Why talk about boards?

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15 May 2019

John Coutts
Policy Advisor - Governance
NHS Providers


NHS Providers is about to publish ‘We still need to talk about boards’, which makes a strong case for the continuation of the board model of governance in the NHS. Boards of directors have been around in the NHS for some considerable time and at NHS Providers we have long been a vigorous advocate of board leadership as the best means of delivering strong but responsive and accountable leadership and direction. Among trust chairs, non-executive directors (NEDs), governance professionals and many executive directors the role of boards is quite well understood. But outside this relatively small group the role of boards and what makes them distinctive is far less well understood. So what is it about a board that distinguishes it from a committee or other forms of leadership groups?

Before seeking to answer that question it is worth talking about what boards are not. They are not a failsafe way of leading organisations, because there is no such thing. They are not immune from making mistakes nor are they endowed with abilities greater than those of their members. What distinguishes boards is their composition and what they do.

NHS trust and foundation trust boards are quite deliberately made up of a mix of executive directors and non-executive directors, with independent NEDs in the majority and a balance in power between the non-executive chair and the chief executive.

John Coutts    Policy Advisor - Governance

NHS trust and foundation trust boards are quite deliberately made up of a mix of executive directors and non-executive directors, with independent NEDs in the majority and a balance in power between the non-executive chair and the chief executive. This is known as the unitary board. This mix brings outside expertise and independence to the boardroom which brings diversity of experience and opinion and helps guard against the dangers of group-think. So boards are constructed in a way that generates a dynamic constructive tension that acts as a bulwark against complacency and promotes robust debate.

The second thing that distinguishes boards is what they do. It is the job of the board to stand for the owners of an organisation. For the NHS, that means us, the people who use NHS services. It is the job of the NHS board to ensure that the public enjoys the full benefits of NHS services and to ensure that the organisation is focused on delivering those benefits. This duty of the board is in no way inconsistent with system and collaborative working because ‘the public’ means all of us, not just those who live in a particular catchment area.

It is the job of the NHS board to ensure that the public enjoys the full benefits of NHS services and to ensure that the organisation is focused on delivering those benefits.

John Coutts    Policy Advisor - Governance

Boards do not manage or ‘run’ organisations – that is the job of the executive. Rather they are responsible for their leadership, direction and for accountability – for corporate governance. Boards do this by working together to set an ambitious but achievable strategy to give direction for the future, by setting and modelling the culture of the organisation so that ‘the way we work here’ is clear and new members of staff are socialised into positive work behaviours. Boards work as a team – executives and NEDs together to oversee the work of the executive so that risks to service delivery are managed and strategy is delivered. This is where the dynamic structure of the board comes into play with the use constructive challenge to test the information boards receive from the executive directors and use triangulation – obtaining information form more than one source – to verify what they are told. The objective is to obtain assurance – confidence backed by sufficient evidence – that strategy is being delivered and risk properly managed. Finally boards seek to make themselves accountable to the people who use their services, to those who pay for them, to regulators and to politicians via the central NHS bodies and directly to parliament.

Boards are made up of people and people fail as well as succeed. When boards don’t have the right balance, when NEDs are too complaint or executives overly dominate or where too much is taken on trust boards can and do fail.

John Coutts    Policy Advisor - Governance

None of this is fool proof. Boards are made up of people and people fail as well as succeed. When boards don’t have the right balance, when NEDs are too complaint or executives overly dominate or where too much is taken on trust boards can and do fail. The strength of the board’s composition and the process it uses to control and direct is that potential failure is likely to be identified and dealt with.

As the NHS goes through a transition to embed a more collaborative approach in local health and care systems, there is a gap at system leadership level, where ideally a board should be.

John Coutts    Policy Advisor - Governance

As the NHS goes through a transition to embed a more collaborative approach in local health and care systems, there is a gap at system leadership level, where ideally a board should be. In the short term this gap is being filled by committees of executives, committees in common and groups of NEDs, CCG lay members and councillors to provide an oversight function. This is not ideal in governance terms. But rather than undermining the position of local boards system leadership structures actually make the role of local boards more important. Boards remain accountable in law and in practice for the delivery of services. In working in partnership they will need to redouble their efforts to ensure that risk to service delivery within and between organisations is managed. They will need to seek assurance on collective as well as local service delivery and they will need to be accountable to their partners and well as those who rely on their services. Further into the future we might wish to introduce systems led by unitary boards in complement to smaller, board led ‘units of delivery’ at the provider level. So we still need to think and talk about boards.

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John Coutts
Policy Advisor - Governance

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