News analysis: The kids are alright, but are they ready to be governors?

Young people should be allowed to act as governors, argue children's trusts, with some suggesting children as young as 10 could have a useful input. But foundation trust regulator Monitor disagrees. Kaye McIntosh examines the arguments

Foundation trusts are 'at the heart of a patient-led NHS', according to the Department of Health. And for the first waves of acute trusts, greater public involvement seemed simple. Patients and local people are encouraged to join as members of the trust, receiving regular information or even becoming governors, with the right to approve the appointment of trust chairs and non-executive directors.

But these new roles throw up big challenges for specialist bodies such as mental health or children's trusts. How do you ensure these posts represent your constituency when your patients do not fit the standard template?

When regulator Monitor approved the first children's foundation trust earlier this year, specialist hospitals banded together with the Foundation Trust Network to argue that young people should be able to stand as governors. The network told Monitor: 'A prohibition against including young people in decision-making roles will mean that their patients as a whole are precluded from such roles and decisions will automatically continue to be taken on their behalf, rather than by them.'

But Monitor was unimpressed. Being a governor 'required an appropriate level of maturity and experience', it ruled. And that meant governors had to be at least 16.

Now that other children's trusts are gearing up for foundation status, the problem is becoming even more pressing. How do you ensure patients' interests are represented when they are not allowed to be governors? Chris Emerton is foundation trust director for Birmingham Children's Hospital, the next such trust in line for independent status. 'The vast majority of patients we treat are under five. Children aged 15 or 16-plus are the smallest group we treat. To be representative of the group we serve, we need a lower age limit,' she claims.

Youthful rationality

Ms Emerton argues that much younger children would be able to hold those positions: 'Evidence shows that children as young as 10 can make rational decisions.'

But Monitor will not be moved. A spokesperson says: 'Having looked carefully at what the obligations on governors are, to appoint or remove chairs and non-executives, our view was there would have to be an age limit with regard to whether people had the skills and maturity to carry those functions out.'

There are no plans to revisit the decision, he adds. 'There is a representative role for governors

but that doesn't outweigh the other arguments.'

But children's trusts insist their particular remit means they should be able to move beyond the model of patient engagement used by acute trusts. Network director Sue Slipman says mere membership is not enough: 'You can of course get participation but they also want people to be involved in the decision-making process, and for that you really require governorship.'

Ms Slipman says the issue will not go away. Trusts have discussed appealing to the children's commissioner, Professor Sir Al Aynsley-Green. The recent row over the impact of payment by results on children's trusts had meant the issue had been sidelined but 'as that is now settled, we will return to this'.

Great Ormond Street Hospital for Children chief executive Jane Collins agrees Monitor's ruling is still open to challenge: 'This restriction goes against our philosophy, as children and young people's involvement is a crucial underpinning strand of our work. Their participation is crucial in helping us improve services.' The majority of patients at the hospital, which is also preparing for foundation status, are aged under three. So appointing a 16-year-old governor would not do much for inclusiveness.

Welsh precedent

The network says concerns about the ability of under-16s to cope with responsibility have been resolved in other sectors. The Welsh youth council Funky Dragon is run by young people themselves but has been recognised as a charity. Charity trustees carry heavier duties than NHS trust governors as they have strict liabilities for the running of their organisations, similar to those for directors of limited companies.

A Charity Commission spokesperson says: 'There is no requirement for a director of a company to be any specific age, providing they are old enough to understand their duties and responsibilities.' Under-18s can be charity trustees, although they cannot sign contracts for legal reasons: 'There is nothing to say trustees have to be over 16 once the commission is satisfied the charity is well-run.'

The spokesperson adds: 'It would be redundant to have decisions made by a bunch of 50-year-olds for a children's charity. It might be that they want a 12-13-year-old as a young teenage representative - I can't see any restriction on that.'

For now, trusts have to work within the age limit. Sheffield Children's trust was the catalyst for the debate. The first children's trust to become a foundation, it has two 16-year-old governors but wanted to appoint a 14-year-old. It proposed holding individual meetings with each governor to establish training needs and areas of interest, facilitated by an organisation with experience of working with young people. With that blocked, Sheffield is now using patient liaison groups to engage younger members.

