Foundation Hospitals
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Foundation hospitals are presented as a status that hospitals can earn by good performance that will free them from central control and give them access to extra resources. Ministers also present them as a way of introducing democracy into the governance of the health service. All these aspects are questionable. Some central controls are necessary. For example any medical services that can only be provided on a regional or national basis need to be planned and organised. The decision, published on 05 May 2003, to abandon a planned saving of £500m from standardising financial computer systems and purchasing contracts across the NHS because it would conflict with foundation hospitals' autonomy is a doctrinaire decision of no benefit to the hospitals or to their patients or to their communities. Other central controls should simply be abolished. Financial incentives for hospitals to spread the use of "modern matrons" are unnecessary tinkering. The resources should go to the hospitals unconditionally, and once best practice is clearly established hospitals that are slow to adopt best practice are likely to follow the pioneers. Ministers who want hospitals to be autonomous should restrain themselves from meddling in matters best decided locally. They will still be accountable until a more local democratic accountability is established. As the Government manages the national economy, any extra resources for foundation hospital are not a free resource, but will constrain the resources available to other hospitals. The concept of earned autonomy is self-contradictory. Any autonomy that is dependent on ministerial favour is unreal. The hospitals that most need to be run by people who are democratically accountable are the ones with the poorest performance. My local hospital trust, University Hospitals Coventry and Warwickshire NHS Trust, got a "no stars" rating because of arrogant management spreading dissension and focusing on developing a new hospital while neglecting existing services. Ministers have changed board members but the new members are little known and have not earned public confidence, particularly as the practice of suspending whistleblowers on unrelated charges has continued. The starting point for democratic governance should be the local community. In the health service the local governance is through primary care trusts (PCTs), which affect everybody who is registered with a GP or uses a community pharmacy. Primary care trusts commission services from hospitals and other specialised NHS trusts. Trust members should be directly elected to represent geographical constituencies, possibly groups of GP practices. There should be enough directly elected members to exercise the equivalent of local authorities' executive and scrutiny functions and to include nominees on strategic health authorities and on NHS bodies providing services to the area. Hospitals should include on their boards a majority of PCT representatives, drawn from all the PCTs in the normal area served. One of these representatives should chair the board. If a hospital provides one or more regional specialties (such as cancer services at Coventry), PCTs in the regions served should nominate one or more PCTs to appoint a member (and substitute members if necessary) to represent their communities collectively. It would also be possible to include elected representatives of current and former patients and carers and of staff. All voting members of hospital boards should be elected by a recognised constituency. Chief officers should follow the local government model and advise but not vote. Similar arrangements should apply to other NHS trusts, such as for mental health services and for ambulances.. The Health and Social Care (Community Health and Standards) Bill is imprecise about constitutional issues in foundation trusts. Clause 33 in defining election offences refers to a public constituency and a staff constituency. Voters must make a declaration that they belong to one or other constituency. Schedule 1 covers constitutions in more detail. The public constituency is primarily geographical but may
This is badly drafted, as "to comprise" would exclude the geographical qualification, and some hospitals primarily serve a local community but also draw patients from a wider area. It would be clearer to say "to include", and to make special provision for hospitals that take patients indifferently from the whole country. Voters and candidates for election must be members of the "public benefit corporation". To be members they must not have a disqualification similar to those for councillors, and they must agree to pay £1. Disqualifications for voting for foundation trusts are unusual, and some people are able to vote for parliamentary and local elections who will be excluded from electing governors for their local hospital. Also there may be a low take up of registration of members, as it will not be a public duty to register and members will have to positively agree to make a small payment. The requirement for payment could particularly disenfranchise people who are disadvantaged by poor hospital transport or by charges for car parking etc. There will be a minority of appointed members, including one Primary Care Trust representative. So for University Hospitals Coventry and Warwickshire NHS Trust (when it eventually become a foundation trust) only Coventry PCT is likely to be represented, although the level of services to be provided in Rugby, and access from outside Coventry to the main site, are likely to be ongoing issues. Primary Care Trusts should be directly elected and must have stronger influence both on strategic bodies and on bodies like hospitals providing services to their localities. |
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Sheila
Porter-Williams |