Improving Foundation Trusts

Suggestions  for approving the current arrangements

1.  Improvements to the actual election process, which in many places show signs of having been devised by people who know nothing about elections. Minimum standards should be established for the election processes and for eligibility.  In particular constituencies should be neither too big nor too small.  Candidates should be given enough space to say something about themselves in the election process and why they want to be Governors – say half  a side of A4.  They shouldn’t have to be proposed or seconded by other members, as they have no way of knowing who the other members are.  Should they be elected by Alternative Vote?

2. FTs should be prevented from calling Governors by other names like “Councillors”, as some do, because it just confuses the public.  This set up is confusing enough without introducing extra terminology.

3. The rules some FTs have which prevent LINK members from being Governors should be scrapped.

4. It should be possible for members or the public to contact Governors without going through the paid staff of the Trust.  The Trust should supply a public email address for each Governor.

5.  Reaffirming that the equality legislation applies to Governors – people who need provision for disability, money to pay for child care etc.

6.  Governors should be entitled to time off work for public service as magistrates are.  Staff Governors will need time off with pay and probably someone to cover their work

7. Governors meetings should normally be open to the public.

8.  I don’t think, on balance, that the Chair of the Governors should be separate from the Chair of the Trust. That is because of my experience in Manchester.  But the answer to a chair who doesn’t work with the Governors is to get rid of them.  The Governors have the power to sack the Chair.  They may have to use it.

9.  Most important  –  more independence.  The rule should be that ONLY the governors can sack the Chair.  If the Secretary of State or Monitor want to sack the Chair or intervene in other ways they have to go through the Governors.

10. There should be allocated central funding to every FT specifically ring fenced for governor training and development and member engagement.  Funding should be linked to membership level to encourage mass membership.  The FTGA should also get appropriate funding, for example for developing training courses and materials, and its role should be acknowledged.

11. A national one day induction course should be established and no governor would be able to take office until they have been through the course.  Annual follow up half day courses should also be mandatory.

12. There should be a national Code of Conduct which every FT has to adopt and enforce on their governors (they could add to it).  This should make clear issues around conflict of interest, communications with the media, standards of behaviour, role and responsibilities. It should also cover how governors could be removed for unacceptable conduct in breach of the code, or non attendance.

13. The governors of an aspirant FT should operate in shadow form for at least 6 months before full FT status is given.

14. Monitor should consult again and then publish new guidance around the roles and responsibilities of members, governors and members’ councils.  Some independent research and publication of best practice should be undertaken.

15. Monitor should have one nominated board member responsible for liaison with governors .

16. Nobody who has had a board level position in any NHS trust should be allowed to become a governor for at least 2 years.  No governor should be allowed to become a NED of any Trust for at least 2 years.  (MAR does not agree with this)

17. Governors should be given lots of opportunities to meet with governors from other FTs.

18.  A good job description for the role of Governor should be published before an election so candidates really know what is involved – in terms of formal tasks, opportunities for involvement in the hospital, and time commitment.

More meaty considerations from Richard Bourne (his simpler proposals are incorporated above):

The consensus is that there is something in the FT model but it is far from a finished product.  Most FTs accept that it will be 2/3 years before they adapt to the new form governance and before governors could begin to have a real impact (if they were allowed to).

The wider care system around FTs makes it much harder for them to actually use any freedoms they may theoretically enjoy. The coherent system model in which FTs should operate would be where commissioning and provision are fully separated; all providers would be regulated and would be a mixture of, FTs, tier one local authorities, private sector, or 3rd sector. The quasi market levers, like choice, tariff and PBR, would operate and “market” mechanisms would be in pace to deal with failing providers, through merger or acquisition. There would be no traditional NHS providers.  Commissioning would be integrated with social care and that could be directly through local government (Milburn) or else by some joint/shared functions.

The FT model has departed from the initial aspirations but it does allow some freedoms, especially around access to and use of capital. The appointment and accountability of executive directors is much clearer in an FT and the Board does have a genuine role unlike in a PCT or SHA, which take their decisions based on top down instruction. Performance management by the SHA is replaced by regulation by Monitor plus indirect performance management by the SHA operating through the commissioners.  FTs can, in theory, establish their own terms and condition of employment but so far only one has done so.  In general FTs are still bound into the same constitution, operating frameworks with the same targets and funding flows – scope for other income being strictly (now) restricted.  The overheads from having to run the FT model are significant and there is no additional funding for this.  Some very well known large acute trusts are not close to becoming FTs and it is wholly unclear what and when any action will be taken about the stragglers – every deadline so far has just been ignored.

Monitor has accepted that FTs do not progress faster than non FTs, but they claim the process of authorisation does raise standards. In the top 40 acute trusts, as scored by Dr Foster’s Good Hospital Guide, only half were FTs; which is a shock given that they had to be high performers to get FT status.  Only 50% of acute trusts are FTs and currently 16 out of 76 acute FTs are rated RED for governance which shows a concern level as high as with non FTs.  The story is better for MH FTs but they are less of an FT in the sense that they already have governance spanning other stakeholders.

There is no published evidence to show FTs being influenced by their Members Council (Board of Governors), but it is anecdotally happening to some degree across many FTs.   It is clear that the regulator is largely indifferent to any role for governors. The real power in an FT lies with the NEDs who are in the majority on the unitary and largely autonomous FT board. The power of governors to appoint the Chair and NEDs is the current key role.

Governors just about everywhere struggle to understand their role and even when they do, they try to change it!  There is often a poor understanding of the fact that it is the commissioners which lead on service development and configuration and governors struggle with the need to keep away from management and the operational aspects.  They are unable to balance their role as representatives with the need for collective decision making. Little of value has yet emerged about how governors are held accountable and report to their electorate – the membership has a very vague role other than as a base for elections.

Much like local government there appears to be a mismatch between the skills and knowledge of those that are actually elected compared to what is needed.  Much of the NHS, including within many FTs, wish to limit and manage the governors into being cheer leaders and a sop to involvement and consultation; there is no desire to transfer real power to plucky amateurs.

For the Socialist Health Association the model has to fit into a vision where the main characteristic is of a community owned organisation, responsive to the needs of local communities and with some degree of autonomy from DH/SHA imposition; but still firmly within the traditional NHS family with the values that implies. If we are serious about local ownership and accountability then there has to be an element of trust and an acceptance that there might be aberrations, unintended consequences and even failures (welcome to our NHS)!

If we accept the model as a step in an acceptable direction how can it be improved and developed? Some suggestions:-

  1. The long term future for FTs within the NH System should be agreed.  The system rules should spell out what happens to trusts which cannot make FT status and what happens should an FT fail or opt out of FT status. If the strategy has been changed so that, for ever, we continue to have NHS (provider) Trusts which are not FTs then how exactly will that work? Because of the overheads and governance complexity no FT should have a turnover less than £100m.
  2. Drop any idea that FTs are in some way part of a process to deal with the democratic deficit in the NHS.  The key issue is how to bring accountability into commissioning and resource allocation.
  3. Someone should work out how the existence of an FT in a locality impacts on commissioners and their duty to consult of strategic needs assessment and service configurations.  (No sensible answer can be found so commissioning should be undertaken by tier one authorities as with other public services and social care).