YORKSHIRE TERRIER

The words 'non-executive director'make my heart sink. It is not that there is anything wrong with 'neddies', it is simply the very existence of that curious title which gets my goat.

I blame Margaret Thatcher, or at least those who in the 1980s adopted Thatcherite philosophies and decided the NHS would be a better place with more business-like practices.'More business-like' sometimes meant form as much as substance, which is where neddies entered. If Marks & Spencer had executive and nonexecutive directors, went their thinking, then obviously the NHS would be a more efficient place if it had them too.

Who first used the neddy title in the NHS is unrecorded.No such nomenclature appeared in the relevant statutoryinstruments concerning the membership of NHS authorities.And yet the terms 'executive' and 'non-executive director' quickly became ubiquitous.

It seemed l ike a good idea at the time: such a title, however unofficial, would help provide NHS boards with the aura of being more like a business, and coincidentally boost their members' status.Like many apparently good ideas, it failed - perversely achieving almost the exact opposite of what was intended.

Using the board of directors of successful public companies as a paradigm for running parts of the NHS is understandably attractive, although far less so when you consider that most commercial companies do not survive long.Even such apparent exemplars of commercial success as Marks & Spencer can experience paralysing commercial catastrophe in a short time.Commercial companies are not, and never were, guaranteed to be successful.Taken collectively they merely tend towards success as, in the economic equivalent of Darwinian evolution, the unsuccessful go in their thousands to the wall.

Public bodies are quite different enterprises.Commercial concerns have a clear and unambiguous measure of success: profit as a return on capital invested.The NHS does not have such a clear focus.The ends, if not the means, for the NHS are ultimately subjective, based on value judgements which do not require cutthroat commercial acumen but rather more subtle qualities, not least decency, disinterest and realism.

To be effective, even as small-p political entities, public bodies need boards entirely separate from those who carry out their work.That fundamental principle was spelled out long ago by the Maud committee and is adhered to in most of public life.

Sensibly, there are no civil servants sitting in Parliament, nor, for example, does a social services director have an ex-officio seat on the local council.So why should the NHS be different?

The division of NHS authority members into executives and nonexecutives has had two thoroughly undesirable consequences: executives have gained a degree of power inconsistent with public service, while non-executives have had their importance eroded to the point where they are inevitably less effective than they would otherwise be.

One illustration of the shift in the historic relationship between 'officers' and 'members'has been the quality of material presented at board meetings.

When managers were not themselves board members, agenda papers tended to be meticulously prepared, invariably written in the third person and scrupulously devoid of any subjective statement containing the author's own opinions - all of which combined to allow members the opportunity to exercise their own judgement.With the advent of executive directors a remarkable change occurred: papers became peppered with authors'personal views, they were frequently deficient in hard data, sometimes laughably so, and boards began to rubber-stamp rather than control events.

It is all too easy for executive directors, the most senior managers in the NHS, to become at best complacent and at worst contemptuous of their non-executive colleagues, especially so for chief executives.A chief executive who may be the line manager of half a board's members can count on their support and will inevitably be tempted to use that authority to stage-manage meetings.More often than not an official or unofficial sub-committee, made up of the chief executive and their subordinates, will have already met to discuss the agenda and intended outcome - making the real board meeting a sham.

Power tends to corrupt, and not just in a financial sense. Spiritual corruption can flourish in a system in which executive directors are almost institutionally encouraged to be disdainful of non-executive colleagues.

This is not a new phenomenon:

Shakespeare referred to 'the insolence of office', and one of the earliest ombudsman reports criticised a senior NHS manager in the Midlands for his arrogance in objecting to a member of the public reminding him that he was 'merely' a public servant.

All NHS managers need to be subject to regular reminders that they are public servants, that their status, however well recompensed, is one of voluntary servitude to the community in which they work.

Elevating the most senior NHS managers to seats on the boards of public authorities, however well intentioned, denigrates and demeans non-executive members in whom the ultimate moral legitimacy of NHS management should reside.Board membership actually tends to diminish managers' roles as honourable servants of the public.

At a time when the whiff of more NHS reorganisation is in the air, someone should take the opportunity to return to the natural order of things.Can we ensure that in future all NHS boards are made up exclusively of non-executive directors? Then we could happily dispose of that unhappy title.

Steve Ainsworth is a former primary care manager.