NHS Foundation Trusts - a democratic failure?

10 years ago Alan Milburn launched the first Foundation Trusts. But despite his rhetoric of 'greater local control' the reality is apathy and powerlessness. Is it time for a different approach?

Richard Berry
16 April 2014

NHS Foundation Trusts are ten years old this month.

The Foundation Trust model was designed to allow NHS hospitals and other services a greater degree of operational and financial independence. The model has proven popular with politicians and NHS managers. There were 20 Foundation Trusts established in 2004, and that number has now risen to 146.

The current Coalition government wants to go further and transform all NHS trusts into Foundation Trusts.

It has also taken the highly controversial step of lifting the cap on Trusts’ private income – up to half their revenue can now come from non-NHS sources, including treating private patients.

The launch of the first Foundation Trusts was accompanied by great fanfare about the democratic credentials of the model. New Labour’s Health Secretary Alan Milburn claimed that Foundation Trust status meant “local democracy will play an important part in health service provision,” and that, “for the first time since 1948 the NHS will begin to move away from a monolithic centralised system towards greater local accountability and greater local control.”

Foundation Trusts are supposed to be democratic in the sense that patients, staff and anyone in the local community can join the Trust. Trust members then vote to elect a Council of Governors, the body which holds the Board and Chief Executive to account on behalf of members.

Unfortunately, new research I have conducted suggests that participation in these democratic processes is so low that we have to consider this aspect of Foundation Trusts to be a failure.

Only a tiny number of people have chosen to become a member of a Foundation Trust. Milton Keynes Hospital Foundation Trust serves an area of quarter of a million people but has a membership of 6,000 – only 2.4% of that population – and many Trusts are even less representative. Most Trusts have a public/patient membership of somewhere between 3,000 and 20,000. However, the core population served by each Trust is invariably hundreds of thousands of people, even millions.

Not enough people are interested in becoming Governors of Foundations Trusts. One troubling statistic is that half of all Governors were elected unopposed.  And one in 10 posts were unfilled because not enough candidates came forward, even for an unopposed election. This compares very poorly to ordinary local authority elections, where uncontested wards are almost unheard of.

Average turnout at contested Foundation Trust elections is 20%, far lower than the 35-40% that is standard for local elections. And that’s 20% of the Trust membership, not of the wider population. Returning to Milton Keynes Foundation Trust, only 14% of its members voted for the governors in  2013 – just 0.3% of the local community.

The system needs to be reformed. As an immediate priority, the Coalition Government needs to consider putting a hold on the authorisation of any new Foundation Trusts until these failings have been assessed and necessary changes identified.

As for what those changes should be, if the Foundation Trusts model is to survive then the first step is to increase their memberships. New Labour had considered the option of allowing people to join their local Trust when they registered to vote in ordinary elections – this step would only require coordination between the local authority and the Trust, but it has never been introduced.

Part of the problem is that Foundation Trusts are allowed to have tiny memberships. When first authorised a Trust must set a minimum number of members in their constitution – if they drop below this their elections become invalid. But most have absurdly small minimums. For instance, Central and North West London Foundation Trust covers a population of over two million, but has a minimum membership of just 160 people. The regulator Monitor needs to be empowered to refuse any applications for Foundation status unless the minimum membership is, say, 10% of the local population.

We need to re-consider the role of Governors, to make this a more meaningful position that will appeal to a wider range of people. Governors have some power to hold the Trust Board to account and appoint the non-executive directors. They have the power of veto over some major decisions such as a potential merger with another Trust.

But there is a central flaw in the model, in that the Chair of the Council of Governors is also the Chair of the Trust Board, which undermines the independence of elected members.

Governors need better support. For instance, agenda paper for Trust meetings should be designed to enable independent, non-specialist Governors to make well-informed decisions. Currently they often comprise hundreds of pages of complex material, poorly presented in arcane language. At the very least, NHS Trusts need to replicate practice in local authorities, where there is a strong secretariat function supporting elected councillors to negotiate this sort of terrain.

The most effective reforms of all may lie beyond the scope of Foundation Trusts. Power in the NHS has increasingly shifted away from hospital trusts towards commissioners, now in the form of Clinical Commissioning Groups (CCG). CCGs can set the direction of health service provision across an entire community. The public would have more influence on the NHS if they could be elected to the management structures of CCGs, rather than Foundation Trusts.

There are also the new Health and Wellbeing Boards, situated within local authorities. These allow elected councillors to help shape local health and social care services, in partnership with the NHS. Empowering these bodies to oversee both NHS commissioning and delivery would perhaps be the most effective way to strengthen democracy in the health service.

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