Shaky foundations

What are foundation hospitals? Readers of the British press will have read a lot about these over the past two days – and come away none the wiser as to what they are, let alone how they fit into what has been presented as Blair’s major controversial programme of ‘NHS reform’.

Maybe that’s because this is a symbolic debate over a largely symbolic proposal, in which the health service is used as an excuse for talking about something else.

What is it, exactly, about foundation hospitals that so upsets Blair’s critics? From the shrill tone of the debate, anybody would think that the government was plotting to sell off the NHS wholesale to the private sector, or at least planning a complete overhaul of this linchpin of the welfare state.

But while it is true that the government’s intention to reform the health service through the establishment of ‘NHS Foundation Trusts’ will have some impact upon the operation of the health service, this is hardly a bold attempt to rip things up and start again. The proposals currently debated have been heavily watered down, and the Department of Health’s (DoH) propaganda about what foundation hospitals actually are takes pains to emphasise just how little will change.

In the DoH’s information sheet giving ‘Ten key points about NHS Foundation Trusts’, readers are reassured (in bold type) that these foundation trusts ‘will be firmly part of the NHS’. They will ‘prevent privatisation of the NHS’, they will be there ‘to treat NHS patients, not to make profits or to distribute them’, and they are ‘not about elitism’ (1).

In an attempt to anticipate every conceivable criticism, the 10 key points reassures us that foundation trusts will not be left to ‘“sink or swim”’ or allowed to ‘“cherry-pick services”’; that private work ‘will be strictly limited’; that they will be accountable but not subject to ‘direction from Whitehall’ – rather, they will have ‘freedom to develop new ways of working that reflect local needs and priorities’ (2). And so on.

If you were to take this propaganda at its word, the only thing that makes the foundation hospitals proposal remarkable is how completely uninspiring and defensive it is. NHS foundation trusts are justified largely by how little they will change things for workers in, and patients of, the health service. But what does the government’s word mean, if nobody is prepared to believe it? This debate purports to be about a specific aspect of policy – NHS foundation trusts – but really, the trust part is the only bit that matters.

For those of us unfamiliar with the internal workings of the health service, it is hard to say whether the reality of foundation hospitals will make things better or worse. The idea is to have hospitals that constitute ‘new legal entities’, which have ‘far greater local ownership and involvement of patients, the public and staff rather than control from the Department of Health’ yet are also ‘subject to NHS standards, performance ratings and systems of inspection’, and which will be ‘at the cutting edge of the government’s commitment to devolution and decentralisation in the public services’ but also ‘have a duty in law to cooperate with other local partners using their freedom in ways that fit with NHS principles’, while all the time using a mixture of private and public money to ensure free healthcare…. (3)

All of this looks like a recipe for disaster. Who is in charge of it all? How is it supposed to work? Unison, the largest public services union, objects that this is all part of the ‘marketisation of the NHS’ (4). In fact, it looks like a desperate mishmash between public and private healthcare – neither one thing nor another, with the incentives of neither and the problems of both.

Insofar as Unison and the other unions of the ‘awkward squad’ put forward an alternative, however, it is simply to leave the NHS as it is. Preserve the memory of the postwar welfare state, protect the public sector ethos, keep plodding towards the holy grail of state socialism.

Those of us in the real world know that, without the project of state socialism, the public service ethos that held the NHS together no longer exists. Without the public service ethos, the practices and frameworks that traditionally made the health service work now account for the inefficiency, low standards and low horizons that make the NHS the unhealthy embarrassment that it currently is. New Labour’s solutions may not solve the problems, and may even make things worse. But something does have to change, somehow.

It is precisely this idea of changing things that the Labour leadership’s critics are reacting against. The government can bend even further backwards in watering down its reforms and attempting to persuade people that this is not private healthcare on the sly, but it will make no difference. The thoroughgoing distrust of anything Blair does, together with a more generalised notion that change is a threat, will mean that any proposal about how to move on from the past is likely to be slated.

Meanwhile, the real, glaring problem with Blair’s foundation hospitals agenda goes completely unchallenged. This is the pledge, number three in the DoH’s key points, that ‘NHS Foundation Trusts will be democratic’ (5). Here is the true reason for the government’s commitment to foundation hospitals: not a desire to create a better health service, so much as a desperate attempt to use the health service to forge closer connections with the electorate.

‘The principles behind NHS foundation trusts build on the sense of ownership many local people and staff feel for their hospital’, the DoH says (6). Subtext: people may be left cold by the politics of society, but they care what happens to them, as individuals, when they get sick. ‘Local managers and staff working with local people – rather than remote civil servants – will have the freedom to innovate and develop services tailored to the particular needs of their local communities’, the DOH says (7). Subtext: people cannot be expected to put their trust in politicians, or their faith in a national health service. So they should be brought in directly, as hands-on managers in helping to distribute the resources close to their home and their heart.

As the critics carp on about money, resources and the dictatorship of centralised pressure, the preposterous notion that the government can solve its isolation from the electorate by engaging them in the daily minutiae of running a hospital is barely recognised. For democracy, we want the ballot box. For our health, we want a doctor. If the government persists in politicising the health service in this way, we are in grave danger of ending up with neither.

(1) A Short Guide to NHS Foundation Trusts, Department of Health

(2) A Short Guide to NHS Foundation Trusts, Department of Health

(3) A Short Guide to NHS Foundation Trusts, Department of Health

(4) Keep the NHS public: Foundation hospitals, Unison

(5) A Short Guide to NHS Foundation Trusts, Department of Health

(6) A Short Guide to NHS Foundation Trusts, Department of Health

(7) A Short Guide to NHS Foundation Trusts, Department of Health