Published: 06/05/2004, Volume II4, No. 5904 Page 12 13

When it won foundation status last month, Royal Devon and Exeter Healthcare trust struck a quiet blow for rurality.

As chief executive Angela Pedder says: 'In the South West, there is often a feeling that many of the national policies have been designed around cities and major conurbations.We are an organisation that focuses on our delivery of services locally.'

The long arm of the centre, expressed through strategic health authorities, meant that reacting to local need had been curbed, she claims. The trust could ask local people what they wanted but the iron law of target delivery meant 'we had no flexibility to work that through'.

'In the past we have not just been told what the targets are, but also told how to do it - what this begins to give us is more room.'

She says the trust will no longer be able to plead 'if only the Department of Health would let us'.

The most profound change will be in local engagement - not just asking local people what they want, but the power to respond.

'All the [foundation hopefuls] started the process thinking it was all around the financial freedoms, but actually the way you work with the local community and the engagement/involvement that you have with members is the exciting part in terms of developing healthcare.'

The 850-bed trust has about 9,500 members, putting it second behind London's Moorfields Eye Hospital foundation trust in London in terms of numbers.

Even more impressively, it achieved a 56 per cent turnout in elections for governors.

Lessons have been learned from the past. Although there was little or no public opposition to foundation status, a plan two years ago to reconfigure acute services in Devon was dropped after local campaigns opposed change.

This time the consultation process was long drawn out and extensive - in fact, Ms Pedder says delays in legislation were not unhelpful in allowing genuinely in-depth engagement.

Many foundation applicants suffered from poorly attended consultation meetings - the Royal Exeter and Devon was no exception.

However, it relied less on them and more on linking with existing groups and meetings.

Often this meant on a villageby-village basis (in rural communities, social networks are often based on a very small geographical areas).

Foundation project manager Pauline McCluskey estimates that unofficial contacts with local people outnumbered the formal consultation by about eight to one: 'Our official consultation has been a tiny fragment of the overall process. At the outset there was no indication that we would have to have a formal process, but along the way it became clear that the DoH wanted a 10-week consultation in the traditional sense. That was overlaid on the work we were already doing - which meant that when they were running concurrently. It was interesting to manage.'

A prime example of a solidly local issue that surprised managers in the consultation was transport - rural populations mean long travelling distances for patients, often poor public transport and a reliance on parking.

Although in no way unique to the South West Peninsula SHA area, the strength of feeling on this issue was striking.

Ms McCluskey says: 'We were slightly taken aback. It was absolutely the top of the list, consistent across staff, patients, carers - far from being something rumbling in the background, we had to take real account of it.'

As a result of the consultation, the trust is talking to the local authority about respective transport networks. At its simplest, it has picked up on the fact that council need is heaviest at the start and end of the school day while NHS need is heaviest in the middle of the day.

Ms Pedder argues: 'There is a potential there to be released.

Some of that might require pump-priming but if we are in surplus - and we plan that we will be - and that is a priority identified by governors and members, it is a legitimate way of applying that.

'If we came up with a novel solution we could use the foundation freedoms to create the entity needed to take that work forward.'

She also points to an unexpected focus from stakeholders on the trust's role in social and economic development.

It is a major employer in Exeter and the surrounding area, 'but we had underestimated in the past our role and seen socio-economic issues as about the relationship between local authorities and primary care trusts'.

The trust deals with 12 community hospitals in north and east Devon, and Ms Peddar says it became clear that the public wanted its role to be expanded.

The need to introduce earlier transfer to non-acute settings is particularly pressing given that over-75s make up more than 10.3 per cent of the population in the trust's catchment area, and that figure is growing much faster than the national rate.

Similar development of the community hospital base is also being considered in neighbouring Cornwall.

Under the current reference costs, the trust, with an annual budget of£170m, should benefit by around£20m over the first four years of foundation status.

But it does not suffer from the deficits experienced by other trusts in neighbouring Cornwall.

Last financial year, three primary care trusts in the county and Royal Cornwall Hospitals trust posted deficits above£5m.

A National Audit Office report, published last week, identified a number of financial pressures in the area, including the dispersed rural population, above-average activity in areas including primary care and accident and emergency, and the need to hit waiting-list targets.

South West Peninsula SHA is expecting a deficit of around£17m this year, following a deficit of just over£20m last financial year.

Up to a point, the Royal Exeter and Devon can now consider it free of these problems, although Ms Pedder urges caution: 'It would be a foolish foundation that wanted to cut itself off completely from a relationship with peers and colleagues, ' she says.