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EDITORIALS: Rudolf Klein The first wave of NHS foundation trusts BMJ 2004; 328: 1332 [Full text]

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Change takes time

Martin Rathfelder   (4 June 2004)

Experience of Foundation Hospital Elections

Richard J Toye   (4 June 2004)

Historic changes take time to development

Geraint J Day   (6 June 2004)

Governance: still no answer

Marcus J Longley   (10 June 2004)

Principal Agent Theory and Foundation Trusts

Hitesh Patel, Mitesh Patel.   (22 June 2004)

Change takes time 4 June 2004
Martin Rathfelder, Development Director, Socialist Health Association Manchester UK M16 8NS Send response to journal: Re: Change takes time	Recruitment of members and turnout in ballots for the first wave of foundation hospitals was indeed unimpressive. It must be borne in mind however that the hospitals had only about 6 weeks between being established and having to organise a ballot. Democratic processes takes time. If the public is to be convinced of the notion that they can exercise some sort of ownership of hospitals by electing governors then time will be needed for this idea to percolate. Mass democracy depends on engaging people whose focus is often elsewhere and convincing them that they can have some real influence by voting. Structural change, so beloved by politicians of all sorts, confuses people and impedes involvement. There were a number of difficulties with the processes used by the hospitals. One was the requirement that candidates needed to be backed by other members, when they had no way of knowing who the other members were. Another was that most limited the material that candidates could submit about themselves to 100 words. That did not give them the opportunity to do much more than say where they lived and how old they were. We need to give this experiment a bit more time before we reach conclusions about its effect. Competing interests: The author is a Labour candidate for election to Manchester City Council
Experience of Foundation Hospital Elections 4 June 2004
Richard J Toye, Lecturer in History Homerton College, Cambridge Send response to journal: Re: Experience of Foundation Hospital Elections	I recently stood for election as a Governor of the proposed Addenbrooke's Foundation Trust, covering the Cambridge area. I agree with many of Professor Klein's criticisms of the new system. I raised some of them myself - notably the point about the self-selecting nature of the electorate - during the public consultation process that preceded the application for Foundation Trust Status. However, that process was, in my view, a sham. As Professor Klein notes, democratisation is one of the government's aims. Yet it was clear from the start that Addenbrooke's was intent on applying for Foundation Trust Status regardless of anything that local people might say. The 'consultation' questionnaire had many questions relating to the details of the application - e.g. 'Do you agree with the proposed area of the Trust?' - but no explicit question on whether or not one approved of the principle of applying. When I asked why, I received the baffling response that this was because this issue was subject to public consultation! However, I incline to slightly more optimistic view than does Prof. Klein. He believes, on the basis of the first round of elections to the boards of governors, that the assumption that local people want to be involved in running the NHS is overoptimistic. Yet, on the basis of my own experience, I would say that the apathy he describes is by no means universal. The 'Meet the Candidates' event I attended was packed; I can hardly imagine a 'Meet your local council candidates' event would have been so well attended. And there were many candidates for each place; I received approximately 200 votes and was defeated; the successful candidates each received in the region of 700 votes. Arguably, none of this is enough, and the system remains flawed. I do believe, though, that the public, at least in some areas, are interested in partcipating. Whether or not their participation rates will in the long term be high enough to secure democratic legtimacy for the Trusts remains to be seen. Competing interests: None declared
Historic changes take time to development 6 June 2004
Geraint J Day, Member, Co-operative Party National Executive Committee 10 Southampton Street, Swindon SN1 2JS Send response to journal: Re: Historic changes take time to development	Professor Rudolf Klein is right that the development of National Health Service (NHS) foundation trusts represent an important experiment in the history of the NHS. It is also important that the new types of hospital trust be allowed a chance to succeed, and that they learn from best practice and their own experiences. That is one of the main planks of the Government's desire to make for more autonomous service delivery, alongside local engagement and governance. One thing that should not happen is that things be rushed. Many of the changes to the NHS since 1948 seem to have been based on largely untried - and more unfortunately - untested schemes. The gradual introduction of NHS foundation trusts in England is de facto a way of piloting the initiative. Even by October 1 this year the total number of foundation trusts would be only about one third of the total number of NHS hospital trusts in England. On the governance front, some of the Government's thinking is exlicitly based around the co-operative and mutual sectors here in the United Kingdom and overseas. The UK consumer co-operative societies, which are the direct descendants of the Rochdale Society of Equitable Pioneers, which set up a shop in 1844, are still going after nearly 160 years. Neither Rome nor the Rochdale Co-op were built in a day, and this is how things should be. It took time to progress from 28 founder members to a movement that encompasses many millions of people. The Rochdale Co-op was also instrumental in the creation of a worldwide co-operative movement which has activities in all sectors of life and some 700 million members (with many countries having active healthcare co-operatives, as it happens). As with the development of the co-operative and mutual sectors, things ought to be allowed to take time. Whether they be in matters clinical or electoral, the foundation trusts will learn from their own and others' practices. On the actual matter of voting for the boards of governors, the average turnout of 50% or so of the actual membership seems pretty impressive rather than something to give cause for concern. After all, the number of people who have a vote for anybody to play a stewardship role in any part of the non-foundation trust style NHS is precisely zero. Competing interests: Director of a regional consumer co-operative society. Member of the National Executive Commitee of the Co-operative Party. Member of the former Department of Health NHS Foundation Trusts External Reference Group on Governance.
