Feature

Power without accountability?

Non-executive directors may bring much to the governance of the NHS—but they don’t bring democracy, says Stephen Burke

Recent correspondence from Sir William Wells, who chairs the NHS Appointments Commission, has prompted considerable debate among non-executive directors about their role.

I hope the debate does not stop there because Sir William has raised important issues about governance in the NHS — issues that deserve a much wider airing.

I have been a non-executive director since 1997, first of a community trust and since 2002 of a primary care trust. At the same time I have been a local authority councillor, with (for some of the period) cabinet level responsibility for social services.

There is no comparison between the two positions and this is not just regarding their roles and responsibilities, but also their accountability. As a councillor directly elected by my constituents, it is clear to whom I am answerable and who holds me to account. I have daily contact with my constituents on all sorts of matters. My phone number, home and email addresses are publicly available. And, of course, there are elections to the council every four years.

Direct elections to NHS trust boards are the only way to make the health service locally accountable. Since that is unlikely to happen in the near future, we have to look at how to make the role of the non-executive director as effective as possible.

Which brings me back to Sir William’s recent letter about new terms and conditions for non-executive directors. He makes it clear that from April non-executives will be expected to undertake their core duties in two and a half days a month (rather than the existing five-day commitment).

I welcome this and not just because it is a realistic way to ‘attract a broader cross-section of the working population on to our boards’, although certainly it should achieve this.

The important issue is not the amount of time spent but how it is spent. As Sir William suggests, this change should focus non-executives’ minds on their governance role as set out in Governing the NHS.

Interestingly, Sir William draws parallels with the role of private sector non-executives, which of course was the key influence for the NHS non-executive role and the Higgs report. He argues that some of the country’s largest companies are run successfully with a non-executive input of no more than two days a month. It is debatable whether such parallels are either appropriate or helpful.

So what should the role be in a public service such as the NHS? What is effective governance? Inevitably there are different interpretations of the role of non-executive and how it should be undertaken. How do we ensure that the health needs of our local population are met and that public money is well spent? How do we go beyond basic functions of audit and remuneration? How do we set strategic direction and hold the executive to account? Can we be independent and team players?

Sir William suggests trimming non-executive responsibilities. Clearly some non-executive directors are perceived to have crossed the line and stepped on the toes of the executive. One activity that is ruled out is executive ‘shadowing’, which must be a relief to all concerned.

I’m also relieved that non-executives are not expected to ‘compensate for skills gaps in the executive team’ — just surprised to hear this might have been happening.

I do think ‘trimming’ gives us opportunities:

• to reduce the number of committees (and the number non-executives sit on) and to refocus their terms of reference;

• to ensure executives fulfil their responsibilities and provide non-executives with the information they require to fulfil their responsibilities.

Non-executives can ask all the right questions but we do need timely, accurate and accessible information to do so effectively.

Non-executives have a responsibility to ensure their trust is outward facing — not just with the myriad of partner organisations but also through ‘patient and public involvement’. The jury is out on how far the new arrangements for public involvement will assist engagement with our local communities.

Non-executive directors are an immensely talented pool of people, hugely committed to the NHS and the community they live in. They are also struggling to work within resources and structures and constraints set nationally.

The role of a non-executive director — according to Governing the NHS — is to challenge, question, probe, be assured, maintain confidence, contribute, scrutinise and so on. These are all key to effective governance but they are essentially reactive.

Effective governance does not and never will equate to real accountability — accountability to the people the NHS should be serving and who need better healthcare that meets local needs.