Why we need an NHS election day

Voters will go to the polls on May 7th for the general election and hundreds of local council elections. There is no equivalent of this election day for NHS Foundation Trust elections, which traditionally see lower levels of public participation. In this post Richard Berry proposes that NHS elections be held simultaneously in order to raise awareness among the public.

How can the NHS raise awareness of its democratic processes? Image: Eye on Rights (CC BY-NC-SA 2.0)

Each NHS Foundation Trust is overseen by a council of governors, whose members are directly elected by local communities, patients and staff. When the model was introduced in England in 2004, it was heralded as the beginning of local democratic accountability in the NHS.

One of the challenges for NHS trusts, however, has been that participation in these elections has been fairly low. Anyone can take part, as long as they become a member of a trust. But even among those people who choose to become trust members, turnout in governor elections is relatively low: in 2014, only around 19 per cent of Foundation Trust members exercised their right to vote.

There are various ways this could be addressed, for instance by considering constituency design, voting methods or, more fundamentally, the powers of the council of governors in the running of the trust. But one fairly simple reform that could be attempted is to hold Foundation Trust elections at the same time, rather than spreading them throughout the year.

Integration with regular elections

Holding elections for disparate public bodies simultaneously is not a revolutionary idea. It is the normal way of doing things. Local authorities across the country hold all of their elections on the same day every year. Indeed, this day is often used for other types of election too: in May, the general election will be held alongside local elections for 279 councils.

Elections are integrated in other ways, too. The UK has a single electoral register, which since last year people can join via one central website. If you register to vote for your local councillor, you are also registered to vote for your MP, MEPs, Police and Crime Commissioner, Mayor, and so on. We also have a single Electoral Commission to regulate and monitor elections, although on the ground elections are administered by local authority officials.

Foundation Trusts are not party to these integrated electoral processes. We do know, however, that some degree of coordination was considered by the government before the first Foundation Trusts were established. Specifically, there was a proposal to allow people to join their local trust – therefore registering as a voter for NHS elections – at the same time they joined the main electoral register.

This reform, which hasn’t been implemented, would have been relatively straightforward. People could simply tick a box when registering to vote, saying they wanted to join an NHS trust, too. Indeed, membership of the local trust could be automatic (perhaps with an opt-out). We might even do away with the concept of trust membership altogether. The electoral register would in effect be the trust’s electorate, although trusts may retain separate processes for electing staff and patient governors.

The complicated part of this equation comes on the NHS side. If the NHS’s organisation was ever simple, it certainly isn’t now. NHS trusts serve overlapping geographies, some very large and some small, with different specialisms. A patient or member of the public is likely to be interested in affairs at more than one hospital trust, not to mention mental health trusts and their regional ambulance service. And with trust mergers in recent years, the idea of a local NHS trust is becoming ever more quaint.

An NHS Election day

Full integration of Foundation Trust elections with regular elections seems a distant prospect. But there is one simple change that change that could be introduced, which would allow the NHS to replicate one of the key strengths of the integrated system. Foundation Trusts could hold their elections at the same time. At present, they are spread across the year, with elections in different areas taking place every month.

Part of the reason all council elections are held on the same day is that having one election day helps raise awareness among the whole population. NHS elections are always postal or online ballots, without physical polling stations, but they could still be held simultaneously, with the deadline for the return of ballots serving as.the ‘election day’. Trusts could oversee a single publicity campaign, utilising NHS infrastructure and the networks of stakeholder groups – currently this is not feasible because an individual trust will not have the resources to do this alone, and because the uncoordinated timing means people would need to be inundated with exhortations to vote all year round. A single election day could also help attract media attention, which at present is minimal at best.

The key challenge to overcome would be the capacity of the companies that manage NHS elections. Spreading elections throughout the year, I am sure, helps companies to manage their resources. Concentrating elections into one short period of time might mean, for instance, that they need to hire lots of temporary staff at election time, and lose the expertise that a permanent workforce can develop. One solution to this is to continue holding staff governor elections throughout the year – the imperative for a single election day really only applies to public and patient governors.

We might also consider having regional election days, rather than a single, national election day. If we look at examples of when geographically close trusts held their elections in 2014, the need for greater local coordination appears obvious:

In South Yorkshire, Rotherham NHS Foundation Trust held its election in March (the date nominations closed), the Rotherham, Doncaster and South Humber Trust in June, the Sheffield Children’s trust and Sheffield Health and Social Care in July, and then Barnsley Hospital in October.
In Merseyside, there were elections for Aintree University Hospitals in March, Alder Hey Children’s Hospital and the Cheshire and Wirral Partnership in July, and Liverpool Women’s in August.
In Tyneside, Northumbria Healthcare elected new governors in June, the North East Ambulance Service in September, and Gateshead Health and the Northumberland, Tyne and Wear Trust in October.

Whether nationally or regionally, coordinating the timing of NHS elections is a simple reform that could be piloted and rolled out without significant disruption to trusts or their voters. It has the potential to raise awareness, and the level of participation, in the democratic processes that are so integral to the Foundation Trust model.

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Note: this post represents the views of the author, and not those of Democratic Audit or the LSE. Please read our comments policy before posting.

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Richard Berry is a Research Associate at Democratic Audit and the LSE Public Policy Group. He is a scrutiny manager for the London Assembly and managing editor of Health Election Data. View his research at richardjberry.com or find him on Twitter @richard3berry.