doi: 10.1111/hex.12274
Service user governors in mental health foundation trusts: accountability or business as usual? Dee MacDonald,* Marian Barnes,† Mike Crawford,‡ Edward Omeni,§ Aaron Wilson§ and Diana Rose¶ *Research Fellow, †Emeritus Professor of Social Policy, University of Brighton, Brighton, ‡Professor in Mental Health Research, Imperial College London, London and §Research Worker, ¶Professor of User-Led Research, King’s College, London, UK
Abstract Correspondence Dee MacDonald Research Fellow School of Applied Social Science University of Brighton Falmer Brighton, BN1 9PH UK E-mail: D.M.MacDonald@brighton. ac.uk
Context National Health Foundation Trusts present opportunities for individual mental health service users to be active in the governance of trusts. This is one of a range of mechanisms for patient and public involvement and one which promotes an individual rather than collective approach to involvement.
Accepted for publication 2 September 2014
Objective Within the context of a broader study of the impact of service user involvement in mental health services, the objective of this article was to explore the experience of service user governors in foundation trusts and their capacity to hold boards to account.
Keywords: foundation trust governors, governance, institutional theory, mental health service user involvement
Design, setting and participants The Council of Governors in three foundation trusts were observed for a year. Focus groups with service user governors were undertaken in each trust. Results Service users had different expectations and understandings of the role and approached it in different ways. Key themes that emerged concerned: the role of a governor, conduct and content of meetings, agenda setting, relationships and representation. Discussion and conclusions The experiences of mental health service user governors need to be understood within the complex environment of patient and public involvement in general and of mental health service user involvement in particular. The dislocation of the service user governor role from other forms of service user activity and involvement result in confusion about how notions of holding a trust to account and representation of other service users can be addressed within a boundaried institutional environment.
Introduction The development of National Health Service Foundation Trusts in England was promoted as one way of reducing the democratic deficit within the National Health Service. Concern
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over such a deficit had been expressed by analysts and academics for many years, and diverse initiatives and policies had attempted to respond to such concerns.1,2 Foundation trusts (FTs) have been described as mechanisms for giving local stakeholders and the
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public opportunities to be involved in the strategic development of the organizations and to guide their operations.3 They were introduced by New Labour following the Health and Social Care Act 2003 and the coalition government elected in 2010 remained committed to this model and set a timetable for all trusts to achieve FT status by 2014. Reforms to the 2003 legislation (2012) continue to inform their regulation. FTs are independent legal entities with financial flexibility and specific governance arrangements including opportunities for patients and the public to become members or governors. They are overseen by an independent regulator, Monitor, and by the Care Quality Commission.4 Individual trusts develop their own constitutions under the umbrella of national regulation and guidance. Councils of Governors (CoGs) are a mix of elected and appointed governors with a built in majority of ‘public and patient’ governors. Monitor states that governor bodies have significant power at their disposal via their statutory duties which include appointing and, if necessary, removing the chair, trust auditor and non-executive directors, as well as approving the appointment of the chief executive. More recently, their duties have expanded to include decision making around private patient work and approving proposed increases in non-NHS income.5 FTs were introduced in the context of an evolving and diverse set of mechanisms for patient and public involvement reflecting very different discourses underpinning the involvement of service users and citizens across the public sector as a whole and the NHS in particular.6,7 The lack of an overarching framework, indicating how involvement mechanisms relate and interact, has created a confused and complex landscape for service users and staff to negotiate.8,9 In principle, FTs’ governing structures provide valuable opportunities for service users to be involved in senior-level decision making. However, evidence from the limited empirical research into CoGs, all of which focus on acute rather than mental health
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trusts,9–11 highlights that the scope for influence is constrained by the lack of clarity and agreement around who lay governors represent, and how they communicate with their constituencies. This, alongside confusion about or ignorance of other mechanisms for involvement, may result in uncertainty about the scope of power and influence held by CoGs. A key rationale for establishing FTs was to increase accountability to local people with an ensuing increase in legitimacy for the organization. However, early assessments of governance processes indicate that notions of accountability and legitimacy are problematic. An increase in accountability to the local community and members has proved difficult to achieve when trust boards remain legally responsible to national regulatory bodies.8,12 Wilmot,13 in an analysis of the legitimacy of FTs, questions the extent to which greater legitimacy results from wider accountability. This, it is argued, is not only because trust boards have a legal responsibility to government and regulators, but also because the diverse make up of lay governors means it is unlikely that they will work in a ‘concerted or focused way’ (164), presenting opportunities for priorities of other stakeholders to dominate. Empirical evidence suggests that upward accountability, combined with a lack of clarity around the scope of the role of governors, limits the influence that any governors can exert.10,11 In this article, we consider the specific experiences of patient or user governors in the context of mental health FTs. Data for this were part of a broader study which explored the impact of mental health service user involvement, and whether new ways of delivering services and new systems of governance could be understood to be promoting individual rather than collective approaches to involvement, for example, via the ‘empowerment’ assumed to result from personalization, and through election of individual service users to trust governance bodies. We argue that a key factor affecting the experience of service user governors is the boundaried nature of this form of involvement which provides limited scope for
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influence. We use institutional theory14 to explain how bureaucratic and cultural norms constrain governors’ opportunities to hold trusts to account and thus limit the potential for this mode of involvement to address democratic deficits. First, we offer a brief analysis of the development of mental health service user involvement as a context for understanding this new form of participatory practice.
User involvement in mental health services: history and issues Action by users of mental health services to shape policy and service provision predates the consumerist initiatives of the late 1980s/1990s, as well as policies such as the introduction of FTs with roles for users in the governance of health services. Since the mid-1980s, users of mental health services have been creating their own spaces to support each other, reflect on what living with mental illness means and advocate for service change. Some groups entered into ‘partnerships’ with NHS agencies and sought to work within the system to achieve change. Others opted to provide alternative spaces where people could spend time with other service users; some focused on creativity as a way of giving expression to their experiences; others promoted and carried out user led research to generate new knowledge and understanding.15,16 The impact of mental illness on the whole lives of those who live with this has meant a broad focus for action. Organizing through collective action has been important as a means of receiving support from those sharing the experience of mental illness as well as achieving impact on services.17 The significance of action within the service user movement for the identities of those who have often been considered incompetent or irrational is profound.18 In this respect, the identity of ‘service user governor’ may have a particular significance for those who have often been subject to others’ decision making and a failure to give recognition to their contributions in this role may be particularly damaging.
