First, there was 'world-class commissioning' maestro Mark Britnell's departure, which few people apart from himself were expecting.

Then, there was Lord Darzi's departure: although DH officials knew of his irritations with the system, it was not as common knowledge that he was heading out the door as has sometimes been suggested subsequently, with the virtue of 20-20 hindsight.

Now Monitor's executive chair Bill Moyes has confirmed what everybody has been expecting since the latest drip-drip-drip of ministers and officials seeking to reduce the perception of FTs' autonomy: he will be stepping down in six months' time, in January 2010. His recent on-the-record comments to HSJ were a resignation letter by proxy.

Moyes' resignation letter (copied in full at the bottom) pulls no punches. He states that, "Parliament has not yet fully grasped that it is the regulators and the Boards of foundation trusts, and not Ministers, who are accountable to them for the performance of the regulatory system and individual foundation trusts. So Ministers are left feeling that
they retain a degree of direct accountability in certain cases of failure, which partly explains the thinking behind the recent consultation document on de-authorisation of NHS foundation trusts.

"My Board will therefore be pressing the Department of Health to ensure that their avowed intention of maintaining Monitor’s independence and strengthening our powers is carried through in practice, both in finalising whatever legislation flows from the consultation on the de-authorisation of foundation trusts and also in the appointment of my successor here".

A good job, well done
Foundation trusts have tended to be well-run, and have also tended to be the top-performers in quality inspections. There is the obvious exception of Mid-Staffordshire FT, which was missed by all the regulators, the SHA, the PCT, Old Uncle Tom Cobbley and all.

Mid-Staffs tells us a lot about the ability for the NHS to overlook really bad, life-threatening or life-ending performance. It does not tell us a huge amount about FTs per se, as I have suggested previously.

The expenses non-story
The Sunday Times non-story about Moyes' expenses, smuggled out in the considerable media wake of the Daily Telegraph's blanket coverage of MPs' expenses claims, looked like a none-too-subtle hatchet job from somebody.

Who (if anyone) did the dirty? Moyes' highest-profile antagonist seemed to be NHS chief executive David Nicholson, as I reported had became explicitly obvious at the 2008 NHS Confed Conference.

Earlier in February 2008, Moyes copied his email warning David Nicholson off the turf of FT independence to all FT chief executives and chairs.

The two, in short, have serious form. However, Nicholson's style is probably more direct than this ineffective attack via the Sunday Times.

Little love was lost between Monitor and the Healthcare Commission, as the row over Monitor's refusal to sign up to the 2004 regulation-reducing 'concordat'showed.

More recently, anonymous briefing to HSJ accusing it of "sharp-elbowing" the Care Quality Commission, which replaced the Healthcare Commission, show that little love has grown.

Monitor appears to be a well-regarded regulator. Its sector likes it, which is not particularly usual. It has not over-used its powers of intervention.

Banking on regulation
Moyes' banking background was evident when I interviewed him in 2006 for British Journal of Healthcare Management, and a few of his comments stand out as topical: "trusts have to assume that the Government will continue to drive efficiency through the tariff. That's the best mechanism they've got". We haven't really seen this yet, but it's coming.

Likewise, on productivity, Moyes said, "in the next two or three years, improving productivity is going to be a key issue to the next stage of NHS reform, and I think a regulator has a part to play in that". On this one, we have seen little action - unless there are figures on FT productivity.

Finally, the credit crunch has lent enormous relevance to an anecdote Moyes used about regulation: "I've been saying to the DH ... that back when the Bank of England supervised the UK banking system, the Governor's stated policy was to maintain confidence int he banking system, so the BoE would go to extraordinary lengths to ensure that solutions were always in place by the time problems (like Barings) reached the public domain - if they did. I'm sure lots of little problems ... never came out and were just sorted, so that savers and overseas invesrtors could have total confidence in the integrity of British banking.

"We should take the same approach in the NHS: I think it's quite important that we maintain public confidence in the quality of healthcare, while not allowing that to dictate sub-optimal management".

Moyes' notification letter to FT chairs and CEs is quoted in full below:

To: All NHS Foundation Trust Chairs
All NHS Foundation Trust CEs

Dear Colleagues

I am writing to let you know that I shall be stepping down at the end of January 2010. I was appointed by Alan Johnson in February 2008 for a second term of 2 years. Therefore, for some considerable time, my personal plans have been based on the assumption that I would step down from this role at the end of January 2010. By that time I will be past the normal public sector retirement age and will have done this job for 6 years.

I am proud of what has been achieved in that time by you and by Monitor. Despite the recent problems the foundation trust system is regarded as a considerable success. You have more capable Boards, stronger finances and better governance. And this is reflected in a consistent pattern of higher performance by foundation trusts than by non-foundation trusts.

I am also very proud of the system of regulation we have developed. The assessment process continues to drive improvement in the quality of Boards and in the quality of their business plans. Our compliance system is proving highly effective in identifying financial and non-financial problems and in focusing the attention of Boards on securing effective and lasting solutions to them. Our financial reporting regime has improved the transparency of foundation Trusts annual accounts. The work we have done on service line management and quality reporting has already had a material impact on how Boards and senior clinicians understand the performance of their organisations and how it might be improved. That impact will broaden and deepen as we develop our approach to these two issues in the future. And together they provide an essential platform for clinicians to assume top leadership roles in hospitals.

I do not believe there is any longer a serious desire in Government on the part of Ministers, officials or senior NHS leaders to turn the clock back and abolish the concept of foundation trusts. Indeed, there is a widespread recognition that ensuring hospitals are well-led and financially robust becomes even more important as the pressures on public expenditure increase over the next few years.

However, Parliament has not yet fully grasped that it is the regulators and the Boards of foundation trusts, and not Ministers, who are accountable to them for the performance of the regulatory system and individual foundation trusts. So Ministers are left feeling that they retain a degree of direct accountability in certain cases of failure, which partly explains the thinking behind the recent consultation document on de-authorisation of NHS foundation trusts.

So, my concern is whether independent regulation will be allowed to continue. I am aware of growing concerns that the forthcoming pressures on public expenditure will require a wide range of services to be reshaped or reconfigured and that to achieve this in a sensible timescale will require greater central direction and management than is consistent with independent regulation. I do not believe this to be a valid analysis. I believe a rigorous assessment of changes to services – whether acquisitions, mergers or disinvestments - is essential to their future success. And the very large number of acquisitions and other transactions that are currently taking place would suggest that independent regulation is not of itself an obstacle to service change but will contribute significantly to ensuring that such change is in the best interests of patients and taxpayers.

My Board will therefore be pressing the Department of Health to ensure that their avowed intention of maintaining Monitor’s independence and strengthening our powers is carried through in practice, both in finalising whatever legislation flows from the consultation on the de-authorisation of foundation trusts and also in the appointment of my successor here.

Finally, on a personal note, let me thank you warmly for all the support I have received from you and your colleagues in the foundation trusts. No regulator can do its job really effectively if it lacks the support of the sector it oversees. Monitor has enjoyed considerable support, and I very much hope that that will continue in the future.

Yours sincerely

William Moyes
Chairman, Monitor