BETWEEN THE DEVIL AND THE DEEP BLUE SEA

There is nothing like the public sector suddenly befriending you (or, worse, claiming to value you) to bristle the hairs on the back of one's neck. The residents of Camden and Islington, of which I am one, are undergoing this process at the moment. The reason? No, don’t be silly, it’s not because the great and the good of the local NHS Mental Health and Social Care Trust has suddenly woken up to how influential we all are. It’s because it wants to become a Foundation Trust, and it needs our help.

Foundation Trusts (FTs) were the brainchild of Alan Milburn, the former Health Secretary, who stated that they represented a crucial component of the new “patient-led” NHS. It was claimed that they would be freed from the bureaucratic constraints of Whitehall and more publicly accountable. Mr Milburn said that he wished to see all hospitals achieve foundation status by around 2008, even though a hospital would need a three-star rating in order to qualify. The establishment of FTs was narrowly agreed by Parliament in 2003, and ten hospitals were given the go-ahead to achieve foundation status.

But the arguments against FTs were always far more coherent than those in favour. Trade Unions, led by Unison, argued that FTs would create a "leaky bucket" in the NHS. Whereas surpluses and monies raised by the sale of assets were redistributed within the NHS economy, FTs would be able to re-invest funds into the private sector. The fact that FTs can retain money raised from asset sales provides a strong incentive for Trusts to sell off property.

Nor did the Government's claims of increased accountability stand up to scrutiny. In the case of Camden and Islington, there are more than 250,000 people who are eligible to vote in those two Boroughs, and to whom the local Mental Health Trust must account. But to become an FT, the Trust must recruit only 1800 members ; the line of responsibility, however tenuous, which runs from each of the rest of us to the Secretary of State, will be lost. As Dave Prentis wrote in Healthmatters magazine in 2003,

Foundation trusts appear unlikely to deliver increased social ownership and local accountability. There is no guarantee that foundation trust members will be representative of the local community or a hospital's users. And if the members of a foundation trust feel strongly about an issue, it is unclear how effectively they will be able to make their views heard and how much power they will have to achieve change.

Such suspicions are borne out by a study conducted by the King's Fund at the Homerton Hospital in 2005, which dismissed the claim of increased patient ownership as "rhetoric". One governor describe his feeling of impotence thus : "I regret to say that I wouldn't be able to pinpoint a particular point or issue that I have been able to achieve by my being a governor."

Although the government has always denied that the establishment of FTs is a first step to privatisation, it has publicly stated that it is part of a much wider policy of opening the NHS up to the market:

We are shifting away from an integrated system in which the NHS provided virtually all of the care to a much more mixed one in which the private sector will play an increasingly major part - first of all in hospital care and diagnostics and probably, in time, other kinds of care from chronic conditions to what has traditionally been seen as family doctor services.

- Chris Ham, former head of strategy at Department of Health, April 2005

FTs may be a kind of "third way" between public and private provision, but they remain subject to the competition of the marketplace. Once a few hospitals in a particular area achieve foundation status, there are incentives for them to compete for both patients and staff. This is the challenge that faces Camden and Islington Mental Health and Social Care Trust. There are five FTs in north London (CNWL, the Homerton, Moorfields Eye Hospital, Tavistock & Portman, and UCL), one of which (T&P) is also a provider of mental health services. C&I is therefore left with a choice : sink or swim.

For the residents of Camden and Islington, this is what the mantra of "choice" boils down to. If you oppose foundation trusts, you have a choice between two evils : sign up for a policy which you believe is wrong, or refuse to enter into the charade, in which case you will be served either by a Foundation Trust which does not represent you, or by a non-Foundation Trust which is constantly under threat of extinction. Some choice...