Beyond Councils of Governors: rethinking public accountability

Background: Foundation Trust status and Councils of Governors

As set out in NHS Providers Guide to Good Governance in the NHS, foundation trusts (FTs) were introduced by the Health and Social Care (Community Health and Standards) Act 2003, and the first FTs were authorised in 2004. The Labour government of the time envisaged that every NHS trust would eventually become a foundation trust with its own council of governors (CoG). However, subsequent changes in policy direction and legislation have led to a ‘mixed economy’ of NHS trusts and FTs.  

CoGs are a quasi-democratic means of making FTs accountable to the public they serve. While technically FTs still have greater autonomy than NHS trusts, in practice the distinctions between NHS trusts and FTs have diminished. CoGs are arguably the feature that most often comes to mind when considering the difference between FTs and NHS trusts. 

Governors are elected by trust members and are responsible for representing the interests of the public, patients, service users, carers and staff and for holding the board to account for its performance, via the non-executive directors (NEDs). Governors appointed by partners represent key stakeholders, such as local authorities, universities and the third sector. Where they are given sufficient support and encouragement, governors can challenge trust boards on things like board performance, strategic direction (to ensure it aligns with the needs of patients and service users) and quality of care. 

Policy context: impact of the new Health Bill

Recent national policy proposals would significantly reshape the architecture of patient and public accountability within foundation trusts. The 10‑year health plan sets out significant reforms to local accountability, including removing the statutory requirement for FTs to maintain CoGs, abolishing Healthwatch England and creating a patient experience directorate in the Department of health and Social Care (DHSC), and transferring local Healthwatch functions to ICBs. These measures are expected to be reflected in the forthcoming Health Bill, alongside the abolition of NHS England.

Should these proposals pass into legislation, FTs will need to design and implement new, credible routes for patient and public accountability to ensure that board‑level scrutiny, community insight, and independent challenge are not weakened by the loss of CoGs.

To inform the briefing, we held a peer learning event which consisted of two case studies from experts in patient leadership and a series of safe-space breakout rooms. The event was attended by a diverse audience, including NHS provider chairs, company secretaries, NEDs, and patient experience leads. A range of sectors were represented, including acute, mental health, ambulance and community which enabled a rich discussion.  

This briefing describes trusts’ views about the potential impact of the removal of governors, and where good practice is in the sector, and sets out some recommendations to help ensure the transition is as smooth as possible. 

It became clear during the session that attendees believe removing CoGs without a clear replacement creates a significant accountability gap. However, there is also a real opportunity to create something better, provided the transition is well-supported and grounded in some nationally agreed principles for what good public engagement and accountability looks like. 

Attendees described the current landscape as complex, uneven and under strain, shaped by differing statutory responsibilities, limited resources and variation in local practice. Attendees pointed to the fact that trusts have significant responsibility for maintaining public accountability in environments where there is often limited support, unclear expectations and sometimes inconsistent statutory mechanisms. 

To fully outline the impact of removing CoGs, it is important to distinguish between the different functions that patient and public involvement mechanisms currently fulfil. Participants distinguished between a wide range of internal and external mechanisms, each delivering different forms of assurance, representation, engagement and influence. 

1. Assurance – mechanisms that provide independent scrutiny of the board’s performance and decision-making. 
   
   
2. Representation – structures that ensure the views, priorities and demographics of local communities are reflected in trust governance.
   
   
3. Engagement – mechanisms that enable trusts to listen to, consult or involve people in understanding experiences and shaping services. 
   
   
4. Influence/ co-production – partnership approaches that involve patients and communities in designing or improving services. 

Many mechanisms are strong in one category, but not in others, which is why using a mixed-model approach is often most effective. It was clear, from discussion, that CoGs are most useful from an assurance angle and, to an extent, for statutory representation but this mechanism is weaker in terms of engagement and co-production.

Attendees highlighted the range of formal and informal mechanisms that trusts currently rely on; each of which carry out differing expectations and level of impact.   

External scrutiny and engagement mechanisms

1. CoGs – these remain the primary statutory route for accountability in FTs. It was agreed that, whilst it can be a flawed mechanism, CoGs provide vital assurance functions (particularly with regards to NED appointments and remuneration) that would make it challenging for trusts without them. CoGs are also intended to represent the local community.
   
