5.1 This section examines the impact of the pilots on how the Health Boards operate, with a focus on public engagement and accountability.
5.2 The pilots altered the mechanism by which non-executives were appointed to the Boards, and removed some senior executives' membership. It is important to be aware that these pilots were not the only changes taking place in the NHS over the two initial years of the pilots. Territorial Health Boards, including non-pilot Boards, continued to innovate. We had opportunities to discuss innovations that were unrelated to the pilots with staff of the pilot Boards and NHS Tayside. Clearly, there are many other factors that affect how Boards operate besides the institutional means of selecting non-executives. As the Higgs Report emphasises, "Effective boards depend as much on behaviours and relationships as on procedures and structures". Changes resulting from the pilots need to be seen in this broader context.
5.3 Changes must also be seen in light of traditional norms of Health Board behaviour, some of which came under pressure during the pilots. Throughout the pilots, but with particular effects in the early stages, some uncertainty was evident regarding the appropriate role that elected non-executives should play, and the extent to which this should vary from a standard appointed non-executive.
5.4 Chris Skelcher describes the three roles of Board members as:
- contributing an independent view and expertise;
- an 'internal role' focused on corporate strategy and performance monitoring;
- and an 'external role' dealing with stakeholders and the public.
In Scottish Health Boards, interviews suggest that the 'internal role' has been the focus of the non-executive workload. Broadly, the expectations of the Health Boards was that their boards of directors are corporate bodies with corporate responsibility (meaning that it is inappropriate to disown or speak out against collective decision) and do not engage in operational matters, which are the province of the executives. Board non-executive members, are seen to be responsible for governance, meaning monitoring performance (e.g. inspection of annual accounts) and deciding high-level strategy (e.g. approval of the budget and identification of the Board's overarching priorities). In this understanding, widely shared among our interviewees, it is not appropriate for non-executive directors to engage in operational issues, impugn collective decisions once they have been taken, or play a particularly visible public role. Additionally there is minimal opportunity for members to initiate or pro-actively raise issues for discussion, as their role is primarily one of scrutiny and holding to account. The Board as a whole is then accountable to the Scottish Parliament via the Scottish Government, a point made clear at the central induction for elected members.
5.5 However several newly elected members stated that they felt an additional, or in a few cases primary, accountability to the public of their Board area. They felt this required greater activity within the external (public-facing) role, and accordingly greater emphasis on pro-actively contributing to Board decision-making. Where particular issues relating to this difference of perspective arose, with a key example being whether elected non-executives should hold 'surgeries' or public meetings, difficulties could arise. In Dumfries & Galloway, guidance was sought from the Scottish Government on whether this was an appropriate activity for elected non-executive members. The Government's position was that Boards themselves should decide. This context of uncertainty frames most of the following findings.
The Impact of new non-executive directors
5.6 This section summarises the impact of adding new non-executives by election or amended appointment processes.
Skills, experience and learning
5.7 Several of the elected members had served on boards of one kind or another, and some had experience within the NHS as clinicians. A small number had previously served on Health Boards, including three appointed members who had been removed from NHS Fife only a few weeks earlier to make way for newly elected members. However, interviews with existing personnel suggested that they saw many of the new members as having less experience in corporate governance than would be the norm for appointees who had come through a conventional selection procedure.
5.8 There was a general feeling that many new members' behaviour differed from established members' due to their relative inexperience. This was partly a normal part of adding new non-executives to a Health Board. Interviewees in Fife in particular had more difficulty in distinguishing the new members' behaviour from that of newly appointed non-executives they had encountered in previous years. Interviews with existing non-executives and members of all-appointed Boards further emphasised that new non-executives typically take several months, sometimes over a year, to develop in the role. What made the impact of these new members different was at least partly that ten and twelve of them arrived simultaneously. In our interviewees' past experience non-executives had arrived as individuals or in pairs and would take some time to become active members, during which time they would develop a sense of how the Board operated. With many new members being added at once this slow socialisation process was interrupted.
5.9 One dimension in which this relative lack of experience manifested itself was in the focus of new members' questions around the Board table. Several continuing members in Dumfries & Galloway expressed concern that elected members became too involved in operational matters (for example, engaging in long discussions about the technical specifications of new equipment to be purchased) at the expense of the strategic discussion that they expected to dominate Board meetings. Several of the elected members had backgrounds in medical practice, which gave them particular interests in areas which established members considered to be more the 'operational' domain of professional managers than the kinds of higher-level aspects of Board business with which they would expect non-executives to concern themselves.
