Item 12: Foundation for a healthy future?
Matter for discussion submitted by the RCN Suffolk Branch
That this meeting of RCN Congress considers whether foundation status is a healthy option for the NHS (applies to England only as foundation trusts do not apply in Scotland, Wales and Northern Ireland)
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Will patients, staff and families bear the brunt of ticking financial boxes? This was the matter for discussion posed by Pauline Entwhistle of the RCN Suffolk Branch. She questioned whether a service judged on its business, HR and strategic plans could effectively deliver the quality and levels of patient care required.
Christopher Butler, chief executive of a foundation trust, was the first to speak in support of the status. He argued that being free from the control of the strategic authority and involving the community closely in the trust were key strengths of his service. Investment in more nurses and better facilities was a direct result of being a foundation trust, he said.
Zeba Arif stressed that 'good financial management' stuck out in bold letters when it came to foundation trusts. She continued that nurses needed to be very assertive and take the lead in standing up for putting patient care first.
Mike Travis stated that in his opinion nurses lose out when they don't engage with employers and foundation trusts were the opportunity to engage. As a governor he said his job was to ensure the trust was doing its job by meeting the needs of the community and delivering excellent patient care.
Andrew Parker called for a system where foundation trusts don't fall into 'toxic debt'. He pointed to a need to ensure large amounts of integrity in the governors and executives.
Comparing foundation trusts to a curate's egg, John Hill said that they were very good in parts. Patient care benefited from reactive health care based on local needs, which is accountable through its governors. However, he cited one example where more than 90 nurses had been made by redundant when a foundation trust could not afford to pay them. The jury is still very much out, he concluded.
John Black, a staff governor, stated that nurses know what patients need, recognise priorities and want to provide the care that is needed. He said there was no problem with targets if they were properly agreed with nurses.
Roderick Nisbet - the only member speaking from outside of the England - said that in Scotland, the best trusts were those that worked closely with HR, consulting and working with staff.
Andrea Spyropoulos recounted her experience of sitting on the executive board during a transition to foundation trust status. She said at first she couldn't see any benefits from the change but gradually came to recognise that for the first time there was a long-term strategic plan that was realistically deliverable and not simply a wish list. She began to understand the crucial role that governors play and the enormous input they contribute. For staff she saw a win/win situation where financial stability provided more freedom to direct resources into nursing and nurses, ultimately providing them with a more stable working environment.
Jean Rodgers put forward her belief that success depends on the chief executive of the foundation trust and the executive team. She said: "You as nurses should make them answerable."
Pauline Entwhistle returned to the podium for closing remarks stating that the important issues are not to be ignored.
Background
With the establishment of the first wave of NHS foundation trusts (FTs) in April 2004, the Department of Health (DH) signified the creation of a new generation of health service provider organisations: organisations based on NHS principles, but with increased autonomy, greater local accountability, and new extended powers (including greater financial and managerial freedoms) that represented a significant shift in the way 'traditional' NHS services are managed and governed. In October 2005, the DH announced all NHS trusts in England were eligible for FT status. By 2007, eligibility was also confirmed for ambulance trusts.
Created to devolve decision-making from central government to local organisations, deliver greater responsiveness to the needs and wishes of local people, and give communities social ownership of their FT, foundation trusts have a duty to engage with local communities and encourage local people to become members, ensuring that membership is representative of the communities they serve. Currently, membership of FTs stands at over 1.2 million.
The government has actively pursued the creation of FTs in England, despite the ongoing debate as to whether such organisations can deliver solutions to the challenges the NHS faces. On the one hand, supporters claim FTs will lead the way to a new understanding of public services and public ownership that frees the NHS from central government control. Critics, however, argue that FTs represent a creeping form of privatisation that undermines the fundamental values of care on which the NHS was founded, and signifies the first step in the break-up of the NHS.
Monitor, the independent regulator established to authorise and regulate FTs, announced in December 2008 that half of all NHS acute and mental health trusts had achieved foundation status: in January 2009 there were 113 authorised FTs in England.
In response to the introduction of foundation trusts, the RCN's position has been that members, activists and staff should evaluate applications for FT status on a case by case basis at a local level. While the RCN has not opposed the government's policy on FTs, this approach allows for RCN members to determine their support for, opposition to, and concerns about each and every application for authorisation. To assist with this process and maintain the scrutiny of FTs the RCN has published a number of resources, including the RCN NHS Foundation Trusts Scorecard (Royal College of Nursing 2004), and the RCN Principles (Royal College of Nursing 2008b) which describe the principles and criteria against which proposals must be evaluated.
In 2007 the RCN submitted evidence to the Health Select Committee Inquiry into Foundation Trusts and Monitor, reporting the findings of its 2007 membership survey. (Royal College of Nursing, 2008a)
The survey found that some members had indeed seen benefits from the adoption of a more business like approach to organisational development and service management. However, the survey also highlighted that where foundation trusts were disproportionately focused on costs, this had a detrimental impact on staff morale and clinical engagement.
References and further reading
Royal College of Nursing (2004) The right foundation? Guidance on foundation trusts for RCN representatives, London: RCN.
Royal College of Nursing (2008a) NHS Foundation Trusts survey: big business or everyone's business, London, RCN (PDF 125KB) [how to access PDF files].
Royal College of Nursing (2008b) RCN principles to inform decision making: what do I need to know? (2nd edition), London, RCN. Available from the publications section on the RCN website.