Long hours, overwork and the feeling they're playing second fiddle to executives - so what exactly do non-executive directors get out of it all? Barbara Millar investigates

Angus Walker had to have his arm twisted to become a non-executive director in the NHS. 'I had not explored a non-executive role because, politically, I was not a (Conservative) government supporter and had mistrust of its policies towards the health service, ' he recalls.

'But when it became clear that trusts would be established, I was interested in Nottingham City trust because I had been brought up next to it, my wife had briefly worked there and both our children were born there.'

Mr Walker became a NED with the trust for four years, until 1996. 'I believe I was appointed primarily because of my community interests and links, although I became increasingly involved in financial and strategic issues.'

Mr Walker, a chartered accountant with a background of 25 years' work in paid and unpaid capacities in the voluntary sector, had once worked with the trust chair, 'so he knew my strengths and idiosyncrasies'.

He found his time on a trust board 'interesting and rewarding , particularly trying to understand and influence the bureaucracies and power groupings that exist in the NHS'.

But he was frustrated by the lack of focus on preventive health issues and the extent to which boards added value to the overall range and quality of services. 'The actual number of decisions made by the board was very few, ' he says.

'We were more part of a check and balance process than an independent body. Clearly, executives were regularly meeting outside the board, so one felt that debate and options had often been sorted out before board discussions.

' The chair took his role seriously, but it was a rare occasion when the views of the chief executive did not predominate.'

Despite some misgivings, Mr Walker is prepared to become a health service NED again, which should be reassuring to those who believe that a lack of attention given to the role might lead to fewer applications.

Earlier this year the NHS Executive and the NHS Confederation produced a set of guidelines clarifying the role of NEDs and designed to be the basis of a handbook which will be published next year. At the same time, the government announced an increase in remuneration of 2.8 per cent for NEDs, the first rise since 1991.

The NHS Confederation, in particular, believed that work was needed to address the imbalance between rising expectations and the NEDs' increased workload, and the fact that remuneration did not reflect the importance of the role.

'The last guidance on the role of NEDs was written four years ago and a lot has changed since then, ' says Andrew Foster, chair of Wigan and Leigh Health Services trust and chair of the NHS Confederation's human resources committee.

'There were deep concerns about how NEDs have been valued and treated. For instance, in 1997 and 1998 the appointments process was very slow and delayed.

'Some people found out from their successors that they had not been reappointed, while other trusts and health authorities were left without quorate boards, seriously undermining their work.'

The joint guidance suggests that retiring chairs and NEDs should be invited to remain in office until replacements have been appointed and a clear indication of the timescale involved should be given. Chairs and NEDs should ideally know whether they are to be reappointed at least a month before their term of office expires, and those retiring should, ideally, be reminded before their successors are told about their appointments.

The new guidance also says retiring chairs and NEDs should receive signed, individually addressed letters, recognising their contribution to the NHS.

'I am a trust chair and I can see with my own eyes just how valuable non-executives are, ' says Mr Foster.

'They bring impartiality and their own experiences, expertise and perspective and are the eyes and ears of local people, which is absolutely essential to the service.'

Potential appointees also need to be given a realistic expectation of the workload. Although the amount of time involved is, officially, five days a month, many work much more than this on board matters, Mr Foster points out.

Roger Moore, who runs the NHS Executivee system for appointing NEDs, says the appointments procedure was delayed last year because former health secretary Frank Dobson wanted the job description 'changed radically' halfway through the process. 'This year things have gone much more smoothly, ' he says.

NEDs in the past have also complained that they did not know what the NHS expected of them and what they could expect from the NHS, in terms of training and development, he adds.

These, and other issues, are being addressed by a working group, led by Ken Jarrold, chief executive of County Durham health authority, for the NHS Confederation and chaired by Janet Trotter, chair of the NHS Executive South West regional office, which will report early next year.

Some observers believe training should be mandatory if NEDs are to understand and fulfil their role. Andrew Wall, visiting senior fellow at the health services management centre, Birmingham University, says many are completely unprepared and unaware of the extent - and limits - of the position.

'A situation recently came to light in an HA where non executives were not allowed free entry into healthcare premises and HA meetings lasted for 40 minutes with no discussion. And the non-executives accepted this because they did not know any better, ' he says.

He believes there are many instances of non-executives who are, or have been, local councillors, who bring a completely inappropriate model of how an NHS board should operate, and try to treat the executives like council officers.

'Non-executives are there to bring a whiff of the outside world, ' he says. 'They need proper training - a mandatory day before becoming a non-executive, followed by a mandatory day every year. And training should be organised properly and paid for by the centre, so there is no argy bargy about not being able to afford it.

'The problems don't need to be redefined again. It just needs the secretary of state to insist training is carried out.

If non-executives are not knowledgeable about their role it is at tremendous public cost.'

Current NEDs certainly share the view that the five days-a-month commitment is unrealistic. Peter Dean, a NED with Oldham trust, says at least nine days a month is necessary 'if you really want to do the job well'.

