- Commissioners elected by local people and required to be responsive (we need to distinguish the how from the what; the latter is a matter for national debate and decision in terms of the coverage the NHS offers but how that coverage is delivered can be a local matter)
- Provide enforcement mechanisms for the NHS Constitution.
- Local people involved in Clinical Commissioning Groups in the same way as parents are involved with schools
- By introduction of democracy to the NHS – and this needs to be for provider organizations as well as for commissioning ones (if we stick with this wasteful split).
- By introducing deliberative democratic processes for policy decisions at local, regional and national level (the Brazilian participatory budgeting process is one viable model of this).
- Make very public the expectations of basic courtesy and kindness required of all health staff – I had a hospital appointment yesterday and only one of the two staff who attended me bothered to introduce himself. My mother was in hospital last summer and still staff came and did interventions on the ward without explanation or introduction.
- Commissioners have less demands from above and more from below.
- Providers are ranked by responsiveness.
- Ensure that *every* service provider is covered by the same rules of transparency and accountability, regardless of whether they are public, voluntary or private sector. This means open board meetings, FoI-able, a single standard complaints system, and a mechanism for patients to challenge decisions. We have yet to see how the “lay” members on CCGs will perform their duties, I suspect that we will need to ensure common standards. My feeling is that lay members should attend each GP patient involvement group at least once a year, and similarly for patient support groups. I think lay members should have a “direct connection” with patients.
- Legislate for transparency of decision making (including non-financial contract details) and a wider social base of non-execs.
- Make Board members personally liable for misuse of public funds by paying whistleblowers to keep silent
- More power to Foundation Trust Governors. Specifically: We propose a series of measures which might improve the Foundation Trust governance model but unless there is a genuine will to transfer power then the model is fatally flawed. (We accept that some Foundation Trusts will already have implemented some of these.)
a) Most important – more independence. We should strengthen the idea that the members own the hospital and the Governors are their elected representatives. The Secretary of State, Monitor or any other regulator (apart from CQC on issues of patient safety) should only be able to intervene through the Governors. If Governors represent the owners of the Trust and are there to hold the Board to account then any external regulation must involve them.
b) As well as approving the annual plan the Council of Governors should have to formally approve all major transactions and all major changes to service delivery, including any closure of facilities, any changes to the limit on private patient income and any Trust wide changes in staff terms and conditions.
c) The power to appoint or remove the Chair or Non executive directors should only be exercised by the Council of Governors in special session.
d) The targets for recruiting more members should be scrapped. Instead there should be measures of the effectiveness of their involvement.
e) Governors meetings should be open to the public.
f) It should be possible for members or the public to contact Governors without going through the staff of the Trust, and Governors need to be able to communicate with members without interference from the staff. The Trust should at least supply a public email address for each Governor.
g) Governors should be entitled to:
a) ask questions about any aspect of the Trust’s business and have their questions answered;
b) membership of any senior Trust committees;
c) observe and contribute (without a vote) at Board meetings and to see all the papers;
d) attend closed sessions and Board in committee sessions;
a) a governors’ own Steering Group with responsibility to determine the Council of Governors agenda; regular joint Board/Council of Governors meetings. All major policies must be timetabled to allow full Council of Governors advice and to be signed off by Council of Governors.
h) There should be radical improvements to the actual election process. Minimum standards should be established for the election processes and for eligibility. In particular:
a) constituencies should be neither too big nor too small – big enough for a contested election, but small enough for candidates to know the area.
b) Candidates should be given sufficient opportunity to say something about themselves in the election process and why they want to be Governors.
c) If they have to be proposed or seconded by other members the list of members must be published.
d) The Trust should facilitate hustings meetings where possible
e) Governors should be elected by the Alternative Vote model.
i) Governors should be able to have recourse to the regulator to ensure the above are enforced.
j) Any rules which prevent members of Local Involvement Networks or any similar bodies from being Governors should be scrapped.
k) We should reaffirm that the equality legislation applies to Governors and support must be provided to people who need provision for disability, money to pay for child care etc.
l) Governors should be entitled to time off work for public service. Staff Governors should be entitled to time off with pay and cover for their work.
m) There should be a national Code of Conduct which every Foundation Trust has to adopt and enforce on their governors (they could add to it). This should make clear issues around conflict of interest, communications with the media, standards of behaviour, role and responsibilities. It should also cover how governors could be removed for unacceptable conduct in breach of the code, or non attendance. These matters should not be open to local decision making.
n) There should be appropriate funding for governor training and development and member engagement. The Foundation Trust Governors Association should also get appropriate funding, for example for developing training courses and materials, and its role should be acknowledged. A national one day induction course should be established and no governor would be able to take office until they have been through the course. Annual follow up half day courses should also be mandatory.
o) Governors should be given opportunities to meet with governors from other Foundation Trusts. Membership of the Foundation Trust Governors Association should be open to individual Governors, even if their Trust does not subscribe.
p) A good job description for the role of Governor should be published before an election so candidates really know what is involved – in terms of formal tasks, opportunities for involvement in the hospital, and time commitment.
q) Foundation Trusts should use common terms and be prevented from calling their Governors by other names, such as “councillors” as some do, because it just confuses the public.
r) Monitor should
a) consult widely and publish new guidance around the roles and responsibilities of members, governors and members’ councils. Some independent research and publication of best practice should be undertaken.
b) have one nominated board member responsible for liaison with governors.
c) have responsibility for supervising the democratic governance arrangements for all Foundation Trusts.
s) All Councils of Governors should consult with their membership and propose formal arrangements through which members are regularly informed, given the chance to participate and consulted formally on major issues before the Council decides its position.