primary care trusts

Published: 24/10/2002, Volume II2, No. 5828 Page 26 27 28 29

The appointment of non-executives in the NHS has been overhauled following criticisms of cronyism.But concerns remain and the NHS Appointments Commission is considering another review. Andrew Cole reports

It is fair to say that the recruitment process for primary care trust non-executive directors has changed a lot since Isabel Walker was brought on to the Watford and Three Rivers PCT board, around 18 months ago.

At that time, most people interested in joining PCTs in a lay capacity normally had to respond to advertisements in the national or local press and then face a regional interview. The process varied between regions.Ms Walker's interview took place in autumn 1999 - after which there was silence for 18 months.

'I would pretty much forgotten about it when, in March 2001, I was called by the woman who is now my chair saying they were setting up the board and she would like to put my name forward to the secretary of state, ' she recalls.

A few weeks later, she learned she had been successful and three days after that she was attending her first board meeting. 'I met the chair for lunch just before the first meeting, but it was a complete baptism by fire, ' says Ms Walker, who is now vice-chair of the PCT board.

'It took me quite a while to get to grips with what PCTs were and what my role was in them.'

Much has changed since then, which is just as well given the frenetic activity generated by the arrival of PCTs, with around 150 new ones having been rolled out in April. As a result, an unprecedented number of non-executive directors have had to be selected and brought up to speed in a very short time.

The old system varied between regions, but usually candidates were interviewed by a regional panel consisting of two NHS non-executives - ideally from outside the area - at least one of whom was a chair, plus an independent assessor and sometimes a regional officer. Their names were then placed on a regional register and the appointments were made by ministers.

Now, the interview panels normally consist of two local NHS chairs - including that of the PCT with the vacancy plus an accredited independent member. Successful applicants have their names forwarded to the regional commissioner who passes them on to the NHS Appointments Commission, which makes the final decision on who to appoint.

It is now clear that without last year's establishment of the NHS Appointments Commission, this exercise could have descended into chaos. The commission is at the heart of the new set-up, following a damning report on cronyism in the NHS by commissioner for public appointments Dame Rennie Fritchie.

1Dame Rennie found that the process had 'become politicised in a systematic way', with political allegiance rather than merit being the decisive factor in the appointment of many candidates, little transparency in how decisions were reached, and huge delays between interview and selection.

In its first 14 months, the NHS Appointments Commission has made more than 2,000 non-executive appointments, the vast majority of which have been to the boards of PCTs.

Dianne Jeffrey, chair of the NHS Confederation and also chair of High Peak and Dales PCT, says most non-executive posts around the country have now been filled, and she attributes that in large part to the new regime. 'I have been just staggered at the amount of work the commission has got through in its first year.'

The process of selection is also far more consistent and transparent. 'Everybody knows the rules and knows what the specifications are.'

Excluding ministers from the process has speeded it up enormously, while involving local PCTs more closely has allowed them to match need to availability, she says. 'We now have the opportunity to create boards that are fit for purpose.'

NHS Appointments Commission chief executive Roger Moore says: 'I think We have done pretty well considering where we started from.' There has been healthy competition for posts, with more than 10,000 applications being received for the 2,000 jobs filled so far.

Everyone who was appointed in the first half of the year received a two-day training and induction session provided by an outside company, Health Skills. There will also be ongoing development, as well as regular appraisal of all non-executives.

'The fact is that We are training people to do something That is not completely defined yet, ' says Dr Moore. 'The whole role of PCTs is new. The jobs are developing at the same time we are developing the people. To an extent, everybody is learning on the job.'

Birmingham University's health services management centre senior lecturer Judith Smith was co-author of a report that was highly critical of some of the selection procedures adopted by primary care groups.

2But as a new non-executive member of South Birmingham PCT, she has witnessed what she calls a 'sea change' in how board members are selected.

'Looking back 10 or 15 years, I think the boards now consist of a far more diverse and exciting group of people. It is not perfect, but I think It is a much better mix in terms of age, of ethnic minority representation and where people are in their life and careers.'

By April this year, the proportion of men and women appointed to NHS boards was almost equal, while 12 per cent of non-executive appointees come from an ethnic minority - a figure that is actually above the government target of 7 per cent.

But in the area of political affiliation, little seems to have changed. Dame Rennie's inquiry revealed that in the late 1990s Labour had five times as many declared supporters on trust boards than the Conservatives, and three times as many in health authorities.

Latest figures show that the proportion of chairs and nonexecutives declaring Labour affiliations has actually risen from 16 per cent in 1999-2000 to 26 per cent in May 2002.