He finds the role 'immensely rewarding', adding: 'People can make a significant contribution - but they have to be prepared to put in a significant amount of time and effort.

Things do go slowly in the NHS and this does lead to frustration - for instance, when you can see that a service just needs a piece of equipment which will make all the difference, but the bureaucratic hurdles have to be got over first and this takes time.

'But we can make a difference to our local communities, which has to be one of the main driving forces for getting involved.'

Christine Sheppard, a NED with East London and the City HA and a freelance consultant, agrees that the time commitment 'has to be watched'. It can be tricky, she admits. 'Every time I am working for the HA I am not earning my living. I have to put paid work first, but if I am asked to do something for the HA and I am free, I will do it and I never let anything conflict with HA board meetings.'

Though this balancing act is sometimes difficult to achieve, she believes the non-executive role is an extremely important one.

'Our role is to think and apply our intelligence to the strategic aim of improving the health of local people.'

But she adds that she sometimes feels 'I am skating along the surface trying to catch up, because NEDs don't have all the information at our fingertips, as the executive directors do, nor are we as steeped in the issues as they are, and yet we are expected to make strategic decisions.'

Just the job: what non-executive directors must do

Contribute to the development of long-term plans for healthcare in the community.

Help ensure the best use of financial resources to help patients.

Take part in the appointment of the chief executive and other senior managers.

Sit on various committees, such as the remuneration committee (to ensure appropriate pay for executives), or the audit committee.

Ensure the health authority, trust or primary care trust promotes equality of opportunity in the treatment of staff and patients.

As complaints convenor, have responsibility for overseeing responses to complaints from the public.

Contribute to building and maintaining a close relationship between all those in the community concerned with healthcare delivery, promotion and prevention.

Essential qualities Live in the area served by the HA, trust or PCT.

Have a strong commitment to the NHS and be able to demonstrate an interest in healthcare.

Be able to demonstrate a commitment to the needs of the local community.

Be committed to public service values.

Be available for about five days a month.

Desirable qualities Have experience as a carer, or as a user of the NHS.

Have experience in the voluntary sector, particularly in an organisation working in health issues.

Have already served the local community in local government or some other capacity.

Be able to offer specialist skills or knowledge relevant to the work of the HA, trust or PCT.

'I had seen the advertisements, but it never occurred to me to apply' Melba Wilson, non-executive director, South West London and St George's Mental Health trust, for more than four years Why were you interested in the role?

I was approached by someone who thought I would be good at it. I had seen the advertisements, but it never occurred to me to apply. I had a good mix of skills which I thought could be useful, including a background in health journalism and membership of the King's Fund mental health task force. I also knew the local community very well.

What is your understanding of the role?

To ask the 'why' questions and follow them up.

What time commitment is involved?

Five days a month is pretty unrealistic. To do the job in a way I would feel really happy would require two days a week - but that is not always possible because of my other commitments. Currently, I am co-chairing the clinical governance committee. I really wanted to do this because it offers us the opportunity - as a board - to demonstrate our accountability and to develop outcome measures for services we deliver.

How fulfilling or frustrating do you find the role?

I am the only black person on the board. It is fulfilling because I find my views are listened to and respected. But it is frustrating because things move so slowly in the NHS.

Sometimes you want to cut to the chase, but you can't.

What are the relationships on the board like?

The chair can make or break a board, as can the relationship with the chief executive. We have a good relationship with the chair and it is not heavy; we are all able to laugh together.

We take our work seriously, but we don't take ourselves too seriously. We have a chair who can pull things together and make it work.

We are a good mix on the board and no-one feels under utilised - there are also no shrinking violets.

What have been your best - and worst - moments?

The best moment was when I realised I could talk openly with the chair. He was open and honest and I knew we could work together. I was also pleased when it was agreed there would be race awareness training throughout the trust - starting with the board. No real worst moments. But there needs to be more training and development. NEDs have to hit the ground running - some of us can and some can't.

What adv ice would you give to anyone interested in becoming a NED?

Don't undervalue your experiences - all become useful at some point.

Make an appointment: how to recruit NEDs No. of health authorities 99 No. of NEDs 619 No. of trusts 369 No. of NEDs 2,200 256 posts with HAs must be filled by 1 April 2000, the same date that vacancies on primary care trust boards must be filled, and 640 posts with trusts must be filled by 30 November 2000.

NEDs of trusts and HAs receive£5,140 a year. The level of remuneration for PCT NEDs will be similar.

NEDs are appointed for an initial period lasting up to four years.

Appointments can be renewable at the end of the term, but there is no automatic reappointment.

How applications are handled All appointments are made on merit, in accordance with the code of practice laid down by the commissioner for public appointments.

Application forms are assessed to see whether candidates have the general personal qualities and skills specified for the post.

Interview panels consist of two local trust or HA chairs and an independent member.

If the candidate is successful, their name is placed on the register of approved candidates. When board vacancies arise in the area in which they live, applicants may be invited to an informal meeting with the chair of the HA, trust or PCT with a vacancy.

