The government's controversial legislation to create foundation hospitals cleared its first Commons hurdle on Wednesday night.

The plans to allow elite hospitals to be freed from Whitehall control and given fundraising powers have been backed by the Commons - despite a revolt by Labour MPs and opposition from Conservatives and Liberal Democrats.

Critics say the new hospitals will create a "two-tier" health system by taking the lion's share of NHS money, leaving ordinary trusts behind.

What do you think? Is it a two-tier strategy or the freedom that hospitals need?

The following comments reflect the balance of views we have received:

The money must come from somewhere Danny Lim, Brunei

Why is having a "two-tier" system seen as such a bad thing? At the end of the day, good health care doesn't come cheap. The money must come from somewhere. So either pay much more tax or rely on a "two-tier" system. At present, health care in the UK receives little funding compared to the rest of Europe.
Danny Lim, Brunei

I am yet to be convinced about foundation hospitals. However, if they are left to actually manage themselves and to plan to achieve targets within realistic timescales then I believe they can succeed.
Dr Jane Scott, UK

As a member of the Co-operative Party I am delighted to see proposals being pursued that will bring hospitals closer to their patients, closer to their local communities and for the first time be accountable to both patients, local people and the staff that work so hard. An excellent way forward for a modern National Health Service.
Timothy Godfrey, UK

If people want a gold standard health service it will have to be paid for Peter, England

Having worked in the NHS for 27 years I have witnessed it worn down by chronic underfunding and constant reorganisation. The general public continue to believe that by tinkering with the workings it can all be made to provide for their every need. Unfortunately it never has and never will. If people want a gold standard health service it will have to be paid for, either in increased taxation or at source.
Peter, England

Better to have a two-tier system where some succeed and others fail than the current one-tier where all are doomed to fail.
John B, UK

I have worked in the NHS for 10 years. The Tory internal market was divisive and destructive. Foundation trusts will re-introduce that atmosphere. Blair has brought national cohesion to the NHS. Steady as you go, consolidate, no more reorganisation for a long time yet, is my heartfelt plea.
Anita, England

It doesn't matter how much money is thrown at any hospital. If there aren't enough medical staff it's really rather pointless. Increase the wages of staff, encourage more people to work in that sector, and see the dramatically improved outcome.
Antonia, UK

Is it time that we faced up to things? Gordon, Scotland

"They're damned if they do and they're damned if they don't" The problem with the NHS is that the general public would never accept a massive upheaval of methods and practices in the NHS. No matter what the government proposes by the time it got through the Commons and various public committees - it would just be another watered down scheme that had big intentions. Is it time that we faced up to things and finally start to plan things in the long term and give up being scared of change?
Gordon, Scotland

Will these changes actually make any difference to waiting times? My wife has been told we will have to wait over a year for a gall stone operation, weeks after losing a baby. Great for her state of mind!
Mark Harrison, UK

So Foundation Hospitals can only raise private finance to limits within the overall NHS budget. Thus there is no more money going into the NHS, but the Government gets to spend less as private investment replaces public funding. Clever strategy and a surreptitious step towards the inevitable privatisation. I am very sad it is a Labour Government engaged in such tactics.
S, UK

It is regrettable that some in the Labour Party would rather see all hospitals as second rate rather than some reaching a higher status. This is the mentality which abolished grammar schools, if everyone couldn't attend one then no one should.
Peter W. Elliott, England

It is another way of encouraging privatisation and health inequalities Robert Wilkinson, UK

This is yet another New Labour "big idea" causing yet more administrative chaos and demoralisation amongst staff. Above all it is another way of encouraging privatisation and health inequalities. Why don't they come clean and admit they want more fat cat profits by greedy and inefficient "entrepreneurs" rather than the spin of greater local accountability.
Robert Wilkinson, UK

There is a real risk of a 'two-tier' system emerging out of the foundation hospital policy. However, the NHS badly needs reform. There isn't going to be any painless way of achieving it.
Zachary Mann, England

I want to know that when I have hospital treatment, I get the best. Setting up "flagship" hospitals will create an "us and them" situation. All hospitals need to have the same high standard. What Mr Blair needs to do is remove all the highly paid managers and stop trying to run the National Health Service as a profit making concern - it is a necessary service not a business. The whole point of my paying National Insurance contributions is to ensure that treatment is immediately available when I need it.
Alan Jones, England

