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

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.


0.1 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. It should be read in conjunction with the accompanying literature review that presents relevant research findings and experience from around the world.

0.2 Parliament's declared legislative intent in passing the 2009 act was to increase local accountability and to address a perceived democratic deficit in wholly appointed Health Boards.

0.3 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 2 new appointed members each.

0.4 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 numbers. The electoral turnout was low. In general, those who stood showed similar characteristics to those who were appointed under the existing system; they are middle aged or older, mainly male, white and professional. However amongst those elected, approximate gender balance was achieved. It also appears that in some cases, reasons for standing in elections differ from those generally seen as motivating the seeking of board appointment. 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.

0.5 This 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. By comparison, the impact of the alternative pilots was more subtle. This was probably a result of relatively few new members being introduced.

0.6 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 £112,308 per appointment round, at 2010 prices.

0.7 This report provides in its Conclusion and Summary section an explanation of the advantages and disadvantages of three possible ways forward in terms of filling non-executive positions.

0.8 The current system 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.

0.9 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.

0.10 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 about Health Board elections. 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 £12M (incurred every four years) is relatively modest in comparison to the budget of NHS Scotland as a whole.

0.11 The complex process of weighing these somewhat subjective factors means that the decision on which system to adopt is of necessity a political and parliamentary one rather than a technical one. However we hope our research findings will inform this decision by outlining the advantages and disadvantages of the different strategies and their costs (including the uncertainties surrounding those costs) as well as the possible impacts on the Boards, and resultant changes in the relationships between the Government, the Public and the NHS.


Email: Fiona Hodgkiss

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