The regional chair makes recommendations on appointments to the health secretary. At this stage references are taken up.

The health secretary makes the final decision on all appointments.

If the candidate is not successful, their name is kept on the register of approved candidates for consideration for future vacancies in their area.

Source: NHS information pack for applicants for appointment in year 2000 .

'There are so many business issues to be looked at it would be easy to lose sight of what it means to users' Ros Levenson, non-executive director, Forest Healthcare trust, Walthamstow, for two years Why were you interested in the role?

I had been involved in healthcare issues for a long time - as a community health council member and as director of the Greater London Association of CHCs. I am passionate about health issues from the users' point of view. I wanted to see if I could make a difference at board level and bring these issues to the fore with people who were in a position to do something about them.

What is your understanding of the role?

It is complex. To some extent you have the same responsibility as an executive director - to ensure the trust runs smoothly and fulfils its statutory duties. But you are also trying to ensure that what we are doing makes sense to the local community - people need to be able to talk to us and inform our thinking. There are so many business issues to be looked at it would be easy to lose sight of what it means to users of services. My job is to ensure health and healthcare is the first thing we talk about, not the last.

What time commitment is involved?

It is always more than five days a month. The reading and going to meetings are always there but you get drawn into other things - I am complaints convenor and also involved in hearing Mental Health Act reviews and appeals. A number of NEDs spend a lot more time on it than I do - you have to be careful to keep it down to the amount of time it is reasonable to manage. Also, if you do a lot more you have to look at whether you are straying into executive territory. It helps for some of us NEDs to have an NHS background but also to have some people who don't - some of the most useful contributions come from people who are aghast at the way the NHS does things.

How fulfilling or frustrating do you find the role?

It is both. It is fulfilling, otherwise I would not carry on doing it. It can also be frustrating, struggling to inject the notion of development, of making services more responsive, into debates. We have to make sure we don't just do what is in this week's circular. It is frustrating for NEDs and executives because there is never enough money to do what you want to do. It is fulfilling because you can make sure discussions include a user dimension.

What are relationships on the board like?

Usually good. We have a good chair who has a clear view of what NEDs are there for. On the whole, the executives value our role, though they don't always find it comfortable. It can slow down the process because we are always asking why, why not, what is the implication for the community? But this leads to creative tension which can produce a better quality decision when boards function well. It is important we don't get into an adversarial role with executives. We have to retain respect for the fact that they are the ones with a grasp of detail and they have responsibility when things go wrong.

What have been your best - and worst - moments?

It is not a question of sudden triumphs - it is a much longer process - but my best moment is that I have survived on the board and that we are improving things for the local community. It is not sudden revelation stuff at all. The pace of change is gradual and slow. In one sense the worst moment is always there. In spite of new monies coming into the NHS we are always struggling to make ends meet.

Advice for anyone interested in becoming an NED?

Go for it. I hope a wider range of people will come on to boards.

But you have to think carefully about whether you can afford to do it. People in full-time employment, might find it difficult to take enough time out to do the job properly, and the£5,140 a year might not compensate for loss of earnings. There needs to be better remuneration - not because NEDs have any hopes of getting rich on the back of the NHS - but, even now, boards have a preponderance of middle-aged, middle-class people who can afford to do it. There need to be real ways of encouraging people on low or no incomes, or those in jobs where it is difficult to get time off, to become board members. We need boards with a broader range of backgrounds and expertise.

'From time to time I would really like to get to grips with things and manage them' Mike Cosgrove, non-executive director, East Kent Community trust, for one year Why were you interested in the role?

It was about transferable skills. As an area director with Kent county council I had some skills which I thought could be of value.

What is your understanding of the role?

I have been a local councillor with a district authority, so I assumed this role would be representational. I was pleasingly disabused of that - it is representational but very hands-on as well and highly enjoyable.

What time commitment is involved?

Because of the increasing change agenda and people with operational and strategic experience moving into NED roles, being prepared to devote more time to the task and being used more, it is something like two to two-and-a-half days a week - but it does depend on your commitment. Research and reading takes a good deal of time.

How fulfilling or frustrating do you find the work?

From time to time I would really like to get to grips with things and manage them. I also think that, because there are now more NEDs with public sector experience, many with operational roles, there are advantages to the NHS, because we understand the pressures operational managers are under and understand the way things work. We are a sympathetic bunch and prepared to work hard and make a contribution.

Most of the time I do find it fulfilling but, clearly, the NHS has a different culture to local government - there are more levels of management and more central directives.

What are the relationships like on the board?

We are very fortunate - our chair is excellent and the chief executive very experienced. Both have enormous commitment to the NHS and to making the trust work well.

Communication is open between us and our East Kent HA colleagues, the acute trust and the primary care groups.

What have been your best - and worst - moments?

Best are when you know you can make a positive contribution to something you instinctively know is worthwhile. Not really had a worst moment. But some things are just Byzantine - such as the way NHS property management works. It has been a real surprise to me to see how much consultation is involving in just selling a property - this gets very frustrating.