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.

6 Suggestions For Improvement

6.1 In the course of our research, many respondents made suggestions for improving on the pilots. We also had ideas of our own based on our experience and reading of the relevant literature. In this section we bring together, and offer a preliminary assessment of, suggestions that came up repeatedly. The majority of these relate to the electoral pilots. However this simply reflects the relative complexity and scale of change involved in the electoral (as opposed to appointed) pilots and does not imply a recommendation. The summary chapter that follows provides a balanced view of the advantages and disadvantages of each system.

Electoral pilots

6.2 We uncovered evidence that many voters found the number of candidates overwhelming. There was considerable concern that electors were either abstaining because they could not process so much information or were choosing candidates solely because they were already familiar with them, because they lived in the same area as the elector, or because their credentials were instantly obvious on a very superficial scan of the ballot paper. This may have disadvantaged some candidates and advantaged others. Many suggested that any future elections electors should be faced with fewer candidates.

6.3 This suggestion is problematic for several reasons. Firstly, any barriers erected to reduce the number of candidates would need to be equitable. Secondly, because it is difficult to predict the likely number of candidates in advance, the risk of having an unmanageable number of candidates needs to be balanced against the competing possibility of having too few candidates to offer voters a meaningful choice. When health board elections have been introduced abroad (as discussed in the attached literature review, and as seen in National Parks Scotland) there has been a general trend for the numbers of candidates to fall over time. This suggests that the numbers of candidates would decline naturally after any rollout. On the other hand, the possibility of having an overwhelming number of candidates if elections were held under the same rules as the pilot in the larger Health Boards is serious.

6.4 One potential solution that came up repeatedly was to divide Board areas into smaller 'wards' within which candidates would compete. For example, the NHS Fife area is currently composed of three Community Health Partnership (CHP) areas, and each of these could be treated as a separate ward[20]. However, dividing the Health Board areas into separate wards could have ramifications for the Boards' governance arrangements and perceptions of corporate responsibility. If some members were seen as having been elected by particular parts of the Board area, they could well perceive themselves to have a greater responsibility to the area that elected them. There would be a tension between such sentiment and their responsibility according to current the Code of Corporate Governance to act in the interests of the population of Fife as a whole.

6.5 The timing of the elections was not ideal. We understand that the Health Board elections were so close to the General Election because of a coincidence that was beyond Scottish Government or Health Boards' control, but that coincidence probably reduced the impact of the publicity campaigns and contributed to low public awareness. However, this problem is unlikely to arise again. As the UK Government has now moved to fixed-term Parliaments the Scottish Government should usually have ample advance notice of a General Election.

6.6 In our focus groups with young electors, several participants independently suggested that candidate photographs on the ballot papers or candidate statements would make the materials more appealing. Voters would presumably have a greater chance of recognising familiar candidates. The issue of how photographs on ballot papers affect voter behaviour has been examined by academics before and there is some evidence that photographs on ballot papers give an electoral advantage to certain demographic groups, such as younger candidates[21].

6.7 Ballot papers and booklets of statements listed candidates in alphabetical order by surname. A few respondents did suggest the possibility that candidates whose surnames gave them prominent positions on the ballot and among the statements gained an unfair advantage. There is some academic research on the effects of name order on election performance, which does tend to suggest that some positions on a ballot paper offer a modest advantage[22]. There are clearly many factors that attract voters to candidates, and these modest effects would probably not be enough on their own to elect candidates who did not win support for other reasons. It is important to remember that the elections referred to in the literature would not have involved such a large number of candidates and would have involved party labels, which are known to be an important cue for voters. It is not feasible for us to estimate how much of an impact name order may have had, but to dispel any doubt we suggest that it may be worthwhile to randomise name order on the ballot papers and candidate statements in any future elections. This would have cost implications.

6.8 There was some misunderstanding of the rules of the election. For example, we came across a few instances of voters and candidates who believed that they could only vote for ten (rank-ordered) candidates in Dumfries and Galloway and twelve in Fife because those were the numbers of seats available, rather than being able to rank-order all candidates if they wished. It is difficult for us to get a sense of how common such misunderstandings were and why they arose; it is possible that they always arise with STV elections and that we would find the same confusion in local government elections.

6.9 Voters appeared to have very little information about the role of non-executives on NHS Boards. Presenting electors with a brief introductory statement on the context of the election as well as the rules might help to disperse this information. Electors needed to be informed about the election either on the day their ballot papers arrived or beforehand as there were reports of some disposing of their papers on the day they arrived if they were unaware of the contest. Given the large volume of information being delivered to electors during the General Election campaign in April and May, information may not have been picked up; providing some alongside the ballot could reduce this.

6.10 A few candidates had reservations about their home addresses being printed on ballot papers. Some had held sensitive positions in the past and were concerned at being approached by former acquaintances. As far as we are aware there was no mechanism in place for candidates to stand without advertising their addresses. For example, candidates who had held judicial appointments, sensitive child protection roles, or who had previously been subject to harassment, may have legitimate grounds for wishing to conceal their address. We suggest such a mechanism be put in place in the event of a rollout.

6.11 One candidate complained that a statement had been printed incomplete, with a second paragraph missing. Ideally, candidates would be given an opportunity to see proofs of their statements before these were delivered to printers.

6.12 There were some minor practical issues around electoral registration. For example, the electoral registration rules obliged Returning Officers to send electors' voting packs to the addresses listed for them on the 1st of April 2010 register. This meant that *some* electors who moved to a new address between the cut-off date for this register (in early March) and the 10th of May *needed to specifically request that their ballots be sent to their new address, which would have been very inconvenient*. While a few electors inevitably find themselves in this situation at any election, the numbers might have been minimised had Registration Officers been able to use a more recent register. Similarly, the rules only allowed replacement ballot papers to be issued to electors who claimed they had not received a voting pack, or who claimed they had inadvertently spoiled the paper but could not produce evidence, within seven days of the voting deadline. Those electors had to wait *until the 3rd of June for their request for a new ballot to be acted on, even if this was reported in mid-May* and Returning Officers had no discretion to issue a new paper earlier. There may be an argument for relaxing the wording. We would recommend that the Scottish Government confer with Electoral Registration Officers on such issues if elections are rolled out across Scotland.

Appointment process

6.13 Recruitment and selection for the appointments took longer than initially envisaged, largely due to the unprecedented numbers of applications received, and this delayed the process considerably. As a result, some of the new members did not join the alternative pilot Boards until November 2010. Ideally, systems would be put in place to speed the process.

6.14 There were some delays in getting feedback to applicants for the appointed pilots. Again, this was linked to the unusually high number of applicants. While the high level of interest generated may be an encouraging sign, if this were repeated in any rollout it would be beneficial if the Scottish Government were to slightly increase the resources devoted to administrative support of the selection process. This should allow officials to process applications at normal speeds despite a substantially increased workload.

6.15 It is worth noting that the alternative pilots altered the application process only up to the point at which applicants submitted their forms. From that point on, the Scottish Government Public Appointments Unit and the Office of the Commissioner for Public Appointments in Scotland (OCPAS) ran a conventional selection process. We were not instructed to evaluate any changes to the selection process beyond those made by the Health Boards as part of the pilot, so we are not in a position to say whether changes to the selection process might help to meet the Scottish Government's policy objectives. If encouraging greater diversity in the backgrounds of Non-Executive Directors of Health Boards is a policy objective, then there may well be scope for further study to find out how the selection process could enhance diversity.


Email: Fiona Hodgkiss

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