Involvement from 10

Great Ormond Street Hospital originally planned to recruit members aged 12 and over, but has now dropped the limit to 10 following consultation with stakeholders. A trust statement says: 'The board felt that as a leading children's institution we are obliged to involve as many of our patients as we can. Ten, as the age of criminal responsibility in England, seemed the lowest practical age.'

The trust is also looking at other ways to engage under-16s. A project called hearRvoice will see up to 100 members of staff appointed as 'participation champions'. They will be trained in order to ask patients their views on improving services and the experience of being patients of the trust. The views will feed into the foundation members' council. Great Ormond Street is already recruiting potential members in preparation for its foundation bid.

Birmingham is seeking to recruit children as young as four as members, registering through their parents. Those aged 14 and over will be able to join in their own right.

Ms Emerton says: 'Many of the patients we treat are under five so we felt it was appropriate that four to 16-year-olds can be members, to make our membership representative of the patient population.'

Small children can communicate their views about treatment, such as which hand to put a cannula in. So one can use age-appropriate techniques to involve them in decisions about the way their hospital is run, she argues. For instance, young children will often communicate more readily with puppets than with adults.

The trust is carrying out separate pieces of work with different age groups. Trust staff including play therapists visited the Castle Vale play scheme to consult 20 children aged nine to 11. They used drawings and activities to gauge opinion on a range of issues, says Ms Emerton, such as what information children wanted, and whether foundation trust status was a good idea. Fortunately, feedback was positive.

Engaging service users in mental health

The Foundation Trust Network argues that changing the way organisations communicate is the key to engaging with excluded groups - not just children but also adults, particularly mental health service users and people with learning disabilities.

Using plain English and banning jargon used by NHS insiders, for instance, helps to focus minds on what patients want.

The network warned Monitor against restricting the involvement of service users. A spokesperson for the regulator said this 'never became an issue' as there was never any intention to bar service users from taking part.

Three mental health trusts have now gained foundation status. South Staffordshire Healthcare trust has members aged from 14 and a long history of including patients and carers (chief executive Mike Cooke is himself a service user). The trust had already created six associate director posts for patients and carers.

Foundation status meant applying the lessons learned from working with associate directors to a new group of people - members and governors.

The trust prepared easy-to-use nomination forms and voting papers. It now has a 40-strong governors' council, with 21 members of the public including 11 service users.

Director of business development Stephen Grange says service users are 'very engaged'. Keeping the process of recruiting members in-house, rather than handing it to an external company, helped promote engagement, he believes.

And something as simple as sending an acknowledgement card to thank members for joining can have a big impact.

The trust has appointed liaison officers from existing members of staff to support governors. Each officer supports three or four governors. There was a thorough induction process, with meetings to establish what issues the governors wanted to be involved in and to provide orientation.

At induction days and governor sessions, the trust has used voting technology to gain and display feedback in a manner Mr Grange compares to 'ask the audience' on the TV programme Who Wants to Be a Millionaire?

'We were able to ask &Quot;what do you want more of&Quot; and have a way of scoring the response. It's not a didactic way of communicating but inclusive,' he says.

Real involvement

Governors are joining trust committees, getting involved in social enterprise projects and service planning and the trust membership strategy - setting up an editorial team for the members' newsletter and helping recruit new members.

One project where governors will become involved in raising the profile of the trust is in setting up a young people's walk-in centre in Burton-on-Trent, due to open in January. The steering group includes trust governors.

Mr Grange says the governors point out 'that's a really good idea or that's bad'. For instance, debates about the name of the building have been passionate. 'People want to call it ?That thing? so that it is not stigmatised.'

The only big problem Staffordshire has found so far is the election process. Mr Grange says the Electoral Reform Society, which runs the process, had a 'lack of experience in dealing with mental health clients'.

Hustings events would have helped to improve participation, for instance, rather than relying on postal votes.

His lesson to other trusts is 'be as inclusive with your members as possible but don't let them sit idle. This is not just a tick-box exercise. The reason people want to be involved is that they were engaged and communicated with through the process.'