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Editor's blog 26 June 2008: 100 not out - foundation trusts march on

It's nice round numbers all the way, isn't it? We have the ongoing NHS 60 feeding frenzy, and now we have the 100th foundation trust. Step forward and take a bow Pennine Care Foundation Trust, as its signage and stationery will read after 1 July.

Monitor's executive chair Bill Moyes' statement calls this authorisation "an important milestone. The sooner that all acute and mental health providers can meet the standards required to achieve foundation trust status, the more patients will benefit. NHS foundation trusts are showing the way on clinical leadership and have demonstrated that they can run themselves well as autonomous organisations, with effective management and stronger finances resulting in better services for patients."

Moyes is right. Of the 19 trusts rated 'excellent / excellent' for quality of care and resource use by the Healthcare Commission and the Audit Commission, every one was an FT.

Moyes is, however, understood to be a fraction less delighted about FTs' attitudes to their surpluses. Like Narcissus, FTs appear to be staring into the glossy pools of their surpluses and getting lost.

It's an issue. FTs were legally constituted to make a profit, and unsurprisingly, that is what they have done. However, as Alan Maynard pointed out in the first instalment of his column The Maynard Doctrine), fluctuations to the tariff likely to be announced next Monday in the Darzi review affect the predictability of future income.

Jolly good, some will say: that can drive FTs to be more efficient and more effective.

However, Maynard points out that the FTs' freedom to borrow will de facto be constrained not only by the current credit crunch, but by potential lenders regarding tariff fluctuation as unfavourable predictors of FTs' future earning power - and thus ability to repay loans for capital developments.

Maynard also raises the question of whether FTs are continuing to challenge and stretch themselves, or merely treading water.

The statement from health minister Ben Bradshaw, however, is interesting. It contends that FTs "put both patients and clinicians in the driving seat, allowing local people to have a say in how their local hospital is run ... This tipping point proves that NHS foundation trusts have been a popular success".

This is much less clear. FTs can count their membership, but frankly, it's about as much use as being able to weigh their membership: possibly slightly less. Monitor's own recent report on FT governors (www.monitor-nhsft.gov.uk/publications.php?id=1131) found that 16% of governors are dissatisfied with their access to the FT's directors. and 20% are not clear about their roles and responsibilities. 42% do not feel that their organisation is good at communicating its activities to its members. 50% have not been involved in exercising their statutory powers.

Yes, there are some reasonable excuses. There is a significant cadre of newer governors in the newer FTs. Good non-executive directors can be hard to find.

However, excuses is what these are. Foundation Trust network director Sue Slipman's comment that "foundation trusts demonstrate the progress and potential of the NHS" gets the balance more clearly right.

FTs are clearly not NHS privatisation (as their fiercest ideological critics feared). They are undoubtedly part of the solution, as the irritation FTs and their regulator can cause DH centalists makes amply clear. But high performance leads to high expectations, and freedom should always be maximised.

Happy 100; but remember that not all laurels are evergreen before you rest on them.