What is it like working with a high performing NHS board? Penny Lock and Margot Corbin took a look inside the very best.
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Last June, Naomi Chambers and Alison Pryce published an article in HSJ about the features of high performing NHS boards.
Of 19 boards classified, only three were high performing on indicators from each of the three perspectives they considered – the customer, the employee and the business.
Each of these three boards were specialist or tertiary trusts and the authors commented that although there are some common sense reasons for why this might be, the culture, management and leadership of such organisations are worthy of further study.
Having completed a board development programme with Clatterbridge Centre for Oncology Foundation Trust, we were not surprised to see this trust among the top three.
We want to contribute to this discussion by painting a picture of what it is like to witness a highly effective board. We have taken a step back from all the data we gathered as part of the board assessment exercise, and here we highlight what it was about this board that made us so sure from early on that they were highly effective.
The NHS Institute for Innovation and Improvement’s leadership directorate - now part of the new NHS Leadership Academy - has developed a methodology for assessing NHS boards which, in different versions, has been used with more than 300 organisations.
The academy’s board development tool (BDT) is underpinned by evidence on effective board working and looks particularly at behaviours and relationships on the board.
The approach is developmental – our objective is to help the board to evaluate its performance and identify how and where this can be improved in order to serve its organisation and population.
The process is confidential and the board at Clatterbridge has given us permission to disclose some of our impressions.
The strengths of the Clatterbridge board
Chair/chief executive relationship
This is widely recognised as a relationship crucial to the health of any board. What struck us about these two leaders were their very different personalities but their total alignment with purpose. Each recognised the contribution and tendencies of the other and found their own way of defining their respective roles.
They seemed able to approach the boundaries in their relationship and test them without risking the mutual respect they obviously feel. They accurately predicted the differences we would find in their views when we came to interview them separately and were clearly able to play to their respective strengths.
They see leadership of the board as formally in the chair’s domain, but in practice take joint interest in both executive and non-executive parts of the board.
Consistency and diversity
The board was diverse in terms of gender - five female board members and six men - longevity of tenure on the board, and background, but not in ethnic mix.
We learned that the board takes a very strategic approach to the appointment of non-executive directors, carefully appraising skills and backgrounds they believe will be useful in facing future challenges. What was notable was the inclusion of the senior governor in board business as a fully active member of the board whose contributions were clearly welcomed and influential.
Board members knew the skills and experiences of their colleagues and drew on them both during and outside of board meetings. We heard how a non-executive director with strong strategic financial skills joined the chief executive at short notice at a critical meeting with external stakeholders.
The diversity of perspective in the board helped create a high level of challenge; the consistency of their strategic objectives and motivations provided the frame around this challenge. We witnessed them challenging themselves as to whether their views were too cosy or consistent and asking themselves what alternative voices would say.
We noticed the consistent use of “we” when members talk of the board or the organisation. While people were clear about the different responsibilities of the executive and non-executive members, and there was no shortage of examples of the non-executives holding executive directors to account, both roles were seen as contributing to the whole of the unitary board.
Focus and commitment to purpose
Each board member voiced energetic commitment to the purpose of the organisation. In every discussion, behind every comment or behaviour there was never any doubt that the provision of the best oncology services for patients was their uppermost priority. There was excitement about innovative approaches to patient care but a strong sense of history and of duty to the population.
As with many teams with a strong overarching purpose, their certainty over “which way is north” enabled them to navigate through difficult decisions and alternatives. We didn’t see differing lists of the key strategic priorities or main strategic risks, which is sometimes the case.
A board that can give such a cohesive account must surely achieve this through the active engagement of each board member in setting and owning those priorities?
The importance of relationship permeated the operation of this board: relationship between the board members, with patients and staff and with stakeholders. The chair voiced his view that organisations are all about relationships, a perspective that echoes that of many organisational thinkers.
The chair was active inside the organisation, connecting with patients and staff and, beyond the organisation, connecting with stakeholders, but all board members seemed committed to maintaining relationships through building trust.
In many trusts, when we ask the question “what do you worry about in terms of governance” non-executives will report a sense of insecurity, saying that they believe things are working well but aren’t completely sure.
In this trust the non-executives were more likely to answer along the lines of: “I have faith in our processes and that I’d know either directly from the patients or staff or through the executive if something were going wrong. If it did, I know that that we’d address it quickly.”
What you notice in the board is a sense that people know where each other is coming from, and that each contribution and perspective are important to the functioning of the whole. When a board member was absent, the others would ask, “What would x say?”
The combination of an engaging purpose plus commitment to relationships made it safe to challenge hard without this being seen as personal or a threat to relationships. We saw a range of healthy challenge, from the direct “I’ll go on about this at each board meeting until I’m satisfied” to subtle thought-provoking questioning. We saw executive directors challenge back when they thought that a challenge was coming from a need for reassurance rather than assurance.
The chair conducted board meetings with a light touch, which seemed to reflect his confidence that everyone was sailing in the right direction, was competent in their role and needed to be enabled not directed. He was attentive to facilitating relevant discussion and getting all voices heard, only adding his own opinion after others had spoken and ensuring that actions were clear. The chief executive allowed directors to speak for themselves and saw no need to be protective of them.
Absence of complacency
We imagine that the board members were surprised and a little embarrassed to find themselves at the top of a list of high performing boards. In our experience of interviewing boards, many have at least one or two members who appear to talk the board up.
The culture of this board was quite different; members appeared sincere in their appraisal of the board and candid in teasing out less favourable aspects. They took the exercise seriously and were particularly enthusiastic about us uncovering areas in which they could improve. They had no hesitation in critiquing themselves or the board to us, or to each other.
They were much more uncomfortable with positive feedback. One of the governors commented during our focus group with the governing body “they are doing a good job and they need to blow their own trumpet more”.
We observed them reviewing a board meeting at its close. As well as joking that they had had more breaks because we were watching, they seriously appraised how they had handled items and where they could improve.
As a specialist trust, they were conscious of the risk of insularity from the broader health system and were keen that the assessment of the board should include all aspects of the BDT methodology, which includes taking in the view of governors, staff and external stakeholders as well as the board members themselves.
They were aware that their clarity of purpose and narrowness of focus on oncology could put them at odds with the direction of other local players and these potentially conflicting perspectives were considered in the board meetings we observed.
During our feedback to them and a follow-up visit some months later to review progress on their action plan, they were still on a quest to work out how they could continue to improve.
The corporate philosopher Roger Steare asks: “Is it better to be proud of being the best, or to have the humility to strive for excellence?” Clatterbridge would hate to be referred to as the best, but we believe would emphasise a board’s duty to strive for excellence if it is to do justice to the organisation it serves.
Penny Lock and Margot Corbin are independent consultants and associate team coaches with the NHS Leadership Academy.