   
2. Local authority scrutiny committees – these can provide robust oversight in some areas, but attendees noted that meetings can be numerous, can vary in effectiveness by geography and that they have not been designed to replace structured engagement.
   
   
3. ICS neighbourhood boards – these are emerging routes for community insight, but they sit outside trust control and vary in maturity.

A recurring theme in discussion was the need to understand not only the strengths and limitations of individual mechanisms, but also how these approaches can align with the engagement plans of system partners, including integrated care boards (ICBs), local authorities and voluntary, community and social enterprise (VCSE) organisations, to avoid duplication and create a coherent systemwide model of accountability. 

Internal assurance and engagement mechanisms

1. Trust board NEDs – the ‘critical friend’ role played by NEDs is a core safeguard. Attendees agreed, however, that it would be unfair to rely on NEDs to fulfil the public accountability role of the CoGs, not least because NEDs already have broad assurance portfolios and they must be safeguarded. 
   
   
2. Patient and family forums – advisory structures like patient panels or lived-experience panels are an area where trusts are investing significantly. Attendees note that these panels can provide rich and representative insight. It is worth noting, however, they do not have the same statutory power that CoGs have and therefore may ‘lack teeth’ – the onus is on FT culture and leadership to ensure such panels are impactful.
   
   
3. Freedom to Speak Up Guardians – Freedom to Speak Up (FTSU) Guardians provide an independent and confidential route for NHS staff to raise concerns about safety, quality, or wrongdoing without fear of detriment. They play a critical role in organisational assurance by identifying systemic issues early, supporting a culture of openness, and escalating concerns where necessary. 

The wider patient voice landscape was described as a key concern by attendees. Whilst the move to abolish Healthwatch England was intended to streamline bureaucracy, the decision risks removing a fundamental mechanism for patient advocacy that could have serious implications for the quality of NHS care. In particular, Healthwatch England was felt to serve a unique role in amalgamating concerns thematically and presenting trends. 

To explore alternative models of accountability, the session heard two case studies illustrating how trusts have embedded lived experience in governance and decision making.

David Gilbert, Patient Leadership Expert, InHealth Associates

David Gilbert presented a model he developed at Sussex MSK Partnership, where he served as the organisation’s first Patient Director. Central to the model is a patient leadership triangle. At its apex is the Patient Director, responsible for embedding patient-centred cultures, systems and processes, and for brokering meaningful dialogue between staff and patients and carers at all levels. The second element is a Patient and Carer Forum, which operates as a formal governance committee alongside groups such as Finance and Operations. The Forum provides reflective governance and oversight of the Patient Director’s programmes. The third element comprises patient and carer partners, who are equal partners in decision-making across the organisation, by formalising and paying patient roles, giving them defined authority and embedding them in core decision forums (MDTs) when quality and safety decisions are made.  

David discussed how the model contrasts with more traditional engagement mechanisms, which can rely on parent–child feedback models (“institutional paternalism”) that inadvertently position patients in opposition to professionals and deliver limited impact. Establishing a Patient Director at board level helps ensure that operational decisions remain grounded in patient experience, while creating a credible mechanism to challenge and hold the board to account on behalf of patients and communities. This model moves beyond “them and us” dynamics and brings patient engagement and accountability from the margins into the centre of day-to-day decision-making. David described the Patient Director as a powerful broker, enabling patients, clinicians and non-clinicians to co-design new approaches. This model also represents a fundamental shift in organisational culture, moving patient experience from the margins into the core of how the organisation thinks and behaves.  

David also highlighted the challenges of patient leadership. Drawing on his own experience, he noted the high risk of burnout among patient leaders, often due to limited peer support networks. He also reflected on the tension that the Patient Director must handle, as they must be embedded within the board whilst also maintaining sufficient distance to provide constructive challenge on behalf of patients. Finally, he emphasised the importance of a dual approach to board scrutiny of patient experience, combining independent external assurance with strong internal accountability mechanisms. 

Attendees acknowledged the personal cost of performing patient leadership roles, and it was agreed that those performing these roles must be supported and valued.

Alison Kirk, Head of Participation, Coproduction and Patient and Carer, Leicestershire Partnership Trust (LPT)

Alison presented the model in place at LPT which is a multi-layered system, embedded in trust governance, for ensuring that people with lived experience influence decision making across LPT. It integrates paid lived experience roles, formal advisory structures and co-production leadership.  

