Foundation trust governors: the promise of local accountability?

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Ten years on from the introduction of the governor role, and five years since The King's Fund’s review of foundation trust (FT) governors warned of the opening of an ‘accountability gap’, our conversations with governors suggest they are still not fulfilling their potential as the voice of local populations on hospital boards. Not through a lack of will, but rather through a lack of clarity and support.

This is the feeling lead FT governors on the first cohort of The King’s Fund's FT governor leadership programme expressed about their role as representatives of members and the public.

That is not to say that foundation trusts are not engaging members, nor that governors are not fulfilling other parts of their role. Monitor's 2011 report of FT activity in this area shows that many FTs are doing well to recruit members – by 31 March 2011 the combined membership of foundation trusts was approximately 1.9 million, up from 1.76 million at 31 March 2010 – and some are engaging their members through activities like open days, tours and workshops. Some governors, individually and as boards, are making an impact using their powers to hold to account, to appoint to the trust board and to provide some challenge and scrutiny.

But doing something isn't the same as doing the role you have been elected to fulfil. Nearly all the trusts surveyed by Monitor (98 per cent) stated that their engagement with members comes through governors, and 67 per cent rated this as effective. Yet the governors we spoke to told us they are seeking member views only sporadically, or not at all. Barriers stated were lack of financial, administrative and strategic support from trusts. The principal enablers were chair and trust secretaries who support governors to reach out to members and communities and feed those views back to the board.

This situation isn’t easy for FT chairs either. The increased emphasis on the governor role comes in the context of increased pressure on hospital boards to do better, in the wake of the Francis, Keogh and Berwick reports. But recommendations from Keogh and others to involve governors more came with little guidance on how far and in what ways. In this state of strained ambiguity, it’s difficult for both boards and governors to find a common definition of their role and how to do it.

But it is worth trying. Given the scale of financial and service pressures in the NHS and the drive to make major changes to the configuration of hospital services across England, some of the new powers introduced by the Health and Social Care Act may push the representative role of governors into the spotlight. For example, the agreement of a majority of governors is needed by the trust to approve all significant transactions, including mergers, acquisitions and ‘disposal’ of services. In this context, their potential power as a link to the local public is considerable and should be grasped as an opportunity rather than a threat. As boards seek ways to ensure a consistent focus on the interests of patients, staff and the public, governors could be critical to FTs delivering against that elusive but much-stated aim of 'patient-centred care'.

There are costs of course. It takes time and investment to support governor outreach and engagement. Creating real dialogue about the impact service changes will have for members and the public requires mature conversations and transparency which can feel risky for boards. Good governance requires the development of relationships built on trust.

The promise of governors as the link to local accountability is a good one. They could be an invaluable critical friend to trusts and chairs: speaking with the voice of the people and helping trusts and chairs speak back. To access that voice, governors need support: training and a strategy for how to engage with members and how to feed views back; links to local advocacy groups; financial and practical support to implement engagement; and a willingness in the boardroom to make changes as a result of feedback. Without a voice for governors that truly speaks for members and the public, the promise of local accountability for hospitals remains just that.


R Scott

Company Secretary,
Acute FT
Comment date
14 November 2013
re: your suggestion that 'governors suggest they are still not fulfilling their potential as the voice of local populations on hospital boards' I would say this is not true in all cases. Last year we had over 4,600 paper responses (we have 13,000 members with 700 of these on e-mail) to our membership survey which governors read from their respective constituencies becasue we collect the first part of a postcode (no other personal details are collected). Governors then feed their constituency views (one governor nominated from three public constituencuies) back to a Board-to-Council meeting in March each year before the business plans / annual plans are finalised. Add this feedback to over x hundred inpatient and outpatient survey responses, over 400 staff surveys, over 100 real-time surveys every month on the the wards plus the latest friends and family test and you've pretty much exahusted the wider general public's voice in respect of their views which governors can tap into. Governors have access to all the above and receive presentations on the results if not reviewing themselves. The latest collection of voices is by the local CCG running numerous events around the patch of which of course our governors will be patients, members of the public and governors.

Harry Wood

Comment date
12 November 2013
Governors are limited in what they can do as they have no budget for engaging with FT members independently of the Trust. Trusts organise all the formal meetings, send out all the mass communications, newsletters etc, manage social media. They don't have access to the FT membership list. So they are handicapped. There are tools such as Patient Opinion that could help engage with members, but how many trusts would pay the subscription fee of £10,000/year? How many trusts even invest in online group management systems (eg Yammer) so governors can communicate effectively with each other?

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