The diverse experience of non-executive directors is something to be valued as the NHS attempts to drive up its historically poor productivity.

Non-execs’ dissatisfaction is well established

Non-executives, including the chair, comprise the majority of an NHS trust’s board and hence hold enormous potential power, but have they been as effective as they could or should be?

Their dissatisfaction over the time commitment - considerably more than they are led to expect on appointment - and the level of remuneration, a fraction of the private sector equivalent, is well established. It is also apparent that at least as much disenchantment exists over their ability to make an impact.

This is usually attributed to the cumulative effect of constraints including extensive centralisation (determining not just performance targets but pay scales for most staff, for example); financial opaqueness (such as the rationale for non-contractual supplements, particularly bailouts, and use of jargon); the political dimension (unclear and unpredictable); and the lack of competitive pressures (removing an impetus for organisational adaptation).

The crucial task of holding executives to account can also be constrained in less obvious ways. Executives routinely report to the central hierarchy and are in regular contact with local counterparts. This confers not only an apparent advantage over non-executives in interpreting the local impact of political and financial imponderables, but also a sense that accountability and creative stimulation have already been satisfied before non-executives get involved. This disconnect is aggravated by the lack of substantive, market-influenced non-NHS experience of most executive directors, who can easily come to regard non-executives’ views, influenced as they usually are by an abundance of such experience, as of little value.

Variations obviously exist between trusts, but non-executives too often feel their “value added impact” represents a meagre yield on their investment of expertise, time and goodwill.

Playing to strengths

So what could be done to improve their effectiveness? The NHS and its relationships are complex; with centralisation linked to strong political involvement unlikely to change, non-executives need to be pragmatic. They should explicitly accept a joint responsibility for their organisation’s success, recognise the reality of the constraints as quickly as possible and periodically meet with others in their local health economy to share good practice.

More importantly, non-executives should focus on the issues most relevant to their expertise. Organisational culture and management capacity (clinical and non-clinical) are the prime candidates. Are patient-impinging policies and priorities in line with the best service based organisations and rigorously applied? How are conflicts of priorities resolved in practice? Can fitness for purpose be demonstrated in the structuring, selection criteria, training, empowerment and appraisal of management at every level? Is clinical engagement effective where it matters most? Addressing such constituents of culture and capacity and routinely regarding performance failings as manifestations of their practical shortcomings are likely to prove much more productive forms of “holding to account”.

Greater urgency

Ongoing development should centre on raising non-executives’ expectations by identifying ways to achieve high impact with less emphasis on expanding knowledge of NHS detail. The practical effect of the constraints should be articulated more explicitly in recruitment and induction training, and research into the role of NEDs in the context of board effectiveness is badly needed. A National Leadership Council project, involving partners including the Appointments Commission, is addressing these areas.

Extraordinary pressures face an NHS with a historically poor overall productivity record. NEDs are not infallible, but their perspectives and distinctive expertise have never been more potentially valuable. They need to be galvanised into asserting these strengths and the Appointments Commission and strategic health authorities, in particular, should show greater urgency in helping NEDs deploy their time to maximum - and more satisfying - effect.