The argument between the foundation trust lobby and the Department of Health over foundations’ freedoms goes to the heart of the debate about the role of politics in health policy.

Foundation trusts were one of the most radical public service innovations championed by Tony Blair. They were an acknowledgement that regulation, inspection and targets alone would never transform services; the big prize would come through providing freedoms and incentives to innovate.

Seven years after their introduction we are about to reach a tipping point, with more than half of all trusts securing foundation status and the day fast approaching when everyone will be in the foundation camp. The government has to determine its relationship with foundation trusts for the long term.

Monitor executive chairman Bill Moyes has brought the matter to a head by choosing DH pressure to cut infection rates as the field of battle. He has publicly objected to NHS chief executive David Nicholson writing directly to foundation trusts, in the wake of the Maidstone and Tunbridge Wells infection scandal, and told him to write to primary care trusts instead.

The row has stirred Foundation Trust Network director Sue Slipman to push for Monitor to take an even tougher line, accusing the regulator of risking being a conveyor belt for DH policy and calling for foundations to have the freedom to ignore core government policies such as the 18-week referral to treatment target.

It is unrealistic in practice and wrong in principle to expect the government to all but cease communication with the country’s hospitals, in effect handing over around£55bn of tax each year then only getting in touch via the local PCT or Bill Moyes.

It is a legitimate political action for a party to stand for election promising to slash waiting times and improve patient safety, then communicate that to the hospitals they fund. Voters would expect nothing less.

The issue is where the boundary is drawn to keep the government from behaving as if it has “line management responsibility”, which Mr Moyes points out puts it in breach of the legislation. Interfering in severance pay for managers and allowing Downing Street speech writers to determine cleaning regimes are two recent examples of the government trying to micromanage hospitals.

This public bust-up comes as the DH considers the future of foundation trusts; it has just renewed Bill Moyes’ contract for two years only, it has implied to HSJ that the regulator will be subservient to the new Care Quality Commission, and it has explicitly refused to confirm that Monitor will continue after 2011.

On top of this there are tensions in the department over what the long-term limits of foundation trust freedom should be, and rumour has it that Moyes and Nicholson are not exactly close.

Foundation trusts would have better grounds for taking a hard line on freedom from government control if local accountability was stronger. There is virtually no evidence that a trust’s membership strengthens links with the local population, while PCTs, despite being the commissioners, still have a long way to go in shifting the balance of power in the health service away from hospitals.

The foundation trust lobby is right to defend local autonomy, but tackling this complex web of issues by publicly confronting the DH, especially over patient safety, is a serious tactical error.

It fails to recognise political realities and heightens the chances of Monitor eventually being disbanded and the centralisers at the DH reasserting direct control over acute trusts.

The way to secure the foundation principle is to strengthen the role of PCTs so they provide local accountability as the alternative to central control, develop trust membership so that it becomes more than a fig leaf of patient involvement, and win the confidence of ministers by relentlessly delivering on patient safety.

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