Minister capitulates to establishment over health board democracy

The Scottish Government has announced that it is to abandon the idea of directly elected health boards in favour of a return to appointees who can be removed my ministers. A bold attempt at introducing a small element of local democracy has been strangled by government that is increasingly prone to centralise services and undermine local democracy.

In the 2007 election, the SNP pledged to introduce elected health boards, citing concern that health authorities had not always properly listened to local views when considering changes to services. Scottish Labour also agreed to support the pilot elections held in Fife and Dumfries and Galloway in 2010, in which 16 and 17-year-olds were allowed to vote for the first time.

The turnout was low, with fewer than one in five voting in Dumfries and Galloway, and one in ten in Fife. However, this was the first time people were asked to vote and there was only limited promotion. An independent assessment of the pilots found that it is possible to successfully hold direct elections for NHS health boards and members of the public are prepared to stand in considerable number. It also buried myths about politicisation, although it also found that elected members were more willing to challenge officials. No wonder the health establishment was so opposed!

Now Health Secretary Alex Neil has capitulated to those interests, he said: "This pilot project was designed to ensure that the views of local people about their NHS are heard effectively, and to encourage them to be more involved in how the health service is run. These pilots have demonstrated that the most effective approach was a pro-active approach from boards to advertising and recruiting to posts. I am confident that these new measures will help to increase public engagement and improve local accountability. I am confident that these measures will help to increase public engagement and improve local accountability more effectively than when we tested direct elections as part of the pilot."

Sadly, there is little evidence to support this view. Officials and the health establishment’s patronising top down approach to public engagement has eventually worn the new health minister down.

Of course directly elected health boards are not the only way of extending local democracy into NHS Scotland. Other options include greater local authority involvement up to and including the creation of unitary authorities. Reform Scotland has recently argued for the merging of councils and health boards. However, they also argued for fewer and more remote councils. A point well argued by Lesley Riddoch in the Scotsman, who points out that we have the most remote local democracy in Europe. Its not apathy, wrong size governance is to blame.

Health board elections

The Scottish Government has published the reports from the evaluation of the Health Board elections and alternative pilots.  The research describes the statutory evaluation of the pilot projects, arising from the Health Boards (Membership and Elections) (Scotland) Act 2009. 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 two new appointed members each.

The main finding is that it is possible to successfully hold direct elections for NHS health boards and members of the public are prepared to stand in considerable number.

The elections did not radically change the demographics of board members but an approximate gender balance was achieved. In some cases, candidates’ motivations for standing were very different from the motivations described by non-executives who had come through the appointments route. Specifically, those who stood on electoral platforms such as planned hospital closure or transfer of services. Most elected board members were not strongly political (including some with long experience in politics) and acted in ways that were similar to appointed non-executive directors.

Electoral turnout was low. 16 and 17 year olds had notably lower turnout than voters aged 18 or over and only one ran for office. Focus groups suggest that this group felt uninformed about both the role of health boards, and about their ability to stand for election and vote. The costs of mounting the elections for the two boards totalled £773,256. It is difficult to predict the cost for all boards, but it may be £11 to £12m - modest compared to the size of NHS Scotland.

Candidate profiles and election subsequently impacted the way board business was conducted. In one of the elected Boards, votes on issues became more common and dissenting opinions were more likely than previously to find their way into the press. There was also more challenge to Executive Director's.

Alternative pilots that sought to broaden recruitment methods without changing the selection procedure did expand the range of applicants beyond those who apply for appointment under the existing system. The effects of the new board members were much smaller, primarily because they added two people each to large and well-established boards.

An international literature review suggests that the Scottish experience is not unusual; New Zealand, some Canadian provinces, and English Foundation Trusts all had relatively low turnout but did not experience predicted problems with politicisation and division.

The research found that 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. However, the researchers saw no evidence of this during the pilot period.

The research is unlikely to change minds on this issue one way or the other. You either believe that public services should be locally democratically accountable, or believe that they should be run by political appointees and others picked for their expertise.