Paper presented at the Manchester Centre for Healthcare Management Conference, – Foundation Hospitals: a new way to run the NHS? on Friday 13th June, 2003
Johnston Birchall (Stirling University)
Mutuality and the governance of foundation trusts
Foundation trusts (FTs) are being set up as independent public interest organisations ‘modelled on co-operative societies and mutual organisations’ (Dept of Health, 2003). What does ‘modelled on’ mean? At its simplest this means that FTs will be member-owned and controlled businesses. It could also mean that they should share some other characteristics of co-ops and mutuals, such as a similar governance structure, member recruitment or member relations strategy. To find out how far FTs should be modelled on co-ops and mutuals, we need to know more about these existing member-owned businesses, and to identify good practice and possible management strategies for FTs.
FTs will also share some of the characteristics of non-profits, since it is likely that, unlike co-ops and mutuals, they will never be surplus distributing but will retain surpluses for expansion and improvement of the service. Some of these non-profits are charities, whose governance structure is guided by charitable law so that they cannot be membership organisations. There is not much to be gained by examining these for possible models. However, many non-profits are non-charitable (registered as industrial and provident societies or companies limited by guarantee) and have a more or less open membership/shareholder base. Again, good practice and management strategies could be identified that are transferable to FTs.
FTs will be multi-stakeholder organisations. Local people, employees and other key stakeholders will be able to become members. Most co-ops and mutuals have a single stakeholder, usually consumers or workers. Where multi-stakeholder models have been tried, lessons can be learned for the governance of FTs and for member relations. We have to look for examples of these. Of particular interest are various kinds of health co-operative that are well established in countries such as Japan and the USA.
We begin by appreciating something of the history of the mutual type of business the way it has evolved to meet the needs of members in many different sectors, and the way it has grown to become a worldwide phenomenon. Then we define the form, in a simple way as a ‘member-owned business’ and then in a more complex way that takes into account the deeper meaning of mutuality. In order to gain insights into how a health mutual works in practice, we then present two case studies: Japanese health co-ops and the Puget Sound Group Health Co-operative in the USA. These demonstrate that health mutuals can successfully promote member participation, and that it enhances rather than detracts from good governance.
A short history of the mutual and co-operative form of business
Mutuals began as a distinct form of business organisation in the late 18th century in Britain, in the form of friendly societies that provided mutual insurance to their members against sickness, unemployment and death. Then, from the 1840s onwards, and in response to the uncertainties caused by industrialisation and the growth of a market society, the form developed in several directions; consumer co-operatives, building societies, mutual banks/credit unions, housing co-ops, worker co-ops, agricultural and fishing co-ops and, by the 1920s, health co-ops (Birchall, 1994). Different forms appeared simultaneously in different countries – consumer co-operation and agricultural credit seem to have been invented many times in many places between the 1840s and 1860s. However, after models had become firmly established firmly in one country, they were sometimes adopted consciously by others. The British consumer co-operative model of the ‘Rochdale Pioneers‘ spread rapidly around the industrialised world, while the German model of co-operative banking spread to the rest of mainland Europe. The agricultural supply and marketing co-operatives that had begun in the USA and Germany gained a strong grip in Denmark and then spread worldwide. Sometimes a form that began in one country really took off in another; the housing co-operative model that had failed to become established in Britain became the main way in which urbanisation was achieved in Scandinavia (Birchall, 1988). It is important to note that these forms predate the now predominant form of the joint stock company. Friendly societies were recognised as a legal form in 1793, consumer co-ops in 1852, while joint stock companies had to wait until the 1860s to gain recognition.
Then, in the first half of the twentieth century, colonial governments wishing to accelerate the modernisation process in developing countries applied the same models. In the postwar period, the nationalist governments continued to favour co-operatives, seeing them not just as an economic accelerator but also as a politically acceptable alternative to capitalism. The economic results were mixed, and this form of economic organisation has been badly affected by the new environment of structural adjustment and privatisation (see Birchall, 2003, ch.1). In the ex-communist countries of Central and Eastern Europe, Russia and the Confederation of Independent States, a wave of privatisations of quasi-co-operatives has been followed by a gradual building up of genuine member-owned co-operatives, particularly in the consumer and agricultural sectors. However mixed their economic and cultural history has been, there is no doubt that mutual and co-operative sectors have now become established in virtually every country in the world. The International Co-operative Alliance now claims to be the largest non-governmental organisation, with over 700 million members worldwide. It includes nearly all co-operative business organisations, and (in its banking committee and the affiliated International Co-operative and Mutual Insurance Federation) some of the mutuals. However, unlike those businesses that call themselves co-ops, those that use the term ‘mutual’ tend to have a less strong sense of common identity.
