Evaluation of the Health Board Elections and Alternative Pilots - Research Findings

This report describes the statutory evaluation of the NHS Scotland health board electoral and alternative pilot projects arising from the Health Boards (Membership and Elections) (Scotland) Act 2009. The Act follows several other measures in Scotland which have aimed to increase public involvement and accountability in NHS decision making.

Evaluation of the Health Board Elections and Alternative Pilots

Main Findings

  • This evaluation shows that it is possible to successfully hold direct elections for NHS health boards. Members of the public are prepared to stand in considerable number.
  • In general, those who stood showed similar characteristics to those who were appointed under the existing system; they are middle aged or above, mainly male, white and professional. However amongst those elected, approximate gender balance was achieved. In some cases, candidates' motivations for standing were very different from the motivations described by non-executives who had come through the conventional appointments route. Specifically, a number of candidates, including some who were successful, stood on electoral platforms that were clearly driven by contentious local issues, for example, planned hospital closure or transfer of services. Most elected board members were not strongly political (including some with long experience in politics) and acted in ways that were similar to appointed non-executive directors.
  • Electoral turnout was low. 16 and 17 year olds had notably lower turnout than voters aged 18 or over and only one ran for office. Focus groups suggest that this group felt uninformed about both the role of health boards, and about their ability to stand for election and vote. Given that efforts were made to inform them, this suggests the difficulty of reaching out to younger voters.
  • Candidate profiles and election subsequently impacted the way board business was conducted. In one of the elected Boards, votes on issues became more common. Members were more likely to ask for their specific and sometimes dissenting contribution to be specifically recorded in the minutes. Dissenting opinions were more likely than previously to find their way into the press. Managing the arrival of large numbers of new members, often with little background in finance or management, was a major part of the workload of executive directors and, in particular, Chairs.
  • The costs of mounting the elections for the two boards totalled £773,256. For a number of reasons, it is not easy to accurately predict the cost of holding elections on a national basis, but a reasonable minimum estimate would lie in the range of £11m to £12m. Again the cost of rolling out the alternative pilots would be much smaller, about £224,000 per year, and £112,000 per appointment round, at 2010 prices.
  • Alternative pilots that sought to broaden recruitment methods without changing the selection procedure did expand the range of applicants beyond those who apply for appointment under the existing system. The effects of the new board members were much smaller, primarily because they added two people each to large and well-established boards.
  • An international literature review suggests that the Scottish experience is not unusual; New Zealand, some Canadian provinces, and English Foundation Trusts all had relatively low turnout but did not experience predicted problems with politicization and division.


This research evaluated four pilots of mechanisms for selecting members of the Health Boards that provide health services in Scotland. Parliament's declared legislative intent in passing the Health Boards (Membership and Elections) (Scotland) Act 2009 was to increase local accountability and to address a perceived democratic deficit in wholly appointed Health Boards. Two NHS boards, Dumfries and Galloway and Fife held elections for 10 and 12 members respectively. Two other boards, Grampian and Lothian, explored alternative ways of recruiting and selecting two new appointed members each. The elections were held in May-June 2010 and, notably, extended the suffrage to 16-17 year olds. The alternative pilots in Grampian and Lothian were running and had selected members slightly later in 2010.


The research set out to identify the advantages and disadvantages of the four pilots relative to the existing method of appointing non-executive directors to health boards. This involved understanding what took place during the selections (elections and alternative appointment mechanisms) and the effect of those changes on the subsequent operation and public engagement of the boards.


The methods were designed to produce relevant data on both selection and the subsequent functioning of boards. The research on selection included:

  • a survey of voters in Fife and Dumfries and Galloway;
  • interviews with candidates for election in Fife and Dumfries and Galloway;
  • comparison of the focus groups with
    16-17 year olds to identify reasons for their electoral participation rates
  • interviews with returning officers about election process, as well as comparison interviews with other election administrators in Scotland
  • interviews with stakeholder groups involved in the elections
  • interviews with successful applicants in Grampian and Lothian and those involved in the selection process.

The research on board functioning included:

  • interviews with executive and non-executive directors before and after the start of pilots, repeated multiple times with some key informants;
  • interviews with elected and alternatively selected non-executive directors in their first eighteen months on the boards;
  • observation of board meetings and selected other meetings such as Area Partnership Forums;
  • a small number of interviews in a non-pilot board (Tayside) in order to keep track of public and patient involvement and other changes in NHSScotland that were taking place at the same time as the pilots.

This original research was complemented by an international literature review that examined available academic and grey literature on elected boards and advisory bodies in comparable institutional settings (e.g. Canada, New Zealand, and England).


Elections and turnout

  • There were 70 candidates in Dumfries and Galloway, and 60 in Fife. Turnout in the (postal) election was 22.6% of eligible voters in Dumfries and Galloway, and 13.9% in Fife.
  • 16 and 17 years olds had significantly lower participation rates, in both voting and running, than voters over 18. There was only one under-18 candidate in Dumfries and Galloway, and none in Fife. In voting, the 16 and 17 year olds had a 12.9% voting turnout in Dumfries and Galloway, and 7% in Fife. Focus groups suggested that they felt uninformed about the role of health boards and their opportunity to engage, especially relative to the nearly concurrent General Election. This sense of not being informed existed despite efforts by Boards and councils to inform them about the election.
  • Based on the survey, there was a pronounced tendency for candidates and voters to be older.
    A person between 60 and 80 years of age was more than twice as likely to vote as a person between 18 and 40.
  • Voters and candidates were generally in good health, were not carers, and did not have disabilities at any statistically high rate.
  • A few elected board members were closely identified with local campaigns (e.g. to save hospitals from closure) or were experienced local activists. Most were retired or semi-retired professionals or local politicians, often with previous connections to the NHS. Many candidates reported that they would not have put themselves forward for appointment through the ordinary process.

