In opposition, the SNP was critical of several Health Board decisions and came to power with the radical policy of allowing the public to elect most Directors, displacing Scottish Government appointees. Their experiment to ‘democratise’ the Scottish NHS, however, proved to be no panacea and was quietly scrapped. Iain Wilson, Ellen Stewart, Scott Greer, and Peter Donnelly explain what happened. 

Elected MPs and councillors may get the publicity, but most political decisions in Britain are actually made by appointees. Thousands of unelected members sit on a disparate collection of boards and committees. They are often little-known, but they make decisions that affect all our lives. Political parties regularly call for ‘democratisation’ of their trusts, quangos, committees and agencies, but a recent experiment in the Scottish NHS showed how challenging this goal can be.

The National Health Service in Scotland, as in England and Wales, is largely overseen by appointees. Although strategy is set in Edinburgh many significant decisions are made by the territorial Health Boards which manage hospitals and employ most NHS staff – no small responsibility since the NHS is by far Scotland’s largest employer. For added confusion, these Boards are directed by Boards (of Directors) which include top NHS managers and stakeholders but are dominated by ministerial appointees.

When such appointees do attract attention it is often for the wrong reasons. As Matthew Flinders and his colleagues put it, appointed Directors are stereotyped as ‘pale stale males’, middle-class white men doing a part-time job as they coast from comfortable professional jobs into retirement. The stereotype may be unfair, but appointed Directors in the Scottish NHS genuinely are much older and better-off than the populations they serve. They are also insulated from popular discontent. The general public can vote out the minister who appointed them, but cannot remove individual Directors.

The Scottish National Party was critical of several Health Board decisions in opposition, and came to power with the radical policy of allowing the public to elect most Directors, displacing Scottish Government appointees. After all, elsewhere in government having to stand for election is the gold standard of public accountability (and legitimacy). Elected members were touted as bringing ‘accountability to’ and ‘engagement with’ local communities. But what could elected members actually achieve on Health Boards? The Government authorised pilot all-postal elections in Fife and Dumfries & Galloway to find out.

The elected members had a rough start, not helped by several unfortunate quirks in the elections. Firstly, voting was scheduled within a few weeks of the 2010 General Election, which sucked attention away from these local contests (although it may also have distracted interest groups from trying to sway the outcome). Secondly, candidates had great difficulty communicating with the electorate. Health Boards cover large areas and are wary of appearing to favour one town or village over another, so candidates were expected to campaign across the whole Board area. But their spending was limited to £250, around £0.001 per resident. Unless they were already well-known their most important method of communication was a 250-word statement printed in a booklet sent out with each ballot paper. These contests each attracted 60 or 70 candidates. As a result, voters received booklets containing around 10,000 words of small print.

Unsurprisingly, turnout was low: 14 per cent in Fife, 22 per cent in Dumfries & Galloway. And the skew towards older voters was even more extreme than usual. An elector in the 60-80 range was twice as likely to vote as someone under 40. Moreover, the candidates who were eventually elected did not have strikingly different demographics from appointed Directors – although one or two of the personalities might not have been likely appointees.

We spent two years following these newly-elected members as they adapted to their ambiguous and sometimes uncomfortable position. Health Boards are an odd environment for politicians because their decision-making is almost always collective: in the jargon, they are strongly corporate bodies. Existing Directors emphasised social norms against public confrontation, and an expectation that conflicts would be resolved privately. Many established figures were concerned that public divisions would make the Boards unworkable because they have to come to collective, corporate decisions. Paradoxically, elected members could be held accountable by the public if they ever sought re-election, but the only way they could do anything was as part of the collective Board. And that Board remained accountable to a minister for all its decisions.

New members were divided on how they ought to behave, with few trying to act like conventional politicians. This was easier because voters remained uninformed about them, with few people able to name an elected Health Board member. Most elected members were not being pressed by the public to rebel against established policy. As a result, those members largely accepted the pragmatic, consensus decision-making process which had been in place before their arrival. This might represent socialisation into the norms of corporate behaviour, but elected members also emphasised their desire to be effective Directors. Boards monitor huge volumes of information about local NHS performance, and checking that cancer treatment or waiting times were satisfactory often seemed more important than arguing a case.

A few important exceptions did try to act more like conventional politicians. They had to face the mismatch between corporate decision-making and their individual electoral accountability. These were usually elected members who had campaigning experience or had made very specific manifesto-style commitments in their candidate statements before being elected, such as promising to hold surgeries with local residents. This was a serious worry for both pilot Boards, which were understandably worried about some parts of their areas being seen to have greater influence over the Board than others. From the elected members’ perspective, of course, meeting the public was the least a ‘representative’ could do – and even that proved problematic. Some struck compromises (such as holding surgeries far from their own homes) but one particularly committed campaigner eventually left the Board and resumed campaigning against its policies.

Suffice to say, grafting elections onto the Scottish NHS’s existing systems did not prove to be a panacea. This chimes with the experience of other countries which have tried to introduce elections into single-payer systems. In 2013 the Scottish Government quietly announced that no more elections would be held. Instead, Boards were to seek a wider pool of candidates for appointment – a much less radical change.

Note: This article gives the views of the authors, and not the position of the British Politics and Policy blog, nor of the London School of Economics. Please read our comments policy before posting. Featured image credit: Dave Conner CC BY 2.0

About the Authors

Iain WilsonIain Wilson is Sessional Professor in Political Science, Laurentian University at Barrie.



ellen stewartEllen Stewart is Chief Scientist Office Postdoctoral Fellow at Edinburgh University. She is leading a project on public engagement and protest around hospital closures and tweets from @EllenStu.


Scott L GreerScott L Greer is Associate Professor in the School of Public Health, University of Michigan. He tweets from @scottlgreer.


Peter DonnellyPeter Donnelly is President and Chief Executive Officer at Public Health Ontario. Prior to that, he was Professor of Public Health Medicine at the University of St. Andrews.

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