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EDITORIALS: Richard Q Lewis NHS foundation trusts BMJ 2005; 331: 59-60 [Full text]

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Can Foundation Trust Governors Really Govern?

Andrew G Craig, Colin Adamson   (11 July 2005)

Can Foundation Trust Governors Really Govern? 11 July 2005
Andrew G Craig, partner London SW12 8LG, Colin Adamson Send response to journal: Re: Can Foundation Trust Governors Really Govern?	Richard Lewis' editorial on the Healthcare Commission's survey of Foundation Trusts identified lack of clarity in the FT governor role as a potential weakness in new governance arrangements. We concur that governors may not be faring well in their challenging new governance roles, but research is scarce and at an early stage. We reviewed some recent published perspectives and suggest that governors' role coherence and effectiveness remain elusive objectives. This deficit must not be ignored. In January 2005, a Kings Fund “straw poll” reflected roles and effectiveness from some 60 elected governors representing 14 out of 20 1st wave Foundation Trusts (FTs) (1). A broader perspective on governor effectiveness comes from the Royal College of Nursing’s (RCN) survey of all 1st wave FTs (2). More in-depth findings come from the Moore Adamson Craig Partnership’s “beliefs and values” development programme for governors at two 1st wave FTs (3). They present a mixed picture. Straw poll found confusion The Kings Fund poll revealed majority confusion about roles and only minority confidence about effectiveness within FTs so far. Worryingly, some governors thought operational management was their job. Others chose “select committee member” or “community barometer” role descriptions. Future confidence was encouragingly high however.(1) If this small group is representative, there is a yawning gap to close before governors start making a difference in FTs’ public accountability. Making a difference? The RCN’s national FT survey found evidence in only 4 FTs that elected staff or public governors had made a difference to services (what “difference” actually means, however, is unclear). In the other 16 FTs the survey reported confusion over role and potential of Governors and Board members. It concluded: “governors must play a central role in establishing and maintaining the democracy in NHS Foundation Trust services and their role must be fully supported to enable them to do so. This will require investment and must form part of the review of “governance risk” in the Compliance Framework adopted by Monitor.”(2) It is positive that there are signs the NHS Confederation’s Foundation Trust Network and Monitor, the independent FT regulator, are picking up these warning signals. Consensus on beliefs and values The MAC Partnership’s governor development programme at two high profile 1st wave FTs revealed another dimension. As early as July 2004, Homerton University Hospital FT Governors were able to agree key beliefs and values as a “basis for the conduct of affairs in the interest of the hospital and its membership” and recommended it to the Board of Directors. This included “working closely together, widening the membership base and scrutinising the Board when necessary” (3). We believe that achieving early consensus on beliefs and values reduces role fragmentation risks and puts governors in a position to grapple with governance issues. The aims and objectives that evolve from these beliefs and values are still general and rather fuzzy. In a sense they must be. When we look back at the work done by the first Governors and FTs, we may well see that their job was to hold the ring and give some space and time while everyone worked out what was supposed to be happening. Outcome-based criteria of effectiveness – whether of service levels or clinical outcomes – cannot be applied to what governors are doing in this first year. A realistic definition of success in this new form of governance is, in our view, an “absence of failure”. And there is no evidence of overt governor failure. No melt-down Despite confusion about role and purpose, governor melt-down with mass resignations or a gradual falling away in attendance and interest has not happened. Before we all rush off to create the bright new future of the ‘effective’ governor, we should stop and say thank you and give some recognition to all those governors – elected staff and public members in particular – who have stayed the course They have dared to believe in their role and potential contribution. More than optimism needed Of course in future, FT governors will have to show they make a difference and will need more than belief to sustain them. Appointing and agreeing remuneration of future FT non-executives (up to £14K pa would be fair, with chairs getting £60K according to the Foundation Trust Network), to name but one task, is not for people unsure of their governance roles and relationships. Seen against escalating Board development and reward criteria, proportionality will demand training and realistic support – perhaps even remuneration - for Governors. A “new era for public accountability” has not yet arrived. The challenges are only too obvious: can governors add value? can they contribute, through seeking Members’ and community views, to the strategic planning process? will they own and drive the membership strategy? crucially, will they become “guardians” of the organisation? The research thus far shows that answers have to come from the governors themselves. In their search they are entitled to much enhanced levels of support from their FT Boards, their Membership, the FT Network and, of course, Monitor. Andrew Craig andrew@mooreadamsoncraig.co.uk Colin Adamson colin@mooreadamsoncraig.co.uk Moore Adamson Craig Partnership LLP, London References 1. Lewis R, Governing Foundation Trusts: a new era for public accountability. Kings Fund, London: May 2005 7pp www.kingsfund.org.uk/pdf/governingfoundationtrusts.pdf 2. Survey of First Wave NHS Foundation Trusts. RCN, London: April 2005 14pp www.rcn.org.uk/downloads/policy/FoundationTrustsReviewSurveyApril2005.doc 3. Brown P, Craig A. Laying the Foundations for Governors in Hackney MAC Partnership, London: November 2004. 5pp www.mooreadamsoncraig.co.uk/Articles/Laying_the_Foundations_for_Governors_in_Hackney.pdf Competing interests: Andrew Craig, Colin Adamson and MAC Partnership LLP consult with Foundation Trusts on development programmes for FT governors.