Central to the approach is a cohort of paid Lived Experience Partners (LEPs) employed on bank contracts, giving them access to training, development and wellbeing support. These partners work across the organisation in substantive roles, including co‑chairing co‑production groups and clinical reference groups, advising major programmes such as the Patient and Carer Race Equality Framework (PCREF) and Culture of Care, and supporting children’s, young people’s, learning disability and autism services. Alison noted that the lived experience cohort does not have governance or assurance responsibilities, which ensures that the model clearly separates voice and scrutiny from formal governance; something she believes is essential.  

A key feature of the model is its integration into existing governance structures and processes, ensuring lived experience perspectives influence decision‑making rather than being included retrospectively. LPT also has a People’s Council, which provides structured challenge and holds twice‑yearly development sessions with the Trust Board, strengthening organisational accountability. 

Finally, the model incorporates a Youth Advisory Board; a structure ensuring children and young people have an independent and influential voice in shaping services. 

Overall, LPT’s approach moves beyond traditional engagement by positioning lived experience as a source of expertise, leadership, and governance-level influence, while recognising areas for continued development such as maintaining representativeness and sustaining capacity. Alison noted that trusts could utilise existing ICS and community-level structures to continue the voice work that CoGs were doing, which was supported by attendees.  

Together, these models demonstrate practical ways to strengthen accountability and embed patient leadership, even in the absence of statutory mechanisms.

Attendee reflections on the case studies shared

Attendees responded positively to both models, particularly the way they reposition patient experience as a driver of strategic decisions rather than an adjunct activity. 

There was also acknowledgement that patient experience practice across acute settings is variable, not least because of the highly pressured environments in acute settings. An attendee specifically noted how acute episodic care can make it harder to track or understand patient experience (the same would also be true for ambulance services), but some areas (such as respiratory services) have stronger, ongoing relationships with patients which can help generate deeper insights.

There was a discussion about the importance of ensuring that patient experience is everyone’s responsibility, which requires active leadership and prioritisation. Attendees described how responsibility for patient experience and public accountability can tend to fall under the responsibility of the Chief Nurse’s portfolio, which is challenging because they already have incredibly busy portfolios. It was agreed that the benefit of such models can be found in the way that they can help ensure responsibility for patient engagement and public accountability is more evenly spread across the board and the organisation. Attendees also acknowledged that there is often a missing dimension at board level, which is patient experience-led challenge. Decisions can often be made without understanding the practical impact on care experiences.

Attendees appreciated the dual approach to engagement and accountability in both models and recognised the value of having codified structures for patient experience embedded into governance models.  It was also noted that governors can sometimes be detached from the day-to-day workings of the trust and in comparison, the models presented in the presentations demonstrate a more continuous and embedded relationship between patient and public voice, and organisational decision making.

Attendees also reflected on the fact that CoGs and lived experience partners serve fundamentally different purposes; governors are statutory and focus on assurance and governance whereas the lived experience model is less focused on governance and more on perspective, advice and constructive challenge. The danger was seen to be that trusts may conflate these two roles, which could cause confusion in the new landscape. 

Overall, attendees valued the way in patients/ public structures were truly made part of the system in the models presented. 

It was widely acknowledged that many high performing CoGs are currently feeling undervalued due to the national policy changes. 

Strengths

• When discussing CoGs’ role in accountability and patient voice, some attendees noted how patient representation and the formal governance role played by CoGs can be complimentary, and that losing governors may risk losing local accountability and genuine public connection. Local insight has been important for many trusts. 
  
  
• Attendees noted that CoGs can be very effective in holding the organisation to account, particularly in areas such as executive pay and providing additional checks and balances, which offer reassurance to Chairs and Boards. 
  
  
• There was discussion about the fact that CoGs also helpfully create an obligation for boards to engage and act upon patient and public feedback, which can sometimes be lacking in ‘softer’ accountability mechanisms.
  
  
• There was recognition that Governors often have a strong passion for patient experience and can provide meaningful lived-experience insights through thematic challenges, place-based audits, structured visits and roles for patient governors.
  
  
• Attendees discussed how CoGs also play an important role in challenging NEDs and through them, the board. When supported properly, governors can push for deeper patient experience improvement, especially as the system shifts towards more patient agency. 
  