5.10 Similarly, the largely reactive role of scrutiny is conventionally fulfilled through careful reading of Board papers and questioning of Executive members. In both Fife and Dumfries and Galloway, some elected members expressed frustration about the lack of opportunity to make a pro-active contribution in the manner they had anticipated, finding Board meetings more focused on scrutiny and accordingly offering less opportunity for debate than expected. Closely related to this, a number of elected members expressed surprise or frustration at the extent to which Board activity and decision-making is circumscribed by central Government policy. Having been elected, they had expected Boards to have greater autonomy and thus more scope for decision-making.
5.11 The new members' questioning also tended to include more general queries (what several members referred to as "daft laddie" or "daft lassie" questions) than had been the case before the pilots began. Despite the informal moniker, "daft laddie" or "daft lassie" questions are often seen as helpful in a non-executive's role. Non-executive lay members are after all brought onto Boards precisely to question conventional wisdom within the organisation, and this seems to be an important part of the rationale for limiting their terms of appointment. Being willing to ask questions to which the answers seem obvious to longstanding NHS 'insiders' can be an important and constructive part of the role. On the other hand, too many might detract from strategic discussion and monitoring within a finite amount of time. The kinds of questions asked were different after the elections, but there was not a clear consensus among interviewees on whether this represented more rigorous and creative scrutiny or a diversion from important questions.
5.12 There was a general consensus that adding large numbers of new non-executives simultaneously put greater pressure on staff to provide appropriate support and training. This clearly had a significant opportunity cost for the Boards in that staff time spent on supporting new members could potentially have been used for other activities. On the other hand, adding the elected members as a large group did allow for some specialised, dedicated induction training when they arrived.
5.13 The variability of elected members' backgrounds and skills appears to be an inherent consequence of electing, rather than interviewing and selecting, non-executives. As such, it is impossible to guarantee that new members will arrive with all the skills needed to perform a corporate governance function. Elections prioritise other characteristics - electoral appeal - over the skills matrix previously used to identify the desirable characteristics of new non-executive directors. To some extent the alternative pilot model, which selected a new member from a Public Partnership Forum, also prioritises a non-skill-related characteristic - being a PPF office-bearer - over possession of particular skills. While the electorate may choose candidates with skills that are perceived to be required for Board roles, there is no guarantee that the factors that make someone appealing to voters will always be matched with such skills. To some extent similar considerations apply to the alternative model, which selected a member of a PPF, where the pool of applicants was restricted to PPF office-bearers and skills were only one criterion for selection within that pool. On the other hand, an interview process can prioritise skills of corporate governance over other qualities. Thus, support and training beyond that normally required by new non-executives may well be needed for members who join Health Boards by these routes.
5.14 Different elected members varied in their initial attitude to the existing Board. While there had been controversies surrounding the centralisation of services within Fife in previous years, the Board's general strategy was well-established by 2010. In Dumfries and Galloway, the election took place against a backdrop of campaigns against service reorganisation. In general, our interviews with elected members before they were elected suggested that they were open to being persuaded to other points of view and compromising with other Board members. However, some elected non-executives were felt to have arrived with a more confrontational attitude to existing members than others. Voters in several rural areas had concerns about small local hospitals being closed. Proposals to replace these 'cottage' hospitals, which were circulated before the beginning of the pilots, led some residents to believe a decision had already been made to centralise health services in the region. Candidates picked up on this. Where candidates who were elected saw their role on the Board as being primarily to represent electors who wanted to protect small local hospitals from the threat of closure, this could lead to confrontation.
5.15 In addition, the removal of several experienced non-executives combined with the addition of a large number of new non-executives was an unprecedented change in Board membership in Dumfries and Galloway. Trusting working relationships, which had built up over years, were broken up within a short time and understandably members took some time to build up similar working relationships with their new colleagues. In Fife, while the change was also unusually dramatic, there was a relatively greater degree of continuity in personnel due to formerly appointed non-executives winning election. Chairs of Board committees were initially allocated to experienced non-executives who had previously served on NHS Boards either in Fife or elsewhere. Important decisions on hospital provision had already been made, and contracts signed, before the pilot began.
5.16 Board agendas are circumscribed by legislation, and non-executives' opportunities to add specific points to the agenda are limited by the need to cover a fixed agenda within a limited time. Typically, within formal Board meetings non-executives react to reports from committees and officers rather than raising matters. There were notable deviations from this pattern in Dumfries and Galloway as several elected members wishing to raise issues of concern used the 'Matters Arising' or 'Any Other Business' sections of the agenda. These interventions became quite extensive. However over time, and in particular with the departure of a particular elected member, this became less frequent.
