In good health? Membership of NHS foundation trusts

New figures reveal that there are over 2.2 million members of NHS foundation trusts in England. But what does it mean to be a member?

NHS foundation trusts were introduced in 2003 as organisations within the NHS structure, but which had a degree of control over operations and budgets. The Department of Health says they are “independent public benefit corporations modelled on co-operative and mutual traditions.

“Transferring ownership and accountability from Whitehall to the local community,” it adds, “means that NHS foundation trusts are able to tailor their services to best meet the needs of the local population and tackle health inequalities more effectively.”

As a move towards mutualising public services, the model received support from the coalition government. The influential 2010 NHS White Paper, Equity and Excellence: Liberating the NHS, states that it “will support all NHS trusts to become foundation trusts.”

New figures from Monitor, the government body that oversees foundation trusts, show that as of March, there were 147 trusts that together have 2.23 million members. This is an increase of two Trusts and 32,000 members since last year. Of the members in 2014, 136,000 are members of the public, 1.4 million are or have been patients, and the remaining 664,000 are NHS staff – the three categories of membership in NHS foundation trusts. 

With two million members, do NHS foundation trusts give patients, public and staff a say in how their hospital services are run, and are they learning about mutuality?

The foundation trust model primarily gives members the power to elect and stand for the council of governors, a strategic body which oversees a foundation trust by appointing and dismissing the chair and non-executive directors of the main board of directors, holding the non-executive directors to account for the performance of the board; shaping strategy; and representing the interests of the wider membership and the public.

Councils tend to have between 10 and 35 governors who sit for three years and represent the different constituencies of members – patients, public and staff. 

The Foundation Trust Network, the national membership body for trusts, says: “Members receive regular information about their foundation trust; they can also contribute their views about current services and future developments, and, critically, elect fellow members to become governors to represent them.”

To demonstrate how member involvement goes beyond governance, Claire O’Neill, governor development programme manager at the Foundation Trust Network, cites the example of Alder Hey Children’s NHS Foundation Trust in Liverpool, which used patients’ and community views in the design of a new hospital.

“A brand new Alder Hey in the Park, with a design inspired by children is underway and will open in 2015,” says Claire. “A hospital built entirely in a park is something new in the treatment and care of children. The trust listened carefully to children who shared their own vision for the new hospital and thousands of families took part in one of the NHS’ biggest ever public consultations.

“Once the new Alder Hey opens, a Children’s Board will take an active role in the hospital and make sure that young people are given a voice.”

However, in Ten Years On, a 2013 report on NHS foundation trusts, 

Co-operatives UK’s Ed Mayo – who was personally involved in establishing the foundation trust model a decade ago – expresses disappointment in the way their democracy has developed.

“Given the way in which patient focus, service quality and health development have moved into the mainstream discourse of health policy, we might expect such examples to have informed the development of NHS practice. If anything, the opposite is true. Although there are some models of good practice, most notably amongst mental health providers, the overall field of foundation trusts has widened but it has not deepened in terms of democratic practice and participation.”

There are no up-to-date figures on member engagement or turnouts in governor elections, though a 2011 report to government stated  “governor election turnout rates have reduced from 48% on average across all constituency types in 2004, to 25% in 2010”. It says these may “have reflected smaller membership numbers and initial enthusiasm for a new membership model and type of trust.”

The report also questioned trusts on how active their members were, reporting that “on average 10% of staff, 14% of public and 16% of patient members are described by trusts as ‘active’, representing approximately 1,800 members on average being regarded as being actively involved in each trust.”

There are indications that election turnouts may have dropped further, however. The largest foundation trust by membership in England is the Heart of England Foundation Trust in Birmingham and surrounding areas. It has a membership strategy of maintaining 100,000 members and currently has 105,921 members. 95,533 are members of the public; the remaining 10,388 are staff.

Members are able to stand for the 34 strong council of governors and, beyond this, the Trust offers three levels of member involvement, ranging from “periodic newsletters” to a “high level of engagement, including newsletters and seminars.”

All of its nine wards were contested in the last election, although the average turnout was 11%, indicating a relatively limited connection between the governors and the wider membership.

A similar pattern is replicated at one the smallest foundation trusts by membership, the Birmingham Women’s NHS Foundation Trust. It has 5,593 members – 570 are patients, 3,383 from the wider public and 1,640 are staff.

Like Heart of England, it offers three levels of member involvement and has relatively limited engagement in elections: the 2013 elections to the 12 seats on Council of Governors required no ballot because the candidates for each seat were uncontested; the previous year’s election were contested with an average turnout of 16% turnout.

While figures show that membership of foundation trusts is high and there is democratic engagement, it is less clear that the wider membership is engaged in how trusts are run.