Dr Moore is puzzled by these figures, which seem to fly in the face of the new, politically neutral procedures. As a result, the commission plans to bring in an independent body to examine its data to establish whether any unwitting bias has crept into the system, or whether the political affiliations of those appointed reflects those of applicants. The results of the investigation will be made public later this year.

White, middle-aged people still predominate among NHS nonexecutives.

The big challenge for the future, says Dr Moore, remains getting the right balance of skills and expertise on PCT boards. 'It is very easy to get retired professional males, but what you really need are people who can represent the health needs of their section of the community. And There is more reluctance to come forward if you're young, or do not have a professional background or come from an ethnic minority.'

One way forward, he suggests, would be to reduce the time commitment expected of PCT non-executive directors. At the moment, they are expected to put in at least five days a month in return for their£5,295 a year pay.

Dr Moore thinks this could be reduced to two or three days a month, without harmful effect.

'There is a tendency for nonexecutives to be seen as a spare pair of hands. But we believe their role should be focused only on strategy, challenging the executive rather than being part of it.'

Hand in hand with this goes the question of payment. 'If someone is putting together a portfolio of jobs, they might not consider£5,000 for a quarter of their time was really sufficient.Whereas if they were getting this for two days a month, they might consider it quite worthwhile. That starts opening it up to more people.'

Another problem at the moment is that one of PCTs'main target groups - those who are disabled - would stand to lose a significant chunk of their benefits if they took on paid work with a PCT.With the help of its disability advisory committee, the commission is trying to resolve this issue. But the scale of the problem should not be underestimated, Dr Moore warns.

And of course, because this is the NHS the goalposts are constantly shifting.When PCTs were set up, the boards were to consist of five executive members, five non-executive directors and a chair.

However, the government has now stipulated that there should be an extra non-executive director, drawn from the ranks of the new patients' forums, while the executive team should include the trust's public health director - moves that could increase the overall numbers to 13 or more, bearing in mind that non-executives must always be in the majority.

All this underlines the importance of having nonexecutive directors who are able to hold their own in what can be intimidating company. But it also highlights the tension between the need for representativeness and for appropriate skills.

Ms Smith believes a good non-executive director must know their way around the NHS, have an ability to get to grips with complex material and a healthy degree of scepticism. In the final analysis, she believes these qualities are more important than ensuring that the board is an exact representation of the community it serves. 'It is a responsible job and you need people who are skilled to do it.'

Though the NHS Appointments Commission accepts the need for people with relevant professional skills, it believes there is also room for more people from non-professional backgrounds, and is actively examining the idea of pre-board training to increase the pool of potential recruits.

The commission is determined to 'get outside the box' and find more 'feisty' people who can make a contribution, says Dr Moore. 'But I am not convinced We have got the complete answer yet.'

Skill mix: becoming a non-executive director According to the NHS Appointments Commission, the main attributes are:

demonstrating an interest in healthcare issues and a strong personal commitment to the NHS;

showing a commitment to the needs of the local community;

demonstrating an ability to contribute to the work of the board;

showing common sense, an ability to think strategically, understand complex issues and make decisions;

being a good communicator;

demonstrating an understanding of public service values of accountability, probity, openness and equality of opportunity.

Primary care trust boards consist of a chair and at least five non-executive members appointed by the NHS Appointments Commission.There are also five executive members, including the chief executive and finance director as well as three professional members from the trust's executive committee.

The size of the board is due to increase next year with the addition of the public health director to the executive team and a patients' forum representative to the non-executive team.

Non-executives are the voice of the local community.They are expected to supervise and have an overview of the delivery of integrated healthcare for their local community as well as holding to account the executive.But their job is not to run the business; it is more to challenge and monitor.

Their main roles include:

contributing to the strategic development of health plans;

ensuring the best use of financial resources;

taking part in the appointment of the chief executive and other senior managers, as well as overseeing the appointment of professional members of the executive;

sitting on various committees, such as the remuneration and audit committees;

ensuring equality of opportunity;

representing the board at various occasions;

Rise to the challenge: defining the role noverseeing the trust's response to complaints from the public;

ensuring the trust meets its clinical targets;

helping to build partnerships with other sections of the community.

Non-executive directors must live in the area served by the trust and should be registered with a GP in the area.

They are expected to give up to five days a month to board business and receive£5,295 a year in remuneration.They can also claim travel and subsistence expenses.

An appointment lasts for four years, which can be renewed for a further four years subject to satisfactory appraisal.

'There is a real shortage of young people' Isabel Walker: non-executive director, Watford and Three Rivers PCT Background: medical journalism and founder of the medical charity Action on Pre-Eclampsia The job came along at just the right time for me. I would decided to leave the charity and work as an independent consultant, and this seemed to fit in.A lot of freelance work is just you, the phone and the computer.This would involve me in my local community and I would be helping an important local enterprise.

