The Meaning of Independence

Civitas, 3 August 2009

Health secretary Andy Burnham wants powers to formally to ask Monitor, the independent regulatory organisation for foundation trusts (FTs), to intervene with FT management where there is “demonstrable poor quality, demonstrable poor governance or a failure of leadership.” The proposal is set out in a current DH consultation.

If passed, this would be a clear wavering of the government’s current policy push for escalating organisational autonomy within the NHS. Until now the focus has been on encouraging all secondary care providers (and eventually PCT provider arms) to get on track to become FTs—a status enabling certain financial and governance freedoms, along with independence from DH management. The NHS Confederation and other bodies have said this policy would threaten Monitor’s independence and undermine the principle of Labour’s post-2002 health service reforms.

This new policy is proposed in response to the Healthcare Commission’s report on the failings of Mid Staffordshire NHS Foundation Trust earlier this year, stating “Recent events…have demonstrated that a gap exists in the regulatory architecture of NHS foundation trusts, between existing Monitor intervention powers and the unsustainable provider regime.” Mid Staffordshire had been granted FT status in February 2008, and the Healthcare Care commission findings dated back before this, signaling Monitor’s assessment processes, and subsequent regulation were lacking.

But would the situation have been reported sooner had it not been appointed as a foundation trust?

Even if the trust had been an FT for a longer period of time, it is quite likely that those clinicians who were afraid to speak up about the poor standards of cleanliness, patient involvement, staff supervision and case assessment would have been just as hesitant to blow the whistle. The problem was not lack of regulation so much as a harmful organisational culture (one prevalent throughout much of the NHS).

Part of being granted independence (think of parents and children) means being given the opportunity to make mistakes and to learn from them. It is a tricky call to make, however, when those mistakes can result in preventable errors, patient harm or even death. This is a good reason Burnham is also proposing that Monitor have the ability to de-authorise underperforming foundation trusts, a process that probably should have been enabled from the beginning. Going as far as giving the Secretary of State for Health the authority to intervene in trust affairs whenever he or she deems it necessary seems a bit regressive in relation to the current policy agenda, and a futile attempt at solving a much wider problem.