Mental health user groups have faced dilemmas when deciding on strategies to work within the system or to remain outside a system that is itself sometimes identified as a source of harm. Many have sought to take advantage of the opportunities created by official sponsorship of involvement, whilst also maintaining a separate identity, control over their own organizations and the capacity to criticize as well as work with service providers and commissioners. Some have been unable to retain a distinct and independent identity in the face of NHS organizations that have ‘taken over’ responsibility for user involvement.17 A survey conducted in the early 2000s demonstrated that there had been a reduction in activity at national level since the previous decade and that the level of campaigning had also reduced.19 However, there were a substantial number of small local groups, most of which had active involvement with services. Research that has explored the experiences of groups operating at local and national level has demonstrated both the extent of expertise and learning generated by this activity, and the enduring nature of the challenges and barriers associated with effective user influence. These include personal challenges for people whose fluctuating mental health can mean consistent attendance at meetings is difficult, the enduring tendency to pathologize emotional responses to poor treatment, as well as being faced by complex and constantly changing structures within both the NHS in general and systems of patient and public involvement in particular.20,21 Relationships between mental health user groups and the mental health system have been considered by reference to the user movement as a new social movement. This movement emerged out of negative responses to services, has been supported by official policy regarding ‘user involvement’, but is arguably weakened by association with ‘the system.15,22 At a microlevel, interactions between service users and managers and professionals demonstrate tensions evident in many contexts in which ‘officials’ and ‘users’ interact, and which can be
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understood by reference to the conflict between institutional rules and norms shaping participatory practices, and the ambitions motivating user participants.6,23 The introduction of FTs and resulting opportunities for mental health service users to achieve both recognition and influence via becoming user governors needs to be understood in this context.
Methods The research took place over the course of a year in three mental health FTs: Trusts A (established 2006) and B (established 2007) were metropolitan and Trust C (established 2008) served a mixed rural/urban population. The metropolitan trusts service a younger, more ethnically diverse population with greater mental health needs than other parts of the United Kingdom.24 Trusts were selected to reflect different contexts for involvement: Trust A was undergoing reconfiguration affecting service delivery. Trust B was paying close attention to lay representation at a strategic level, whilst Trust C covered a wide geographical area with areas of dispersed population. In addition to statutory requirements relating to user governors, all adopted diverse methods for involving service users including consumerist mechanisms such as user surveys, as well as more deliberative methods such as topic- and service-based forums, and via user input to recruitment and staff training. The overall study utilized a mixed methods approach, appropriate for the study of organizational dynamics and change.25,26 Methods included surveys of staff and users and interviews with senior professionals to explore perceptions of the impact of user involvement, as well as case studies of user groups and (the subject of this paper) service user involvement as governors. A report of the full study has been published.27 Three data gathering methods were used for the case studies of user governors. We observed the public parts of three quarterly CoG meetings in Trusts B and C and of two such
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meetings in Trust A. Secondly, minutes of meetings were scrutinized, allowing comparison between observations and formal recordings of meetings. Thirdly, we held focus groups in each trust involving a total of 14 service user governors. Access issues in Trust A allowed only one focus group, whereas two were held in the others. Our experiences of accessing service user governors varied. An element of ‘gate-keeping’ was encountered in Trusts A and C. Access was most problematic in Trust A where we had difficulty in establishing who the service user governors were due to inadequate or inaccurate information on websites and a lack of response to enquiries. Observations of CoG meetings focussed primarily on service user governors’ contributions and responses to these. We used a framework for recording observations, noting who contributed, who they directed their comment to and the nature of the contribution, that is question or comment, initiating a point or responding, challenging or facilitative. In Trusts B and C, we were invited to attend other meetings associated with the CoG. We attended two subcommittees in Trust B: one concerned with member engagement, chaired by a service user governor, and one addressing social inclusion and recovery. In Trust C, we attended a pre-meeting for governors only where the upcoming agenda was discussed and responses agreed. Focus groups with service user governors were held away from trust premises. Topics for discussion were based on analysis of national guidance as well as observations of meetings. They included processes for agenda setting, the role and impact of service user governors and how service user governors negotiate and value various relationships associated with the role. Three researchers worked with the metropolitan trusts and two with the rural one. A qualitative data analysis programme, NVivo version 9 (QSR International, Warrington, UK), facilitated management and analysis of data across sites. Findings were derived from adopting a triangulation approach to analysis and synthesis of themes from observations,
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document analysis and focus groups. Data were analysed using coding frameworks underpinned by insights from new social movement and institutional theory and previous research in user involvement which had informed research questions. These were adapted as necessary (i.e. deletions and additions made as appropriate) producing final versions which were used to populate a combined coding framework for each trust. Thematic content analysis was carried out by trust and later, between trusts, incorporating identification of ‘negative categories’, that is instances where participants appear to be contradicting what has been said elsewhere. This process involved a ‘constant comparative method’ (derived from grounded theory approach28), which facilitated consideration of who was saying what and, importantly, in what context. This allowed for cumulative insights to emerge. This process facilitated the identification of similarities and differences across the sites and across a range of issues.29
Findings Key themes emerging from focus group discussions and observations concerned the role of a governor, conduct and content of meetings, agenda setting, relationships and representation. The role of a governor Being a governor is attractive to service users as it is perceived to offer potential for a higher level of influence than other involvement opportunities. However, participants expressed varying degrees of confusion and frustration surrounding the scope of the role in practice. Levels of satisfaction related to the degree of difficulty experienced by researchers in accessing governors in different trusts, and with the organizational processes surrounding CoGs such as associated meetings and committees. Thus, user governors in Trust A were most dissatisfied. In all three trusts, service user governors commented upon a lack of clarity
about the role and for many, there was a mismatch between expectations and reality. This lack of clarity was cited by some as contributing to service user governors’ frustration with the role and their level of influence. Whilst national guidance indicates that a key element of their role is to hold trust directors ‘to account’, evidence from focus groups highlighted that some service user governors in all three trusts felt their ability to do this was limited. Many shared a sense that decisions had already been made by trust directors with governor input being more ‘rubber-stamping’ than deep involvement in consideration of alternatives. An example of this was noted in observations in Trust C where CoG approval of changes to the constitution was sought. Meeting conduct and content CoG meetings are formal, operating with agendas, dominated by presentations of information from trust boards, supported by dense paperwork. Members of each council directed contributions to the chair or senior managers. In all three trusts, openings for questions and comments were closely managed by the chair. Opportunities for discussion or debate were very limited. In contrast, subcommittees and governor pre-meetings, where they were in place, were more informal, offering opportunities for exploration of issues. Evidence from observations and focus groups highlighted that in Trusts A and C, service user governors’ requests for information from managers were responded to by signposting to lengthy documents that may have been circulated or on a website. Governors found such responses suggesting service user governors explore dense, technical paperwork to find answers, unreasonable. Comparison between official records and researchers’ observations indicated that adoption of a formal approach by service user governors in meetings, accompanied by explicit wishes for contributions to be minuted, lessened the likelihood of their contributions being omitted from minutes or recorded inaccurately.
