In the light of the Fritchie report, the health secretary has proposed changes to the appointments system that will fundamentally alter the relationship between HAs and trusts. Paul Stephenson reports

Conservative politicians must have been delighted by the NHS appointments watchdog's report into allegations of Labour cronyism.

The publication of Dame Rennie Fritchie's long-awaited report was the perfect opportunity to get back at all those allegations of the Conservatives having packed health boards with their appointees dur ing the last government .

The timing could not have been worse, however. Coming, as it did, the day after a massive giveaway Budget rather took the sting out of the finding that Labour had indeed been filling boards with its own supporters.

It is not as if the report pulls its punches.Dame Rennie, the independent commissioner for public appointments, says that when Labour came to power, then health secretary Frank Dobson's 'wish that appointees be more representative of the community led to a critical shift of emphasis'.

It has meant that equal opportunities policies have sometimes been promoted over ability, she suggests.

'Raising a question in the minds of some about the principle of selection on merit. . . less successful candidates have been brought forward to replace those already identified on merit.'

Overall, 'it is clear from the evidence presented . . . that appointments have not always been made on merit.

Moreover, I would go further and conclude that the process has become politicised in a systematic way.'

Inviting MPs and local authorities to nominate candidates and asking MPs to comment on shortlisted candidates for chairs are two of the problems.

Dame Rennie told HSJ that she is also concerned about the way ministers can reject an entire slate of appointments and suggest alternative candidates. In the report, she concludes: 'There are examples where a candidate's political association has been a decisive factor in their early selection and appointment, and that decisions have not always been based on merit. I also conclude that the process itself has been politicised.'

Most complaints to Dame Rennie focused on Northern and Yorkshire and North West regions. In 1999, the report finds, the proportions of Labour supporters appointed in the two regions 'reflect the balance of applications received in those areas'.

There is no 'conclusive evidence' of bias at interview stage. But, crucially, candidates who are active in Labour politics 'do seem to be more successful than those of other political hues'.

Leeds health authority chair Clive Leach says he is not convinced that politicians have such a big influence: 'As far as MPs are concerned, it is important they are asked their views.

There is a big difference between influence and consultation.'He admits that he, as a Labour supporter, had 'nominated the [Labour] leader of Leeds city council on to the board' because he thought it was appropriate for him to be there.

Health secretary Alan Milburn met the report with a swift promise that he would consider fundamental changes to the appointments system. 'In the future we are planning that 2,000 nonexecutive directors on NHS trust boards will be appointed by local health authorities rather than by ministers.' Trust chairs, and chairs and non-executive board members of HAs will continue to be appointed by the health secretary.

This year Mr Milburn is due to appoint 138 chairs and 660 non-executive directors to trusts and HAs, and about 50 chairs and 250 non-executive members to primary care trusts.

Mr Leach would prefer chairs to play a bigger role in their own organisations, before mixing HA and trust appointments: 'I believe the chair should have more authority in picking the board'.

Les Howell, who was suspended as chief executive of Preston's Guild Community Health Care trust prior to the entire non-executive board being removed by then health secretary Frank Dobson, said he fundamentally disagreed with the report's findings.

However, he says in his experience, candidates for non -executive posts 'had to pass the BSW test - if you could breathe, stand and walk you were appointed'. He says the board 'should include business people' as well as 'people elected from local authorities'.

In the north west, he says 'nepotism was a bigger problem' than political involvement, and he thinks the current system 'is open to all sorts of abuse'.

York University visiting professor of nursing and clinical management Ray Rowden, who has served as a trust non-executive, is also critical of appointments by HAs: 'I think it would make trust non-executives feel accountable to HA boards. I think trust board non-executives would feel second-class citizens.'

Mr Rowden thinks appointing too many Labour nominees has damaged the health service: 'If you stuff boards with too many people on-message, there is not enough grit in the oyster. It might suit control freaks in Millbank, but it's not good for democracy.'

NHS Confederation human resources chair Andrew Foster says there could be major problems: 'At present there is no suggestion that trusts are accountable to HAs. Does it mean a more strategic role for HAs?'

He suggests that giving NHS Executive regional offices a bigger role would be better than the route suggested by Mr Milburn.

One person who straddles the nonexecutive/executive divide is St Mary's Healthcare trust chair Trevor Campbell Davis, soon to start work as chief executive of London's Whittington Hospital trust. Mr Campbell Davis has problems with the health secretary's proposals: 'You need to think carefully about HAs appointing to trusts.We would not want to do damage by allowing the process to be centrally controlled. I feel the close links with HAs may feel compromised.'

East Riding HA chair Ronald Wing says the main problem is the length of time it can take to make appointments, up to six months locally.

So Dame Rennie's recommendation that the process of appointing should not face delays is likely to be popular.

This is also the case for the recommendation that the roles of non-executives should be made clearer, for which there was unanimous support among everyone HSJ contacted.

Dame Rennie says: 'It is clear to me that not everyone involved in the public appointments process understands the role of an NHS board, its lines of accountability or what skills are required in non-executive directors.'

She calls for 'ministers to commission a fundamental look at the role and purpose of NHS boards'.

The review should make clear that 'an NHS board is collectively responsible for developing the strategy for the trust or health authority'. Further, it needs to sort out the confusion that some councillors have had in their role, she says.NHS managers have long warned that locally elected non-executives sometimes try to get involved in the day-to-day running of trusts and fail to understand that the NHS responds to national as well as local priorities.

Dame Rennie hopes her annual report, which will give details of complaints about political appointments, will be out by the end of June.

While it might provide interesting reading in terms of events over the past couple of years, it looks as if there might be more interest in the changing relationship between HAs and trusts.

Local councillor appointments (all NHS regions): 1 May 1997 - 11 November 1999

Political party Trusts HAs Total

Labour 238 46 284

Conservative 16 7 23

Liberal Democrat 29 7 36

General political activity No. of appointments % politically % of those who made active support Labour

1997-98 974 27.8 77.7

1998-99 1,642 22.8 77.0

1999-00 831 27.8 62.3