Editor's blog Thursday 10 February 2011: Worst-kept secret in the NHS no longer secret - FTN splits from Confed

Health Service Journalbreaks the news that the worst-kept secret in the NHS has come to pass: the Foundation Trust Network is to take its independence of the NHS Confederation.

The reverse-Oedipal conflict between the FTN's Sue Slipman and the Confed's Nigel Edwards is over: Sue has won.

Or has she? I wouldn't be at all sure.

FTN chair Peter Griffiths' statement to HSJ that "the future role for the FTN (is) one of independence, acting unequivocally on behalf of foundation trusts, and interdependence, working closely with the NHS Confederation and its networks across the system to support the development of the breadth of health and social care organisations" is straight out of NHS Supreme Soviet Leader Comrade Sir David Nicholson's 'AND' school of dialectical materialism. (You remember - "look out to your community AND up to Whitehall"; or "competition AND co-operation".)

The problem here is that the central tenet of dialectical materialism - as of course you all know, and Sir David certainly does - that every economic order grows to a state of maximum efficiency, while at the same time developing internal contradictions or weaknesses that contribute to its decay. (Thanks, Wikipedia).

Peter Griffiths has an un-squared circle in his argument for a reason: it is un-square-able. An independent future for the FTN is not going to be interdependent with the rest of the Confed's activities.

As all NHS trusts must become FTs, the FTN will have a lock on providers as they are now.

The important point is that the future isn't what it used to be.

The future is about tariff and teeth for commissioners to reshape things, using if not the tools then the threats of competition and any willing provider.

By and large, that is not going to be to the detriment of commissioners - other than reputationally, which they will be able to manage.

By and large, it will often be to the detriment of FTs' interest as they are configured now.

By and large, if the reforms work, hospitals will do less. Quite possibly, a lot less.

FTs were designed for a time of activity and funding growth. We are now facing a decade of funding contraction, as the economic order grows to a state of maximum efficiency.

In dialectical materialist terms, what developing internal contradictions or weaknesses may contribute to the economic order's decay? Well, if commissioning drove people to get serious about the management of long-term conditions in the closest setting to patients' homes (i.e. in them, with a spot of technology), then the growth in acute activity could be seen as such.

But of course, FTs won't be internal any more. They'll just be willing providers.

And if the position of the Coalition Government on AWP and competition does (as many think it may) open the NHS scene to challenge under European laws regarding state aid, things could start looking a whole lot more challenging still for providers configured as they are today.

The Coalition Government's politics involve getting the state out of the NHS provision business. Their vision for the NHS is as a massively simplified, non-risk-stratified single-payer insurance system. Their vision for the NHS is for healthcare to become, as Nigel Edwards has pointed out, a regulated utility.

The NHS family is leaving the state's home.

When families fall out, the scars from the fighting can last a long time - and the memory of the fight echoes for a long time.