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However, it was not only accuracy that emerged from comparison. In Trusts A and C, service user governors expressed their views with a strength of feeling that was not reflected in minutes. Nor were obvious agreements expressed by other governors always recorded. Service user governors’ inputs to meetings can be divided into those that focussed on specific aspects of the operation of the trust, and others related to the operation of the CoG itself. The former often focused on specific service delivery issues. These included the following: the implementation of a telephone helpline, phone answering/messaging issues, complaints procedures and impact on service users of trust expansion/reconfiguration. In Trust B, service user governors were satisfied that service delivery issues could be raised and addressed via the well-developed subcommittee structure. However, participants in Trust C expressed frustration that management discouraged contributions classified as ‘operational’ within the main CoG meetings. Governors were told that their role was a strategic one and therefore the CoG was not an appropriate forum for raising service delivery matters. In a focus group, one reported attempts to restrict input. She cited efforts to ensure that concerns relating to the trust’s mental health phone line became a standing item on the agenda: I feel that every time I have brought it up it’s actually been swept completely and utterly under the carpet and I keep raising the banner on it and I shall keep raising the banner on it and I shall not let go.
Contributions relating to the operation of the CoG itself included seeking assurance that support for governors would continue, and be delivered appropriately, and suggestions about how CoGs and associated subcommittees could operate better, for example by implementation of a timeline for responses to governors; better facilitation of members’ meetings; development of links with Clinical Commissioning Groups and development of systems to better accommodate service user governors’ fluctuating
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health. At times, contributions focused on trust business. Examples include requests for information on issues such as untoward incidents or the management of risk associated with restructuring, feedback on the Care Quality Commission’s response to trust work or questions regarding use of trust funds. Agenda setting One way of exerting influence within a formal meeting is the ability to put issues on the agenda. Service user governors discussed how this worked within their respective CoGs. Understandings of their ability to contribute to the agenda differed, although overall it was agreed that they are not actively encouraged to do so. I don’t think we’re personally invited to. I don’t personally feel we’re encouraged to, I think that’s a better word, to contribute to it. . .. (B)
Governors in Trust B, in which service user involvement is more embedded, tended to be most positive in this regard and commented on the effectiveness of the subcommittee system. In Trust C, service user governors generally had lower levels of satisfaction. They felt their ability to introduce topics for discussion was limited to raising issues under ‘Any Other Business’ and they expressed varying degrees of satisfaction with this. Service user governors in Trust A expressed deep discontent with their ability to influence the agenda of the CoG in any way. Service user governors did not refer to the mechanism outlined in their respective trusts’ constitutions, all of which indicate clear processes for submitting requests for items for inclusion to be sent to the chair in advance of meetings. Whilst in Trust B, the Trust Secretary was observed reminding all governors of the formal process for contributing to the agenda, the chair of Trust C failed to refer to the constitution when responding to a service user governor’s comment that there did not seem to be a mechanism for governors to propose agenda items. Rather, the response was
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that she was welcome to put forward suggestions which would be considered (presumably by the Chair). Relationships Service user governors in Trusts B and C saw opportunities to develop relationships with trust managers as central to their ability to achieve influence. In contrast to other mechanisms for involvement, they saw their participation in this context as a way of ‘getting to know people’, of having access to named individuals and being able to network with them. This tended to occur in the informal spaces before and after CoG meetings and within subcommittees: In terms of making a difference as a service user governor, I think it’s more around the access and being able to bend someone’s ear (C)
In Trust A, however, relationships between service user governors and trust management were described in more negative terms, and communication appeared poor. These responses suggest that service user governors view access to the development of individual relationships with management, forged in informal spaces, as a key mechanism for influence. It is unclear whether relationships (understood here simply as knowing who the person is) with those who are also governors or managers reporting to governors meetings are sufficiently robust and well focussed to enable service user governors to pursue issues that may, for example, derive from their involvement in other user groups. Indeed, during the research period, the Chief Executive Officer of one user led organization resigned from her position as governor within Trust C as she was frustrated by the lack of influence this role offered. Arguably, her networking opportunities came from the length of her experience within the user led organization, not from her formal status as a governor. An alternative set of relationships was discussed by participants in Trust C. This was the importance of relationships between service
user governors as a group. A newly elected service user governor suggested that these governors meet together, allowing exchange of information and distillation of key issues pertinent to the wider service user population. Representation Service user governors are elected by the FT membership. However, views on issues related to representing other service users varied. Some participants questioned the extent to which they could represent other service users. A number expressed a sense of duty to those who had elected them, but concern and frustration when they felt that they had failed to represent them, talking in terms of ‘letting them down’. Others felt less exercised on this issue, expressing doubt about whether they could adequately represent other service users. Some questioned whether it was actually a core part of their role to represent other service users. One participant questioned his mandate as he, in common with some others, was no longer a service user himself, nor did he belong to a user led organization: it raises the issue about where we get our information from, about how services are used, how services are working and whether the information is accurate or representative. (C)
Those user governors who are active members of user led organizations differed in their views of whether, as a governor, they should represent the views of their group or those of service users as a whole. One described a disjunction between her expectations of the role of governor and her experience in terms of being able to represent other service users. The majority felt that they could use information from their involvement in groups to inform their practice as governors, but that there is insufficient clarity about appropriate forums for raising service users’ concerns. In Trust C, governors indicated unease with a situation where they perceived the then lead governor to have strong allegiances to the board of directors. Concerns centred on his
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attempts to use his influence with governors to encourage them to comply with board wishes. There are important practical issues related to enabling governors to represent constituents. We found that available mechanisms and resources varied in the three trusts. In Trust B, the work of a subcommittee of the CoG was dedicated to maintaining such contact whereas this mechanism was less well developed in the others.
