I did not say that foundation trusts should have the right to ignore government targets and that Monitor should stand up for them when they do (leader, 21 February). All foundation trusts should rightly meet the expectations that ministers have for patients, including government targets, writes Sue Slipman

My point is that while Monitor must make sure the trusts do not breach their terms of authorisation, it must do this in a way that retains its independence as a regulator and allows it to act fairly. The genuine dilemmas of its role would be impossible if it were a 'transmission belt' for government.

I mentioned an example that was hypothetical but which could arise where two government priorities intersect: 18 weeks and patient choice. Where a foundation trust has an agreed plan to deliver 18 weeks, it could be hit by an unpredicted high demand from patient choice. It may not be able to flex capacity to deal with such demand for several reasons, including that its board may see the necessary investment as uneconomic or inefficient. This would put the foundation trust at risk of breaching the 18-week target.

This is a genuine dilemma in which Monitor faces potential conflict in its jurisdiction. It must ensure government targets are delivered, but also that investments are efficiently made. If not, it could impact on the foundation trust's risk rating. As an independent regulator, Monitor will have to judge whether or not the board's unwillingness to invest is breaching its terms of authorisation or is a reasonable response in difficult circumstances.

The system will work only if independent boards operating in the best interests of patients can also make intelligent, efficient investment decisions. All providers, including foundation trusts, will be expected to deliver government targets, but where it has not been possible, the regulator's complex job will be to decide whether the failure is justifiable in the circumstances or not.

Sue Slipman, director, Foundation Trust Network

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