Published: 03/02/2005, Volume II4, No. 5941 Page 18 19

The NHS is struggling to recruit non-executive directors capable of holding their boards to account. NHS Appointments Commission chair Sir William Wells is the man charged with rallying the troops

Trusts are finding it increasingly difficult to recruit non-executives.

There are also widespread concerns about their ability to meet new governance challenges, particularly in the case of foundation trusts. And the organisation charged with ensuring the quality of non-execs is unsure what its future role will be.

All told, it will not be a quiet year for NHS Appointments Commission chair Sir William Wells.

Recruitment is the most immediate issue. He says a combination of broad and rapid policy changes, greater scrutiny on performance and relatively poor pay are making non-executives more difficult to recruit.

Sir William says his organisation is seeing roughly the same level of interest in vacancies - about 30,000 expressions of interest a year - but fewer applications.

He is concerned about 'patchy' figures for applications for non-exec positions and says chair applications are 'becoming a bit of a worry'.

The lack of interest is felt most by primary care trusts, and in rural areas, the problem in PCTs not helped by rapid evolution of their role. 'There is still confusion as to what the heck they are, ' adds the commission chair.

Sir William says the recruitment problem is not just down to the more demanding performance regime and the need for chairs to 'fall on their sword' if they 'do not come up to snuff'. It is also because of the level of change in the NHS.

'People are a little bit wary unless they understand what all the changes mean and how they intermesh, which tends to mean that we look for our chairs from among the existing cadre of people.' These factors are compounded by the risk to people's reputation if things do go wrong and the balance of whether the pay makes the hassle worthwhile - non-executive directors are paid£5,673 a year for 2.5 days a month.

Sir William says he will be discussing with ministers the need for audit committee chairs to spend more time on the job, with better training and more money.

He says the commission has made 'considerable strides' in introducing training and annual appraisals for non-executives and chairs.

This may not be the 'quantum leap' he was looking for when he appeared in front of the Commons health select committee in 2002 to be quizzed about what one MP called the 'silent stooges', but he says the£1m a year spent on training of non-executives is starting to pay dividends. A total of 4,000 have received training to date.

'People are beginning now to be much better equipped to carry out their roles and there are far fewer silent ones. People are much more confident about their own abilities and therefore tend to ask the challenging questions.' But only last month the commission instructed the entire non-executive board of Royal Wolverhampton Hospitals trust to stand down for its role in allowing the trust to run up a£10m deficit.

An independent review had found that financial stewardship in the trust had failed, compounded by a board that did not challenge the situation.

In December, Monitor chair Bill Moyes removed John Ryan from his position as chair of Bradford Teaching Hospitals foundation trust.

The trust's recovery plan to address a forecast£11.3m deficit was rejected because it was not 'credible'.

And with the introduction of payment by results and choice, there are more testing challenges for trusts that will put 'huge emphasis' on proper governance, says Sir William.

'These [payment by results and choice] are going to impose upon boards huge responsibilities to ensure that the governance of all of that doesn't lead to meltdown. Both of those inevitably introduce a much greater degree of volatility into the system.' He says boards will have to cope with 'significant financial stresses and strains' from situations where, for example, an acute trust may have to stop certain procedures because a nearby provider is getting more business.

The commission will publish a manual on integrated governance in the next few months.

Part of this will be a training and development pack for boards and, for the first time, executives and non-executives will be trained alongside each other to get a better grip on governance.

Although the commission has no remit to appoint chairs and nonexecutives in foundation trusts, Sir William wants this to change.

Complaints that foundation trust non-executives and chairs are not up to the job do not necessarily reflect well on the commission and its appointments - the chairs and non-executive directors automatically transfer over when an acute trust takes foundation status.

Sir William defends the commission, pointing to the 'minority of cases' where Monitor has had to intervene.

The commission also talks to acute trusts aspiring to gain foundation status about the makeup of their boards.

'We are saying you have got to strengthen the financial expertise on your board and you haven't got a proper mix of people, so if you want to become a foundation trust we suggest that between us we shake the board up.' And although it is foundation trusts' board of governors that are responsible for appointments, there is concern that governors may struggle when non-executives and chairs come up for re-appointment.

One chief executive says governors' desire not to 'upset the apple cart' would result in the majority of non-executives and chairs being re-appointed regardless of their performance.

The commission, says Sir William, 'can provide a specialism and an expertise which they can not, other than buying it very expensively from private sector headhunters.' And he has made his feelings clear to the Department of Health.

'There will be huge pressure on governors to say 'well why do not we appoint so and so?'. There is a danger of going back to when favoured sons or daughters were arriving on the boards, which would be a pity.'

The CV

1994: chair of South Thames Regional Health Authority

January 1997: receives knighthood

January 1999: chair of NHS South East Region

March 2001: appointed chair of NHS Appointments Commission

January 2003: accepts further four-year term to lead the commission through to March 2007