Discussion The experiences of mental health service user governors need to be understood within the complex environment of patient and public involvement in general, and of mental health service user involvement in particular. Collective action amongst service users has been theorized by reference to new social movements and the tensions between autonomous action and experiences within official involvement forums can be understood to reflect the coming together of very different ways of thinking about such involvement.30,31 Drawing on institutional theory, we explore the boundaried nature of involvement in formal governance mechanisms within a broader context of mental health service user involvement. We situate our analysis in relation to Lowndes and Roberts’ ‘third wave’ institutionalism23 which argues that all institutionalism is underpinned by common core concepts of rules, practices and narratives which act as forms of constraint. Rules are formally constructed and recorded, practices are demonstrated through conduct, and narratives refer to what is implied or expressed through the spoken word. Our findings illustrate how the institutional rules and practices of the NHS are embodied within CoG meetings and that there is little evidence to suggest a new narrative of public accountability is being expressed through these forums. This is arguably due to the adoption of familiar bureaucratic approaches to debate, and of recruitment mechanisms that ignore the existence of organized groups of service users. This is particularly significant in the mental
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health context where collective organization has been important in enabling individual service users both to develop confidence and to give voice to experience, and which offers a way of connecting to the wider experience of service users in general. We suggest this runs the risk of missing beneficial linkages between such organizations and CoGs, as well as creating confusion due to the different, disconnected routes by which service users are invited to take part. CoG meetings are bureaucratic, requiring governors to engage with dense, and sometimes technical, paperwork. Our findings resonate with those of Horrocks et al.’s32 in that the majority of time in meetings is taken by presentations from managers with limited opportunities for questions and debate. This practice is familiar to managers and some governors. However, such taken for granted practices cause some service user governors discomfort and frustration. Robust subcommittee structures are characterized by greater informality and acceptance of different forms of behaviour and expression. Service user governors’ expectations included that the role would offer a route for raising service delivery, or operational, issues of importance to service users. Whilst the guidance for FT governors clearly states that their responsibility lies at a strategic level, our evidence highlights how trusts operated in different ways in relation to this. The practice in Trust B was use of a system of subcommittees, offering opportunities for greater collective working, with which service user governors were generally satisfied. However, service user governors in the other trusts felt constricted by emphasis on the strategic nature of their role and the implicit disconnect between strategy and service delivery. This, combined with an absence of alternative trust-wide mechanisms for addressing operational issues, contributed to frustration. Service user governors’ use of individual relationships with members of management to affect influence illustrates a practice dependent upon interpersonal interactions and goodwill rather than a governance mechanism that
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supports the raising and addressing of issues with associated recording and tracking. So in terms of accountability, evidence suggests that many service user governors’ priorities are to hold the trust to account on service delivery issues which, in the absence of strong supporting mechanisms such as effective subcommittees feeding meaningfully into CoGs’ business, the strategic focus of the role precludes. FTs adopted an unquestioning approach to government guidance. There had been no discussion with governors in the three trusts in our study about terms such as ‘hold to account’ and ‘representation’ and what they mean in practice to different stakeholders. This exacerbated governors’ uncertainty about their remit and the scope of their role. The expectations and hopes for influence offered by a senior role in governance were neither anticipated nor surfaced in any of the trusts. Rather, traditional ways of working and a tendency to look upwards in terms of accountability, rather than to constituencies, prevailed. Practices such as agendas being prepared by trust management continue with apparent ignorance of constitutional rules indicating governors can contribute. The example of a chair’s response to a service user governor’s query on this issue illustrates an assumption of power. So whilst rules indicate a shift in accountability, everyday practices and narratives restrict opportunities for change. Our qualitative study suggests we should be cautious about Monitor’s33 findings regarding the capacity of governors to hold FTs to account. This large-scale survey of all categories of governor may have generated over positive results in relation to the experience of service user governors. As noted by Ham and Hunt,34 the needs and experiences of different categories of governor should be given greater attention.
Conclusions Our study of the role and experiences of service user governors was limited in terms of length (restricting the tracking of issues over time) and numbers of user governors engaging in
focus groups. However, data suggest that a key factor that influences user governors’ levels of satisfaction with the role, and perceptions of influence, is the structure that supports the CoGs. That is, a robust structure of effective subcommittees appears to be more relevant than the length of time an organization has been an FT as the most dissatisfied governors were those within the trust that has been established the longest. Service user governors’ experiences differed within individual trusts and between trusts. We have focussed on exploration of issues that were common to the three trusts in our study. We have argued that the experiences of service user governors in mental health FTs need to be understood within the broader context of the history of user involvement. Service users who have, in the past, either found effective involvement in the delivery of mental health services elusive or, at worst, damaging, are attracted to an opportunity to be part of governance processes and have expectations of meaningful levels of influence. However, the dislocation of the service user governor role from other forms of involvement result in confusion about how trusts can be held to account and other service users can be represented. This continues to risk negative impacts on those who do get involved. New narratives of public accountability and prioritization of service user involvement are not being translated in a coherent way into revised rules and practices which reduces the potential for CoGs to address the democratic deficit within health services. Previous research and Monitor evaluations of the work of CoGs have predominantly explored the role of all governors as a group. We have illustrated the added value gained from focussing in greater depth on the role of service user governors in mental health FTs and suggest that such is necessary to help inform future guidance for governors and regulators.
Conflict of interests No conflict of interests has been declared.
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Source of funding National Institute for Health Research Service Delivery and Organisation Programme, NIHR Service Delivery and Organisation programme.
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Service user governors in mental health trusts, D MacDonald et al. 27 Rose D, Barnes M, Crawford M, Omeni E, MacDonald D, Wilson A. How do managers and leaders in the National Health Service and social care respond to service user involvement in mental health services in both its traditional and emergent forms? The ENSUE study Health Service Delivery Research, 2014; 2, doi: 10.3310/hsdr02100. 28 Glaser B, Strauss A. The Discovery of Grounded Theory. Hawthorne, NY: Aldine Publishing Company, 1967. 29 Yin RK. Case Study Research Design and Methods, 4th edn. London: Sage, 2009. 30 Barnes M. Passionate Participation: emotional experiences and expressions in deliberative forums. Critical Social Policy, 2008; 28: 461–481. 31 Rogers A, Pilgrim D. ‘Pulling down churches’: accounting for the British mental health users movement. Sociology of Health and Illness, 1991; 13: 129–148.
