Health Board Elections and Alternative Pilots: Final Report of the Statutory Evaluation

1 Introduction

1.1 Scotland has enjoyed the benefits of a National Health Service (NHS) since 1948. Throughout its existence the delegation of powers to geographically-defined boards has been a key feature of its management arrangements. The exact number and function of these local entities has varied, with hospital and community services being run separately at times. However, by and large the Scottish NHS has been characterised by stability, integration and an adherence to the founding principles of the NHS. In recent years this adherence has included a reemphasis of the concept of mutuality. Long-standing debates have continued around a number of issues. For example, there has been debate about how to balance a desire for local autonomy with the need to support rational regional planning. Governance arrangements have also come under scrutiny. Again, balance is a key issue with national imperatives and delegated managerial autonomy needing to be tempered with local community engagement and accountability. Central to achieving this balance is the way in which non-executive directors are selected/elected to boards.

1.2 Until the 1990s, appointments to boards tended to be in the gift of the UK government of the day. From 1995, the Nolan Commission reported on standards in public life, in the first of a series of reports that would enunciate clear principles for public sector activity and transform public sector practices, including the selection of board members^[1]. Nolan principles and practices meant that nonexecutive directors had to be, among other things, selected on merit by panels with a substantial independent element (although ministers retained the ultimate power of appointment). Government and the public sector invested in formal appointment mechanisms designed to produce this independently validated, merit-based selection, including the Public Appointments Commissioner for Scotland and reformed mechanisms within boards for identifying merit and advertising board positions. In Scotland, 'unified boards of governance' for NHS services were created in 2000, but it was with the 2004 dissolution of NHS Trusts and Primary Care Trusts that the current structure of unified territorial Boards emerged. The current 14 territorial Boards have responsibility for the planning and delivery of almost all health care in their geographical areas, including public health. Whilst the 2000 and 2004 changes returned NHS Scotland more closely to its traditional organisational arrangements, it did not address what some perceived as the "democratic deficit" inherent in appointed governmental bodies. The rest of this chapter describes the introduction of electoral and alternative pilots as a means of seeking to address issues of engagement and accountability.

1.3 By 2010, the board of directors in each Health Board was made up of

• Between five and nine non-executive lay members: appointed by the Cabinet Secretary for Health & Wellbeing in a process overseen by Office of the Commissioner for Public Appointments in Scotland (OCPAS)
• Non-executive stakeholder members: including a senior Councillor from each of the local authorities in the Board area; an Employee Director; the Chair of the Area Clinical Forum; and a University Medical School member (in the main teaching Health Boards)
• Executive members: senior managers within the Health Board.

1.4 The Health Boards (Membership and Elections) (Scotland) Act 2009^[2] was introduced by the Scottish Government with the stated objective of improving public confidence in the health system. Prior to the 2007-11 Parliamentary session the Scottish National Party manifesto had contained a commitment to "Introduce direct elections to health boards" so that "at least half of health board members will be elected by the public."

1.5 This commitment was made against the backdrop of a number of high profile campaigns against NHS service reconfigurations.

1.6 The Christie Commission has suggested that enhancing public engagement and accountability should be a priority for Scotland's public services^[3]. The legislation that enabled these pilots makes direct reference to both.

1.7 The Health Boards (Membership and Elections) (Scotland) Act 2009 follows several other measures that have aimed to increase public involvement and accountability in NHS decision making. Measures introduced by previous administrations include a statutory duty for Boards to involve the public in decision-making, encouraging Boards to establish Public Partnership Forums, the inclusion of representatives of Local Councils on Boards, and establishing the Scottish Health Council to promote greater public involvement in the NHS and support NHS Boards in improving their patient and public participation. Since 2007, as part of the agenda for a mutual NHS, the Government has introduced its NHS Quality Strategy, which has a "person-centred" ambition, the Participation Standard against which Boards self-assess how well they are doing in meeting its three specific elements and increased opportunities for members of the public to ask questions at their Board's Annual Review event.

1.8 The Health Boards (Membership and Elections) (Scotland) Act introduced direct elections to the Health Boards. It did so by allowing the Scottish Government to pilot direct elections to two of the territorial Health Boards, namely NHS Dumfries and Galloway and NHS Fife. The Act and supporting regulations required that

• Direct elections be held for new Non-Executive Directors
• These new members, together with Councillors nominated by Local Authorities and appointed by Ministers, form the majority of the members on each Health Board.
• All voting in the elections be postal
• The elections use the Single Transferable Vote system and the whole of each Health Board area form a single electoral ward
• The franchise be extended to include 16 and 17 year olds in the pilot areas
• Candidates' campaign spending was limited to £250 each

1.9 In effect, these rules meant that NHS Dumfries and Galloway needed ten new elected members while NHS Fife needed twelve. The appointment of the Chair of each Health Board would continue to be a Ministerial one following the standard public appointment process. The Health Boards would remain accountable to Ministers and be required to comply with regulations and Ministerial directions.

1.10 Notices of election were to be published between the 15^th and 22^nd of April 2010. Members of the public were then able to put themselves forward as candidates for election until the 6^th of May 2010. Candidates needed to live or work in the Board area, and a few senior NHS Executives and staff working closely with the Board were not able to seek election, but otherwise the eligibility criteria were similar to those for candidates for election to the Scottish Parliament or Local Councils. Between the 8^th and 13^th of May, Returning Officers in the pilot areas issued voting packs to eligible electors. The packs contained their ballot paper plus a booklet of 250-word candidate statements from each person seeking election. The poll closed at 4pm on 10 June 2010.

1.11 During the passage of the bill, Scottish Ministers also agreed to two alternative pilot schemes. These were to attempt to enhance the existing public appointment processes and increase the diversity of candidates applying to become members of Health Boards without direct elections. The alternative pilots were assigned to NHS Grampian and NHS Lothian. These Boards were each given two new Non-Executive Director posts, and the number of Executive Directors who were formal members of the Board was to be reduced. The Boards were to be allowed to innovate in the recruitment of applicants for these new non-executive positions, but the selection process was to follow Office of the Commissioner for Public Appointments in Scotland (OCPAS) guidelines.

1.12 The Act stipulates that the pilots must be evaluated, and a report on the evaluation laid before Parliament, before any decisions can be taken on whether any of the pilots will be rolled out across Scotland. The evaluation was commissioned by the Scottish Government in January 2010 and undertaken by a consortium which included London School of Economics Enterprises and the University of St Andrews. This report summarises the evaluation methods and results.

The report starts with a methods section (chapter 2) in which we lay out how we have responded to each of the aims of this statutory evaluation. In chapter 3 we explore how the elected and alternative pilots worked in practice. Starting with the elected pilots we cover the demographics of candidates and those elected, review data on turnout rates including comparing it to general election rates. We also here detail the processes involved in the alternative pilots. Chapter 4 explores the costs of these pilot schemes and seeks to extrapolate to a national level should the parliament decide to proceed with their more widespread introduction. Chapter 5 explores the impact that these pilots have had on the functioning of NHS boards. In chapter 6 we present suggestions for improving the pilots should they be rolled out and in chapter 7 we conclude by looking at the relative advantages and disadvantages of each approach.