Select Committee on Health Written Evidence

59. Evidence submitted by Monitor (PPI 118)


  1.  There are currently 54 NHS foundation trusts which have around 625,000 members drawn from the public, patients and staff. The patient and public members elect the majority of the Board of Governors of each NHS foundation trust.

  2.  The numbers involved, and the degree of engagement which is taking place, indicate that membership is providing an effective route by which patients and public can engage with their local NHS foundation trust.

  3.  The governance structure of NHS foundation trusts has brought a new dimension to patient and public involvement in the NHS. The right to elect governors, who have specific powers in relation to the trust, ensures that members have a specific role in the governance structure of an NHS foundation trust. This is a distinct position from other patient and public involvement initiatives in the NHS.

  4.  The 54 NHS foundation trusts have around 930 patient and public governors. The boards of governors have been working effectively with the boards of directors, for example liaising on appointments of non-executive directors and overseeing the development of strategy. In Monitor's view it is as yet too early to say whether governors will be able to have the necessary blend of experience, skills and influence to successfully shape the long term strategy of each NHS foundation trust.

  5.  The number of NHS foundation trusts will grow steadily over the next two years. This will ensure that the membership concept is firmly established in the majority of acute and mental health trusts and, through the planned creation of community foundation trusts, in primary care settings too.

  6.  Where patient and public involvement initiatives overlap there is potential for confusion as to the different responsibilities of each organisation. It is therefore essential that the development of the new Local Involvement Networks avoids any duplication with the responsibilities of the governors of NHS foundation trusts.


  7.  Monitor's statutory name is the Independent Regulator of NHS Foundation Trusts. Monitor was established in January 2004 under the Health and Social Care (Community Health and Standards) Act 2003. Monitor's statutory responsibilities include the authorisation and regulation of NHS foundation trusts. Monitor is independent of the Department of Health. It is accountable to Parliament.

  8.  NHS foundation trusts are autonomous organisations. They are no longer subject to direction by the Secretary of State for Health, although they must continue to work within the framework of national targets and standards established by the Secretary of State. Their primary purpose must remain the provision of services to the NHS.

  9.  The Board of Directors of each NHS foundation trust is responsible for strategy and performance. They are accountable to local members through the Board of Governors.

  10.  There are now 54 NHS foundation trusts, including five mental health trusts. Their annualised total income is around £10.8 billion (based on 2005-06 figures), accounting for over a quarter of acute trust activity in England.


  11.  Each NHS foundation trust has public members drawn from their local population and staff members; it may also have patient members. Members can elect representatives to the FT's Board of Governors. A majority of the governors must be elected by patient and public members. The Board of Governors has a number of statutory powers including:

    —  appointing or removing the chair and non-executive directors;

    —  approving the appointment of the chief executive;

    —  appointing the auditors of the trust; and

    —  considering the trust's annual forward plan.

  12.  The 54 NHS foundation trusts have around 625,000 members—see table at Annex A. Around 75% of members are from the patient and public constituencies. There are around 930 patient and public governors. A governor profile for a recently authorised NHS foundation trust is shown at Annex B.

  13.  Membership provides an effective way of engaging with the local community. All NHS foundation trusts are required to take steps to secure membership which is representative of the communities they serve. The plans received for 2006-07 showed NHS foundation trusts undertaking a variety of activities to engage effectively with their members including:

    —  Newsletters.

    —  Open Days.

    —  Leaflets and letters to constituency members.

    —  Targetted letters to local groups or local authorities.

    —  Seminar and lecture programmes.

    —  Surveys and questionnaires.

    —  Membership stands at local events.

    —  Emails.

    —  Articles in local media.

  The two examples in paragraphs 14 and 15 illustrate the type of engagement that NHS foundation trusts have had with members.

  14.  Cambridge University Hospitals NHS foundation trust has one of the largest memberships. Governors have taken responsibility for communicating with members with monthly meetings held in local towns and villages. Meetings take place both in afternoons and evenings to make them more accessible to any member wishing to attend. The trust identified that giving the meeting a theme will increase attendance and so the local member meetings have incorporated topical themes such as the role of the modern matron and hospital food.

