Personal Views: Foundation hospitals: we've been here before
Authors: Neville W Goodman
Journal: BMJ (2003)

Here are some headlines. “Health reforms `no cure for cash crises'.” “A private hospital by any other name...” “Unsafe hands when the heart's not in it.” Here's an editorial entitled “Doctor, they're in trouble” and which starts, “Imagine the fuss if an untested and untried drug appeared on the market.” Here's another: “When the NHS market crashes”—it begins, “Doctors must be uncertain whether to laugh or cry.”

These headlines are the main reason that foundation hospitals are doomed. The headlines are from news-papers in 1989-90, at the time of the Conservatives' reforms. They could be recycled. Politicians show no signs of learning the most important lesson: stop fiddling about. The difference now, 13 years on, is that those working in the NHS have already seen the failure of numerous other attempts to reform its structure—18 since 1980, according to Kieran Walshe, reader in public management and director of research at Manchester Centre for Healthcare Management (Journal of the Royal Society of Medicine 2003;96: 106-10 [PubMed]).


Politicians show no signs of learning the most important lesson: stop fiddling about


The Labour party had 18 years in opposition to think about its favoured structure. Taking advantage of its large parliamentary majority in 1997, it could have boldly implemented that structure, bolstered by tax increases to start correcting the obvious under-investment of the previous administration. But it didn't. Instead it cowered before the right wing press, to which it attributed a large part of its electoral success. It took four years, and much rhetoric about “modernisation,” before there was even proper acknowledgement that the NHS was massively underfunded and under-resourced. After more structural lurching, and an obsession with waiting list targets that has poured millions of pounds down a private sector drain, we are now presented with foundation hospitals as the saving grace of the NHS.


Alan Milburn's tactics seem designed to outrage


It is bad enough that, yet again, there is no proper evidence for health policy, for foundation hospitals being the correct medicine for the NHS. It is worse that, after six years of a Labour administration, the arguments for and against foundation hospitals echo so closely the arguments of an earlier time and of the previous administration, whose political descendants' most vocal complaint about foundation hospitals is that they don't go far enough.

What else has changed since 1990? Consultants then were merely depressed that financial imperatives were taking precedence over clinical ones. Labour's first spasms, including clinical governance and the National Institute for Clinical Excellence, were flawed but at least they stressed the clinical issue of quality. Now consultants are also angry. Clinical governance is elbowed aside as clinical priority too often takes second place to the “long waiter.” Instead of making allies of consultants, managers and the government seem almost proud to make them resentful enemies. Managers see consultants as standing between them and their targets, and the government stubbornly insists that the proposed consultant contract is not up for negotiation.

Health secretary Alan Milburns tactics seem designed to outrage: he refuses to meet the BMA but meanwhile writes consultants quasi-personal (“Dear colleague”) letters. Hearing Mr Milburn (“I can'tsay I always agree with everything the BMA says but we have extremely good relations which I think both of us have gone out of our way to foster,” BMA News Review April 1994) repeat his mantra that “most consultants do a great job for the NHS” now sounds to me like a direct threat. In the past few weeks he has made enough concessions that, had they been offered last October, would likely by now have secured an acceptable compromise. Instead his seemingly preferred local negotiations “will create divisions within the consultant body, between specialities and between colleagues”—something he must have been told during his earlier good relations with the BMA, from whose Central Consultants and Specialists Committee newsletter of March 1990 that statement was taken.

The headlines are being recycled. We've not yet seen “Secret junkets held at luxury hotels to speed NHS `opt-outs'” (the Observer, 4 March 1990), but we have had “Foundation hospitals will kill the NHS. Don't be fooled by the rhetoric: this is about privatisation” (the Guardian, 7 May 2003). NHS staff are fed up. Kieran Walshe thinks that foundation hospitals will work—if Mr Milburn and his successors learn to keep their hands off. Foundation hospitals might have worked in 1997, but we've seen too much since then. We've had too much experience. What comes next in the series “trust hospital,” “foundation hospital”...? We think it will be too soon before we find out and further reams of headed notepaper fill the recycle bins.