5.17 One behaviour we observed in both of these Boards (which seemed to mark a distinction between elected and appointed members) was discussion about the minuting of individual contributions. Neither Board had traditionally produced verbatim minutes of Board or committee meetings; instead, minutes summarised the key points of discussion. In both Fife and Dumfries and Galloway some elected members were keen to have their personal contributions to discussions noted. This reflected some elected members being keen that they be judged based on their own personal performance, as well as the outcome for the Board collectively. Again, it is difficult to be certain of whether this reflected their having been elected - and therefore feeling that members of the public can hold them to account as individuals rather than parts of a collective - or whether new appointed members tend to share this feeling and lose it over time. In Fife the concern over minuting related specifically to a particular issue of governance (a question of whether one of the Board's committees was exceeding its mandate) whereas in Dumfries and Galloway similar concerns were expressed repeatedly in different contexts.
5.18 Not all changes in the dynamics of Board meetings were necessarily caused by the fact that new members were elected, as these pilots also led to other changes in the Boards' make-up. The elections also made both Boards significantly larger. In Fife especially, where the Board increased to 23 members plus several attendees, increased size was associated with much longer meetings. This resulted partly from elected members asking more questions and pursuing them for longer, but also from the simple increase in the number of people around the table. While the rationale for increasing the number of Board members is clear from the legislation, it is worth being aware that there is a cost to increasing numbers in that large Boards can become ponderous (as noted, for example, by the Higgs Report on corporate governance). There are inherent costs to increasing the number of members, which need to be balanced against the benefits of introducing a larger number of different perspectives.
5.19 While elected members were seen as behaving differently from appointed members, interviewees were sometimes unclear on why this was. Differences could be attributed to their being elected, to their arriving in a large group (such that 10 or 12 members who were appointed to the Board simultaneously might have behaved in the same way), or to personal idiosyncrasies that might also have occurred in new appointees. There was a strong sense that the new members who were elected to the Board quickly developed a commitment to keep the Board operating effectively, even if they had not necessarily approved of all the Board's decisions in the past. Existing members had some concerns before the election that elected members might behave in ways that impeded the functions of the Board. After the elections, however, these continuing members perceived the new cohort as developing what one Executive Director referred to as a "social norm of non-executiveness" - a set of informal expectations about how it was acceptable (and unacceptable) for themselves and other non-executives to behave. New members continued to ask critical questions, and press for improvement on specific points, but this was done in a constructive manner comparable to the behaviours that we and our interviewees had observed in other (all-appointed) Boards.
5.20 Hence, while there were instances in which the new non-executives in Fife did behave differently from their predecessors, these instances need to be seen against a broader pattern of the new members being willing to compromise with each other and established members. The NHS Fife Board voted only once between June 2010 and the beginning of 2012, on a complex issue surrounding a General Practitioner in Balmullo's permission to dispense prescriptions (which had aroused strong feeling in the local community). A few of the elected members found themselves in the minority, but once the decision was reached they did not pursue the opposition further. By contrast, the Board in Dumfries and Galloway began voting regularly and on several occasions a dissenting member wrote to local newspapers after votes had been taken, arguing that a collective decision of the Board members was incorrect. Publicly opposing corporate decisions in this way represented a major departure from the norms of non-executive behaviour, although only a few of the new members engaged in such activity.
5.21 Most of our interviewees were unable to identify significant differences of approach between the new members in Grampian and Lothian and other non-executives that could be attributed to the selection process. While there was recognition that they brought assets from their own personal backgrounds and experience, and they were viewed positively as individuals, it was much more difficult to identify instances where their behaviour was very different from other non-executives' at similar stages in their appointments. This is probably unsurprising, as the process they passed through was very similar to the normal process for appointing non-executives from the application stage onwards. Interviewees also stressed that typically non-executives who join the Board in small numbers take several months, or even over a year, to develop fully into their new role and for their personal characteristics to begin to influence the overall dynamic. In later interviews, pilot appointees in Lothian emphasised that they had were encouraged and supported to attend particularly to a 'patients'-eye' perspective in their Board activities.
Impact on public engagement
5.22 All NHS Boards in Scotland have strategies for Patient Focus and Public Involvement, which are monitored and supported by the Scottish Health Council. Their PFPI or Participation practice is self-assessed against the Participation Standard, with levels reached and plans for improvement agreed by the Scottish Health Council. However, public engagement activities tend to be carried out at operational level, and in most cases have not been seen as the appropriate role for the Board of Directors. Most (pre-pilot) appointed non-executive members in the pilot Boards affirmed the importance of public engagement activities, but did not understand this as a central part of their own functions, which were understood as concerned with a more corporate vision of governance. This is not to say that appointed non-executive members were not supportive of these activities, but they were understood as operational, not strategic functions. Existing appointed members said they occasionally received representations from members of the public, but that these would be passed on to the appropriate member of staff.
