The chair-chief executive relationship is at the apex of a health authority or trust. Effective joint working by the two is widely seen as a prerequisite for effective board working and more general organisational effectiveness. Conversely, tension or poor working relationships can be detrimental to the performance of the board, the organisation and the individuals concerned.

In recent years considerable attention has focused on a number of well-publicised breakdowns in these relationships. Although there is no firm evidence on the size of the problem, a confidential unpublished survey by the NHS Confederation in 1997 suggested that significant difficulties between chairs and chief executives may have been experienced in up to 10 per cent of NHS organisations. More generally, there are few partnerships in which stresses and strains have not been experienced at some stage.

Despite the importance of these relationships, there is little current research on the subject. It was in the light of this deficiency that the NHS Confederation, the NHS Executive leadership programme for chief executives and the Institute of Health Services Management commissioned a research project on chair-chief executive working relationships from LSE Health for the period from 1 February to 30 June 1999.

1The aims of the research were to identify:

the main determinants of effective chair-chief executive relationships;

problems that are likely to lead to dysfunctional relationships;

measures that can be taken to build and maintain effective relationships.

We interviewed 13 pairs of chairs and chief executives from HAs, boards and trusts in England, Scotland, Wales and Northern Ireland. Each person was interviewed individually. We also interviewed two regional chairs and two regional directors, all from different regions. In the table, 'joint reference' refers to where a pair from the same organisation referred to a topic.

Given the sample size, we do not claim that the results can be generalised to the entire NHS - this was not the purpose of the study. Rather they offer a range of personal perspectives on important issues. Some of these will resonate with chairs and chief executives beyond our sample and may form the basis for action. Others are preliminary and raise issues for further investigation. In short, the study was designed to contribute to an ongoing policy process rather than to offer definitive results. Some of the main messages to emerge from the study are set out below.

Personal qualities

The personal qualities of a working relationship emerged as crucially important. Attributes such as mutual respect, trust, shared values and openness were all emphasised.

Interestingly, chief executives emphasised compatibility and communication rather more than chairs - no doubt reflecting their need to adjust to a chair's working style rather than vice versa - while chairs placed greater relative emphasis on competence (see table).

Examples of where relationships broke down were generally related to chairs' behaviour and ranged from the use of abusive language to unethical practices - for example, rifling through a colleague's private correspondence. Problems were far more likely to arise because of poor personal relations than through external pressures.

In fact, critical incidents associated with outside events tended to define and test a relationship. In several cases, joint experience of adverse events actually strengthened a relationship (see box overleaf ).

Clarity about roles

Chairs and chief executives occupy potentially overlapping domains, and problems associated with chairs intruding on the chief executive's territory are well known. For this reason, agreement about lines of demarcation is important.

In fact, most of our respondents had achieved a clear working agreement. A model of partnership in which the chair leads on public relations and, importantly, political issues while the chief executive takes responsibility for operational management and media relations was widely accepted.

Despite having agreed their roles, however, some chairs experienced problems. Some had difficulty adjusting to the new political climate. Those who had been appointed under the previous Conservative government found that their access and influence reduced with the arrival of newly elected Labour MPs.

Others continued to be wedded to a competitive approach and found partnership working problematic. We heard of overly proprietorial attitudes among some trust chairs, who continued to view the world in terms of 'their' organisation rather than the NHS overall. Some chairs without previous experience of working in large organisations found NHS culture difficult to understand.

Relations with consultants continued to be a potential flashpoint.

For their part, chief executives were sometimes criticised for a failure to keep the chair fully informed. An approach based on 'no surprises' was a high priority for most chairs, and being inadequately briefed was seen as a serious impediment to carrying out their function effectively.

Appointment procedures

Appointment procedures for chief executive posts are usually rigorous and satisfy best practice standards. In contrast, despite the introduction of Nolan principles on standards in public life, chairs are still subject to appointment (and re-appointment) procedures that are far less rigorous. We heard accounts of how 'party politics and patronage' still apply.

The post-Nolan procedures were described as 'a smokescreen to choose politically correct people'.

'Amateurish' was how one experienced chief executive described the process. A regional respondent said it was 'riven with pitfalls'. Given the importance of compatibility between a chair and a chief executive, it was surprising to learn that, in some cases, the chief executive does not even meet the chair before the chair's appointment.

Set against these shortcomings, some regions are clearly making significant progress in developing more effective chair selection and appointment procedures. Databases containing the names of potential chairs are drawn upon, as are extensive consultations and searches within the wider health economy. Interview procedures are probing and considerable trouble is taken to match chairs' skills with the needs of particular posts. But despite these initiatives, the national picture remains patchy.

Induction, training and development

At the moment, the provision of induction training for chairs is very patchy: in some regions structured programmes are in place; elsewhere provision is minimal.