It may be for this reason that the the recent wave of demutualisations has occurred mainly in the financial mutual sectors of mortgage-lending, insurance and pensions, where mutuality was not very well understood or valued (though some agricultural co-operatives have also demutualised and others have developed hybrid forms with some outside shareholding). It has also occurred in some countries and not others: the UK, USA, Canada and South Africa but not the francophone countries, Germany or Japan. There are legal restrictions in some countries, and cultural barriers in others, and the impact of demutualisation seems to have been greatest in those countries that have an ‘anglo-saxon’ business culture. Despite the demutualisations, co-ops and mutuals remain among the world’s biggest businesses. In the USA for instance, credit unions hold 13 percent of the consumer credit market. In Japan consumer co-ops are the leading retailers. Agricultural co-ops are predominant in most developing countries. For instance, in India there are 70,000 milk co-ops, with nine million members (see Birchall, 1997). They also have a large market share in most developed countries, particularly in Japan, Denmark, the USA and Canada (18 farm co-ops are among the Fortune 500 companies). In Japan, the agricultural co-operative federation is the seventh largest trading firm, while its insurance arm is the largest insurer in Japan (which means one of the largest in the world). Co-operative housing is strong in Scandinavia and Germany, but it is also quite strong in the USA where, despite the dominant culture of home ownership there are around a million co-op homes. In some parts of the world – notably the Mondragon region of Spain and the Quebec region of Canada – co-operatives dominate local economies. They are involved in just about every kind of business, including utilities such as electricity and telecommunications (rural USA, Argentina, Bolivia, Brazil, Chile), and water supply (eg Bolivia). They are developing in new directions such as computer services and tele-communications (cf Poptel and the Phone co-op in the UK) and social care for the elderly (particularly in Japan and the USA, but now also in the UK). They seem to be relevant to both very advanced societies and the least advanced; they are a vital component in economic development among tribal societies in India and Latin America (see Birchall, 2003), and are particularly relevant to the needs of women (Nippierd, 2001).
What do we mean by a mutual?
What is distinctive about the mutual form of business? It can be defined as an organisation that is owned and controlled by its members, who are the primary users of its products or services. Ownership implies two rights: to take part in governance and to appropriate the economic results. On the first point, because a mutual is owned by people as users rather than as investors, voting rights are usually allocated on a one-person-one-vote basis. The size of the shareholding is irrelevant. Second, because it is a surplus-making business and not a non-profit, any surplus that is created is returned to members, either equally or in proportion to the amount of use they have made of the business (the famous co-op dividend). They can also choose to have a ‘community dividend’ that benefits the group or the local community (as practiced by UK co-operative societies and some building societies), and they can choose not to distribute surpluses but to use them to lower prices in the future. Together, these two principles of equal voting rights and right to the surpluses make up the minimum requirement for an organisation to be considered a mutual. Mutuals that call themselves co-operatives acknowledge several more principles. Based on the ‘Rochdale principles’ and revised periodically by the International Co-operative Alliance (the last time in 1995), these include:
- Voluntary and open membership
- Democratic member control
- Member economic participation
- Autonomy and independence
- Commitment to education and training
- Co-operation among co-ops
- Concern for community (see Birchall, 1997, Ch7)
Another way to see mutuals is as ‘people-centred businesses’ (Parnell, 1995) that are deliberately designed to put users rather than capital at their centre. Capital then becomes just one stakeholder among others, supplied by members or by outside investors. In both cases, capital receives a ‘fixed and limited’ amount of interest, which is detached from ownership rights and is seen as a business expense. Finally, there is a distinction between fully mutual organisations that only trade with their members and semi-mutuals that also have customers who are not members. Consumer co-ops in Japan are forbidden by law from trading with non-members, while those in the UK trade with customers, some of whom happen to have chosen to be members. The Co-operative Group made a decision when its dividend card was launched to make it available to all customers, and is now revisiting that decision through a ‘real dividend’ initiative that would limit it to members only. Health mutuals in Japan would be forbidden to trade with non-members, except that the law on health insists that they do so. Health insurance mutuals in the UK are generally fully mutual, but foundation trusts would not be, as they serve a wider community and, like the Japanese co-ops, have to deal with emergencies.
