It is not possible to talk about boards without also addressing accountability.  The UK corporate governance code addresses the accountability of boards to their shareholders, the owners of their businesses, rather than accountability to whatever their industry regulator might be. Who then is the 'owner' of a foundation trust or NHS trust?

Clearly the state has a stake. Healthcare services are funded centrally and the government has a legitimate claim to be part owner, an 'institutional shareholder' for the NHS. However, this is equally true of the people who use and receive NHS services and the local communities made up of people who at one time or another will have recourse to use their services. Trusts also need to be answerable to the general public for the stewardship of the service – that they use their resources prudently and what they pass on to the next generation of leaders and service users is fit for purpose.

This cannot be done as part of some monolithic bureaucracy. Good accountability needs a strong local dimension, not just because it the 'right thing to do', but also because the local perspective can differ greatly from the perspective of the regulators or that of central NHS organisations. Those who work in the sector are well aware of the fact that if patient and service user engagement is to be meaningful there is a need to move beyond the accumulation of data and to listen to the authentic voice of those who use services. The same argument applies to the voice of staff and to the public in a trust’s catchment area more generally.

NHS foundation trusts are required by law to have councils of governors elected by their members – their staff, patients, service users and carers and the public. Councils of governors have a number of important statutory duties, not least of which is to hold the NEDs of the foundation trust to account for the performance of the board. System working makes the role of councils of governors more challenging as a legitimate route to public accountability. Not all trusts are foundation trusts with councils of governors. Councils have no standing outside their own trusts and can only work together on an informal basis. There is also a significant question as to how councils can be both party to an informal decision-making process at system level while holding their boards to account for these same decisions at local level.

The long term plan is silent on the future of groups representing the interests of patients and the public, such as councils of governors. This leaves scope for a sector-wide debate of how best to bring local accountability to systems.