After 10 years as a non-executive director of my local NHS trust, including six years as deputy chair, I felt tuned-in to what local people wanted from their hospital. But looking back on the experience, it is interesting to reflect that if I were applying now, rather than a decade ago, it is extremely unlikely that I would be appointed.
In conversation with colleagues, I have come across several people who have unsuccessfully applied to be NHS non-executive directors in the past year or two. All had extensive knowledge of their local communities and highly relevant skills.
One had been a chief officer of a non-NHS public service organisation, holding a high-profile post at regional level, as well as having served on a range of NHS boards in the past. He applied to join the board of his local mental health trust. However, he was not even shortlisted for the vacancy. He felt that his skills and experiences were not valued because they had not been obtained in the commercial sector. As he explained: "It would seem that being a CEO in the public sector, with all the governance and financial experience that brings, just does not count."
Another candidate had a fine reputation as a researcher, with relevant experience in health policy and health promotion and a detailed knowledge of patient and public involvement. However, even during her interview, she felt it was made plain that she was not the sort of person her local primary care trust was looking for.
"It became quite clear during the course of the interview, and particularly after I had given an intelligent, though partially critical, analysis of some aspects of current health policy, that they were not even considering me for the position," she said. "I left the room in no doubt that there was no place at the table for an independent thinker who might ask too many questions."
I know only one person who was recently appointed as a non-executive director. He had an illustrious career as a finance expert and entrepreneur in the private sector, but had, by his own admission, absolutely no knowledge of the NHS.
In addition, I have come across examples of existing non-executive directors being made to feel they were past their sell-by date, even though they were greatly respected in the community.
All this made me wonder what was going on. Did "new blood" have to be of a particular type? Were those with a public service or voluntary sector background actually at a disadvantage?
I systematically examined the information on the Public Appointments website to find all the non-executive director vacancies in NHS trusts (excluding those specifically seeking chairs) that first appeared between 20 February and 31 March.
This amounted to 36 vacancies, including 13 in PCTs (including the entire non-executive complement for a newly established provider organisation), two in ambulance trusts, seven in mental health trusts, four in trusts offering mental health and learning disability services and nine in acute trusts. There was also one vacancy in an NHS trust that specialised in neurology and neurosurgery.
Of the 36 vacancies, seven were specifically aimed at candidates with a finance background that would enable them to serve as audit committee chairs. My analysis does not extend to these posts as the requisite finance-related skills and experiences might be assumed to be obvious.
The official line, set out on the Appointments Commission website, is that NHS boards need a range of skills and experiences among their non-executive directors to reflect the communities they serve.
It is stated that candidates should have experience in some of the following areas at senior level: finance, governance, strategic planning, commercial management, voluntary or community roles, professional areas related to the type of NHS organisation recruiting. They should also live in the area served by the trust and should demonstrate a range of competencies, including commitment to patient needs, forward planning capabilities, the ability to challenge constructively, influencing and persuasion skills, a team-working approach, self-motivation, and clear and creative thinking.
Skills in demand
Almost all the posts sought a range of skills, although inconsistencies in the way information was set out made a comparative analysis difficult. However, it was clear that some skills are sought far more frequently than others.
Most vacancies were aimed at people with predominantly commercial experience and finance skills. Fourteen vacancies specifically wanted applicants with commercial experience, such as marketing or business planning, although other skills were often required in addition to those.
The next most popular requirement, with 13 explicit references, was skills and experiences related to governance and/or risk management. Nine posts (in addition to those for audit committee chairs) specifically wanted finance experience at a significant or senior level. Nine wanted legal expertise and/or qualified lawyers. Seven wanted experience of the voluntary sector or the regeneration field, but this was often sought in conjunction with other skills in such a way as to be likely to exclude many people with a background in the voluntary and community sector.
Indeed, the range of essential plus desirable qualities required was often very wide, and while skills like "customer focus" and "patient-related skills" were sometimes seen as desirable, they were often apparently seen as secondary to the "essential" expertise, such as finance experience.
A handful of posts wanted specific attributes such as experience in organisational development, human resources or property development, or knowledge of corporate social responsibility, sustainable development or the needs of children and young people.
So, what is going on here? This snapshot analysis highlights a risk of throwing the baby out with the bathwater, particularly in the run-up to seeking foundation trust status.
In the quest for a new type of non-executive, there is a danger that people who know and understand their local communities will not be appointed unless they have a particular kind of skill, probably acquired in the commercial sector. Indeed, it may be more extreme than this, since a number of the posts were clearly aimed at people who had worked for large and complex businesses, although people with experience working in small enterprises, including the voluntary sector, may well have had more hands-on experience and more responsibility for day-to-day finance and governance issues.
Equally bizarre is the apparent move towards wanting non-executives to have the same areas of expertise as their executive colleagues. For example, one trust wanted its non-executive to have "senior level experience of clinical or related issues in a health service, regulatory or academic field". One cannot help wondering what their medical director was doing with his or her time.
One of the ambulance trusts saw it as advantageous for their successful candidate to have "senior experience gained in the transport industry, particularly in fleet logistics", which raises the issue of what their director of operations was appointed for.
Clearly, an understanding of the core business of the organisation can be helpful, but more important is an independent mind, the ability to ask good questions and the wisdom to assess whether one is getting good answers. Indeed, it is possible that if executive and non-executive skills are aligned too closely, a critical perspective will be even harder to come by.
None of this is to suggest a rosy past when all was well. Rather, it seems that a historic shortfall in one set of attributes is about to be replaced by another deficit, as only a certain type of person will be appointable in the brave new world of the businesslike NHS.
The risks to the NHS of this would be huge. For one thing, it is by no means certain that these sought-after accountants, lawyers and businesspeople are applying in sufficient numbers. But even if there are sufficient applicants of high calibre from a range of financial and commercial backgrounds, we should be welcoming these people to the NHS to be part of a balanced board, and not as a stealth action to force out those with other experiences and attributes, particularly those with experiences and skills related to the patient experience, the local voluntary and community sector and the local community.