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When M-A-C reviewed the available evidence on Foundation Trust Governors the King's Fund year-long study of the Governors at Homerton Foundation Trust was still awaited. Now that it is published, Putting Health in Local Hands: early experiences of Homerton University Hospital NHS Foundation Trust, M-A-C has considered it and we hope this review will be seen as an extension of the evidence review itself.

We need to state an interest in the topic since we worked with the Homerton Governors over the same period as Richard Lewis. We had an input into the Governors' development programme as well as conducting a small attitude tracking survey over the period. We therefore have a stake in whether or not the Governors learned and progressed over the period.

Put the latest King's Fund qualitative essay side by side with the Foundation Trust Network's recent publication NHS Foundation Trusts: making a difference (October 2005 links to PDF report) . You can't help but compare what is said about the Governors during their first year of operation at the Homerton Foundation Trust and the upbeat report on Governors in the FTN publication. Perhaps this is to be expected, since one of the key messages from the Kings's Fund study is that a year is just not enough time to see much substantive change that would show Governors making a positive difference. We agree: this is a snapshot of "early experiences" in just one Foundation Trust.

To get the bigger picture, what is needed is both qualitative work and a quantitative and chronological framework within which to set anecdotes and personal views so that changes in attitude, activity and output over time can be judged. Letting Governors "speak for themselves" was necessary and useful but we need data to help understand the actions the Foundation Trust could now take on the findings of the year-long study.

Methodology

Three questions are posed:

• What role or roles have been adopted by Homerton Hospital's governors?
• To what extent have foundation trust governors shared power within the decision-making structures of Homerton Hospital?
• What impact, if any, have governors had on the management of Homerton Hospital?

Did the study answer the questions? The questions were formulated before the interviews. They shaped the outcome of the study to the extent that they go beyond the simple description of roles and make judgements and seem to offer conclusions on the impact the Governors have had. Yet as the authors of the report say themselves, the data collected are not a proof of success or failure. More and different work remains to be done - perhaps by the Foundation Trust Network - to build on this early project.

Fifty-five interviews were held with 19 interviewees, but only 15 were Governors, in three rounds of interviewing (June/July 2004, October/November 2004 and April 2005) and observation of five Council of Governors meetings. There are 27 Governors at the Homerton. The untapped views of the other 12 governors could have changed the overall conclusions. Categorising and correlating Governors' views with their constituencies would have given another level of insight.

How was the transcribed interview data used? No particular methodology is stated and we do not know from the quotations who said what when. This approach does not produce a linear study: what Governor A said initially and then six months later about he same topic is important if we are to get an understanding of how the views of a number of Governors evolved through the year. As it stands, the interviews could all have taken place at the end of the 12 months and reached much the same conclusions.

Key Observations

We think the following are among the most insightful observations in the year-long study and they deserve attention in their own right for what they might say about all Foundation Trusts:

• lack of clarity about Governors' role
  Most of the potential for reversing this lies not with the Governors, but with the Board of Directors, especially the reported ambivalence of the executive directors towards issues of membership and democratic accountability which are new to the NHS. It was never intended for Governors to work on their own; they are a new part of the "gears of governance" in the FT public benefit corporation. The Board has responsibilities to work with Governors and through them to communicate with the Members and the wider community.
• worries about "representativeness" and the electoral numbers game
  Local authority councilors have no trouble holding office in a much more obvious and powerful way than FT Governors and with small votes in local elections. So it should be for FT Governors. It is the nature of the election process and the extent of its reach into the community that matters, not playing the electoral numbers game. If FT Members knew about voting and could vote but chose not to, it does not devalue the outcome, but this should be fed back into the Membership Development Strategy.
• advisory, guardianship and strategic roles for Governors
  Envisaged by legislation, these were found by Directors and Governors at Homerton Hospital to be "ambiguous and open to multiple interpretations." They are ambiguous and that's just the point! Each Foundation Trust has to decide for themselves what they mean and then apply them. That is part of what independence as a new type of organisation means - no one is going to tell FTs how to do these things.
• engagement with the Board of Directors
  This is different from forming links with individual executive directors. Collective engagement is the missing element. The Homerton Governors formulated clear and robust statements of how they wanted to engage and work with the Board. These aspirations deserve an ongoing response from the Directors.
• barriers to effectiveness
  For elected, particularly public Governors, there is no reward, no loss of earnings and huge learning and communication demands. As one observed: "paradoxically, perhaps, the more effective a governor, the less that governor can be considered lay." On the contrary. The lesson is that lay does not mean amateur and it also should not mean volunteer or unrewarded. This is going to have to be faced sooner rather than later in all aspects of lay involvement in the NHS.

Conclusion

There is little in the report's conclusions that we would dispute, though the study itself perhaps misses out on a sense of the tensions and passions during the Trust's first year. What is concerning is that others are picking the study's conclusions up selectively for their own purposes. The authors believe "the study provides deep insights into the workings of a key area of government policy". By its nature it does not and could not do this. But neither does it conclude that the Homerton Governors are failing. There simply has not been enough time for the evidence of success, or the lack of it, to accumulate: "one year in to the initiative, the relationship between the Council of Governors and the Board of Directors remained uncertain, notwithstanding sincere attempts by both Governors and Directors to reach a common understanding."

Our reservations are more with the approach than the top level findings. Future research in this area, we believe, must take a different tact. A qualitative study can say anything it wants given that the researcher can pick and choose from the views collected. The rest of us have no access to the raw data and have no basis to challenge any faults of omission or mis-placed emphasis in the methodology.

Uncertainty amongst the Governors about their role and within the Trust about their contribution remained at the end of year one - no one doubts that. But the unanswered question is "was this uncertainty less, more or the same at the end of period and why?" Data from M-A-C's three longitudinal surveys with this group suggests that no one really knows the answer yet, which is why a longer systematic data collection period in all Foundation Trusts is needed. The question must be answered if the induction and development of Foundation Trust Governors everywhere is to be improved.

As one appointed Governor said when interviewed: "if we can't make it work at the Homerton then you won't make it work anywhere." The groundwork for "making it work" is coming into place at this Foundation Trust and will be put in place at the others. It just takes time, planning, investment and support to make it happen. Democracy has no quick fixes and a "year in the life" snapshot of some of the Governors is really only long enough to show that they haven't downed tools in disillusion.

Lewis R, Hinton L. Putting Health in Local Hands: early experiences of Homerton University Hospital NHS Foundation Trust. Kings Fund, London: October, 2005. www.kingsfund.org.uk/publications