Health Board Elections and Alternative Pilots: Literature Review

This report presents the findings of a literature review which explored evidence on methods to enhance public representation on Health Boards. It was undertaken alongside an evaluation of 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.


5.1 Health systems have used methods other than direct election to try to make Boards more representative of the public. Two common models are appointed representatives on Boards and advisory committees (Frankish, Kwan, Ratner, Wharf Higgins, & Larsen, 2002). There is limited empirical evidence on alternative appointment processes. There is more evidence on advisory bodies, particularly from UK health systems and Canadian provinces. Three models from within the UK are also discussed in this chapter, chosen to illustrate contrasting models.

Board appointments

Quebec: hospital Boards

5.2 In the 1970s, Quebec attempted to democratise the Boards of its hospitals by setting quotas for the representation of different groups on its Boards. This was to include two patients, two representatives from local business or civic organisations, four members of the hospital's Corporation (often former Board members), one health professional (nurse), one physician, and one member of non-professional staff (Eakin, 1984).

5.3 In the resulting Boards the percentage of members with a background in business and finance declined from 56% before the reforms to 17% afterwards (Eakin, 1984). One study of the reforms found that technical decisions became slower because there were more perspectives present, and administrators (managers) felt that new members lacked basic committee and administrative skills (Eakin, 1984). Much of the decision-making shifted away from meetings of the full Board to individual contacts and social environments (for example, the local golf club) where the new 'lay' representatives on the Board weren't present (Eakin, 1984).

England: Primary Care Trust Boards

5.4 In June 2009 the Government set targets that for all new public appointments, including for the Boards of Primary Care Trusts:

  • 50% should be women,
  • 14% should be disabled people,
  • and 11% should be Asian, Black or Minority Ethnic (Appointments Commission, 2010b).

The Appointments Commission uses a number of approaches to increase the diversity of members of local NHS Boards in England. Research with existing female public appointees suggested that a lack of time was one of the greatest challenges faced, and identified factors that attracted women to apply (Appointments Commission, 2009). A new advertising strategy for candidates was designed with these findings in mind (Appointments Commission & Department of Health, 2010). Other techniques have included maintaining a database of "near hit" candidates who aren't initially successful, in the hope of supporting them into later opportunities (Appointments Commission & Department of Health, 2010). No primary research was identified on this process, and the Appointments Commission statistics on application and appointment do not show significant improvement across the categories of diversity at this early stage (Appointments Commission, 2010a). Subject to the passage of current NHS reforms in England, the Appointments Commission, which has been responsible for these campaigns, will be abolished in October 2012.

Advisory bodies

England: Community Health Councils

5.5 Community Health Councils were created in the 1974 reorganisation of the NHS to formalise public involvement (or 'consumer representation') while separating it from the day-to-day running and management of health services (Klein & Lewis, 1976). These independent bodies were set up "to represent the views of the consumer" (Great Britain Ministry of Health and Social Security, 1970), with their membership appointed by local authorities, Regional Health Authorities and local voluntary organisations.

5.6 CHCs had a wide remit, including collecting information from users and collecting information about services; for example by commissioning small-scale local research (Ham, 1980). Area Health Authorities had to consult their CHCs about proposed hospital closures (and if they agreed, there was no need for approval from the Secretary of State). There was great variety in the actual activities of CHCs, with one national survey suggesting five roles in practice, ranging from closely cooperative "Health Authority Partner Councils" to "Independent Challengers", who were mostly excluded from decision-making (Lupton, Buckland, & Moon, 1995). Overall, CHCs were not found to have a great impact on their Health Authorities (Lupton, et al., 1995). As early as 1975, one survey of health service administrators found that:

"Administrators felt that CHCs had power without responsibility; that they were unrepresentative; and that they were unwilling to do the background work on problems referred to them." (Ham, 1980, p. 295)

As the NHS was reorganised, various other units were increasingly seen as representing service users (Pickard, 1997). CHCs were eventually abolished in 2003.

England: Local Involvement Networks (LINks)

5.7 In 2008, new organisations known as LINks began operating in every local authority area in England. Their aim is "to provide flexible ways for communities to engage with health and social care organisation in ways that best suit the communities and the people in them" (NHS National Centre for Involvement, 2007). A key element of this model is the attempt to create space for involvement across the whole patient pathway, including primary, secondary and social care.

One evaluation of so-called 'early adopter' sites, which began to develop their

LINks in 2007 found that;

  • LINks felt under-funded. Initial costs of setting up the networks varied from £3412 to £10949 excluding staff costs.
  • Some actors were concerned that Local Authorities would try to control the LINks (Taylor & Tritter, 2007)

A later research project found that LINks were largely doing a good job of outreach and had achieved a fairly demographically diverse membership, but that they were felt to be lacking strategic vision for their activities (Dorfman, Batty, Campbell, Chapman, & Newman, 2010).

Both of these reports are largely concerned with setting up new LINks, and there is a lack of research evidence about the working of this model. Some commentary discusses the options available for the governance of LINks (namely the choice between a network model, a steering group model, or a combination of the two) but is not based on empirical research with LINks (Mullen, Hughes, & Vincent-Jones, 2011). Current proposed reforms of the NHS in England include LINks changing to local 'HealthWatch' organisations (Wise, 2011).

Scotland: Public Partnership Forums

5.8 Public Partnership Forums have existed since 2004, when they were required in every Community Health Partnership (CHP) in Scotland. The model is one of local flexibility but statutory guidance defines three roles:

  • "ensure that the CHP is able through the PPF and other means to inform local people about the range and location of services and information which the CHP is responsible for"
  • "engage local service users, carers and the public in discussion about how to improve health services"
  • "support wider public involvement in planning and decision making and to seek to make public services more responsive and accountable to citizens and local communities" (Scottish Executive, 2004)

5.9 Identified research evidence on Public Partnership Forums is limited to a report commissioned by the Scottish Health Council and published in 2007 (FMR Consulting, 2008). This report found that PPFs became established quickly, particularly where they had been built on existing structures. However much of their activity focussed on establishing their own structures. The report authors found that substantial variation in form of Forum

"reflects the diverse geographical and social make up of different areas, different existing community involvement structures and also different attitudes towards public involvement." (FMR Consulting, 2008, p. 99)

Most PPF members had previously been involved in other community/ voluntary sector activities, and this was a cause for concern from some quarters. However the report authors also highlighted the depth of experience and knowledge this gave to Forums. Lack of awareness of PPFs in the wider public was seen as a key challenge, but most PPF members felt they had good relationships with their Community Health and Care Partnership and were being listened to.

5.10 Instead of holding direct elections for members of health bodies, some systems have sought to improve public representation by making changes to the recruitment and appointment process for Board members, or by creating forums for members of the public to advise conventionally-appointed Boards. Appointed Boards in Quebec were given quotas for representation of different groups in the 1970s, but the impact of these appointees was found to be limited. Boards of Primary Care Trusts in England have had targets for the representation of different groups since 2009, and there is a lack of research on how effective this has been. Advisory bodies have been a common feature of health systems in the UK, although research evidence is largely concerned with Community Health Councils, which were abolished in 2003. As advisory bodies are generally self-selecting groups, they may not be seen as representing the public. Evidence suggests that it can be challenging for these groups to strike a balance between conducting outreach and public engagement work, or working to influence Boards on strategic matters.


Email: Fiona Hodgkiss

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