  15.  Chesterfield Royal Hospital NHS Foundation Trust consulted public and staff members on new proposals to change visiting hours at the hospital. As part of plans to reduce hospital -acquired infection, members were asked if visiting hours should be reduced. In exchange more cleaning would take place on wards and a new visitors' code would be adopted—including a ban on more than two patients per bedside. Almost 5,000 responses were received (nearly 50% of the membership). Over 96% were in favour of the new code. However the trust was asked to extend afternoon visiting from a proposed one hour, to a two hour slot—to help visitors travelling long distances. The trust agreed to this change. The consultation led to major changes in the way the hospital operates being implemented with total support from staff, patients and local people.

  16.  Members' statutory influence over the NHS foundation trusts comes through the election of governors. Participation rates in elections have averaged around 35% within the public constituency.

  17.  Monitor is satisfied that across all NHS foundation trusts governors have been carrying out their formal roles in an effective manner, making sound appointments to non-executive director posts, appointing auditors rigorously and overseeing the activities of the organisation effectively.

  18.  There have to date been no significant cases in which governors have come into conflict with boards of directors. This is to be welcome if it indicates that NHS foundation trusts are running themselves effectively. However, it may suggest that governors have not yet sufficiently found their feet. Monitor welcomes the proposal to establish a governors' forum, to be run by the King's Fund, which will provide a focus for governors to share information and learning. There will no doubt be challenges and changes ahead for many NHS foundation trusts and governors need to ensure that they are properly engaged in giving oversight to their organisations if local accountability is to have real force.

  19.  In 2006 Monitor published the NHS Foundation Trust Code of Governance. This sets out a best practice framework for the corporate governance of NHS foundation trusts, drawing on experience from the private and public sector. In consulting on the Code many respondents suggested that Monitor should provide further guidance on the role of governors. At present Monitor has plans to undertake further work in 2007 on the role of governors and will consider whether it would be helpful to issue further best practice advice on the governors' role.


10 January 2007

Annex A


NHS foundation trust Total


as at 31/3/06

Basildon and Thurrock12,069
Bradford Teaching4,221
Cambridge University Hospitals23,597
Chesterfield Royal13,346
City Hospitals Sunderland9,129
Countess of Chester4,266
Derby Hospitals13,994
Doncaster and Bassetlaw7,870
Frimley Park7,671
Gateshead Health11,171
Gloucestershire Hospitals14,609
Guy's and St Thomas'13,368
Harrogate and District13,557
Heart of England51,038
Homerton University5,968
Lancashire Teaching14,592
Liverpool Women's10,693
Queen Victoria Hospital13,031
Royal National Hospital for Rheumatic Diseases 4,612
Sheffield Teaching18,168
South Tyneside4,963
Stockport NHS11,938
The Rotherham5,502
The Royal Bournemouth and Christchurch 14,990
Royal Devon and Exeter15,600
The Royal Marsden4,893
University College London Hospitals10,194
University Hospital Birmingham91,961


South Essex8,039
South Staffordshire5,026
Royal Berkshire10,173
James Paget12,965
Luton & Dunstable8,336
Sheffield Childrens3,274
Chelsea and West.10,914
Tavistock and Port.2,300
South Manchester9,142
SL and Maudsley2,361
North Hampshire4,037
TOTAL all trusts627,800


  1.  Membership figures for the first 32 NHS foundation trusts are as at 31 March 2006 as reported to Monitor in Annual Plans for 2006-07.

  2.  For trusts authorised in 2006, membership figures are as at date of authorisation.

Annex B



20 patient and public governors

  3  Area A

  5  Area B

  4  Area C

  2  Area D

  1  Area E

  5  Patients' constituency

12 appointed governors

  2  PCTs

  1  University

  2  Primary care clinicians

  2  Local authority

  1  PFI partner

  1  Chamber of commerce

  1  PPI forum

  1  Local regeneration project

  1  Voluntary sector

7 staff governors

  1  Medical and dental practitioners

  2  Nursing and midwifery

  1  Other clinical staff

  1  Non-clinical staff

  1  PFI staff

  1  Volunteer

  Based on constitution of University Hospital of South Manchester NHS Foundation Trust

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Prepared 6 February 2007