The biggest challenge for NHS governance in 2009 will be to breathe life into the NHS constitution and make it an integral part of their decision making. NHS bodies will have to walk the fine line between, on the one hand, mere box-ticking and token compliance and, on the other hand, not having their agenda grind to a halt under the weight of discussion. Finding the right balance could be quite difficult. PCTs will need to ensure that they can justify the difficult choices they have to make in the context of the Constitution. Foundation trusts (FTs) will also need to bear in mind the potentially competing requirements of other strands of corporate governance specifically because of Monitor's Terms of Authorisation which requires FTs to comply with "the principles applicable to best practice in corporate governance in the NHS/health sector".

We envisage clients will feel compelled to take advice in hard cases. We also expect clients will want to include this topic in their board training for 2009 and rolling induction programmes for new directors.