The democratic promise and potential of membership in NHS Foundation Trusts

The “Ten Years After”  paper from Cooperatives UK is a welcome attempt to reinvigorate the debate about the role of members in the Foundation Trust model (FT) model. There are nearly 2 million members of FTs across England – a mass membership of a size rivalling the T&G at its height, but with arguably less influence and profile than a small parish council.
The 2002 Department of Health policy document on FTs stated that “the members of an NHS FT will become its owners, taking on responsibility for their local hospitals from national Government… The members of an NHS Foundation Trust will, collectively, be its legal owners. This is a real and not a paper exercise in social ownership.” In retrospect, this is about as believable as the tooth fairy.
Many FT Chairs would be delighted to jettison the membership model – indeed Lansley’s “Liberating the NHS” included a plan to move to some “staff membership only” FTs, though the appetite for that swiftly dissipated.
Until 2010 the membership agenda was all about size. FT applicants were constantly pressured to acquire more and more members, with no clear policy or rationale about what to do with these 100s of 1000s of recruits once they had been signed up. The main beneficiary has possibly been Electoral Reform Services Ltd, who get paid to send out hundreds of thousands of ballot papers to FT members every year, in the certain knowledge that only a small minority will even be sent back. The only concrete right given to FT members is the right to participate in governor elections – but nationally over half of governor elections are uncontested. On the minority of occasions when elections do take place, turnout averages under 20%. The ‘model’ FT election rules are so outdated that they do not permit electronic voting.
Since 2010, the membership agenda for FTs has essentially been optional. In regulatory terms, there appears to be no downside to having a small or unrepresentative membership. Oxleas in South East London have around a third of the public members of an average FT but it didn’t stop them being one of the winners when the Trust Special Administrator came to town. There is nothing concrete in the Monitor Risk Assessment Framework (previously the Compliance Framework) that holds FTs to account on membership engagement. You can have zero contested elections and zero public attendance at governors and Board meetings, and it will have zero impact on your governance risk rating.
A public engagement model centred around the acute and tertiary sector is clearly flawed. An involvement model predicated on affording the greatest power to those who can attend the most meetings will also gain limited traction. But there remains massive potential to be unlocked from the 2 million FT members who to date in collective terms have been virtually invisible in society. So now is surely the time to be on the side of engaging and empowering patient, public and staff FT members. There are examples of good practice in FT membership engagement which can be easily replicated. Like it or not, the tools are there to incentivise FTs to more genuinely engage their members. If Monitor set down some basic standards for member engagement in the risk assessment framework that put some hard currency – ie, the governance risk rating – on the line, then you would see action from FTs quicker that you could say “industrial democracy.”