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.

7 Conclusion and Summary

7.1 In order to help Ministers and the Parliament to reach a way forward, this section lays out, in concise form, the relative strengths and weaknesses of each model based on the research reported here and the accompanying literature review. This section could usefully be read in conjunction with the executive summary. When comparing relative impact, it should be noted that the election pilots replaced approximately half of the membership of those two boards, while the alternative pilots involved many fewer non-executives relative to the size of the boards.

Current system

7.2 Strengths of the current system are that:

  • it allows recruitment by skills (e.g. advertising for a candidate with specific expertise in finance);
  • selects candidates who are primarily committed to a fiduciary role (i.e. who are seen and see themselves as trustees rather than representatives, delegates, or advocates);
  • and it is well understood by the NHS, politicians, civil servants and the interested public.

7.3 Weaknesses of the current system include:

  • its perceived democratic deficit
  • and board demographics that are not wholly statistically representative of the general population.

Alternative pilots: Public Partnership Forum (PPF) recruitment

7.4 The strengths of the PPF recruitment model used in Lothian are:

  • its very low cost;
  • that it draws on a population with a demonstrated knowledge of and interest in the health board;
  • and in common with other models it led to more accessible board papers

7.5 The weaknesses of the PPF recruitment model are:

  • loss of the opportunity to use specific skill-based recruitment (e.g. recruiting specifically for financial expertise);
  • the risk that it will duplicate existing board information flows;
  • limited diversity compared to elections due to the use of the existing public appointments process;
  • and limited diversity compared to elections due to the limitation of recruitment to existing PPF members, who are not necessarily statistically representative of the general population.

Alternative pilots: Wider advertising

7.6 The strengths of the wider advertising strategy used in Grampian and Lothian are that:

  • its costs are much lower than those of elections;
  • that it increases the diversity of the applicant pool;
  • and that it creates the opportunity to raise the profile of the board and highlight opportunities for engagement other than board membership.

7.7 The weaknesses of the wider advertising strategy are:

  • limitation of skill-based recruitment, as criteria are relaxed to encourage a wider range of applicants;
  • and that the diversity of the actual candidates chosen for the board can be limited by the use of the existing public appointments process.


7.8 The strengths of the elections include:

  • the creation of a new vehicle for boards to link to the general public;
  • the creation of a new vehicle for the public to participate;
  • more diversity of views about the NHS present on the board (e.g. candidates affiliated with specific hospitals were elected);
  • an enhanced degree of challenge (e.g. recorded votes were taken, and elected directors sought to have their contributions recorded by name);
  • increased attention to the role of the non-executives as a result of the need to induct a large number of new and diverse members;
  • more approachable board papers, something not confined to the election pilot boards.

7.9 The weaknesses of the elections include:

  • limited demographic broadening relative to the general population;
  • limited use by boards as a way to find out about community preferences (no board eliminated any existing public and patient involvement mechanism that might have been considered duplicative after the elections);
  • limited use by the public as a vehicle to influence boards (turnout, in the Scottish Board elections and the ones reviewed around the world, was relatively low);
  • the financial cost of running the elections, which could be higher per-voter if rolled out across Scotland;
  • the organisational cost of inducting a large number of new people, defining board member roles, investing heavily in board development, and diverting time of all concerned, but especially the Executive Directors and Chairs, towards board management;
  • and the loss of the opportunity to engage in skill-based recruitment.


Email: Fiona Hodgkiss

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