I want to see the health service run directly by local people, with direct election to the boards that run PCT and hospital trusts. Foundation hospitals will not do that. They will just increase a current trend for them to be run by a well paid elite who look increasingly to health profiteers to run services, taking funds away from patient care.
Trevor Chaplin, UK

Throwing money at chief executives does not make things better - the NHS is a service not a business. I have never come across so many managers in 15 years as an NHS nurse as there are today.
Su Lowe, UK

Are the pension plans going to be privatised also? Kevin, UK

Foundation hospitals will produce two tiers because they are profit oriented... they might pay top consultants top wages, but to balance that they will have to cut wages to nurses and NCCGs. Are the pension plans going to be privatised also?
Kevin, UK

Why all the outcry? You get very few doctors doing NHS medicine anymore. I know because I tried to find one and I am British.
E. Sinclair, Canada

As an NHS worker, an active member of the Labour Party and a usually high regard for Blair and his direction, I cannot support him on this one. It will re-introduce the much hated internal market which the Tories failed with during the 90s. What the NHS needs right now is stability and a slowing of the reforms. The extra money seems to being wasted on "quick wins and gimmicks" with no real long term sustainability.
Colin, Manchester

Why was this government so dogmatic about abolishing fund-holding GP practices? I can't really see much difference in ideology between a foundation hospital and a practice that has its hand on the purse strings...
Peter Gilbert, UK

This government needs to recognise the NHS is becoming increasingly over-managed and that this is where money is wasted. I have just left community nursing after eight years and realised all the changes were only paper exercises and the care patients received in their homes didn't change. It was wasteful to throw away headed paper each year because the name of the trust had changed yet again. When I resigned earlier this year my resignation letter had to be sent to four different people as no-one could tell me who my manager was - a crazy situation.
Peter Bennett, England

When will someone attempt to tackle the real problems in the NHS, and other public services? It's not freedom to spend money which is required but the freedom to do a good job. There's far too much administration everywhere: needless form-filling, hopping from desk to desk, assessments, surveys, etc. Once the administrative fog is cleared there may be some hope that hospitals will be able to see their way to spending their money on healthcare rather than trying to fiddle waiting lists.
John M, Lyne Meads, UK

Healthcare is never going to improve until the politicians let our wonderful medical staff get on with their jobs Mark, UK

Yesterday it was NHS trusts, today it's Foundation Hospitals, and tomorrow it will be something else. Healthcare in this country is never going to improve until the politicians stop playing with it and let our wonderful medical staff get on with their jobs. They can reinvent the structure any way they like, but at the end of the day it will still be the same over bureaucratic and appallingly badly managed system.
Mark, UK

The government has introduced targets for all NHS trusts to meet in order for there to be a national standard. If we all stopped at the required standard, then that standard would never be raised. There needs to be an incentive to meet and exceed targets - but foundation hospitals? With the star rating system, the public already have a misconceived idea of which hospitals are better than others. If the government create another marker from which to judge hospitals, then this problem will be exacerbated.
Rob, UK

I am a frontline NHS worker and Labour party member. I no longer recognise what this government is doing to the NHS. There is already a multi-tier system of care and all foundation hospitals will do is make the problem worse. The government is simply seeking to devolve blame for health service failure. Do this and this will be the end of the NHS as we know it. The next step will be privatisation. Why not admit this, instead of trying to push it through as a Trojan horse? BTW health services workers views have been completely ignored throughout the whole of this legislation.
Dr Jenny Vaughan, UK

I know the government has made many billions available, but it is nothing like the extra 2 to 3% of GDP required Andrew, UK

The only way to really address the problems in the health service is a significant injection of money. I know the government has made many billions available, but it is nothing like the extra 2 to 3% of GDP required to take our health spending to the levels provided by the French and Germans. Of course that means significant tax increases. How many years will it take for the spectre of losing the 1992 election over tax to disappear and for Labour to face up to the hard choices - better healthcare or lower taxes?
Andrew, UK

Its typical of Blair that he believes having less control over managers will improve services. As for comparisons with France and Germany, they spend 50% more than we do - case closed.
Adam Hamilton, Scotland

So Milburn will quit if patients end up having to pay for treatment. Big deal. Assuming this threat isn't of the Clare Short variety, then all that would happen is another of Blair lackey would take his place. Milburn would retire from the scene for a few months. Meanwhile, the rest of us in the real world would be stuck with their mess for a generation!
Nigel, England