These definitions are a good way into understanding the meaning of mutuality, but they are not subtle enough. If members are meant to own and control mutuals, what exactly do we mean by these terms? The UK building societies that have chosen to remain mutual tend to downplay the significance of ownership. Equating ownership with the current members may invite a simple claim to distribute all the assets through demutualisation, whereas current members claim on the assets cannot be absolute. Past members have decided not to distribute surpluses in order to build up the assets for future generations, and so it can be argued that future generations also have a share in this collective asset. This is an important argument also in relation to health mutuals that have to be safeguarded against demutualisation or asset stripping. The argument about control can also be overstated. Members cannot control the day-to-day running of a large mutual, and they have to delegate to an elected board and a management team. They have ultimate control, which means being able to remove board members and managers who fail to perform, and ensuring that the products or services are generally meeting their needs. Not all members share the same interests. In fact, if different categories of member have opposed interests (as between guaranteed annuity and with-profits pensioners in the case of Equitable Life) it may be better not to have a mutual at all (this is the view of Hansmann, 1996). Elected directors and managers have the task of reconciling or trading off between different member interests. Health mutuals are not exempt from this task. Mutual foundation trusts would have to allocate resources to different types of patient and to trade off between different levels of risk; they do this now, but when they become mutual will have to engage in dialogue with members so that a consensus, or at least a majoritarian decision, can be reached. Mutuals internalise conflicts of interests that other organisations deal with either through waiting lists (public sector) or externalise through market transactions (private sector). They have the chance to deal honestly with different interests, but they also have to be good at reconciling them.
Health co-operatives
The largest contribution of the mutual form of organisation in the health field is in mutual health insurance. In many countries insurance-based mutuals provide the main vehicle for channelling both public and private funding into health care provision. In the European Union alone there are around 100 million people who are members of such schemes. For instance, in France they cover 27 million people (half the French population), and they have around 60 percent of the complementary health insurance market. They also own more than 1300 enterprises providing health and social care, including pharmacies, optical and dental services, and medical centres (including 42 hospitals). They employ about 20,000 people, and also run home care services and sheltered housing for the elderly (United Nations, 1997). The same kind of pattern, of insurance-based mutuals also providing health care is apparent in other countries where funding is based on a mix of compulsory state-sponsored health insurance and commercial top-up insurance.
Another strong tradition is in the provision of services in rural areas through rural user-owned health co-ops. Examples can be found in developed countries such as rural Japan, USA and Canada and developing countries such as Sri Lanka. They tend to be formed wherever there is an existing co-operative tradition among farmers, and there is inadequate coverage by public services. For instance, in Japan the agricultural co-operatives have 115 hospitals with over 38,000 beds, 57 clinics, 25 rural health centres, six geriatric health centres, six home visit nursing centres and employed around 37,000 staff (1993 figures, from UN, 1997). Membership is somewhere between six and seven million households, but without the legal restrictions on provision for non-members that applied to consumer co-ops these facilities are also used by the rural population in general. The Federation provides 2.5 million people a year with health screening, using vehicles equipped with medical equipment to reach remote areas. In 1991 the agricultural co-operative federation began to make it a priority to develop social care for the ageing rural population, in collaboration with local authorities.
Urban user-owned health co-ops are less prevalent than rural, perhaps because there is more competition from conventional non-profit and investor-owned providers. However, because they are directly comparable to foundation trusts, they will be featured in the two case studies below. In general, according to figures produced by the United Nations, worldwide around 53 million people are users of user-controlled health co-operatives. However, because many gain access through affiliated organisations (such as trade unions in Malaysia and Singapore) around 40 million are users of their own co-ops. These figures were produced before the nationalisation of the formerly consumer co-operative health care system in Israel (which reduces them by 3.5 million), but they indicate that this model is well established, particularly in Japan, the USA, Canada and India.
