Health Board Elections and Alternative Pilots: Literature Review

1 EXECUTIVE SUMMARY

1.1 The Health Boards (Membership and Elections) (Scotland) Act 2009 introduced pilots of direct elections to two Scottish Health Boards. As part of the evaluation of the pilots, this literature review was undertaken to gather evidence on a range of options used internationally to enhance public representation on Health Boards. In Scotland, the pilot elections are the latest in a series of measures which 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 support engagement with the public. Since 2007, as part of the agenda for a mutual NHS set out in Better Health, Better Care (The Scottish Government, 2007), the Government has introduced the Participation Standard to improve the collection of information on good practice and promote it, and increased opportunities for members of the public to ask questions at their Board's Annual Review event.

1.2 This literature review presents research evidence on methods of improving public representation on Health Boards: direct elections, alternative modes of appointment, and advisory committees. While there is a substantial literature on these topics, it does not necessarily offer evidence neatly packaged to inform policy-making. As others have acknowledged (Barnett & Clayden, 2007), the primary research on Board elections mostly focuses on the views of Board members and so it is difficult to identify wider impacts. This reflects a broader preoccupation in the literature with accounts of process rather than assessments of outcomes (Mitton, Smith, Peacock, Evoy, & Abelson, 2009). Even where research looks at outcomes, the absence of objective measures of community engagement, and the problems with attributing outcomes to specific initiatives, mean that conclusions are rarely as clear as we might like (S. J. Lewis et al., 2001).

1.3 The most directly comparable examples of direct elections to health bodies are some Canadian Regional Health Authorities (RHAs), New Zealand District Health Boards (DHBs), and Foundation Trusts in England. Evidence from these systems suggests that elections are not in themselves sufficient to ensure a high quality or quantity of public involvement.

• Low electoral turnout was a challenge for both Foundation Trusts and Canadian RHAs, although turnout has been higher for DHBs in New Zealand.
• Some Canadian provinces also had insufficient numbers of candidates, while in New Zealand candidate numbers have fallen but remained viable. There is some concern that candidate numbers for Foundation Trusts are on a downward trend.
• Elections do not guarantee a more descriptively representative group of Board members. In New Zealand, the continued appointment of a minority of Board members is intended in part to ensure adequate representation of minorities.

However, fears that elected Boards will harm health services due to a lack of experience or to 'political interference' do not appear to have been realised.

• Many voters seem to value health service experience more than finance or management skills when choosing candidates. Accordingly many elected Board members have a steep learning curve around financial and management issues.
• The role of Board Chairs in supporting learning has been found to be of critical importance in each case.
• Once in place, elected Board members have similar views to appointed Boards. There was no clear evidence that fears about the politicisation of Boards were realised in the three examples discussed.
• The more public role of elected Board members can raise expectations about the degree of influence they have. Boards often focus mainly on day-to-day management, with strategic policy-making remaining with central or provincial Government. In both New Zealand and Canada elected members were frustrated by these limitations on their influence.

Where elections have been tried and then abandoned, as in Saskatchewan, it has generally been justified by reference to low turnout and financial cost, rather than to evidence of problems with Board functioning.

1.4 One alternative to elections is to alter how Board members are recruited and appointed. There is a lack of research evidence on these techniques, but models which have been used include:

• Quotas (Quebec hospital boards in the 1970s, New Zealand District Health Boards) or targets (Primary Care Trust Boards in England) for the representation of particular groups on Boards.
• Rethinking advertising campaigns and supporting 'near hit' candidates to reapply (Primary Care Trust Boards in England)

1.5 There are many examples of advisory bodies in the UK and in Canada, including Scotland's current system of Public Partnership Forums. These are more thoroughly researched, particularly in the UK. Some themes from the literature include:

• Advisory bodies are sometimes criticised for being weak, as by definition they don't have direct decision-making control. It can be difficult to evaluate their level of influence.
• As with appointed Boards, questions of representation arise repeatedly with advisory bodies. People with the confidence and time to take part are often older, and more middle class. Ethnic minorities and young people are often under-represented. Models of 'drop-in drop-out' participation such as LINks in the English NHS are seen as a solution to this, but have other drawbacks.

1.6 International experience shows that neither elected nor advisory bodies can resolve all of the challenges of patient and public involvement; problems of low or intermittent engagement, questions about representativeness, and the cost-effectiveness of any given strategy are common and do not seem to have any one solution.