32 Horrocks J, Lyons C, Hopley P. Does strategic involvement of mental health service users and carers in the planning, design and commissioning of mental health services lead to better outcomes? International Journal of Consumer Studies, 2010; 34: 562–569. 33 Monitor. Survey of NHS Foundation Trust Governors, 2010/11. Available at: http://www. monitornhsft.gov.uk/sites/default/files/Survey%20of %20NHS%20foundation%20trust%20governors% 202010%2011.pdf, accessed 26 September 2013. 34 Ham C, Hunt P. Membership of Governance in NHS Foundation Trusts a Review for the Department of Health, 2008. Available at: http:// www.mutuo.co.uk/wp-content/shared/nhs-ft-review.pdf, accessed 23 September 2013.
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Service user governors in mental health foundation trusts: accountability or business as usual? Dee MacDonald,* Marian Barnes,† Mike Crawford,‡ Edward Omeni,§ Aaron Wilson§ and Diana Rose¶ *Research Fellow, †Emeritus Professor of Social Policy, University of Brighton, Brighton, ‡Professor in Mental Health Research, Imperial College London, London and §Research Worker, ¶Professor of User-Led Research, King’s College, London, UK
Abstract Correspondence Dee MacDonald Research Fellow School of Applied Social Science University of Brighton Falmer Brighton, BN1 9PH UK E-mail: D.M.MacDonald@brighton. ac.uk
Context National Health Foundation Trusts present opportunities for individual mental health service users to be active in the governance of trusts. This is one of a range of mechanisms for patient and public involvement and one which promotes an individual rather than collective approach to involvement.
Accepted for publication 2 September 2014
Objective Within the context of a broader study of the impact of service user involvement in mental health services, the objective of this article was to explore the experience of service user governors in foundation trusts and their capacity to hold boards to account.
Keywords: foundation trust governors, governance, institutional theory, mental health service user involvement
Design, setting and participants The Council of Governors in three foundation trusts were observed for a year. Focus groups with service user governors were undertaken in each trust. Results Service users had different expectations and understandings of the role and approached it in different ways. Key themes that emerged concerned: the role of a governor, conduct and content of meetings, agenda setting, relationships and representation. Discussion and conclusions The experiences of mental health service user governors need to be understood within the complex environment of patient and public involvement in general and of mental health service user involvement in particular. The dislocation of the service user governor role from other forms of service user activity and involvement result in confusion about how notions of holding a trust to account and representation of other service users can be addressed within a boundaried institutional environment.
Introduction The development of National Health Service Foundation Trusts in England was promoted as one way of reducing the democratic deficit within the National Health Service. Concern
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over such a deficit had been expressed by analysts and academics for many years, and diverse initiatives and policies had attempted to respond to such concerns.1,2 Foundation trusts (FTs) have been described as mechanisms for giving local stakeholders and the
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public opportunities to be involved in the strategic development of the organizations and to guide their operations.3 They were introduced by New Labour following the Health and Social Care Act 2003 and the coalition government elected in 2010 remained committed to this model and set a timetable for all trusts to achieve FT status by 2014. Reforms to the 2003 legislation (2012) continue to inform their regulation. FTs are independent legal entities with financial flexibility and specific governance arrangements including opportunities for patients and the public to become members or governors. They are overseen by an independent regulator, Monitor, and by the Care Quality Commission.4 Individual trusts develop their own constitutions under the umbrella of national regulation and guidance. Councils of Governors (CoGs) are a mix of elected and appointed governors with a built in majority of ‘public and patient’ governors. Monitor states that governor bodies have significant power at their disposal via their statutory duties which include appointing and, if necessary, removing the chair, trust auditor and non-executive directors, as well as approving the appointment of the chief executive. More recently, their duties have expanded to include decision making around private patient work and approving proposed increases in non-NHS income.5 FTs were introduced in the context of an evolving and diverse set of mechanisms for patient and public involvement reflecting very different discourses underpinning the involvement of service users and citizens across the public sector as a whole and the NHS in particular.6,7 The lack of an overarching framework, indicating how involvement mechanisms relate and interact, has created a confused and complex landscape for service users and staff to negotiate.8,9 In principle, FTs’ governing structures provide valuable opportunities for service users to be involved in senior-level decision making. However, evidence from the limited empirical research into CoGs, all of which focus on acute rather than mental health
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trusts,9–11 highlights that the scope for influence is constrained by the lack of clarity and agreement around who lay governors represent, and how they communicate with their constituencies. This, alongside confusion about or ignorance of other mechanisms for involvement, may result in uncertainty about the scope of power and influence held by CoGs. A key rationale for establishing FTs was to increase accountability to local people with an ensuing increase in legitimacy for the organization. However, early assessments of governance processes indicate that notions of accountability and legitimacy are problematic. An increase in accountability to the local community and members has proved difficult to achieve when trust boards remain legally responsible to national regulatory bodies.8,12 Wilmot,13 in an analysis of the legitimacy of FTs, questions the extent to which greater legitimacy results from wider accountability. This, it is argued, is not only because trust boards have a legal responsibility to government and regulators, but also because the diverse make up of lay governors means it is unlikely that they will work in a ‘concerted or focused way’ (164), presenting opportunities for priorities of other stakeholders to dominate. Empirical evidence suggests that upward accountability, combined with a lack of clarity around the scope of the role of governors, limits the influence that any governors can exert.10,11 In this article, we consider the specific experiences of patient or user governors in the context of mental health FTs. Data for this were part of a broader study which explored the impact of mental health service user involvement, and whether new ways of delivering services and new systems of governance could be understood to be promoting individual rather than collective approaches to involvement, for example, via the ‘empowerment’ assumed to result from personalization, and through election of individual service users to trust governance bodies. We argue that a key factor affecting the experience of service user governors is the boundaried nature of this form of involvement which provides limited scope for
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influence. We use institutional theory14 to explain how bureaucratic and cultural norms constrain governors’ opportunities to hold trusts to account and thus limit the potential for this mode of involvement to address democratic deficits. First, we offer a brief analysis of the development of mental health service user involvement as a context for understanding this new form of participatory practice.
