What can we learn about democracy from NHS Foundation Trust elections?

logoMy post for the Crick Centre blog, at the University of Sheffield (9 December 2014). I gave an overview of the innovative practices used at NHS Foundation Trust elections based on research for Health Election Data, and also considered the future of NHS democracy after expected changes to the FT model.

The first NHS Foundation Trusts were established just over ten years ago, in April 2004. The Foundation Trust model was designed to allow NHS hospitals and other services to become more autonomous in their finances and decision-making. This has proven a durable reform, with the number of trusts to have achieved Foundation status reaching around 150. The Coalition government set out an ambition for all trusts to become Foundation Trusts, although this aim is unlikely to be achieved before the next election.

There is one aspect of the Foundation Trust model, however, that arguably has not succeeded in the way envisaged ten years ago. Foundation Trusts are democratically accountable to their staff, patients and local communities, primarily through allowing people to become members of a trust and take part in decision-making process, and having members elect a Council of Governors to oversee the trust’s work.

Disappointingly, public participation levels in democratic processes have been low. Trusts typically attract only small numbers of people to become members. In 2013, a study of Governor elections showed that average turnout was around 20 per cent, and in half of all elections Governors were elected unopposed.

However, there is still much we can learn about democracy from examining Foundation Trust elections, which to date have largely been overlooked by the research community. These elections have been the source of a number of democratic innovations, as set out below. For instance, many trusts enable people aged under 18 to participate, use the Single Transferrable Vote electoral system and/or allow online voting. Foundation Trust elections are also remarkable for the relative absence of political parties and the high proportion of female candidates, compared to other types of election.

Party membership

A large majority of candidates for governor elections stand independently of any political parties. This seems to put Foundation Trusts in the same category as parish councils, as elected but largely non-partisan public bodies. Although unlike parish councils, Foundation Trusts spend huge amounts of public money, and deal with an issue, healthcare, that is consistently at the top of the public’s list of policy priorities.

Parties do not nominate official candidates for governor elections, but most trusts ask candidates to declare any party memberships. For these trusts, only 14% of candidates declare any party membership, while 86% do not. One question I considered in a recent analysis of 135 elections in 2013-14 was whether party membership has any impact on electoral chances. It doesn’t: party members were just as likely to be elected as a governor as non-party members (see Figure Two below)

Figure One: Party membership among Foundation Trust governor candidates, all and elected

party membership elected chart

Electoral system

Campaigners have long advocated the introduction of proportional representation (PR) for UK elections. The system favoured by the Electoral Reform Society is the Single Transferrable Vote (STV): this is used for the Northern Ireland Assembly and in Scottish local government, but in England the only types of election to use it are NHS Foundation Trusts.

Trusts are permitted to use either First Past the Post (FPTP) or STV for their governor elections, and STV is a very popular choice. Among elections conducted so far in 2014, about 59% were under STV, and 41% under FPTP. Although we might question the utility of a proportional system for mainly non-partisan elections, Foundation Trusts still provide a rich source of information about how the system operates. One important finding of my analysis is that female candidates are significantly more likely to be elected under STV than they are under FPTP in Foundation Trust elections (the role of gender in trust elections is discussed further below).

Votes at 16

While a great deal of fuss was made, rightly, over the extension of the franchise to 16 and 17 year olds for the Scottish independence referendum, few people seem to have realised that voters aged under 18 have been able to participate in Foundation Trusts for the past decade. The norm is that trusts allow anyone aged 16 to join, and therefore stand or vote in a governor election – for some trusts the age threshold for membership is even lower. To date no research has been done on the participation of young people in these elections, however.

Online voting

Like votes at 16, there is an ongoing debate in the democracy field about the introduction of online voting. This reform has already been used by several trusts including Lancashire Teaching Hospitals, with some encouraging results. Unfortunately, with a lack of data availability it is difficult to draw conclusions about success so far.


Women make up a sizeable proportion of the candidates for NHS Foundation Trust elections. While at general elections only around a quarter of candidates nominated by the major parties are female, for Foundation Trust elections 40% of all candidates are female. This is partly explained by the fact that many governors are elected from among NHS staff, the majority of whom are women (see Figure Three below). Excluding staff elections, women comprise a third of all candidates.

Women perform disproportionately well in NHS elections. While 40% of candidates are women, 42% of those elected (in contested elections) are women. Interestingly, this success is not driven by results in staff elections: female candidates are much more likely to be elected when standing for a public constituency, than they are when standing for a staff post.

Figure Two: Proportion of male and female candidates by constituency class, 2013-14

gender candidates by constituency class

The future of Foundation Trusts

The future of the Foundation Trust model looks secure, but this is not necessarily true of its democratic processes. The Government has commissioned Sir David Dalton, Chief Executive of the Salford Royal NHS Foundation Trust, to review the organisational forms for NHS services, and it seems the outcomes of this may challenge principles established in 2004.

In particular, the Dalton Review is considering how NHS trusts could compete to deliver services beyond their traditional geographical boundaries, and also how trusts could merge or enter federations with each other. The idea that Foundation Trusts will no longer be closely tied to a particular locality will mean the principle of their being accountable to a local community will seem much less relevant.

The relatively low participation of the public in NHS elections may justify this re-think of how their democratic processes work. Still, I would argue that reform must go in the direction of increasing links between local communities and their services, not decreasing them. Regardless of the outcome of the Dalton Review, however, Foundation Trusts have been a source of democratic experimentation over the past decade, and it is important we try to learn what we can about the results.