In my experience as a patient, the NHS for the most part provides an excellent service, but there is real public concern over waiting times following GP referral and for non critical cases in A&E. I am therefore mystified why 'greater local control', 'flexibility', 'choice', and 'release from the stranglehold of Whitehall' are the main issues. These are the words of leader writers, not patients. The current trust structure already gives considerable freedom to the local management on how they meet the government's targets. Is it really suggested that in the UK we want different targets/standards for the different regions? There is already the issue of the post code lottery.
M Gabriel, UK

We already have a two tier system Alison, UK

We already have a two tier system, poor local hospitals and large rich teaching hospitals. The sale of assets will surely help to prop this two tier system up, central London hospitals have millions of pounds of assets - an historic anomaly from the establishment of the NHS. A great deal of time and effort will go into something that will not make an ounce of difference to patient care. A lot of civil servant and NHS management time will be spent on developing this scheme when it would be better spent on actually transforming and developing services to the benefit of patients not power hungry chief executives.
Alison, UK

I have been ill for about five months and have found the NHS appalling - slow, uninterested and overworked doctors. Anything that would make our health system better is welcome - but will this do it? I think not. The best doctors will go for the better paid jobs in the best hospitals (and who could blame them?). But the rest of the hospitals will be left with less talented staff who will have to use inferior equipment and receive less pay. Best go private... if you can afford it.
Anna, UK

The biggest problem the NHS faces is national collective wage bargaining. It's ridiculous that health workers are valued the same regardless of location. Hospitals need the freedom to pay competitive rates and offer competitive terms and conditions to prospective employees.
Rick, UK

This is the beginning of the end for the NHS Bart, England

This is the beginning of the end for the NHS. But it probably won't bother the Cabinet because we all know that THEY will never have to wait two years for an operation. The only viewpoint that matters is that of staff within the NHS. You wouldn't go to a banker if you wanted to rebuild your front wall, so why listen to the view of politicians that are only out for short term gains? Goodbye NHS, I knew thee well.
Bart, England

The government, with its startlingly inept attempts at micro-management, has made a mess of the NHS. It is now going to attempt to distance itself from responsibility and rectification, by shoving hospitals towards privatisation. If this isn't a cop-out it certainly looks like one to me. On the bright side, if this government stays out of the way, there is a fighting chance of NHS services improving. I'd apply a similar argument to education, transport, housing etc. ad nauseam.
Chris Hunter, England

The NHS encourages people to ignore their own health, its a disgusting idea that should never have even been tried. Much better for central government to put up the money needed for a fit and healthy person to be insured, with those that choose to live unhealthily funding the rest of the insurance bill. As a healthy person I feel parasited on paying a huge amount of tax to fund this fatally flawed system. Scrap the whole thing now before it kills more people!
Robert Read, UK

Robert Read: The NHS does not encourage people to be unhealthy. If you want to scrap the NHS, I hope you can sleep at night when the vast majority of people in the UK will not be able to afford doctors, primary health care and will only see the inside of a hospital when they are dying. A private healthcare system supported by a greedy insurance industry does not work, just look at the US. This foundation hospital lark is the first step towards "market forces" entering the NHS and will see the most vulnerable in society being denied the basic human right to healthcare.
Vish, UK

It's right to create this scheme Andrew Dundas, UK

It's important to encourage well managed hospitals with a much lighter touch and to concentrate improvement strategies on those that need to catch up. Therefore it's right to create this scheme. Longer term, I'd like most hospitals to be managed at arm's length from Whitehall rather than in one very large bureaucracy.
Andrew Dundas, UK

Privatisation is on the cards from what I can see. Tony is going along the route of the US system instead of leaning towards the EEC countries. Private companies are there to make a profit. And as we can see from other privatisations, they always ask the government for more funds and the government always gives the money to these companies, out of the taxes that we pay.
Chris Karatzas, UK

We are under enough pressure at the moment Anon, UK

I work in a large trust at the moment. For those without foundation status the pressure to conform to the levels required to become a foundation trust would be enormous. We are under enough pressure at the moment with A&E targets and cancelled operations targets and delayed discharges targets. And the list goes on.
Anon, UK

I am not convinced by foundation hospitals. Certainly we want local accountability in hospitals, but this appears to do little for democratic control.
Ian Ruxton, UK

