Promised NHS democracy in foundation hospitals yet to materialise fully

The government's promise that foundation hospitals will be more accountable to local communities has yet to be delivered as elected governors remain unclear about their role and how best to represent patients, staff and the public.

That is the finding of a King's Fund investigation, Putting Health in Local Hands: Early experiences of Homerton University Hospital NHS Foundation Trust, published today, into the governance arrangements at Homerton University Hospital - one of the first foundation hospitals to go live in April 2004. The report says that, despite the efforts of managers and governors, there remains confusion over the new system with governors struggling to identify a clear role and some expressing frustration that they have so far exerted little or no influence in the year since the start of the flagship health reform.

Many of the governors interviewed had found it difficult to establish links with patients, staff and the public, although they were optimistic that their influence would grow as the arrangements bedded down. The report found no convincing evidence of governors securing better services for members.

Report author Richard Lewis said:

'The government claimed that foundation hospitals would be the voice of local communities, giving people a say in the running of their hospital. The hospital and the governors at the Homerton have worked hard to increase community engagement but after a year, the reality was that elected governors were struggling to get to grips with the new arrangements. This mirrors the situation nationally where there is much ambiguity over the roles and rights of governors. Are the governors, as representatives of staff and the community at large, to set the overall direction of the hospital, or is this the job of the Board? If governors have little real influence it will be hard to claim that foundation trusts represent a leap forward in public accountability.

'The experience of Homerton Hospital shows that foundation trust status can galvanise local communities to become more involved in their hospitals. More than 300 members attended the trust's annual meeting, compared to only a handful before foundation trust status. However, community 'ownership' of hospitals – a key government aim of foundation trust policy – has been harder to achieve. Indeed, the potential for conflict between the rigours of new NHS market disciplines and the structured engagement of communities is a fault-line in current policy. If the governance of foundation hospitals is to evolve successfully, a clearer national vision of what it means for a hospital to be community-owned or indeed the extent to which that is a practical objective is urgently needed.'

There was more positive news regarding the reaction of hospital directors to the new arrangements. Many felt that foundation trust status and the existence of members and governors had introduced more public accountability to the hospital and had made it more responsive to the local community. However, most directors were doubtful that this would lead to a significant shift in decision-making power to members.

The King's Fund chief executive Niall Dickson said:

'Although these are early days and this is only a single case study there are indications it may be reflected elsewhere. We believe that governors are struggling to make the new system work. There was little clarity in government when the system was set up and that now seems to be reflected in practice. It is difficult for individuals to represent local communities in this kind of arrangement and we believe that governors are struggling to make the new system work.'

This investigation followed evidence from a national workshop organised by The King's Fund earlier this year, which brought together governors from 14 of the 20 'first wave' foundation trusts to gauge their views on the new governance arrangements. The workshop revealed that less than half of governors had a clear understanding of their role and less than a third felt they had made a difference. However, 70 per cent felt confident that they would be able to make a difference in the future.

Read the report: Putting Health in Local Hands: Early experiences of Homerton University Hospital NHS Foundation Trust

Notes to editors: 

  1. For further information or interviews, please contact the King’s Fund media and public relations office on 020 7307 2585, 020 7307 2632, 020 7307 2581, or 07831 554927 or 07774 218439.
  2. Putting Health in Local Hands: Early experiences of Homerton University Hospital NHS Foundation Trust is free to download.
  3. The King’s Fund is an independent charitable foundation working for better health, especially in London. We carry out research, policy analysis and development activities, working on our own, in partnerships, and through funding. We are a major resource to people working in health, offering leadership development programmes; seminars and workshops; publications; information and library services; and conference and meeting facilities.