The subsequent use of training and development facilities is also often very limited: two-thirds of chairs claimed to have little involvement with formal education and training. One trust chair expressed the view that training events were offered by 'self-opinionated characters'. Another complained of being 'snowed under with offers for courses' but found them unattractive.

Large national conferences were generally considered a waste of time apart from the networking opportunities they offered. There was far more support for learning sets and mentoring schemes that recognised individual needs.

Chief executives expressed even stronger preferences for personal development through learning sets and coaching schemes. Experienced managers expressed their interest in participating more widely in such schemes as providers who could draw upon relevant experience in assisting younger colleagues.

A working relationship is likely to be at its most fragile immediately following a chair appointment. This is the period of 'courtship' before the 'marriage'. As such, there is a strong case for all chairs receiving a clearly structured programme of induction training and personal support, perhaps through a mentoring scheme. We heard of some serious breakdowns in working relationships which had been mended with the help of skilled, external facilitators .

Unfortunately, there is currently a shortage of such skilled people and access to them can be a matter of chance.

Maximising the chair's potential

Chairs occupy multiple roles. Earlier research has shown that their relationship to the chief executive is part partner, part mentor, part executive and part consultant.

2Achieving a balance and making a contribution in these areas requires fine judgement. Chief executives do not always act to maximise the chair's contribution. Our research confirmed earlier findings that some chief executives see their working relationship with the chair as another task to be 'managed' rather than as a potential source of added value. Minimising the negative impact becomes more important than maximising the positive contribution. Creating a positive culture about joint working can be expected to result in improved performance. With around one quarter of chief executives currently in post at this level for two years or less, this is a major challenge.

Our study identified much good practice. Of 13 organisations, three had strong and positive working relationships between chair and chief executive and this was reflected in high levels of organisational performance.

In another six organisations they appeared to be working together in a satisfactory manner. In four organisations major difficulties had been experienced at some time in the current relationship, but in all but one case, these problems seem to have been resolved.

These findings do not indicate a crisis. But they do reveal uneven performance and considerable scope for improvement. Areas that seem particularly in need of attention are the chair appointment process and the continuing development needs of chairs and chief executives, individually and jointly.

'It brought us closer together': coping with conflict and crisis The chief executive of trust A enjoyed a very close working relationship with his chair, a retired senior civil servant whom he described as 'an old English gentleman'.

The chair cared for the NHS with a passion, was supportive and loyal, and had the status of a legend among the staff of the trust. He had a 'father and son' relationship with the chief executive. The trust was not, however, viewed favourably by outsiders, including the health authority.

When his term of office expired, the chair was not reappointed and was replaced by the deputy chair of the HA. This distressed everyone at the trust, including the chief executive, who devoted little effort to welcoming the new chair. For his part, the new chair came in with a clear view that changes needed to be made in the way the chief executive and the trust operated. An extremely tense relationship developed over a period of about nine months.

The flames were fanned by a senior member of staff who, for personal career reasons, sought to cultivate the chair in a divisive manner in the vacuum left by the chief executive. Recognising that the situation was at a very low ebb, the regional chair recommended some outside expert facilitation. This was undertaken in a series of, at first, gruelling meetings which started the process of mending the relationship. This has strengthened over the last three years and both parties claim that they now work extremely well together.

With hindsight, the chief executive believes that he did not devote nearly enough time to the task of integrating the new chair into the organisation.

The chief executive of trust B is an experienced and long-serving NHS manager. He has been the chief officer at the trust, and before that, the HA, since 1983. Soon after a new chair was appointed there was a critical incident when the trust failed to meet its waiting-time targets.

Considerable publicity was generated when the health secretary named the trust as failing during a speech in the House of Commons. As a result, the chair and chief executive were summoned to the regional office to give an account of themselves and receive a strong reprimand. The chief executive confessed to feeling extremely guilty about placing a new chair in this position (for which he could take little blame) but was also anxious to see whether the chair would, in his words, 'sacrifice him'.

In the event - according to the regional director - the chief executive handled the meeting extremely well, assuming full responsibility. The chief executive explained that the chair was extremely supportive throughout. Both of them now view the incident as one that provided an opportunity for bonding and feel that their relationship emerged from it strengthened.


1 Robinson R, Exworthy M. Two at the Top: a study of working relationships between chairs and chief executives at health authorities, boards and trusts in the NHS . NHS Confederation/NHS Leadership Programme/ IHSM, 1999.

2 Stewart R. Chairmen and chief executives: an exploration of their relationship. J of Management Studies 1991; 28: 511-527.

Key points

The appointment of chairs is seen as political and lacking in transparency. Their training is patchy.

Nearly a third of chairs and chief executives in this study had experienced major difficulties in their relationship.

Relationship breakdown was generally due to chairs' behaviour.