National Health Service foundation trusts (FTs) were brought in to allow a degree of autonomy from centralised Whitehall control, along with a degree of local governance, modelled on traditions of co-operatives and mutuals. FTs are still part of the NHS, but differ from standard NHS trusts in that they have their own local governance via a Board of Governors and Board of Directors (“Trust Board”). The majority of the Board of Governors is elected by local public, staff, and optional patient/carer, constituencies. A minority are appointed from local “stakeholders”.
It is the local governance that research at the University of Southampton investigated. We looked at how democratic NHS FTs are. Interview and questionnaire responses, from individuals selected from politically engaged groups, were assessed against an analytical framework of democracy. Overall, comparing positive evidence against negative evidence, respondents felt that democracy was lacking in FTs. Also lacking were important aspects of democracy from our analytical framework: accountability, popular control, inclusion, legitimacy and considered judgement. There was insufficient evidence to be conclusive about the democratic criteria of transparency and efficiency. Assessment of local involvement and autonomy was positive and generated significant support for FTs.
Our research indicates an encouraging consensus for local involvement and autonomy in FTs in theory, but the practical implementation of FTs has not met theoretical expectations. This evidence is backed up by the theoretical literature on democracy in co-operatives and mutuals, and by predictions made by health commentators such as Day and Klein1 when FTs were new.
One lesson for policy is that there is no doubt good democratic practice occurring in some FTs, as shown by a 2008 Department of Health study2, but that it is somewhat “left to luck”. There are better FTs than others in terms of democratic practice. For example, democratic accountability and inclusion suffers because there is no way to contact individual governors outside of carefully-managed meetings, than to go through the “Governor Co-ordinator”. We have worrying evidence this is an anti-democratic filter, blocking public access to governors (it blocked our access in some FTs!). Further, the governors’ statutory powers are very limited and there is clear evidence even these powers are not frequently exercised or even known by the governors. According to Ipsos MORI in their survey of governors, around a half of all governors had not practiced any of their statutory powers, and very few of them felt they had achieved anything as governors3. And from ours and other research, the policy and parliamentary process did not allow FTs to be properly democratic, whether by design or accident.
Recently, in an interview on mutualism in public services4, Tessa Jowell stated that good governance cannot be “prescribed”. I disagree. Using some variant of our analytical framework of democracy, together with the research methodology employed in our research, is a viable way of assessing each FT’s democratic credentials. Those FTs that are not democratic enough should have their authorisation removed by Monitor, the independent regulator of NHS foundation trusts. The same could apply for mutuals in public services. This answers the question of how much regulation is appropriate, as mentioned by Alex Smith in the interview, and never fully answered by the late Paul Hirst5 in his theory of “Associative Democracy”.
Another lesson for policy is that, in the same interview, Ms Jowell stated that it was “patronising” to say that only the “middle classes” get involved when given the opportunity of democracy. Whilst there may be exceptions, the academic and empirical evidence in FTs, including that described above, is that “capture” by the middle classes is overwhelmingly the case. Here in Southampton, health priorities have been decided by the outstanding pilot schemes of participatory budgeting in areas of deprivation6. But outreach work has had to be done to ensure inclusion. Just as it is so in access to welfare, so it is with democracy. Of course, outreach work costs time and money. But that is the cost of inclusive democracy.
Co-ops and mutuals are not a panacea – as Tony Benn’s “phoenix” co-ops of the 1970s proved in their “well-intentioned” failure7. They have to be financially, socially and democratically viable. The hype needs a sobering dose of reality. Lessons can be learnt from the literature, from the empirical research and from studying healthcare before the NHS existed, when health mutuals were more prevalent. Important lessons for future policy and research follow. So called ‘Red Tory’ Phillip Blond8 seems to largely, if not totally, ignore all of these lessons, particularly the illustrious history of the Co-operative movement. There appears to be a consensus from the left, including the Fabians’ Sunder Katwala9 that “the conservative co-operative movement” is a sham.
Labour must not make these mistakes. Otherwise, mutualism in public services will be another failed experiment that damages the NHS, public services in general and Labour’s electoral chances.
1 Day, P., Klein, R. (2005) “Governance of Foundation Trusts: Dilemmas of Diversity”, The Nuffield Trust, London
2 Ham, C., Hunt, P. (2008), “Membership Governance in NHS Foundation Trusts: A Review for the Department of Health”, Department of Health, University of Birmingham, Mutuo, March 2008
3 Webb, C., Britton, M., Durkacz, S. (2008), “Survey of Foundation Trust Governors”, Ipsos MORI Social Research Institute, June 2008
4 LabourList, “”Mutualism is the next stage of New Labour”: The Tessa Jowell interview”, 16th Dec 2009, http://www.labourlist.org/mutualism-next-stage-new-labour-tessa-jowell-interview , accessed on 14th Feb 2010
5 Hirst, P. (1994), “Associative Democracy: New Forms of Economic and Social Governance”, Polity: Cambridge
6 Participatory Budgeting Unit, “Your Community, Your Health, Your Voice “, June 2008, http://www.participatorybudgeting.org.uk/case-studies/your-community-your-health-your-voice , accessed on 14th Feb 2010
7 Rosen, G. (2007), “Serving the People: A Co-operative Party History from Fred Perry to Gordon Brown”, Co-operative Party: London
8 Blond, P. (2009), “The Ownership State: Restoring excellence, innovation and ethos to the public services”, ResPublica and NESTA: London
9 Next Left, “Whose mutualism is it anyway?”, 15 Dec 2009, http://www.nextleft.org/2009/12/whose-mutualism-is-it-anyway.html , accessed on 14th Feb 2010