Case study: health co-operatives in Japan
Since 1961, the entire population of Japan has been covered in one of eight compulsory medical insurance schemes. Provision is by a diverse set of medical corporations, public corporations, individuals and others including health co-ops. They are all designated as not-for-profit entities as stipulated by the Medicine Law. There is a growing gap between oversupply in large cities and undersupply in remote areas. Providers have weak liaison with each other, yet there is a strong tendency towards horizontal and vertical integration through forming hospital chains and ‘medico-welfare complexes’ (Kurimoto, 2000). The Japanese system has shown relatively good performance but it is in the turning point with rising medical costs associated with a rapidly aging society. Most of these schemes have accumulated enormous losses due to their obligatory contribution to finance the health services for the elderly. The government has tried to solve this problem for many years, but has been hampered by vested interests. The demand side of medical services is characterized by consumers’ free access to medical institutions. They can visit any hospitals or clinics but a coordinated care delivery system is lacking, and patients experience congestion in some large hospitals. Consumers have little opportunity to choose as hospitals/clinics are restricted to advertise and no comparative information is available. The fee-for-service payment system has led to excessive examination and medication, while patients have to pay extra costs for the services not covered by medical insurance. Health promotion is neglected, as are users’ rights to make informed choices.
Until 1961, when a comprehensive public health insurance system began, consumer co-ops were the main way in which low-income households could secure medical services. After 1961, many government officials and experts thought they would disappear. However, they shifted their aims towards preventive health and services for the elderly. During the 1970s, training in leadership in preventive health began to be provided to members in ‘health colleges’. The movement began to campaign on public policy issues, acting as a consumer movement as well as a provider of services. In the late 1980s, there was a reduction in the public budget for health, and decentralisation of financial and administrative responsibility to local authorities. This gave the health co-ops the opportunity to develop partnerships with the local authorities. In 1991 the movement adopted a charter of patients’ rights to be implemented in all its clinics and hospitals. This is designed to secure for members the right to knowledge concerning their own illnesses, diagnoses, alternative treatments and so on. It gives the patients the right to decide the suitability of a treatment plan, the right to privacy, to learn about their own illness, to participate more fully along with health professionals, and so on. In 2000 a long term care system was begun, to provide social support for the elderly so that they could choose the care services that they require. It opened competition among care service providers including private and non-profit operators. It was quite natural for health co-ops to provide long-term care as an extension of medical care, but they seek to create communities based on maximum participation by forming networks involving other institutions and local authorities. Such developments may lead them to adopt a multi-stakeholder model in future.
How large is this movement? In 2001 there were 125 societies, with over 2.1 million members, an increase from 1.5 million in 1992 (The movement is still growing: by 1998 the 118 societies had increased to 125 (Ullrich, 2000; Kurimoto, 2001). This implies a total membership, including dependents, of over five millions. Over 4 million people per year are treated as in-patients, over 15 millions as outpatients. They have 80 hospitals and 246 clinics, with over 13,000 beds, and employ over 20,000 people (a recent study finds that nearly 18,000 of these are also members – Kurimoto, 2001). In 1998, 31,000 members qualified as ‘health committeemen’, able to pass on knowledge of preventive health and ‘right living’. Han groups play a vital role in promoting member’s involvement in learning and practicing health promotion. There are 243,000 members in 25,731 Han groups, the average size of which is 9.4 members. They meet regularly at one of the members’ homes. There are district committees organized by school zone to promote networks in the community, and user panels attached to hospitals and clinics, designed to reflect users’ voices in day-to-day operation. As well as encouraging self-care through han groups, they give around half a million members medical check ups each year.
About 95 percent of the health co-ops’ income comes from the public health and social insurance system, in payments for services to citizens who are also co-op members. The rest is earned income, mainly from health checkups provided in their clinics. Because of cutbacks in public funding due to the Government’s health cost containment policy, societies have been facing financial difficulties. In 1996 their apex organisation reported that only 14 percent were making a surplus, though the number accumulating a deficit had decreased. On the capital side, construction of hospitals and clinics is funded by member share capital and loans. The aim is to encourage members to increase their share capital to 20 percent of capital values (Medical Co-op Committee, 1996).