I have to admit I didn't really understand what was going on at the first couple of board meetings.Health politics had moved on a long way since I was familiar with it.

As non-executive directors, we belong to the community but we do not represent the community in any sense of being typical of it.But part of my job is to be aware of what people in the community are thinking and feeling. If someone tells me about something going wrong, I will try and help. I find the work challenging, but it can also be very frustrating.Primary care trusts have a lot of difficulties.Some have inherited large deficits.There are all kinds of 'must dos'but at the same time we have to reconcile this with the need to come in on budget and contain prescribing costs.

Particularly now with the emphasis on patient and public involvement, the role of the non-executive director has never been more crucial.We can champion the involvement of the public at large.One of our central roles is to ask, 'What are the patient and public involvement aspects of this?'

You have a duty as a non-executive director to be a bit detached.You share corporate responsibility but you're also supposed to be detached, and part of your role is to challenge the board.There is always a danger of being swept along in helping the executive to deal with their day-to-day pressures and forgetting the wider issues.But non-executive directors have to be able to stand back and bring a different perspective to bear.

My advice to anyone just taking up the job would be: do not expect it to be easy at the start, but try not to get put off and intimidated by the complexity of the job.Ask lots of questions.Read a lot. I used to struggle with questions of finance and sometimes just switched off.But after I went on a course, I found it was a lot easier.

It is also very important to protect your time.Officially, you're supposed to work five days a month.The trouble is There is always more work to not always say, 'Yes I can do this'.Think through what you're here for and what your most important roles are.

I do not think We are paid enough, but I do not know of any non-executive directors who are in this for the money. I am sure a lot of people couldn't contemplate being a non-executive director - for example, most people in full-time work.

There is a real shortage of young people - most of us are over 50 and a lot are retired. I find there are an increasing number of people in consultancy because they can control their own time.

You certainly couldn't say that non-executive directors are fully representative of the population of the UK at the moment.

'Initially, I had a feeling of awe at some of the company I found myself in' Audrey Ludwig: non-executive director, Ipswich PCT Background: policy adviser for Mind, working previously for a local disability advice centre I must admit I would never perceived myself as someone who would be considered as a non-executive director. Initially, I had a feeling of awe at some of the company I found myself in.But I am sufficiently confident in my professional capabilities to overcome that.

I decided to apply after somebody I knew professionally, and who was a non-executive director in another primary care trust, suggested it. I am a solicitor by training, but have spent the last five or six years working in the voluntary sector.Then in February, I had a baby and became a fulltime mother.The opportunity came at an interesting time.

The post I applied for had been re-advertised. I believe they tried to appoint in April, but only filled three of the positions.

My first board meeting did feel like going in at the deep end - I am new to the NHS and a lot of the terminology. I did a lot of work on the paperwork beforehand and asked people questions to make sure I understood what it was about.

One thing I didn't appreciate was how new the PCT is, so It is not just us but the executive directors who are still developing their responsibilities. It is quite surprising, but refreshing, to realise that very little is set in stone.

I certainly do not feel intimidated. I am one of the youngest, at 36, but I would say the general profile doesn't fit the conventional stereotype. In our PCT, for example, one of my colleagues has got three small children while I've got a six-month-old.But I think the NHS Appointments Commission has got some way to go to get as broad a spread as you might want.

What are the qualities you need? You have to have the ability to understand some fairly complex material or the confidence to ask for things to be explained.You have to be engaged by how the local community works and be interested in looking for improvements. It is certainly a very steep learning curve.

At the moment, I am probably doing about 10 days a month rather than five, but a lot of that is getting to grips with the role. I am satisfied with the amount I am paid for the work I do, but it doesn't reflect the level of responsibility they're placing on me.As a non-executive director, I am making decisions with regard to the spending of£140m.And at the moment, I have no other salary. I regard this as my job.

I think It is very important that people like the NHS Appointments Commission really looks at the pool of potential recruits, especially from the voluntary sector.The voluntary sector contains a considerable number of people who have got the skills but wouldn't necessarily consider themselves potential candidates. It is particularly important the commission looks at sorting out the benefits system to ensure people are not penalised for being on means-tested benefit.


1Fritchie R. Public Appointments to NHS Trusts and Health Authorities: a report by the commissioner for public appointments. London OPCA.March 2000.

2Regen EL, Smith JA.

Getting on Board: a study of the appointment and induction of primary care group board members in the West Midlands. Birmingham HSMC. 2000.