Published: 24/02/2005, Volume II5, No. 5944 Page 27 29
Non-executive board members often arrive at their posts unprepared for the complexities and jargon of the NHS.
Lynn Eaton looks at a training programme for these recruits
If you start a new job in the health service, it is a pretty fair bet that you not only have the appropriate qualifications and training to do it, but that you will also be given some kind of induction when you arrive.
But for many non-executive board members, entrusted with overseeing the effective management of a trust, it is a question of diving in at the deep end, often with little or no experience of the NHS. Although they may have experience in commerce, or even as heads of private sector finance departments, the complexities and jargon of the NHS can be pretty daunting. As one fledgling trust member told HSJ: 'In the first board meeting I attended I had to ask what a strategic health authority was.' The recent news that the whole non-executive board at Royal Wolverhampton Hospitals trust had been asked to stand down for its part in allowing the trust to amass a£10m deficit shows just how important it is to for members to know the right questions to ask (news, page 7, 6 January). 'What is an SHA?' is probably not one of them.
The NHS Appointments Commission, set up in 2000 and responsible for recruiting chairs and non-executive directors has, in the last two years, run a training and development programme to address the gaps in new recruits' knowledge of the NHS and what their role in it should be.
Head of training and development Chris Dye has spent his working life in various nooks and crannies of the NHS, including corporate governance, with the now-defunct North West regional health authority. There, he saw what a valuable contribution trust non-executives could potentially make.
'But to some degree they were neglected, ' he says. 'Often they were appointed and left to get on with it. Some got very good induction, some got absolutely nothing.' In some areas - such as London, where think tank the King's Fund provides a lot of training for non-executive directors - things have been good. In other parts of the country, says Mr Dye, provision has been patchy or nonexistent.
He freely admits that in the first year anything was better than the void that had previously existed. The commission now has a£600,000 budget, funded by a flat-fee£1,000 levy to all trusts, for an ongoing training programme for board members.
This includes induction training for nonexecutive directors, induction for newly appointed chairs and instruction in doing appraisals - where the chair must appraise the chief executive.
The commission also runs a series of training courses on specific topics, such as health service finance, payment by results, the role of the audit committee and patient safety.
'People say they want a national training strategy but a local training programme, so we have set up eight regional training boards which decide what they want to do locally, and regional facilitators funded by the commission, ' says Mr Dye.
Trust members come from a wide variety of backgrounds, but usually bring some kind of professional expertise with them, whether in finance, management or patient representation.
'We are trying to bring home that their major role is to govern the organisation, it is not an executive position, and they should be taking nonexecutive roles. It is important to say what the job is not as much as what it is. They have to satisfy themselves that systems are in place to ensure quality and to ensure the trust is a good employer.
He continues: 'They need to ask the right questions. Sometimes a board will spend two minutes on finance and talk about car parking for an hour.' In a session at a two-day induction course held in London in January, the 50-odd members were split into groups and given a financial report to read. They were then quizzed about what questions they would ask the chief executive or other executive directors.
Other sessions covered public health issues, mental health, the effect of foundation trusts on health economies, and public-private initiative developments. The group also attended a dinner on the evening of the first day, which allowed for informal networking.
The commission is adopting as many new training approaches to this as it can think of. One is the 'world café' approach, where a small group is brought together for a short meeting over coffee and croissants to discuss a specific topic.
Another is teasingly dubbed 'speed dating' - it uses the same technique, of talking to someone for a few minutes then moving around the room.
In addition to formal training courses, board chairs also have access to a mentor, usually the chair of a similar trust, though it is not mandatory. 'It is all confidential, ' says Mr Dye.
'The only thing we ask the mentor is whether or not they are being used.' All in all, there are some 4,000 non-executive members, with a regular turnover as each will only stand for an initial four years.
'There is an awful lot of people and an awful lot to do, ' Mr Dye admits. 'But two-and-a-half years ago almost nothing was happening, and I came in with a blank piece of paper.' One of those attending the course in London in January, a non-executive who had been reappointed after an initial four-year term, summed up the importance of the initiative: 'I just wished this had existed four years ago.'
'WHAT AM I DOING HERE?'
Andrew Britton joined Nottinghamshire Healthcare trust in December and has attended two board meetings; one as an observer, one as a member.
He admits he was baffled at times: 'I asked what an SHA was.' Mr Britton has a background in accountancy and is financial director of a large retail pharmacy company. His only previous public service experience was several years back, when he lived in Hertfordshire and served as a Conservative councillor for four years, although his current appointment is not political.
His experience is primarily in financial management, but in his current job he also deals with health and safety and property management.
He found the course in London helpful but feels the need to understand better his local trust, which specialises in mental health.
'There is no formal induction programme as such. I have agreed with the chair and chief executive to ask each of the directors if I can spend half a day with them, seeing what they do.
'The difficulty is doing things strategically, not at an operational level, ' he says.
Edward Alport was a Lloyds broker before he became a non-executive director of Essex Ambulance Service trust. Prior to that, his only experience of public service was as a school governor. 'My first impression was that it is very demanding. There is a huge amount of expertise. Nothing prepares you for the technical rigour of the board meetings. The first time I was thinking, 'What the hell am I doing here?'
'I do not find the finance thing too much of a problem. Because I had been a chair of governors for a school I could read the accounts.
But [the way they are presented] is absolutely arcane.
'I can see how daunting it is to someone used to commercial accounting. The thing that is frightening is we are talking about such big numbers.' His trust has been battling with the out-of-hours issue, which it is handling for many of the area's primary care trusts.
Mr Alport has tried to rein in any natural enthusiasm on the part of staff for taking this on too fast.
'Their immediate reaction was to get everything, ' he says, explaining how board members tried to caution against this.
'We gave them the authority so they didn't have to go out there and be macho, ' he says.
'WE ARE THERE TO REFLECT THE COMMUNITY'
Patricia Connell-Julien has been a member of South London and Maudsley trust for two months. She has attended one meeting as an observer and one as a member.
'I sat in on one beforehand, just to see what happened. It was wellorganised and well-managed.' Coming from a background in housing association management, some of the terminology was familiar, 'but a lot of it seemed quite daunting - aspects of finance, new things that were happening and not knowing what the old thing was', she says.
'There was a conscious attempt not to use jargon, as it was a public meeting. But people slip into it and have to be reminded.' Ms Connell-Julien's experience is in user involvement, which she hopes to be able to bring to the trust. 'Part of this is seeing where you can contribute.'
Susan Harrison's biggest worry, as someone who has worked in health and social care, is not to act like a member of staff.
She currently works as an management consultant and was appointed in August to Camden and Islington Mental Health and Social Care trust. It is one of the handful of trusts to include local authority representatives, a model that appealed to her.
'We are there to reflect the community, not to act as experts, she says, admitting later: 'It is very important people like me do not get sucked into becoming operational managers.'
Non-executive board members often take up their positions with little or no previous experience of the NHS.
The NHS Appointments Commission's acclaimed training programme for employees new to the NHS has been running for two years.
Along with formal training, board chairs are also offered access to mentors.