The Department of Health's plan for foundation hospitals to organise elections to their governing bodies was in chaos last night as local NHS chiefs warned they were open to takeover by Trotskyists and other extremist groups.
John Reid, health secretary, defeated a Labour backbench rebellion last month against the foundation proposals after promising they would enhance local democracy. He said control would pass from Whitehall to patients, local residents and staff who would elect the trusts' ruling councils.
But so few people have registered to become voting members of the trusts that the results could be determined by a small number of political activists or patient groups eager to gain a larger share of NHS resources for treating a particular medical condition.
University College London Hospitals (UCLH), a trust that led the campaign for foundation status, said: "It is a real concern of a number of trusts, particularly in the inner cities outside London, that an interest group or Trot element can take over and change the rules."
University College Birmingham NHS Trust said: "The BNP is a concern, but we have no evidence they are organising."
Under the legislation, foundation trusts cannot come into being on schedule on April 1 without elections being held and the results declared, allowing the new governing bodies to elect a chair and non-executive directors.
The department admitted yesterday that it has not yet sent out guidelines to the trusts on how these elections should be organised, but plans to do so next week. A spokeswoman said this was in good time because the electoral process will take 10 weeks.
Some hospital chiefs fear the rules will arrive too late. UCLH started sending election material yesterday to patients and local residents who registered to become voting members.
Senior managers decided this was the last possible date to allow the newly elected governors time to prepare for a board meeting on April 1.
The Guardian contacted most of the applicant foundation trusts yesterday and got answers about electoral plans from more than half.
Guy's and St Thomas trust in London said it has registered 663 prospective members, eligible to vote for 20 seats on its members' council. About 8,000 staff will vote for seven seats and local organisations will appoint 10. It is writing to 45,000 former patients to recruit more members.
UCLH said it has registered 600 patient and public members, Doncaster 801, North Tees and Hartlepool 1,200, Sheffield Teaching Hospitals 1,500, Southern Derbyshire Acute Hospitals 1,200, Queen Victoria in West Sussex 2,000, King's College, London 3,500, Addenbrooke's, Cambridge 2,131, and Moorfields Eye Hospital, London 1,600.
Others were unable to give a breakdown between public and staff members.
All the trusts willing to give information about electoral arrangements were planning postal ballots - some using first past the post, others the single transferable vote. All said they were redoubling their efforts to increase the membership before polling begins.
If they are not successful, their application to become foundation trusts may be refused or delayed by Bill Moyes, the independent regulator appointed by Mr Reid to police the process.
A spokesman said the regulator might block applications if trusts could not show they took steps to boost their membership, including publicity in various languages to get fair representation of ethnic minorities, he added.
Mr Moyes said he might also make some trusts wait for foundation status until later in the year if there were doubts about their financial strength.
Nigel Edwards, policy director of the NHS Confederation, said such delays would be expensive. A hospital would have to close its accounts in mid-year and reopen them as a foundation trust, adding about £200,000 in accountancy costs.
The Department of Health said: "Applicant trusts will have another month or so to recruit members who would be eligible to vote in these first election and still meet the April timetable."