User involvement in mental health services: history and issues Action by users of mental health services to shape policy and service provision predates the consumerist initiatives of the late 1980s/1990s, as well as policies such as the introduction of FTs with roles for users in the governance of health services. Since the mid-1980s, users of mental health services have been creating their own spaces to support each other, reflect on what living with mental illness means and advocate for service change. Some groups entered into ‘partnerships’ with NHS agencies and sought to work within the system to achieve change. Others opted to provide alternative spaces where people could spend time with other service users; some focused on creativity as a way of giving expression to their experiences; others promoted and carried out user led research to generate new knowledge and understanding.15,16 The impact of mental illness on the whole lives of those who live with this has meant a broad focus for action. Organizing through collective action has been important as a means of receiving support from those sharing the experience of mental illness as well as achieving impact on services.17 The significance of action within the service user movement for the identities of those who have often been considered incompetent or irrational is profound.18 In this respect, the identity of ‘service user governor’ may have a particular significance for those who have often been subject to others’ decision making and a failure to give recognition to their contributions in this role may be particularly damaging.
Mental health user groups have faced dilemmas when deciding on strategies to work within the system or to remain outside a system that is itself sometimes identified as a source of harm. Many have sought to take advantage of the opportunities created by official sponsorship of involvement, whilst also maintaining a separate identity, control over their own organizations and the capacity to criticize as well as work with service providers and commissioners. Some have been unable to retain a distinct and independent identity in the face of NHS organizations that have ‘taken over’ responsibility for user involvement.17 A survey conducted in the early 2000s demonstrated that there had been a reduction in activity at national level since the previous decade and that the level of campaigning had also reduced.19 However, there were a substantial number of small local groups, most of which had active involvement with services. Research that has explored the experiences of groups operating at local and national level has demonstrated both the extent of expertise and learning generated by this activity, and the enduring nature of the challenges and barriers associated with effective user influence. These include personal challenges for people whose fluctuating mental health can mean consistent attendance at meetings is difficult, the enduring tendency to pathologize emotional responses to poor treatment, as well as being faced by complex and constantly changing structures within both the NHS in general and systems of patient and public involvement in particular.20,21 Relationships between mental health user groups and the mental health system have been considered by reference to the user movement as a new social movement. This movement emerged out of negative responses to services, has been supported by official policy regarding ‘user involvement’, but is arguably weakened by association with ‘the system.15,22 At a microlevel, interactions between service users and managers and professionals demonstrate tensions evident in many contexts in which ‘officials’ and ‘users’ interact, and which can be
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understood by reference to the conflict between institutional rules and norms shaping participatory practices, and the ambitions motivating user participants.6,23 The introduction of FTs and resulting opportunities for mental health service users to achieve both recognition and influence via becoming user governors needs to be understood in this context.
Methods The research took place over the course of a year in three mental health FTs: Trusts A (established 2006) and B (established 2007) were metropolitan and Trust C (established 2008) served a mixed rural/urban population. The metropolitan trusts service a younger, more ethnically diverse population with greater mental health needs than other parts of the United Kingdom.24 Trusts were selected to reflect different contexts for involvement: Trust A was undergoing reconfiguration affecting service delivery. Trust B was paying close attention to lay representation at a strategic level, whilst Trust C covered a wide geographical area with areas of dispersed population. In addition to statutory requirements relating to user governors, all adopted diverse methods for involving service users including consumerist mechanisms such as user surveys, as well as more deliberative methods such as topic- and service-based forums, and via user input to recruitment and staff training. The overall study utilized a mixed methods approach, appropriate for the study of organizational dynamics and change.25,26 Methods included surveys of staff and users and interviews with senior professionals to explore perceptions of the impact of user involvement, as well as case studies of user groups and (the subject of this paper) service user involvement as governors. A report of the full study has been published.27 Three data gathering methods were used for the case studies of user governors. We observed the public parts of three quarterly CoG meetings in Trusts B and C and of two such
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meetings in Trust A. Secondly, minutes of meetings were scrutinized, allowing comparison between observations and formal recordings of meetings. Thirdly, we held focus groups in each trust involving a total of 14 service user governors. Access issues in Trust A allowed only one focus group, whereas two were held in the others. Our experiences of accessing service user governors varied. An element of ‘gate-keeping’ was encountered in Trusts A and C. Access was most problematic in Trust A where we had difficulty in establishing who the service user governors were due to inadequate or inaccurate information on websites and a lack of response to enquiries. Observations of CoG meetings focussed primarily on service user governors’ contributions and responses to these. We used a framework for recording observations, noting who contributed, who they directed their comment to and the nature of the contribution, that is question or comment, initiating a point or responding, challenging or facilitative. In Trusts B and C, we were invited to attend other meetings associated with the CoG. We attended two subcommittees in Trust B: one concerned with member engagement, chaired by a service user governor, and one addressing social inclusion and recovery. In Trust C, we attended a pre-meeting for governors only where the upcoming agenda was discussed and responses agreed. Focus groups with service user governors were held away from trust premises. Topics for discussion were based on analysis of national guidance as well as observations of meetings. They included processes for agenda setting, the role and impact of service user governors and how service user governors negotiate and value various relationships associated with the role. Three researchers worked with the metropolitan trusts and two with the rural one. A qualitative data analysis programme, NVivo version 9 (QSR International, Warrington, UK), facilitated management and analysis of data across sites. Findings were derived from adopting a triangulation approach to analysis and synthesis of themes from observations,
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document analysis and focus groups. Data were analysed using coding frameworks underpinned by insights from new social movement and institutional theory and previous research in user involvement which had informed research questions. These were adapted as necessary (i.e. deletions and additions made as appropriate) producing final versions which were used to populate a combined coding framework for each trust. Thematic content analysis was carried out by trust and later, between trusts, incorporating identification of ‘negative categories’, that is instances where participants appear to be contradicting what has been said elsewhere. This process involved a ‘constant comparative method’ (derived from grounded theory approach28), which facilitated consideration of who was saying what and, importantly, in what context. This allowed for cumulative insights to emerge. This process facilitated the identification of similarities and differences across the sites and across a range of issues.29
Findings Key themes emerging from focus group discussions and observations concerned the role of a governor, conduct and content of meetings, agenda setting, relationships and representation. The role of a governor Being a governor is attractive to service users as it is perceived to offer potential for a higher level of influence than other involvement opportunities. However, participants expressed varying degrees of confusion and frustration surrounding the scope of the role in practice. Levels of satisfaction related to the degree of difficulty experienced by researchers in accessing governors in different trusts, and with the organizational processes surrounding CoGs such as associated meetings and committees. Thus, user governors in Trust A were most dissatisfied. In all three trusts, service user governors commented upon a lack of clarity
about the role and for many, there was a mismatch between expectations and reality. This lack of clarity was cited by some as contributing to service user governors’ frustration with the role and their level of influence. Whilst national guidance indicates that a key element of their role is to hold trust directors ‘to account’, evidence from focus groups highlighted that some service user governors in all three trusts felt their ability to do this was limited. Many shared a sense that decisions had already been made by trust directors with governor input being more ‘rubber-stamping’ than deep involvement in consideration of alternatives. An example of this was noted in observations in Trust C where CoG approval of changes to the constitution was sought. Meeting conduct and content CoG meetings are formal, operating with agendas, dominated by presentations of information from trust boards, supported by dense paperwork. Members of each council directed contributions to the chair or senior managers. In all three trusts, openings for questions and comments were closely managed by the chair. Opportunities for discussion or debate were very limited. In contrast, subcommittees and governor pre-meetings, where they were in place, were more informal, offering opportunities for exploration of issues. Evidence from observations and focus groups highlighted that in Trusts A and C, service user governors’ requests for information from managers were responded to by signposting to lengthy documents that may have been circulated or on a website. Governors found such responses suggesting service user governors explore dense, technical paperwork to find answers, unreasonable. Comparison between official records and researchers’ observations indicated that adoption of a formal approach by service user governors in meetings, accompanied by explicit wishes for contributions to be minuted, lessened the likelihood of their contributions being omitted from minutes or recorded inaccurately.