The degree of central control in the current NHS would make a Stalinist proud, and it's clear it's not working. These new proposals are far better, putting control in local hands. Standards already differ between different hospitals and regions, and the government must make sure that this policy doesn't make it worse, but don't throw the whole package out just because it won't improve the whole NHS at once.
Paul, London

Money will only be applied in improving a facility that a hospital already has. Where there is limited facility the patient is not going to be served any better. The public needs to be better informed as to what finance has been placed, that a local hospital cannot help you because its not cost effective. Hospitals are certainly not going to change their chosen expertise for uncertain expense. It's typical of a government that seeks to divest itself not of power but of responsibility for poor performance.
JM Davis, UK

Are the objectors to these proposals suggesting that only improvements which can be implemented in all branches of the service on the same day at the same time should be allowed? If so we are never going to see any improvement are we?
Ken Reay, UK

This idea reeks of creeping privatisation W McMillan, Scotland

This idea reeks of creeping privatisation or at least more scope for private finance to get involved. I believe it is both morally and operationally wrong, the private healthcare providers cannot give the UK what it needs in terms of health. These hospitals may not wish to spend on the biggest consumers in the system, ie people with chronic conditions. More money to the NHS is needed at source and wages for medical secretaries and porters needs to go up drastically. This fundamentally flawed, Tory looking idea will not work. After 20+ years of constant change, please give it a rest.
W McMillan, Scotland

W McMillan - foundation hospitals are not privatised as such - they would still be part of the NHS but given greater financial freedom. This is because they will have shown that they can demonstrate value for money in the past.
Bill, UK

We are now paying increased national insurance contributions to fund the NHS. We cannot maintain the status quo. Doing more of the same won't work - and Blair is right to propose a different way of running the NHS.
Wayne, UK

This will absolutely create a two-tier health service. If the new "super hospitals" are able to pay what they like to staff, other nearby hospitals are going to firstly lose out on the best staff, secondly demoralise the remaining staff, and thirdly make the poorer hospitals rely on agency staff due to the general staffing shortages. So the poorest hospitals end up with more costs on staff and less on looking after patients. And what then Mr Blair? Once all the hospitals are trusts, isn't that just stage one of an American-type privatisation plan?
Mark, Bristol, UK

Better a slightly lower standard of health for all, than a better standard for only 20% Colin Heyes, UK citizen living in Germany

If the foundation hospitals cannot raise enough support privately, who will end up balancing the books - the only possibility is the patients (and/or private health insurance). This is the first step on the way to the American system. I lived in the US for 5 years and know first hand how elitist that system is. Please do not shift that way, better a slightly lower standard of health for all, than a better standard for only 20%.
Colin Heyes, UK in Germany

The prime minister's apparent shift in emphasis to a position where ALL hospitals become foundation trusts may well placate many of the critics inside his own party, but this has to be tied to a commitment to retain national pay bargaining. It is essential that staff remain motivated and every encouragement needs to be made to retain stability within each foundation hospital as only then will it be possible to deliver the service to patients that is required.
Robert Crosby, Nottingham, UK

I have never heard such a ridiculous idea in all my life. Do we not pay taxes already to go to the NHS? We have been told on numerous occasions by our prime minister that more is being put in than ever before. Does he really think that both patients and nurses would be queuing up to go to these hospitals which will be at the lower end of the scale? He may as well close them down. It's either all or nothing and I would like to see where on earth my tax is going because it seems to be disappearing into a black hole at the moment.
Suzanne, England

Definitely a two tier system. Which will give chief executives too much power.
B Canning, UK

Change yes, but the way chosen must show progress too Liz S, UK and Indonesia

Is this voice of a Labour government? I fully agree with those who suspect that this move is the first step in privatising the NHS. Better to let Bupa etc have their own private and separate hospitals. Foundations are a change, sorely needed in the NHS but decent wages and better work contracts rather than contract and overseas nurses would go a long way to improving healthcare. There would probably still be a waiting list to get into the star rated hospitals, anyway. Change yes, but the way chosen must show progress too. We must improve what we have, not throw it out wholesale. By the way, the continent may do it better in some respects but most have medical insurance and must pay a contribution to the services they use.
Liz S, UK and Indonesia

Many patients I care for are from a poor background. I envisage different care, food and treatment being given even with one trust. Those who can pay will unfortunately have better of everything.
Mrs E Eyre, Wales

