Three questions of vital importance to NHS managers collide in this week's HSJ - what should happen to trusts with little hope of achieving foundation status, what should happen to chief executives who are struggling to deliver, and what is the right relationship between a strategic health authority and its trusts.

As HSJ reveals this week, 20 trusts across England are not expected to meet the December 2010 deadline to be ready for foundation status and another six are questionable. The Department of Health will be serving most of these up to existing foundations in the hope that either whole hospitals or major portions of them will be taken over.

Whether foundation trusts are keen to scavenge for the roadkill of the application process is far from clear - forced feeding cannot be ruled out where loss-making services need to be retained or closure would be politically dangerous.

Great uncertainty

The list brings great uncertainty for staff and patients alike. It will be heartbreaking for managers and clinicians to see years of work ultimately labelled as not making the grade, when all the hospitals have a dedicated workforce and even the most challenged trusts host examples of excellence.

But at least the problems are now out in the open.

London is by a wide margin the toughest region to lead, with world famous institutions alongside trusts with endemic financial and performance challenges. Even two of the global names - Barts and Great Ormond Street - have difficulties. NHS London has responded by starting to take an uncompromising stand on performance failures.

A dozen of the 20 trusts with no date to achieve foundation status are in the capital, and two - Barts and the London and West Middlesex - have seen their chief executives depart in the last fortnight after failing to meet NHS London expectations.

The SHA clearly felt there were legitimate concerns about performance and strategy which required action. But HSJ's conversations with senior managers in the capital reveal that the effect of these departures has been to make talented and committed staff fear for their jobs.

SHA Stalinism

One trust chair claimed the departures were symptomatic of a culture of Stalinism in the SHAs, while other senior figures described a climate of intolerance in London which was causing managers to keep their heads down and steer clear of risk - whereas risk and innovation are the hallmarks of advances in healthcare.

There must be doubt as to whether these two high profile resignations will help address the huge challenges in London's healthcare system. With four trust chief executive vacancies and the recent decisions by the directors of both the commissioning and provider sides of the SHA to move on, there is a risk of instability.

The Barts post, with a huge and costly PFI project to manage alongside a turnaround programme, will be incredibly difficult to fill. There is already a national problem with securing more than one appointable candidate for any chief executive shortlist, and the London departures will have exacerbated that.

Many managers will struggle to reconcile the Department of Health's mantra of "look out not up" with the events of the last few days. As the deadline for foundation status approaches and each region's difficulties are thrown into ever sharper relief, SHAs must refute by their actions the suggestion that they are reverting to old fashioned command and control as a misguided solution to complex problems.

Are SHAs cultivating an overly harsh regime or are they doing the right thing? Let us know by emailing hsj.feedback@emap.com or clicking on post your response below.

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