Published: 16/06/2005, Volume II5, No. 5960 Page 25

Jonathan Shapiro asks whether the role of non-executive directors can stand up to the rigours of the modern NHS

Why does the NHS have lay boards?

Every body in the health service, whether strategic or operational, commissioner or provider, has a main board comprising executive and nonexecutive directors, the latter always in a slight majority.

But are they still relevant in the era of foundation trusts and independent sector involvement in public services? Now is a good time to ask these questions because, quietly but emphatically, the role of the board is changing.

Like schools and other public bodies that lack democratic control, the local board has traditionally served two masters. Being centrally driven, it has been controlled by Whitehall; but since it has been intended to serve the needs of local populations, a degree of local accountability has been built in, too.

Boards have generally seen their task as ensuring that the central agenda has been delivered in a way that reaps maximum benefit for their local population.

Such a task has inherent conflicts built in: focus too hard on the local population, and the result is an inequitable and unaccountable service.

Thus a sophisticated if underused control mechanism existed with the potential to ensure that vociferous, middle-class populations did not gain excessive resources by dint of decibels while having the autonomy to lobby for better services locally.

The executive/non-executive balance was a typically British masterpiece of government by unwritten constitution:

executives might have to enact locally unhelpful central policy by dint of their line management arrangements, but non-executives (still accountable to the centre) could act as local champions within a national context, ensuring the welfare of the 'little man' in the bureaucracy of the welfare state.

Non-executives were the symbolic 'fuse' in the circuit of the NHS, set to blow if the system overheated. They protected the more expensive and less expendable executive components from the surges of current that occasionally emanated from Richmond House.

But that model of accountability is changing - new governance arrangements are emerging in line with the 'market-driven' NHS. These aim to increase transparency, but risk losing subtlety and sensitivity.

First, provider organisations are increasingly being modelled on the commercial sector, whose boards have the single task of protecting their organisation - and whose salaries reflect this responsibility.

The NHS versions may have governors as well as directors - to root the organisation in its local population - but the board's overall purpose is simple: to ensure the organisation increases market share and improves its bottom line.

Second, the boards of NHS commissioners and regulators will need to ensure that the central 'public' agenda is delivered. They will act as 'control posts' for equity in the NHS.

Again, this is a simpler task, with more transparent accountability and fewer conflicts of interest, but it risks being reductionist, and potentially more insensitive to local and individual needs.

The subtleties of grey are being replaced by the clarity of black and white. Boards may have simpler, more easily comprehensible tasks in future, but can they function, particularly at non-executive level, with the humanity and sophistication of the value-driven, 'constructively challenging' old NHS? At the very least, we should be discussing the issue openly.

Jothanan Shapiro is senior fellow, health services management centre, Birmingham University.

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