Since consumers and employees are both members, one might predict some problems in governance. However, opinion polls of employees have demonstrated their commitment to the co-ops; for instance in one poll 68% of doctors and 83% of member relations officers (fewer nurses) were convinced of the co-op’s social contribution (Kurimoto, 2001). There is a recognition that the involvement of different stakeholders can be beneficial. Boards are, of course, user-dominated, with 2,133 lay board members representing users against 740 board members representing providers. However, in many cases co-op chairpersons are doctors, and top management are expected to bring the different interests together and to promote common values. Han groups play a vital role in promoting members’ involvement in learning and practicing health promotion. District committees are organized in school districts to promote community networks, while user committees are organized in hospitals and clinics. A variety of courses have been organized for doctors, nurses, technicians, care workers, CEOs, administrators, educators, member relations officers and so on to enhance their professional or management skills and understanding of co-operative values.
This is a small sector; the total of outpatients and inpatients is still only around one percent of the total population. However, it has been growing fast. During the 1990s total membership increased by 76%, turnover by 55% and share capital doubled. This shows extraordinary growth in the light of the sluggish economy that Japan has experienced in this period known as ‘Lost Decade’. However, the significance of the movement lies not in its size but in its emphasis on preventive health; members are mainly healthy people who want to stay that way, and who are prepared to take responsibility for their own health. The movement’s apex body, the Medical Committee of the Japanese Consumer Co-operative Union, emphasises the way in which the system is helping to replace the multi-generational family and local community supports that are weakening in modern society. They rely on the central role of women as the basis of further expansion. However, as more women take on full time employment, the han group system may become a casualty of ‘modernity’. The consumer co-operative movement in general is searching for answers to this question. Another concern is with the wider image of the movement. Although they are highly evaluated by the WHO for various innovations in promoting public health, their presence and role have yet to be widely recognized by the public (Kurimoto, 2001).
Case study: the Puget Sound Group Health Co-operative
The Puget Sound Group Health Co-op is of particular interest, because it deliberately set out to provide secondary care in hospitals that are roughly equivalent in size to the foundation trusts, and is now one of the largest consumer-owned health co-ops in the world. It was founded in 1947 by members of farm, consumer and student co-ops who were familiar with the idea of consumer ownership and wanted to extend this into health care. It was set up explicitly in conformity with Rochdale principles of consumer co-operation. The co-op gained the support of some dedicated doctors who had become used to the idea of a prepayment system of medical care during the war, but the medical establishment in general opposed it. In order to be able to buy and operate its first hospital the Co-op gave its doctors the right to autonomous control of their clinical work, without interference from the Board. After the Co-op won a court action against the Seattle Medical Society (arguing that the doctors were operating a ‘restraint of trade’), working relations between the Co-op and the traditional health care system became progressively normalised. However, tensions continued to be felt within the co-op between the medical staff and the Board. These were resolved by the establishment of a joint committee of staff and board members, and by the board contracting directly with self-managing medical staff.
By 1955, membership had increased to 36,000, by 1984 to 332,000, and the Co-op had expanded into adjacent regions. Despite the difficulties, other co-ops followed the same model; already by 1950 they provided health care to over 900,000 people. Six co-operative hospitals were functioning and 40 others were being organised. The Co-op has continued to grow steadily. As of December 2002 it has 586,000 members and ‘enrolees’, about 86 percent of whom are covered by health insurance through their employment. They make up 1 in 10 of the residents of the state of Washington, and 1 in 9 of these living in Puget Sound region. It had become the seventh largest health maintenance organisation in the USA, and the second largest of the consumer-owned health organisations (see Puget Sound Group Health Co-op website). Group Health provides comprehensive health care through hospitals, primary care or family medical centers, and specialty medical units. Offering medical care on a fixed prepayment fee basis, it operates two hospitals, a skilled nursing facility, five specialist medical centres, and 30 primary care medical centres. It contracts with 38 other institutions for specialist services and for services where it did not operate its own hospitals. More than 1,000 physicians practice at Group Health in an affiliated partnership called Group Health Permanente, and it contracts with another 6,500 community clinicians in private or group practices to provide care throughout the coverage area. In total, it employs about 10,000 people in health care and administrative positions, and is Washington’s third largest private employer. As one of the three largest health care plans in Washington state, it had revenues in the year 2002 of $1.7 billion.