Governance: still no answer 10 June 2004
Marcus J Longley, Senior Fellow and Associate Director Welsh Institute for Health and Social Care, University of Glamorgan, Pontypridd, UK, CF37 1DL Send response to journal: Re: Governance: still no answer	Klein's editorial reveals some of the key design flaws in the latest English attempt to solve a riddle as old as the health service itself - what should be the balance between central and local control? This conundrum is given contemporary urgency by the need to make change happen in the health service at a pace never seen before. Which gives rise to the additional question: will local or central control save the NHS? Wales is steadfastly still trying to make the previous model - commissioning - work. The assumption in England's much smaller neighbour is that local accountability and 'ownership' can be achieved through the work of 22 Local Health Boards, which have a small element of their membership drawn from local communities and councils. But they are appointed and not directly elected, and they have no direct control over provision, just commissioning. This latter point must make sense, in theory at least: what most people want (as much as they want to be involved at all) is to influence the big questions about the nature and quantity of services, not the technical intricacies of how they are delivered. The appointment rather than the election route may also be sensible, if the level of response to the English Foundation elections is anything to go by. But what of the question about which approach will make change happen fast? There is real concern that the Welsh model lacks an engine. It has rejected any form of quasi-market - it wants 'citizens not consumers' to drive change (whatever that may mean); it has also ensured that primary care cannot effectively drive change by championing innovative solutions for individual patients, without forging cumbersome collective agreements. And arguably it has even neutred commissioning, by creating 22 tiny commissioners for a total population of just 3 million. Foundation hospitals in England may ultimately prove a (relatively minor) distraction from the much bigger aspects of change in healthcare. The key issue remains: do we have an engine (or preferably several, linked engines) in the system capable of making mjaor change in services happen at a pace sufficient to satisfy rampant public demand? It would be reasuring if the answer was more clearly 'yes'. Competing interests: None declared
Principal Agent Theory and Foundation Trusts 22 June 2004
Hitesh Patel, Medical Student Imperial College, SW7 2AZ., Mitesh Patel. Send response to journal: Re: Principal Agent Theory and Foundation Trusts	EDITOR- Change in the NHS is laborious.1 It is never a smooth and continuous process but rather is achieved in small incremental steps.2 Klein highlights this ‘disjointed incrementalism’ with the problems the NHS foundation trusts are having in producing “a new form of social ownership”.3 The principal-agent theory models the conflicts of interest between the different stakeholders: the providers (agent), the government (principal) and the local population (principal).4 Due to asymmetry of information the agent acts on behalf of the principals. Herein, lies the problem of imperfect agency: providers may not have the information needed to act as perfect agents and worryingly they can exploit the ignorance of the principals to maximise their own utility. The government exerts its influence through National Service Framework targets, which public service agents have to achieve. Performance will only be increased in areas that are monitored resulting in the neglect of specialities that have no targets,5 e.g. non-HIV sexual health services. In the past the end-user has had little influence to determine the care they are provided, as individually they contribute no resources to the Primary Care Trust. Their needs will only be met if they are shared by the goals of the government.4 We share Klein’s concern for the present apathy amongst the local population and hospital staff.3 Foundation trusts aim to reverse the imperfect agency by giving the local population and staff an influence in the care that is provided, liberating them from dependence on government goals. Agents and principals should co-operate to ensure the satisfaction of the Government aims of decentralisation and democratisation3 as both groups have incentives for gain and neither group would benefit from failure of the Foundation trust. References 1. Pettigrew A M, Ferlie E. Shaping strategic change: making change in large organizations, the case of the National Health Service. London, Sage, 1992. 2. Lindbolm C. The Science of Muddling Through. Public Administration Review 1959;19:78-88. 3. Klein R. The first wave of NHS foundation trusts: Low turn out in elections sends a warning signal. BMJ 2004;328:1332. 4. Propper C. Agency and incentives in the NHS internal market. Soc Sci Med 1995:40(12);1683-1690. 5. Whynes D. Can performance monitoring solve the public services’ principal agent problem? Department of Economics, University of Nottingham Discussion Paper 92/16, 1992. Competing interests: HP and MP have both undertaken a Health Management BSc at what is now the Tanaka Business School, Imperial College, London.