NHS Foundation Trusts: 10 years on
Ed Mayo, Secretary General of Co-operatives UK
There are over two million members of NHS Foundation Trusts. They ought to be a bedrock on which a participatory NHS can be built – after all medical professionals are expert on medical treatment, but patients are expert on what care and dignity feels like when receiving that treatment. It is ten years ago that the Act creating Foundation Trusts came into force. I was involved at the time, advising on the framework for this model of participation and have now put together a short report, Ten Years After, reflecting on progress over that time.
In reality, the role of membership in Foundation Trusts, as they have widened, has become more token. Decisions that could be taken by the membership, such as approving changes to the constitution, are the preserve of governors. Stewardship in trusts is predominantly the responsibility of the governors. Beyond elections there appears to be little scope for grassroots membership to influence governors and hold them to account. These problems have been exacerbated by the Health and Social Care Act, which required certain decisions to be authorised by governors rather than members. For instance, the act requires changes to the constitution to be approved by the governors (and directors). Previously trusts could choose for constitutional changes to be approved by their members.
Of the three core features of cooperative membership – information, voice and representation – members of a foundation trust have representation, but patchy information and no voice. This either leads to an ownership deficit, or the feeling that the governors are somehow the members. There are some exceptions, not least in the mental health field, just as there are exceptional health mutuals outside of the NHS. Benenden Healthcare, for example, has a membership of 900,000, organised in branches, and with a highly democratic structure. It has been voted the UK’s most trusted healthcare provider for three years running. But Benenden exemplifies not just satisfaction but also responsibility. The claim rate on services is significantly lower than for private health insurers because, rather than seeing it as an individual consumer transaction, Benenden members are aware that they are drawing on support that is pooled and to be shared equitably for all members according to need.
Worldwide, 300 million people are covered by health coops and mutuals. Membership is something which all mutuals have to focus on and I set out some practical recommendations which could help to restore some of the more active role for members that was core to the original vision.
- Ensure that members have a voice in ownership and governance arrangements, and, create the opportunity for more proactive engagement with members and communities.
- Develop practices at the grass-roots level to reinforce communication between members and governors, including access to elected governors, some right of approach and dialogue, and, the ability to require feedback and updates. This will help to ensure that governors are accountable and will compel them to engage with members and the local community.
- Review whether members should be included in the decisions currently under the control of governors.
- Insist that governors have dialogue with members on the issues upon which the Health and Social Care Act now requires them to decide, and, possibly other issues such as executive pay and patient safety too.
- Require Foundation Trusts to publish clear forward plans to members so that people know what is coming up.
- Through relevant regulatory and inspection frameworks, encourage Foundation Trusts to engage with their local communities via the AGM and other member or public events on decisions that their governors are likely to have to make in the future. When Governors do have to make a decision, they should do so as representatives of their community who are responding to their communities’ wishes, rather than on their own gut-response.
- Take other steps to create a greater sense of ownership. These could include consideration of measures such as the requirement for two-way dialogue, responsibility around health promotion, and, escalated complaints and feedback, as well as closer connections around membership with the operations of HealthWatch.
- Engage employees more systematically as members, for example through its own constituency, following the examples such as Italian social co-operatives and UK parallels such as Rochdale Borough-Wide Housing.
There is far more to do and that can be done to create a health service based on genuine partnership and mutuality between the professionals and the public.