In the wake of the Francis report, the efficacy of NHS boards has come into question. Roger Russell and David Needham look at how they can be strengthened to ensure the trust is performing to the best of its ability

Sadly and perhaps predictably, the inquiry by Robert Francis QC into the care failures at Mid Staffordshire Foundation Trust raised some fundamental questions about leadership and managerial capability within the NHS.


‘The leadership competence, style and tone set by the board has huge implications for the way in which an organisation performs’

The report, which described the deficiencies at the trust as “systemic, deep-rooted and too fundamental to brush off as isolated incidents”, has led to familiar-sounding calls to drive up standards, create a consistent approach and develop shared learning by establishing a “staff college” for senior executives − something that is long overdue. 

But while it is a welcome recognition that developing leadership capability and greater professionalism at managerial level ought to be priorities, it remains to be seen where the investment will come from to make this happen and how it will be monitored and managed.

However it isn’t just the NHS’s capability at management level that has come under scrutiny as a result of the Francis report. There are also serious doubts about the effectiveness of NHS boards. This comes at a time when a combination of unprecedented financial pressure, increased regulation, major structural changes and loss of public confidence means the service is facing one of the most difficult periods in its history.

Monitor and challenge

It goes without saying that the effectiveness or otherwise of the board is one of the most critical factors affecting the performance of any organisation. The leadership competence, style and tone set here has huge implications for the way in which an organisation performs and the kind of culture that is developed.

This is even more true for governance structures in the NHS, which will only be able to navigate this tsunami of change if they have high-performing boards that bring clarity to their strategic planning and instil public confidence in their ability to deliver services.

In order to survive and manage these changes, trusts will require a range of new skills, experience and qualities at board level. They will also need improved governance structures and operating models to ensure senior executives and non-executives meet strict standards of accountability and transparency. For some trusts, this will require a level of re-engineering that is simply unachievable − unable to adapt, they will cease to be viable as a single entity. 

‘Clearly, if some of the board are disenfranchised, this will ultimately lead to poorer decision making’

A vital part of getting to grips with challenges such as cost reductions, finance and transformational change, culture change, and stakeholder and employee engagement is taking a strategic approach to recruiting non-executives who can help make a difference in these key areas. To this end, an increasing number of trusts have tried to boost the overall performance of their boards by appointing more non-executives with commercial or private sector experience.

Rather than being able to make a meaningful contribution, however, some of these non-executive directors have come up against barriers such as a breakdown in trust between executive and non-executive board members, poor-quality management information, resistance to change and the dogmatic adherence to processes that meticulously measure the wrong things. As a result, many have quickly become frustrated and disillusioned.  

While these issues are not unique to the NHS, the magnitude of the challenges trusts face mean they can ill afford to waste the skills and experience of their non-executive directors. At the same time, boards will also need to introduce meaningful succession planning as part of its overall business strategy to ensure its membership is refreshed to mirror the changing nature of the difficulties that must be tackled.

Another issue of fundamental importance is the need to monitor and challenge the things that matter in an objective and constructive way. This obviously requires good quality, insightful management information − but this information is worthless unless board members possess the skills and experience to reach sound conclusions and are given the opportunity to contribute effectively. Clearly, if some of the board are disenfranchised, this will ultimately lead to poorer decision making.

Making the most of talent

One immediate positive step would be for trusts to adopt the senior independent director role on to their boards, something that is common in the private sector and recommended by Monitor in its guidance on board governance. This role could be used to directly address some of the issues around transparency and accountability highlighted in the Francis report, including the duty of candour. Just as important, it would provide a voice for executives and non-executives who have issues of concern that have not been resolved through normal channels.

Features of the role could include:

  • acting as a first point of contact for stakeholders and staff to ensure concerns that have not been resolved or would not be appropriate through the normal channels are heard;
  • conducting the appraisal of the chair, having taken view from other board members on the overall effectiveness of the board and its ability to make a contribution;
  • chairing the appointment panel when considering succession for the chair of the board;
  • acting as an alternative point of contact for executive directors if required; and
  • monitoring specific organisational issues such as inclusion and diversity.

By appointing senior independent directors, trusts may avoid some of the pitfalls of the past. Such a move could also strengthen the working relationship between the board and the governors who represent service users. The role of the senior independent director could act as a conduit for the governing body by providing local representatives with a sounding board on issues that may not reach the main board. Equally, at a macro level, the senior independent director could have an important function in ensuring user insight plays a critical role in helping to shape service delivery and broader business strategy.

The changing nature of the regulatory and service landscape in the health sector, combined with the continuing need to reduce costs and improve efficiency, will require a transformation in the way services are designed and delivered. It is therefore imperative that boards have the range of qualities needed to manage these changes and, once hired, that this talent is used to maximum effect.

Roger Russell is head of board practice and David Needham is head of health practice, interim management, at Green Park