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However, it was not only accuracy that emerged from comparison. In Trusts A and C, service user governors expressed their views with a strength of feeling that was not reflected in minutes. Nor were obvious agreements expressed by other governors always recorded. Service user governors’ inputs to meetings can be divided into those that focussed on specific aspects of the operation of the trust, and others related to the operation of the CoG itself. The former often focused on specific service delivery issues. These included the following: the implementation of a telephone helpline, phone answering/messaging issues, complaints procedures and impact on service users of trust expansion/reconfiguration. In Trust B, service user governors were satisfied that service delivery issues could be raised and addressed via the well-developed subcommittee structure. However, participants in Trust C expressed frustration that management discouraged contributions classified as ‘operational’ within the main CoG meetings. Governors were told that their role was a strategic one and therefore the CoG was not an appropriate forum for raising service delivery matters. In a focus group, one reported attempts to restrict input. She cited efforts to ensure that concerns relating to the trust’s mental health phone line became a standing item on the agenda: I feel that every time I have brought it up it’s actually been swept completely and utterly under the carpet and I keep raising the banner on it and I shall keep raising the banner on it and I shall not let go.
Contributions relating to the operation of the CoG itself included seeking assurance that support for governors would continue, and be delivered appropriately, and suggestions about how CoGs and associated subcommittees could operate better, for example by implementation of a timeline for responses to governors; better facilitation of members’ meetings; development of links with Clinical Commissioning Groups and development of systems to better accommodate service user governors’ fluctuating
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health. At times, contributions focused on trust business. Examples include requests for information on issues such as untoward incidents or the management of risk associated with restructuring, feedback on the Care Quality Commission’s response to trust work or questions regarding use of trust funds. Agenda setting One way of exerting influence within a formal meeting is the ability to put issues on the agenda. Service user governors discussed how this worked within their respective CoGs. Understandings of their ability to contribute to the agenda differed, although overall it was agreed that they are not actively encouraged to do so. I don’t think we’re personally invited to. I don’t personally feel we’re encouraged to, I think that’s a better word, to contribute to it. . .. (B)
Governors in Trust B, in which service user involvement is more embedded, tended to be most positive in this regard and commented on the effectiveness of the subcommittee system. In Trust C, service user governors generally had lower levels of satisfaction. They felt their ability to introduce topics for discussion was limited to raising issues under ‘Any Other Business’ and they expressed varying degrees of satisfaction with this. Service user governors in Trust A expressed deep discontent with their ability to influence the agenda of the CoG in any way. Service user governors did not refer to the mechanism outlined in their respective trusts’ constitutions, all of which indicate clear processes for submitting requests for items for inclusion to be sent to the chair in advance of meetings. Whilst in Trust B, the Trust Secretary was observed reminding all governors of the formal process for contributing to the agenda, the chair of Trust C failed to refer to the constitution when responding to a service user governor’s comment that there did not seem to be a mechanism for governors to propose agenda items. Rather, the response was
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that she was welcome to put forward suggestions which would be considered (presumably by the Chair). Relationships Service user governors in Trusts B and C saw opportunities to develop relationships with trust managers as central to their ability to achieve influence. In contrast to other mechanisms for involvement, they saw their participation in this context as a way of ‘getting to know people’, of having access to named individuals and being able to network with them. This tended to occur in the informal spaces before and after CoG meetings and within subcommittees: In terms of making a difference as a service user governor, I think it’s more around the access and being able to bend someone’s ear (C)
In Trust A, however, relationships between service user governors and trust management were described in more negative terms, and communication appeared poor. These responses suggest that service user governors view access to the development of individual relationships with management, forged in informal spaces, as a key mechanism for influence. It is unclear whether relationships (understood here simply as knowing who the person is) with those who are also governors or managers reporting to governors meetings are sufficiently robust and well focussed to enable service user governors to pursue issues that may, for example, derive from their involvement in other user groups. Indeed, during the research period, the Chief Executive Officer of one user led organization resigned from her position as governor within Trust C as she was frustrated by the lack of influence this role offered. Arguably, her networking opportunities came from the length of her experience within the user led organization, not from her formal status as a governor. An alternative set of relationships was discussed by participants in Trust C. This was the importance of relationships between service
user governors as a group. A newly elected service user governor suggested that these governors meet together, allowing exchange of information and distillation of key issues pertinent to the wider service user population. Representation Service user governors are elected by the FT membership. However, views on issues related to representing other service users varied. Some participants questioned the extent to which they could represent other service users. A number expressed a sense of duty to those who had elected them, but concern and frustration when they felt that they had failed to represent them, talking in terms of ‘letting them down’. Others felt less exercised on this issue, expressing doubt about whether they could adequately represent other service users. Some questioned whether it was actually a core part of their role to represent other service users. One participant questioned his mandate as he, in common with some others, was no longer a service user himself, nor did he belong to a user led organization: it raises the issue about where we get our information from, about how services are used, how services are working and whether the information is accurate or representative. (C)
Those user governors who are active members of user led organizations differed in their views of whether, as a governor, they should represent the views of their group or those of service users as a whole. One described a disjunction between her expectations of the role of governor and her experience in terms of being able to represent other service users. The majority felt that they could use information from their involvement in groups to inform their practice as governors, but that there is insufficient clarity about appropriate forums for raising service users’ concerns. In Trust C, governors indicated unease with a situation where they perceived the then lead governor to have strong allegiances to the board of directors. Concerns centred on his
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attempts to use his influence with governors to encourage them to comply with board wishes. There are important practical issues related to enabling governors to represent constituents. We found that available mechanisms and resources varied in the three trusts. In Trust B, the work of a subcommittee of the CoG was dedicated to maintaining such contact whereas this mechanism was less well developed in the others.
