Building on Good Foundations Or Seeking Our New Mutual Friends

Well, the Bill got through the wrangling in the Palace of Westminster in November 2003. That is, the Health and Social Care (Community Health and Standards) Bill. It covers a host of topics, only one of which was NHS foundation trusts.

Not that one would have thought so from the tenor of the debate around that particular part of the Bill. The arguments around foundation hospital trusts got increasingly bitter and acrimonious in some quarters as the time of final Parliamentary decision-making drew near.

So what now? NHS foundation trusts are in many ways a logical extension of the Government’s stated intentions in its NHS Plan issued in the year 2000: to extend autonomy and free up the creativity of dedicated NHS employees and local trust boards and management.

If one were to only rely on the likes of the Daily Mail one might be forgiven for thinking that the NHS was already in total meltdown. Yet, whatever the reality – and the Labour Government has the avowed intention of improving whole swathes of public services – there is clearly a huge amount of goodwill towards the National Health Service. Bodies such as leagues of friends, local fundraising charities, patient groups and volunteers demonstrate this.

The structures being prepared for the governance of NHS foundation hospital trusts have been deliberately modelled on the experience over 150 and more years of large organisations such as co-operative societies, friendly societies and mutual organisations. While most of these do not operate in healthcare delivery, they are based on community-based democratic control. Leading practitioners from the co-operative and mutual sectors (e.g. building societies) have been giving advice to the Department of Health (DoH) and the 25 first wave of foundation trust applicants on how to run community-based democratically controlled (warts and all!).

Incidentally, the name foundation almost certainly derives from a name used in the Spanish mutual healthcare sector. A visit to that part of the world by UK health officials and the Secretary of State for Health (Alan Milburn at the time) preceded the use of the name in British (or at least English – for the foundation model is as yet confined to parts of the NHS in England) circles.

And it is from overseas that some of the continuing lessons must be learned as foundation trust move closer to coming into real existence next year. That is to say, that in Spain, Brazil, Japan and the United States of America – among other locations – are to be found democratically controlled mutual healthcare providers, with millions of members between them. One of them – Group Health Cooperative, in Puget Sound, Washington State, was set up at around the time of NHS inception, and was deliberately modelled on the Rochdale Society of Equitable Pioneers which opened for trading in December 1844. That is, as a consumer co-operative, trading not in food and other commodities but on the provision of healthcare. The lessons they should be learned, about bad times as well as good. It is good that the opportunity exists for learning from other healthcare organisations. As the present Secretary of State for Health, Dr John Reid MP, said in a speech a few weeks ago, the NHS can learn from overseas good practice. Here is an ideal opportunity now that foundation trusts are to be a reality.

Yet, although mutual healthcare is as yet a rare thing in the United Kingdom, there is one British body that is already a democratically controlled mutual. It has been around for nearly a century. The Benenden Healthcare Society has as many members as work in the NHS, roughly (about 1.2 million). The members of this friendly society are people who work – or have worked – in the public sector. It runs a hospital in Kent, and provides access to other healthcare in other parts of the country for its members. As if to emphasise that its purpose is to be complementary to – not in competition with – the NHS, people working in the NHS are not allowed to become members.

There is one part of the recent arguments about foundation trusts that should leave a nasty taste in the mouth of anybody who purports to be a democratic socialist. At least one Labour peer expressed horror at the idea of political activists and others getting elected to governing bodies or boards of directors of foundation trusts. Critics who are frightened of elections need to have comfort that aspiring to an active membership is one antidote to being taken over by pressure groups. (Anyway, not one NHS committee member or board member can be appointed or removed by the public now – what sort of accountability is that?) Who do these people think elect or even become politicians in the Commons and in local councils? It is an idea not uncommonly heard from some supposed left-wing think tanks from time to time. The irony there is that hardly any think tanks have any sort of membership or democratic base to hold them to account. It seems that anybody can set up a think tank and pontificate in a political vacuum. I have previously dubbed that sort of thinking the New Elitism – as opposed to the New Mutualism.

Co-operatives Mutuals and Foundation Trusts

It is around the experience of large mutual organisations that progressive people in that sector have already been bringing expertise to bear to advise the would-be foundation trusts. People from the consumer co-operative sector, building societies and other mutuals. The think tank Mutuo (which is at least allied to that democratic set of enterprises, the mutuals) is one of the leading lights here. (And its name also derived from Spanish; an unusual coincidence given my earlier remarks about Spain and mutually run healthcare.) Co-operativesUK contributed to the DoH’s reference sourcebook on foundation trusts (NHS Foundation Trusts A Guide to the Governance Arrangements).

As part of putting the foundation concept into practice, the “boards of governors” (or member councils or whatever each trust will call them) would harness some of the local goodwill and energy for the benefit of the NHS trust and for patients. Some of the 25 applicants for foundation trust status had already wanted to adapt patient groups or create new ways of actively involving patients in their NHS trust. What could be better to truly involve people in their NHS?

One other question for now, in the wake of the concluded Parliamentary debate. Should the foundation approach have started with primary care? Probably yes. But even 25 English hospital trusts do not the whole NHS make. So it should be possible – and discussion is already taking place – to introduce similar locally accountable and autonomous units into Primary Care Trusts, perhaps, or even around some progressive GP co-operatives. The most important thing is to do it properly. Among the 25 applicant trusts there is some real creativity and enthusiasm coming through. Watch this space.

Geraint Day

Member, SHA; member Co-operative Party National Executive Committee, and member of the DoH’s NHS foundation trusts External Reference Group on Governance. He has been an advocate of mutual healthcare for nearly four years as the concept has developed from concept to reality.

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