unfounded. The number of scans required seems to decrease at a rate commensurate with the growth of dialogue between GPs and hospital consultants.

We're still learning new ways to manage variation in demand through accident and emergency, which as yet shows no sign of reducing. And on infection control, innovations range from the sublime (trying new antibiotics) to the gorblimey (buying new commodes rather than sharing them between bed bays). Optimism in our case is strengthened by our first choice King's programme, which has put aside time and resources for clinical process change and the overhaul of the trust's core systems. There is support for people working to do better. Beyond King's it is difficult not to notice the strains in the acute sector and the rumble around A&E reconfigurations, the white paper stimulus to opt out of hospital care and the end of the district general hospital as we know it. Reports of the DGH's demise have been greatly exaggerated before, but now we are in new territory. This is fuelled by likely excess capacity once the 18-week target is achieved, the unaffordability of key staff (in small hospitals) after 2009 if we wish to employ them legally, a transparent need for clinical sub-specialisation, sufficient scale to deliver acceptable clinical quality, the inability of PCTs to buy current acute configurations, the arrival of independent treatment centres and the need for service models which are genuinely user friendly in the mind of the modern consumer. This amounts to a tipping point (and that includes King's own DGH component). Accordingly, there are planning processes under way in pragmatic health economies and the consolidation vocabulary - networks, partnerships, mergers, acquisitions, closures - is in the air. Whatever the outcome around the country I hope we don't get bogged down in trying to sell ideas to patients and public they will never buy. And I hope we will recognise the work many chief executives, boards and workforces are currently doing - often with considerable pain - to stay in or get back to financial balance. This isn't an argument for inertia so much as imagination. Perhaps 2007 can be a year of imagination. Malcolm Lowe-Lauri is chief executive of King's College Hospital foundation trust.