New structures of governance are needed

BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7392.764 (Published 05 April 2003) Cite this as: BMJ 2003;326:764
  1. Kieran M J Walshe, director of research management (kieran.walshe{at}man.ac.uk)
  1. Manchester Centre for Healthcare Management, University of Manchester, Manchester M13 9PL

    EDITOR—Klein sees the “cacophony of accountabilities” for new NHS foundation hospitals as a weakness,1 but I would argue that it may be their greatest strength.

    For half a century, the NHS has been organised as an administrative bureaucracy led from Whitehall, and the many structural reforms of the past two decades have done nothing to change this. No other major public service is so centralised. This bureaucracy has struggled in recent years to absorb increased resources and to deliver improved performance, and the difficulties of running this £70bn organisation by administrative diktat from Richmond House have become painfully apparent.

    Foundation hospitals offer a vision of a new model of governance and accountability in the NHS, replacing a vertical hierarchy topped by the Department of Health with a network of more autonomous healthcare providers still working within the values, standards, and requirements of the NHS.2 Foundation hospitals will have a network of accountability relations with their local communities, local government, other NHS organisations, national regulators, and the Department of Health. Plurality will replace the department's current, unhealthy monopoly of control.

    Although the government's guidance on the practical details of foundation hospitals still needs work,3 the principle seems to have been accepted across the political spectrum. It does not make political, financial, or organisational sense to try to run the NHS from the Department of Health in Whitehall, and new structures of governance are needed that will make NHS organisations more accountable to the communities they serve.


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