Its governance structure works in this way. Customers of the Group have to elect to become voting members, and around one sixth have done so. They have the right to elect the Board of Trustees, whose 11 members are the governing body of the Group. They in turn appoint the president and CEO. An Executive Officers Group provides senior leadership, setting long-term strategy, monitoring performance, and overseeing day-to-day functions. Democratic control is also exercised through three regional councils and 23 local advisory councils. These local councils include medical centre councils and district advisory groups, who work with staff to improve the care and wellness of members and their communities. The Board of Trustees is supported by a Governance Services Department. This provides specialist services to support an active membership. Hundreds of volunteers serve on committees, advisory councils, task forces, and special interest groups. Consumer special interest groups are organised to deal with the special interests of women, the elderly, and mental health. For example, the Senior Caucus advocates for seniors’ needs; works on care delivery, health care coverage, and legislative issues; and plans local meetings with health-related programs. It has local chapters throughout the Puget Sound area.
The Group’s website encourages member participation, and provides a great deal of information, such as profiles of all the trustees and details of forthcoming meetings. Board meetings begin with an open microphone session during which any Group Health consumer can address the Board directly on all matters except those related to personal health care. There seems to be a genuine concern to offer members a choice of governors; in the current round of elections the Standing Nominating Committee has put forward six candidates for four places on the Board.
Its Centre for Health Promotion offers preventive health programs to enrolees, with individual life-style assessments, screening programs, health education classes, and so on. There are reduced fees for members committed to healthy lifestyles. Its Centre for Health Studies is a national leader in primary care and in geriatric, mental health and cancer care research, with the emphasis on prevention and health promotion. Its Group Health Community Foundation funds initiatives to build healthy communities. The Department of Clinical Improvement and Education offers continuing medical education programs for physicians and other health care providers including physician assistants, nurse practitioners, and nurses. The Institute for Health Innovation researches new ways of providing care. Like the Japanese consumer health co-ops, the Group emphasises preventive health care and health education, especially aimed at children, uninsured groups and disadvantaged people. Classes are offered in a wide range of health topics for people living with particular conditions, first time parents, expectant families, care givers, elderly people and so on.
It is difficult to find statistics for the extent of this model of health care in the USA as a whole, because of the way in which health co-ops are subsumed under the more general category of non-profit health maintenance organisations, and because people enrolled through employers or through Medicare or Medicaid are not necessarily members. In 1995, the National Cooperative Business Association estimated that this consumer co-operative model now covered around 1.5 million members. The largest are the Puget Sound Health Co-op, the Group Health Association of Metropolitan Washington DC, and the Health Insurance Plan of Greater New York. If we broaden the focus to include not just consumer co-ops but other health maintenance organisations, we find the largest concentration in Minneapolis region, where nine such organisations provide coverage to 1.2 million people, 70 percent of the population.
Taken together, these two case studies show that mutuals can operate successfully in large conglomerates offering a whole range of medical services, including hospital care. Single stakeholders govern them, but both the Japanese and American co-ops offer membership to employees, who seem to exert enough influence on the system to remain reasonably committed to it. The early history of Puget Sound shows how important it is to get this right and allow clinical freedoms where appropriate. The Japanese case shows how the interests of users and providers can be aligned through commitment to common values such as democratic control, and mutual responsibility for health care and prevention of illness. Within a wider system that remains centred on curative medicine, they have managed to build and maintain a radical emphasis on health promotion, self-responsibility and patients’ rights. They have not had problems with a lack of member participation, but that is because they have had clear, well- resourced strategies for promoting and maintaining the interest of members.
Conclusion
These real life examples of successful health co-ops provide reasons for being optimistic about the prospects for involving members in foundation trusts. However, they show that the process has to be actively governed by directors and managed by top managers. It cannot be left to chance. There has to be a strategy for recruitment and ongoing member participation, linked to a clear understanding of the requirements of good governance.
Bibliography
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