Alternative pilots and selection

  • Two other health boards, Grampian and Lothian, piloted alternative methods of selection of board members, dispensing with the existing approach of using skills-based recruitment to identify candidates by their special skills (e.g. finance).
  • NHS Grampian sought to expand the pool of applicants by advertising two positions more widely than normal and reaching out through the board's various networks, such as its connections with the voluntary sector. It attracted 90 applicants, far more than usual (and sought to remain in touch with unsuccessful applicants so that they might be persuaded to engage with the board in other capacities). The applicants were somewhat more diverse than normal applicant pools.
  • NHS Lothian used two methods for one member each. One was recruited in a method similar to the Grampian method, with wider advertising. The other was recruited from the office-bearers of the Public Partnership Forums that advise the board.
  • In both alternative pilots, the experiment was in the recruitment rather than the selection. Once the applications were received, the actual decision process was handled as normal, through the Office of the Commissioner of Public Appointments in Scotland. The potential deterrent effect of the formal selection procedure might be worth considering if policy builds on the alternative pilots procedure.

Board operations during the evaluation phase of the pilot

  • Most elected board members kept a relatively low profile in the press and local politics, taking on an "internal" role at the level of strategy and governance rather than dealing directly with stakeholders or intervening in operational issues. This role was quite similar to that of appointed non-executive directors.
  • The arrival of a large number of new board members, often relatively inexperienced, created costs in terms of staff time for the executive directors and staff of the boards. It is to be expected that some of the costs of the elected pilots were actually due to the large influx of new board members and not just the election process.
  • There was some more public disagreement within boards (which often value consensus), including public votes where there had been none, and requests to minute individual contributions and disagreements.
  • The alternative pilots boards saw smaller effects, in large part because they added two members each to large and well institutionalized boards.
  • Both alternative and elected pilot boards made some changes to increase the accessibility of their operations, e.g. changing the format of board documents to make them more readable.
  • Greater mutuality and public engagement were stated objectives of the legislation. The presence of elected or alternatively appointed board members did not particularly affect the ongoing, and expanding, efforts to increase public and patient engagement in the NHS by other means. Many of the efforts to engage the public and patients run on the operational level and changes to the boards' composition are primarily important on the strategic level of governance. Elected health boards can be viewed as a complement rather than a substitute or rival to other forms of public and patient engagement such as advisory bodies, consultation, and the Scottish Participation Standard.

Findings in international perspective

The literature review found that the results in Scotland are not, so far, surprising. The closest comparators to the Scottish elected pilots were elections in some Canadian provinces, New Zealand District Health Boards, and Foundation Trusts in England. Low election turnout was frequently a problem, and the number of candidates diminished (as also happened in National Parks Scotland, which is the closest analogue to the pilots within Scotland). Insufficient numbers of candidates became a concern in some Canadian provinces. Elections do not guarantee a more descriptively representative group of board members, which led New Zealand to continue appointments in order to represent groups such as the Maori.

Once in place, many fears about elected boards in Scotland were not realised. Elected board members tended to have similar views to appointed members. There was no clear evidence of politicization of boards by parties or local campaigns. Board members in both New Zealand and Canada were frustrated by the fact that boards had limited autonomy within strategic frameworks, priorities, and policies set by government.

Many voters seem to value health service experience more than finance or management skills when choosing candidates. Many elected members had to learn a great deal about financial and management issues. As in Scotland, Chairs were crucial in supporting learning and managing any tensions.

When Saskatchewan, Canada, abandoned elected health boards as part of a larger reform of the health system, the justification was not that direct elections caused problems; it was rather that the contribution to democratic engagement was not sufficient to justify the costs of elections.

Advantages and disadvantages of elected, appointed, and alternative pilots

The current system of appointed boards has the advantage of being well understood, relatively cheap and allowing for the selection of individuals based on specific skills. However it is perceived as somewhat lacking local accountability and as being responsible for generating boards that are not demographically representative.

The alternative pilots demonstrate possible ways of partially addressing the perceived weaknesses of the current system. Specifically, a broader recruitment process which makes clear that interest is particularly welcome from those traditionally underrepresented on boards undoubtedly has something to contribute. However the existing selection process that then follows initial long list recruitment needs careful reassessment, and probably modification, if this approach is to be fully effective in addressing Parliament's legislative intent.

Finally, direct elections have both considerable advantages and drawbacks. They directly address issues of local democracy and accountability and thus have the potential to change the way boards function through increasing the level of challenge to Chairs, Chief Executives and indeed the Scottish Government. One counter argument is that elected boards may not be able to function as effective corporate entities. We saw no evidence of this during the pilot period. The electoral pilots attracted large numbers of candidates. The general public did not turn out in large numbers to vote although those who were older were more likely to vote. Voter turnout amongst 16 and 17 year olds was particularly low, reflecting perhaps the novelty of this group being able to vote for the first time. Many electors claimed they had inadequate information not just about Health Board elections, but about the very existence and role of Health Boards. Furthermore the literature suggests that turnout may fall in subsequent electoral rounds. The process is costly in comparison to the existing system (whether it continues as is, or is amended in line with the alternative pilots). However, it could be argued that even an estimated cost of somewhere in excess of £12m (incurred every four years) would still be relatively modest in comparison to the budget of NHSScotland as a whole.

This document, along with full research report of the project, and further information about social and policy research commissioned and published on behalf of the Scottish Government, can be viewed on the Internet at:
http://www.scotland.gov.uk/socialresearch. If you have any further queries about social research, please contact us at socialresearch@scotland.gsi.gov.uk or on 0131 244-2111.


Email: Fiona Hodgkiss

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