The drive for local autonomy means non-executives and chairs are under ever-closer scrutiny. The body charged with recruiting them hopes to prepare them through improved selection and training

The role of NHS trust boards is coming increasingly into focus. Less central direction, more localised control and calls for increased public involvement all bring the role and quality of local decision making centre stage.

We hear less about how boards are appointed, trained and evaluated - until, that is, something goes wrong. All are in effect run by chairs, with non-executive director boards that set overall strategy and vision and hold chief executives and staff to account. The buck stops with the chair - as we saw very publicly after news broke last October of the C difficile outbreaks at Maidstone and Tunbridge Wells trust, leading to the departure of the chair and non-executive directors.

The demand for better public services and for accountability in the way public bodies are run is increasingly falling on the chairs and non-executive directors who form the governance. So the competence of appointees to such posts is of mounting importance. Gone are the days when these jobs were distributed by political patronage. Now, the independent Office of the Commissioner for Public Appointments regulates, monitors and reports on public appointments procedures. Its code of practice specifies that appointments should be made based on merit and that care must be taken not to discriminate on any grounds.

Following allegations that appointments to NHS boards were becoming politicised, an independent NHS Appointments Commission was set up under Labour in 2001 with the ebullient Sir William Wells as chair. It was charged with recruiting and appointing chairs and non-executive directors to hundreds of NHS organisations, both national and local.

Since then, the commission has faced huge challenges, as the NHS has undergone continued restructuring and the demand for more competent and representative governance has grown. It did manage, though, to highlight the importance of good governance, while beginning to oversee the performance of chairs and boards.

Under review

It is now all change at the commission's Leeds headquarters.

On her arrival in April 2007, Sir William's successor Anne Watts commissioned a review of the organisation. Its recommendations will be taken forward by her brand-new chief executive, the very competent Andrea Sutcliffe, recently recruited from the National Institute for Health and Clinical Excellence.

Inevitably there will need to be changes in direction. In 2006-07 the commission made around two thirds of all ministerial public appointments and reappointments. As the number of reconfigured NHS trusts decreases and as more become foundation trusts able to undertake their own recruitment, the commission's work will shrink.

The review's key recommendations will provide the template for the commission's work in future and all those with a stake in the sector will need to keep abreast of developments.

From now on there will be much greater emphasis on precision when recruiting those with the right skills to be chairs and board members, on consulting with incumbent chairs about their needs when vacancies arise and on planning ahead. The appeal of such roles to a more diverse and talented constituency needs to be improved - the number of women applicants is falling and the number of minority ethnic and disabled appointees is still not good enough.

The key to resolving these difficulties is to engage more widely with stakeholders and the public. For large sections of the population, the opportunities available to serve in these roles are still a closed book.

At the same time, we are promised an improvement in the efficiency of the commission's systems - no more long waits for decisions or lost mail, we hope.

A major change recommended by the review is that strategic health authorities will in future take on responsibility for ongoing training of chairs and non-executives. The commission retains ownership of induction training and is extending this - a very welcome addition to its responsibilities. It is unthinkable that chairs held responsible for such important areas of public service are not given proper induction and ongoing support. Indeed, if we are to attract more diverse sections of the population into such public appointments, a comprehensive induction programme is essential.

An active talent management programme will also be developed. Annual appraisal and objective setting for NHS chairs and non-executives is a mandatory requirement, but the current system has often been described as too rigid for the needs of many chairs. In future, clearer, more flexible performance management is proposed, with the commission setting minimum standards and supplying suitable materials to enable robust and fair appraisals to be conducted.

Comfort zone

More controversially, the review touches on the responsibility of boards in the NHS, but only calls for further work to be undertaken on this. Clarity is needed if the performance of boards is to be measured and if boards are to fully understand their remit. To whom are boards accountable, for example - to the secretary of state, to the Appointments Commission, to their communities? And how much genuine freedom will they have to shape services without central government control? Do boards have the powers they need to match their responsibilities? If those of good standing are to be encouraged to offer themselves for appointment, some comfort on these issues is urgently needed.

The one recommendation that no doubt will be hurried through is for the commission to seek legal powers to suspend people from NHS boards when "urgent action is needed to restore public confidence", and to speed up its existing powers to terminate an appointment. This new fast-track termination process will satisfy the needs of the NHS while ensuring the individual's rights are protected. However, this may yet prove a disincentive to the best talent to apply for public appointments.

Next - an issue close to the hearts of many of us in arm's-length bodies - is the vexed question of remuneration of public appointees. At present the huge variation across the sector is inexplicable and rates in the NHS are tiny. The typical non-executive director will get around£7,000 a year. At these levels, many cannot afford to take up the part-time roles and to some talented people, the risks to full-time work and their reputation will not seem worthwhile. The review suggests consideration should be given to a comprehensive review of remuneration - obviously a salient point.

Finally the review explores the issue of increased democratic participation in the public appointments process. For instance, it raises the prospect of engaging the public in the appointment of primary care trust chairs - an intriguing prospect and one that sits well with growing concern about the lack of democracy in the NHS.

The Appointments Commission will face a real challenge as it prepares to deliver on these promises in the coming year. It is a small organisation with an unenviable task and there is little doubt that this review is asking the right questions. If we are to maintain interest and integrity in our system of public appointments for the future, we must all hope that the commission finds some answers soon.

Adding Value to a 21st Century Health Service: a review of the NHS public appointments process