Mental health foundation trusts: special report

Will involving service users in running mental health foundation trusts make a real difference?

Patrick Geoghegan, chief executive of South Essex Partnership NHS Foundation Trust – one of the first three mental health foundation trusts – sees local and service user involvement as a major benefit of foundation status.

He says: “You can have a real say. You can influence policy and its direction of travel.”

Foundation trusts are run by governing bodies elected by constituencies of members. While trusts must set up two separate constituency groups for the public and staff, a specific group for service users is optional. So far only Oxleas NHS Foundation Trust is planning one.

Foundation status means a significant shift in the way mental health trusts are run, including service user involvement. But it is early days yet to gauge its effect.

What is a foundation trust?
Foundation trusts were introduced by the Health and Social Care (Community and Health Standards) Act 2003.

The first trusts were established in 2004, and on 1 May this year, the first three mental health trusts were announced: Oxleas NHS Foundation Trust, South Essex Partnership NHS Foundation Trust and South Staffordshire Healthcare NHS Foundation Trust.

Six other mental health trusts are having their applications considered and many more are aspiring to foundation status.

The status is open to existing NHS acute, specialist, mental health and care trusts, but the DH has mooted creating new foundation trusts to run community health services, where these are divested from primary care trust control.

Free from Whitehall control?
Foundation status is portrayed by the government as a way of freeing NHS trusts from Whitehall control, making them more accountable to local people and staff and allowing them to innovate with services, while keeping to core national standards.

The government’s intention is for all trusts to have the opportunity to gain foundation status – in part in response to critics who said foundation status would create a two-tier system.

Local/service user influence
Foundation trusts should respond to the needs of local populations not Whitehall diktats:

• They are not subject to direction from the Department of Health and are not performance managed by strategic health authorities.
• Staff and local people can become members of foundation trusts, giving them the right to vote representatives on to the board of governors. A majority of governors must be chosen by members of the public, at least three must represent staff and one represents local authorities in the area.
• Though the board of governors does not run the trust, it appoints the chair and non-executive directors of the board of directors, which does. Its key purpose is to represent the community’s interests to directors.

Patrick Geoghegan, chief executive of South Essex Partnership NHS Foundation Trust,  says a quarter of the trust’s approximately 10,000 members are service users, enabling them to influence services as never before.

“Services are changing because we are listening more to service users,” he adds. “Clinicians are being challenged more by direct contact with the members and the board of governors.”

Andy Bell, director of communications at the Sainsbury Centre for Mental Health, says the greater involvement of staff and members has potential benefits, especially as mental health trusts are “ahead of the game” within the NHS in terms of user focus.

Freedom
Foundation trusts have other freedoms to do with finance.

Geoghegan says the trust’s financial freedoms will enable it to diversify its provision – including providing services outside mental health, such as residential and domiciliary care.

Bell agrees that the freedoms of foundation status could breed service innovation, for instance investment in psychological therapies.

Safeguards
The freedoms of foundation status are balanced by a number of safeguards designed to ensure they provide core services and protect users’ rights and interests:

• Like conventional trusts, they are subject to the Healthcare Commission’s annual health check – its performance assessment of NHS bodies – and on the same terms.
• They are also regulated by Monitor, which ensures that the trust complies with the terms of its authorisation: this specifies the services it will provide, which must include core services they are required by law to deliver, and a list of assets that are protected from sale as a result.
• On the basis of the Healthcare Commission’s findings, Monitor can intervene in a foundation trust by issuing warning notices, requiring the board of directors to take specific actions and suspending directors.
• Unlike conventional trusts, their contracts with primary care trusts are legally binding, meaning they face a greater level of accountability to commissioners for the services they provide.
• They are under a duty to co-operate with other NHS bodies and local partners, such as councils.
• The proportion of patients they can treat privately is fixed at 2002-3 levels.

Bell says the safeguards should ensure services are not threatened. He says it is essential that mental health foundation trusts co-operate with local authorities given the latter’s responsibility for social care.

Geoghegan says relations with Essex, Southend and Thurrock councils have been maintained, as have partnership arrangements governing joint teams. He says this is down to having significant council involvement in the application process.

However, he bemoans the restriction on treating private patients as, in effect, it means this source of income is closed off for mental health trusts, as in 2002-3 most were not treating private patients at all.

Application process
Aspiring foundation trusts face a tough application process:

• Currently, trusts rated as two or three star under the old performance assessment system can apply for foundation status. (The star ratings system was replaced by the Healthcare Commission’s annual health check in 2005-6). However, the government wants all trusts to have the opportunity to apply by 2008.

• The DH supports trusts applying for foundation status with money, training events and technical assistance, while support is also available from the Foundation Trust Network, which represents foundation and aspiring foundation trusts.

A short guide to NHS Foundation Trusts