The fundamentals of an FT

The degree of autonomy an organisation has is determined by how free it is to make decisions without interference, regardless of whether it chooses to use specific freedoms or flexibilities it may have. An organisation can only be meaningfully accountable for things it has reasonable power to control. Autonomy and accountability go hand in hand: the more autonomy a board has, the clearer the accountability for its performance can be. 

The 10YHP emphasises FT autonomy, pointing out that this was the original principle behind the creation of FTs. This approach drove substantial improvements in the 2000s, and gives trusts 'the powers they need to improve local services for the communities they serve'. It acknowledges that provider autonomy has been curtailed over the past decade, and commits to introducing 'a modern form of earned autonomy' where high performing trusts are rewarded with 'greater autonomy and flexibility to develop services free from central control'. 

A reasonable degree of control of strategy, planning, finances and organisational governance allows organisations to govern themselves, and to use many of the relevant levers[ii]

to direct and performance-manage their organisations. But the plan’s focus on autonomy is silent on two other defining characteristics of the existing FT model – both of which were key enablers of that autonomy: robust corporate governance; and local accountability and public participation. 

• Robust corporate governance: FTs operate under a unitary board model[iii], with independent non-executive directors (NEDs) providing scrutiny within a constitution and governance framework modelled on the UK Corporate Code. This creates a capacity for self-governance, which historically was a key criterion for becoming an FT. Where a trust can run its affairs autonomously, regulation and improvement can be managed at arm’s length to minimise political interference. Placing accountability on appropriately autonomous boards in this way was the original assumption when FTs were introduced.
  
  
• Local accountability and public participation: FTs are public benefit corporations, operating a quasi-shareholder model where public and staff FT members have a say in the way the organisation is run, electing a council of governors from among their members to represent their interests and the interests of the wider public. Governors are intended to act as a check and balance on behalf of their members, as they appoint NEDs and chairs, and have the power to remove them should they fail to act in the public interest. This means FTs are genuinely independent of the Secretary of State and accountable to their members. Governors also have statutory involvement in strategy development, and approval over changes to an FT’s constitution[iv]. The 10YHP’s suggestion that the requirement for FTs to have governors will be removed risks undermining the local accountability and constitutional independence they enable. 

The 10YHP's focus on returning autonomy must be matched by attention to the enablers and safeguards of autonomy: robust corporate governance and strong local accountability in place of always looking to the centre. 

However, there is a risk that other proposals in the 10YHP may work against autonomy: the abolition of NHSE makes it likely that responsibility for regulation, improvement, commissioning, provider oversight and board non-executive appointments could revert directly to the Secretary of State[v]. This creates a significant challenge to achieving the useful autonomy and accountability, free from undue interference, the plan seeks to promote. 

As they implement a new approach to autonomy, national policymakers must focus on the factors that enable and safeguard autonomy. These include robust corporate governance, a presumption against political interference, and a default of strong local accountability instead of central control. 

To enable trusts to act autonomously and be held accountable within an appropriate legal, regulatory and policy framework, DHSC and NHSE will need to ensure providers are clear about their responsibilities. They will need to nurture a consistent approach about the scope of providers' freedom to act. And, they will need to be clear about the powers of the Secretary of State or regulators, and when they will be used. This will be the test of the "rules-based" approach, which the 10YHP promises to return to.