  
• An additional strength mentioned was that staff Governors can provide important triangulation of sources on staff voice, especially for Freedom to Speak up. Governors can also understand and communicate the pulse of the organisation ‘from the inside’. This was especially important during COVID, as staff governors were able to provide early warnings and insights into operational pressures. Losing this triangulation mechanism would be a significant loss.
  
  
• One attendee flagged that CoGs also play an important role in representing future patients, not just current ones.

Challenges CoGs face

While many attendees highlighted the strengths of the CoG model, they also noted longstanding challenges that have limited its impact in practice.

• Attendees discussed how CoGs can sometimes not be totally representative of the local population, which can mean that insights fed in are overly reliant on a governor’s personal experience rather than the experience of the local communities. Attendees highlighted that there is a lack of system-wide support/good practice on election. Trusts also find it difficult to attract diverse or younger members for CoGs.
  
  
• It was mentioned that Governors do not receive extensive training or need any specific qualifications which can hinder the extent to which they can perform their role.  
  
  
• Attendees discussed how statutory roles are narrow and can overshadow more meaningful engagement, as the statutory duties can become the dominant focus, crowding out opportunities for real patient-centred work. This limits the usefulness of CoGs as engagement mechanisms.  
  
  
• Some trusts have experienced a lack of structure for governor feedback and follow through, with attendees describing a ‘black hole’ where governor visits happen and the feedback was never acted upon. This points to the need for governors to have clear reporting routes and engagement from executives, and for more accountability mechanisms for acting upon what governors see/hear.  
  
  
• Some trusts have variable approaches to how CoGs are structured and embedded – for example, some CoGs struggle due to operational pressure, some do not integrate governors effectively and some separate patient experience, engagement, complaints and communications which creates organisational silos. This makes organisation-wide coherence hard. 
  
  
• Attendees agreed that the culture of the board and the willingness of the board to listen can heavily impact the success and impact of the CoGs. Boards must nurture their CoGs, invite challenge and create routes to influence and, where this is not done, CoGs can be symbolic entities rather than impactful ones. 

Attendees expressed significant concern that the removal of CoGs, without a clear replacement, risks widening existing gaps in public accountability. 

• The loss of statutory external scrutiny. There was concern that eliminating statutory roles without offering a readymade alternative model leaves trusts to design their own solutions, leading to inconsistency and wide variation in approaches which could lead to unwarranted variation in quality of patient voice, levels of public accountability, and ultimately patient care. 
  
  
• There was a particular concern from attendees that the loss of CoGs could coincide with the loss of Healthwatch, which would create an even bigger accountability gap. 
  
  
• Attendees described how losing CoGs could mean that lived experience groups would risk becoming advisory only, which raises the risk of tokenism. 
  
  
• Attendees also discussed how the loss of CoGs could lead to dilution of local voice within ICS-level decisions.
  
  
• There was widespread acknowledgement that there would be many ‘loose threads’ that would need to be picked up if CoGs were to be removed, including remuneration oversight and codes of governance. 
  
  
• There was recognition that the loss of governors could also mean the loss of volunteers, the connection to areas of deprivation and the loss of a structured way to gather community input aligned with public health analysis. 

Overall, attendees discussed how a reform of the governor model would have been preferable to abolition. It is also problematic that there is no clear roadmap for whatever comes next, leaving trusts with a large amount of uncertainty and a lack of clarity.  

There was also discussion of the fact that the change offers a new opportunity to redesign engagement, and, with the wider system changes, the timing may be right to rethink patient and public involvement more broadly. This point was strengthened by the acknowledgement that patients experience the NHS as one system, not as individual trusts, which reiterates the case for a whole-system approach to engagement.

To safeguard meaningful patient and public accountability as CoGs are removed, attendees identified several areas where government action will be essential.

• Provide national principles on how trusts can assure themselves that they are maintaining accountability to local patients and the public.
  
  
• Develop more specific transition support so trusts have a clear roadmap.
  
  
• Clarify expectations on reporting and governance requirements during this transition period, and then in relation to public accountability, once CoGs are removed.
  
  
• Share good practice and learning from across England, so that trusts can learn from each other and have sight of the different models / mechanisms that exist.