Discussion The experiences of mental health service user governors need to be understood within the complex environment of patient and public involvement in general, and of mental health service user involvement in particular. Collective action amongst service users has been theorized by reference to new social movements and the tensions between autonomous action and experiences within official involvement forums can be understood to reflect the coming together of very different ways of thinking about such involvement.30,31 Drawing on institutional theory, we explore the boundaried nature of involvement in formal governance mechanisms within a broader context of mental health service user involvement. We situate our analysis in relation to Lowndes and Roberts’ ‘third wave’ institutionalism23 which argues that all institutionalism is underpinned by common core concepts of rules, practices and narratives which act as forms of constraint. Rules are formally constructed and recorded, practices are demonstrated through conduct, and narratives refer to what is implied or expressed through the spoken word. Our findings illustrate how the institutional rules and practices of the NHS are embodied within CoG meetings and that there is little evidence to suggest a new narrative of public accountability is being expressed through these forums. This is arguably due to the adoption of familiar bureaucratic approaches to debate, and of recruitment mechanisms that ignore the existence of organized groups of service users. This is particularly significant in the mental
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health context where collective organization has been important in enabling individual service users both to develop confidence and to give voice to experience, and which offers a way of connecting to the wider experience of service users in general. We suggest this runs the risk of missing beneficial linkages between such organizations and CoGs, as well as creating confusion due to the different, disconnected routes by which service users are invited to take part. CoG meetings are bureaucratic, requiring governors to engage with dense, and sometimes technical, paperwork. Our findings resonate with those of Horrocks et al.’s32 in that the majority of time in meetings is taken by presentations from managers with limited opportunities for questions and debate. This practice is familiar to managers and some governors. However, such taken for granted practices cause some service user governors discomfort and frustration. Robust subcommittee structures are characterized by greater informality and acceptance of different forms of behaviour and expression. Service user governors’ expectations included that the role would offer a route for raising service delivery, or operational, issues of importance to service users. Whilst the guidance for FT governors clearly states that their responsibility lies at a strategic level, our evidence highlights how trusts operated in different ways in relation to this. The practice in Trust B was use of a system of subcommittees, offering opportunities for greater collective working, with which service user governors were generally satisfied. However, service user governors in the other trusts felt constricted by emphasis on the strategic nature of their role and the implicit disconnect between strategy and service delivery. This, combined with an absence of alternative trust-wide mechanisms for addressing operational issues, contributed to frustration. Service user governors’ use of individual relationships with members of management to affect influence illustrates a practice dependent upon interpersonal interactions and goodwill rather than a governance mechanism that
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supports the raising and addressing of issues with associated recording and tracking. So in terms of accountability, evidence suggests that many service user governors’ priorities are to hold the trust to account on service delivery issues which, in the absence of strong supporting mechanisms such as effective subcommittees feeding meaningfully into CoGs’ business, the strategic focus of the role precludes. FTs adopted an unquestioning approach to government guidance. There had been no discussion with governors in the three trusts in our study about terms such as ‘hold to account’ and ‘representation’ and what they mean in practice to different stakeholders. This exacerbated governors’ uncertainty about their remit and the scope of their role. The expectations and hopes for influence offered by a senior role in governance were neither anticipated nor surfaced in any of the trusts. Rather, traditional ways of working and a tendency to look upwards in terms of accountability, rather than to constituencies, prevailed. Practices such as agendas being prepared by trust management continue with apparent ignorance of constitutional rules indicating governors can contribute. The example of a chair’s response to a service user governor’s query on this issue illustrates an assumption of power. So whilst rules indicate a shift in accountability, everyday practices and narratives restrict opportunities for change. Our qualitative study suggests we should be cautious about Monitor’s33 findings regarding the capacity of governors to hold FTs to account. This large-scale survey of all categories of governor may have generated over positive results in relation to the experience of service user governors. As noted by Ham and Hunt,34 the needs and experiences of different categories of governor should be given greater attention.
Conclusions Our study of the role and experiences of service user governors was limited in terms of length (restricting the tracking of issues over time) and numbers of user governors engaging in
focus groups. However, data suggest that a key factor that influences user governors’ levels of satisfaction with the role, and perceptions of influence, is the structure that supports the CoGs. That is, a robust structure of effective subcommittees appears to be more relevant than the length of time an organization has been an FT as the most dissatisfied governors were those within the trust that has been established the longest. Service user governors’ experiences differed within individual trusts and between trusts. We have focussed on exploration of issues that were common to the three trusts in our study. We have argued that the experiences of service user governors in mental health FTs need to be understood within the broader context of the history of user involvement. Service users who have, in the past, either found effective involvement in the delivery of mental health services elusive or, at worst, damaging, are attracted to an opportunity to be part of governance processes and have expectations of meaningful levels of influence. However, the dislocation of the service user governor role from other forms of involvement result in confusion about how trusts can be held to account and other service users can be represented. This continues to risk negative impacts on those who do get involved. New narratives of public accountability and prioritization of service user involvement are not being translated in a coherent way into revised rules and practices which reduces the potential for CoGs to address the democratic deficit within health services. Previous research and Monitor evaluations of the work of CoGs have predominantly explored the role of all governors as a group. We have illustrated the added value gained from focussing in greater depth on the role of service user governors in mental health FTs and suggest that such is necessary to help inform future guidance for governors and regulators.
Conflict of interests No conflict of interests has been declared.
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Source of funding National Institute for Health Research Service Delivery and Organisation Programme, NIHR Service Delivery and Organisation programme.
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