Imagine the situation: your local primary care trust is in financial meltdown or your trust has an infection control crisis. A new board is needed at a time of intense political and public scrutiny. Becoming a non-executive director at this moment may not sound like an appealing prospect, but there is often no shortage of applicants.
This is the situation Maidstone and Tunbridge Wells trust found itself in following a damning Healthcare Commission report. It needed new non-executives, and dozens of people put their names forward.
In these situations, a common theme among applicants seems to be that people feel they have something to offer and want to give something back to the NHS, says Mike Sobanja, chief officer of the NHS Alliance. "What they can give is objectivity and freshness when moving into an organisation. I know from my own experience that sometimes you cannot see the wood for the trees. Sometimes it is about asking the tough questions that you almost cannot ask yourself."
David Bowles, chairman of United Lincolnshire trust, came into post when the trust was overspending dramatically and it had gone through four chief executives in three years. As a former chief executive of a county council, Mr Bowles had also worked with councils in trouble. Within a few weeks he had to deal with a waiting list inquiry, suspending the acting chief executive and overseeing the departure of the rest of the board.
Mr Bowles argues that, despite stepping into difficult situations where there is always a temptation to get more closely involved, it is important for boards to step back. He says: "One of the things that was going wrong in the trust before was that non-executives were getting too involved in the detail. We are there to hold them [the executives] to account and to add challenge. We appoint the chief executive and he appoints his team - we do not dabble in these appointments. We make certain that good quality papers come to the board and the financial information is up-to-date and reliable."
Pauline Quan Arrow, chair of Southampton City PCT, says information is crucial for all boards but it is even more so when there have been problems. She points out that the sort of information available to boards in industry simply is not standard in the NHS. But non-executives can be "critical friends" in times of trouble.
Mr Sobanja urges non-executives not to get too involved with the minutiae of the organisation but to ask fundamental questions instead. But Mr Bowles points out the board also has to absorb pressure from above without passing it on to the staff. That balancing act is not an easy one, since it often involves coping with the multiple priorities of the NHS, including financial balance, access and patient care.
Mr Bowles adds: "Getting that right is crucial to the health of the organisation. I think my board is quite firm. We do not get bounced into doing things quickly, we do them properly." The staff are also given the message that it is not just the finances that matter.
New boards often need to think about whether the organisation has an appropriate culture. In Lincolnshire, some staff felt there had been a "climate of fear" and there was a marked reluctance to pass bad news upwards.
Mr Bowles and his board adopted an open and honest approach with staff, the public and the media. He admits, for example, that the trust sometimes finds it hard to provide the patient experience it would like because its facilities are stretched and bed occupancy is high. But he acknowledges that it can take a long time to change cultures and there are always outside influences, such as the representation of the NHS in the national media, which may run counter to what the board wants to achieve.