The description of foundation sounds awful. It seems it would just be a third body vying for the limited staff availability and wouldn't improve waiting time. As for setting its own salaries this already happens here and each hospital has to set up new contracts on a regular basis. Nurses have different wages and benefits even in the same cities. We have a service much the same as the UK but our hospitals are allowed to fundraise and do so regularly including lotteries for money and houses, cars etc. We also have telethons for the children's hospitals.
Elaine Sutherland, Canada

The merits of foundation status for hospitals is a red herring. If the government wants to see any resulting improvement from all the extra cash it is putting into the health service, it needs to stop re-organising it. Otherwise all the senior management who might otherwise work on making improvements are constantly pre-occupied with the re-organisations.
Gyles Glover, England

I firmly believe that the Labour government has a hidden agenda to privatise the NHS hospitals via the back door. Creating a two tier health service, where the poor will be forced into paying for surgery and other types of operations, we could, heaven forbid, end up with a similar system of health which they have in America, or a much worse system altogether. We cannot believe anything this government tells us, because of their past broken and empty promises they've made to us, the electorate in the past.
Allan Damien Goodwin, Scotland

It is likely to improve patient care and should be supported Dr Stephen Thomas, UK

The proposal to develop foundation hospitals deserves support. Now that the Department of Health is able to set and monitor standards and targets, hospitals should have the freedom to determine how these standards and targets are achieved. This arrangement is analogous to the highly successful decision of Gordon Brown to allow the Bank of England to set interest rates, whilst the government's responsibility is to set a target inflation rate. I believe strongly in a healthcare system funded by general taxation and free at the point of use, but it must also be free of political ideology. This proposal is likely to improve patient care and should be supported.
Dr Stephen Thomas, UK

We have a two tier system where the rich or those who can afford to pay to jump the NHS waiting lists by using Bupa etc. But where do private patients go when something goes wrong? Right into an NHS intensive care bed costing thousands of pounds a week. If Bupa and other companies carry out operations, they should look after their patients without needing NHS resources when things go wrong.
Colin Roberts, Scotland

We already have a two-tier system in most public services; some trusts are clearly efficient and well managed and others not. Patients of the latter deserve better. We need to change that so that everyone has access to well managed services.
Emily Thrane, UK

As long as patients are not made to pay extra I don't care whether a hospital can raise money privately or not. The NHS is based on the principle that healthcare is free for all. As long as this is upheld I don't care whether foundation hospitals charge for use of TV or computers whilst in hospital. Make people pay for luxury food or have their wards sponsored by private companies with adverts on the wall.
Graham Haywood, UK

Given the wholly centralised, bureaucratic, slow-moving almost sclerotic methods of financing of public services in this country, almost anything else would be better. The quality and ease of access to medical services that I have seen and experienced in Holland, Germany, France and Switzerland is ample proof that the way it's done here cannot be right. But, somehow, I doubt that foundation hospitals will suddenly bring the whole NHS up to the quality levels of the continent.
Chris Powell, UK

As long as the top tier is an improvement, I don't see the problem Richard S, S Yorks, UK

So what if we do have a two-tier health service? As long as that means that the top tier is an improvement on what there is at present and not that the lower tier is worse than at present, then I don't see the problem.
Richard S, S Yorks, UK

Foundation hospitals will not disproportionately spend away the NHS resource. On the contrary, the ability of these hospitals to seek external funding would provide better care for patients without it being an extra burden on the financially strained NHS. A devolved administration of these trusts brings choice and tailored spending to the needs of people within a community. However the local authorities should be assessed for their suitability to manage such a serious task. Thus various criteria, not just those based on the hospitals themselves must undoubtedly be considered.
Ben, UK

The country doesn't want this so why force it through? A MacLennan, UK

Foundation hospitals will lead to a two tier system. Who are they kidding, themselves or us? The country doesn't want this so why force it through? This betrays the electorate - no wonder the people are disengaged from politics. Tony and his cronies are the best Conservative Party leaders the Tories never had.
A MacLennan, UK

It is very clear that there is a problem with the NHS and I am aware that the problem cannot be improved without more funding. But can't the national lottery help? Millions of people play twice a week and a lot of the money goes to charities funded by the organisation. It is fine helping well built good causes but could the national lottery put some money aside and help a worthy cause - the NHS?
Rowena Day, West Sussex, UK

Who does Rowena work for? Tony Blair or the national lottery?
JCL, London, UK

Bupa, Nuffield and other private hospitals already represent the full pay end. Perhaps a halfway house foundation hospital might be a good idea.
Jon, England