Supplement: NHS non-executive leadership is worthwhile

Having investigated the catastrophic failures at Mid Staffordshire, there are arguably few figures who have as deep an appreciation of the importance of non-executive leadership in the NHS as Sir Robert Francis.

Ask him about the value of chairs, non-executive directors (NEDs) and lay members to the health service and his answer is unequivocal. “I think they’re absolutely essential, because they are the people who hold the executive to account, and are there to challenge them with regard to what otherwise might be accepted nostrums.”

However, he combines his belief in the importance of the role with an understanding of its complexities – one which he says has been reinforced by his own recent appointment to an NED role at the Care Quality Commission.

‘Being a non-executive is a deeply responsible task with accountability attached to it’

“The challenge that any NED has is of course acquiring enough information in order to make a judgement,” he says. “And that requires an open stream of usable information, the means to understand it, and the ability and skills to ensure that the appropriate reaction happens to that information. And clearly in my view that was missing at Mid Staffordshire.

“No one would pretend that being an NED – let alone a chair of an organisation – is anything other than a deeply responsible task which has an ever increasing degree of accountability attached to it.”

Sir Keith Pearson fully concurs. The current chair of Health Education England, he has held chairmanships at a variety of NHS organisations since 1998, and identifies changing demands being made of those in health service non-executive posts.

“Our expectations of the NED community in the NHS go far beyond their role to act as stewards and ambassadors – that old classic role that we saw from them,” argues Sir Keith. “We expect them now to set the tone for the organisation, to be the champions for an NHS that rates so highly in the minds of the public that it’s rarely off the front pages of the media.

Training requirement

“I think it’s fair to say that chairs and NEDs come into the NHS with considerable external experience, often from the private sector but increasingly from other public sector organisations.

“But what is very clear to me is that chairs and NEDs, when they come into the NHS as raw material, will need to be trained and developed quite rigorously and, for some time, to build that range of competencies, sensitivities and skills that are necessary to be part of a board that takes major decisions on behalf of the public.”

Staff at the Healthcare Financial Management Association (HFMA) agree. Indeed, it is the rationale for its Chair, Non-Executive Director and Lay Member (CNL) Faculty. The aim: to enable people in these roles to come together and learn more about the NHS and its challenges.

‘There are induction courses for the newly appointed, regular meetings, e-learning and webinars’

It offers a supportive environment to those in positions that can sometimes prove isolating, as well as providing them with the knowledge they need to carry out their roles to the best of their abilities.

There are induction courses for the newly appointed, regular meetings, and e-learning and webinars. Notably, the organisation has taken an intentionally inclusive approach – members come from both commissioning and provider bodies.

As CNL Faculty’s chair, Heather Strawbridge puts it: “The faculty provides the opportunity for members to share their own experience with colleagues from both provider and commissioner organisations throughout the NHS.”

Sharing experience

She emphasises that the faculty “really respects the experience and knowledge that NEDs, lay members and chairs have”.

“It’s absolutely essential that people who are new to the NHS can come in and get that learning,” says Ms Strawbridge, who is also chair of South Western Ambulance Service Foundation Trust. “But we really do respect the background of the people coming into these roles.”

In other words, it is less about teaching people new skills and more about helping them apply these in a new environment. The necessity of this is emphasised by Sir Robert.

‘It is more about helping them apply their skills in a new environment’

“One of the things that struck me with Mid Staffordshire is that people are often recruited to these roles from a business background,” he says. “That means they are often quite well equipped to understand the accounts and the money side, but perhaps less so the delivery of the service – simply because the information comes to them in a way that is less familiar to them.

“I think that’s one of the reasons why board attenders tend to be driven by finance and targets, which you can measure and see on a piece of paper in a rather easier way than perhaps some of the more difficult stuff about standards of care.”

It is a theme echoed by Ralph Coulbeck, director of strategy at the NHS Trust Development Authority. For the past two years, the organisation has been responsible for appointing chairs and NEDs for NHS trusts.

‘We need a wider pool of people to come and do these important jobs’

Mr Coulbeck says the complexity of the data such individuals need to understand has grown even in that time.

“The expectations on non-executives for the scrutiny of the quality of care have rightly increased substantially in the post-Mid Staffordshire environment. And that can often be a highly technical requirement, to understand complex data, to challenge appropriately, to understand the difference between an outlier and a blip, a trend and a natural variation in data. This is really quite difficult stuff, but it’s essential that non-execs in patient care providing organisations have those skills.”

Sir Robert firmly believes that training plays a key part here, but expresses concern that too often training initiatives come and go.

“I think it does require some national initiative to try and get something on the go which is going to stay there,” he says. “We need a wider pool of people to come and do these important jobs, and if you actually offer them some training, people will not be deterred by the feeling of: ‘I don’t know anything about this; I’d be terrified to try’.”