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Local control over foundation trusts is “rhetoric”

BMJ 2005; 330 doi: http://dx.doi.org/10.1136/bmj.330.7505.1408-d (Published 16 June 2005) Cite this as: BMJ 2005;330:1408
  1. Madeleine Brettingham
  1. London

    Primary care trusts are running elections that would be considered “disgraceful” if they took place in local government, a study funded by the Nuffield Trust has said. The report, written by Patricia Day, a senior research fellow, and Rudolf Klein, emeritus professor, at Bath University's Centre for the Analysis of Social Policy, casts doubt on the government's claim that foundation trusts hand power to local people and represent “a new form of social ownership.”

    The six month study examined government discussions before the policy was unveiled in December 2002. As well as information made available by the trusts themselves, the researchers found unsettling evidence of “governors not governing … and organisations which can hardly be said to be 'owned' by local people.” It says: “Political rhetoric needs to be tested against reality…in what respect, and how, are boards accountable to local people?”

    The writers argue that governing boards are unrepresentative and excluded from the management process. High level decisions are taken by trust chairs and chief executives, who are unelected and unaccountable to the local population.

    The report shows that in most instances the boards of governors—the elected bodies established to oversee the running of trusts and to ensure their accountability to local people—are voted in by an electorate comprising only a few thousand members or less. In one case a governor was elected by only 95 votes.

    Also, “accountability still runs upwards rather than downwards,” with management boards—the bodies effectively responsible for the running and financial affairs of the services—being held accountable to the watchdog, Monitor. The elected governors, meanwhile, are effectively neutered.

    Examination of meeting minutes found that governors were left to immerse themselves in details such as car parking while being deprived of the real strategic responsibility that they were supposed to hold.

    The report was also sceptical of the purported “representativeness” of the boards of governors. Local people are generally required to “opt in,” to take part in trust elections, and the study found that those who did so were generally white men and most were elderly. In one case, more than half the people voting in trust elections were older than 65. Although the writers admitted that there might be benefit in having a “small committed electorate,” with contacts and experience, their data undermined government claims that trusts represented the population at large.

    Dr Day and Professor Klein call for more monitoring of trust governance, and the requirement that individual trusts make the composition of their governing bodies public. They also say that trusts should be set targets for increasing their voting members, possibly combining with local elections to boost participation.

    “It is too early to say what the effects of foundation trusts will be, and I certainly do not believe they are a step towards privatisation,” said Dr Day. “But if the government is going to hand over power they need to make sure there is a system of accountability in place. So far Monitor have concentrated on financial affairs. Now they need to turn their attention to governance.”

    Governance of Foundation Trusts is available from the Nuffield Trust, 59 New Cavendish Street, London W1G 7LP, price £5