Governance for NHS foundation trusts

Where is the pilot? The changing shapes of governance in the European hospital sector

Hospital governance refers to the complex of checks and balances that determine how decisions are made within the top structures of hospitals. This article explores the essentials of the concept by analysing the root notion of governance and comparing it with applications in other sectors. Recent developments that put pressure on the decision-making system within hospitals are outlined. Examples from the UK, France and the Netherlands are presented.

Based on an evaluation of the current state of affairs, a research framework is developed, focusing on the determinants of governance configurations within the national healthcare systems and the wider legal and socio-economic context, as well as on the impact of governance configurations on the efficiency of the governing bodies and overall hospital performance.

The article concludes with a preview of the European Hospital Governance Project, which follows the outlines of the described research framework. New techniques of data mining that are used in this project are explained by means of a real data example.

Accountability of Foundation Trusts in the English Nhs: Views of Directors and Governors

Objectives

To map and describe the formal accountability relationships of foundation trusts in England and to explore the interpretations of these relationships by the key actors.

Methods

Documentary analysis and interviews with chief executives, chairs, directors and governors in six acute trusts and two Strategic Health Authorities.

Results

Although vertical accountability to the Department of Health (via Strategic Health Authorities) has, in formal terms, been removed some foundation trusts continue to be held to accountability by Strategic Health Authorities, albeit informally. Directors of foundation trusts perceive strong accountable to their regulator, Monitor, particularly for financial performance, but there is some confusion about where accountability for quality of care rests. Horizontal lines of accountability to the local population (through Local Involvement Networks and local government Overview and Scrutiny Committees) remain weak.

Conclusions

Contrary to the major policy objectives of giving greater autonomy to foundation trusts and making them more accountable to the local population, they continue to look towards the Department of Health rather than to the local population and its representatives. The accountability of foundation trusts needs to be simplified, clarified and strengthened.

Community involvement in hospital governance in Britain: evidence from before the National Health Service

An important goal of policy in the British National Health Service (NHS) is to increase public involvement in health care governance. In the hospital sector this led in 2003 to the establishment of foundation trusts with "membership communities," which aim to give local citizens a say in management. This is not the first attempt to introduce greater community participation in the running of British hospitals. Prior to the inception of the NHS in 1948, the hospital contributory scheme movement provided ordinary members of the public with the opportunity to sit on hospital management boards. The article examines the nature and extent of this earlier experiment with local democracy in hospital governance. It argues that historical precedent is not particularly encouraging, either for the prospect of broadening popular participation or for making services more responsive to local needs. Although today's context is very different, the tendency for managerial and professional interests to dominate the policy arena is a feature of both periods.

New localism in the English National Health Service: What is it for?

This paper discusses the decentralisation in the English National Health Service (and the new organisational form of Foundation Trusts, in particular) in the context of the trend for decentralising public services generally since the New Labour government started its second term of office in 2001. It considers the likelihood of decentralisation achieving the aims policy makers have set: these are better services and an increase in local people's participation in the planning and running of services (active citizenship). Looking at the evidence to date, both about decentralisation of health services and about Foundation Trusts, the achievement of these goals seems uncertain.

Why some market reforms lack legitimacy in health care

Market-oriented health policy reforms in the 1980s and 1990s generally included five kinds of proposals: increased cost sharing for patients through user fees, the separation of purchaser-provider functions, management reforms of hospitals, provider competition, and vouchers for purchasing health insurance. These policies are partly derived from agency theory and a model of managed competition in health insurance. The essay reviews the course of reform in five countries that had a national health service model in place in the late 1980s: Italy, New Zealand, Spain, Sweden, and the United Kingdom. Special consideration is given to New Zealand, where the market model was extensively adopted but short lived. In New Zealand, surveys and polls are compared to archival records of reformers' deliberations. Voters saw health care differently from elites, and voters particularly felt that health care was ill suited to commercialization. There are similarities across all five countries in what has been adopted and rejected. Some market reforms are more legitimate than others. Reforms based on resolving principal-agent problems, including purchaser-provider splits and managerial reforms, have been more successful, although cost sharing has not. Competition-based reforms in financing and to a lesser extent in provision have not gained legitimacy. Most voters in these countries see health care as different from other parts of the economy and view managerial reforms differently from policies that try to make health care more like other sectors.