5.23 It would not, however, be fair to say that appointed non-executives were insulated from the general public. Appointed non-executive members who were currently or had previously served as CHP or CHCP Chair had more public-facing roles, including regular contact with Public Partnership Forums and other stakeholders. Where Boards had recently undertaken broad strategic consultations on contentious matters such as potential hospital closures, non-executive members had often represented the Board at public meetings. Annual Reviews are held in public, are generally somewhat better attended than regular Board meetings, and include an opportunity for members of the public to ask questions. All pilot Boards have a number of lay representatives on their committees of governance. Notably, a number of existing appointed non-executive members also saw their particular experience or skill-set being about the public (or consumer) perspective, as opposed to management or financial expertise.
5.24 During the pilot period, a number of changes were observed to the Board of Directors' roles in public engagement. Few can be directly causally attributed to the pilot itself: the pilot is only one part of broader moves for the Board of Directors to have a more public-facing role. Some changes were present across all pilot Boards. For example, in each Board there was discussion of how to increase public engagement with Board meetings, whether by making Board papers more accessible or altering meeting arrangements. Each pilot Board already had at least one meeting per year in an alternative geographical location within the Board area. In NHS Lothian, options discussed included webcasting of meetings and holding meetings in evenings. However in this matter, as in other discussions, many Board members expressed concern that there was a trade-off between measures to increase engagement and corporate effectiveness: for example, that non-executive members would feel inhibited in debate if the meeting was being broadcast, or that accessible papers may lack the degree of detail required to adequately hold executive members to account.
5.25 Other changes can be understood as more directly attributable to the pilot. In Dumfries & Galloway, as a result of occasionally heated debates about whether elected non-executive members should hold 'surgeries' in the style of an MSP or Councillor, a series of Board engagement sessions were planned. These were not perceived to have been a success by Board members, and were very poorly attended by the public. In Fife, some individual elected members who had committed to make themselves available to the public in their candidate statements did so by taking part in public events organised by the Board. They appeared alongside existing Board members and NHS staff. In both cases these meetings differed substantially from the kinds of private surgeries held by MSPs and Councillors. Several elected members did not wish to hold surgeries and did not see making themselves directly available to members of the public as part of their role. Most continued to channel any feedback they received from members of the public to Health Board staff, as had been standard practice before the pilot.
5.26 Both existing appointed and newly elected non-executives were asked about whether they understood their role as representing the public. Across both appointed and elected members there was some variation in view. Appointed members were marginally more likely to say that they did not see themselves as representing the public on the Board. Instead, some saw their role as ensuring the effective operation of the organisation for the public. Several explicitly said that they felt the absence of pressure for re-election helped them to make difficult decisions without 'looking over their shoulder' at voters. However other appointed members were quite clear that they saw themselves as public representatives. Elected members told us they understood their role as including representing the public, but there was variation in whether this was seen as but one component of the non-executive role, or was its central purpose. Likewise, some members who felt very strongly rooted in a particular community (whether geographical or of interest) emphasised representing a sub-set of 'the public'. These differences in opinion were not merely semantic: the extent to which an elected member emphasised their role as a public representative made a difference to their preferences for engaging with the public (informally, or in arranged meetings) and taking a visible role in the media.
5.27 As with other potential effects, in both Lothian and Grampian the far smaller number of new members limited the extent to which the pilot could be expected to have an impact on public engagement. In Lothian, the member who was recruited through Public Partnership Forums continued to be a member of his PPF. This created opportunities for him to act as a direct link between the Board and this group of members of the public. However, he emphasised that views from the PPF mostly continued to be fed back to Board level in the usual way, via the CHP. While we can see a theoretical case for this model enhancing public engagement through strengthened and more direct ties between the Boards and PPFs, it is difficult to draw firm conclusions from a single appointment.
5.28 One important finding from all our investigations, from the public survey to voter interviews to Board observations to interviews with Board members, is that Non-Executive Directors of Health Boards typically have a very low public profile. Apart from the Chairmen and Councillors nominated as stakeholder members, very few of the non-executives on any of the Boards would have been regularly mentioned in media coverage before the pilots began, or indeed familiar to members of the public through any other route. If changing the appointment process for non-executives is seen as a means of increasing public engagement with the NHS, then increased publicity surrounding non-executives' roles might be symptomatic of changes in the relationship between Board members and the public they serve. Accordingly, we summarise major changes below.
5.29 In Grampian and Lothian the new non-executives, like many existing non-executives, had virtually no media exposure.
5.30 The elected members in Dumfries and Galloway and Fife varied in how far they sought media attention and how much coverage they actually received. Most appeared in media coverage only immediately after the elections (when their success was reported) and did not attract significant attention thereafter. However, there were several exceptions.
5.31 In Fife, Arthur Morris' contributions at Board meetings were occasionally picked up, but this seems to be linked to his personal background as a surgeon and former BMA official (he was described in the Dunfermline Press of 1st September 2011 as "Board member Arthur Morris, a retired surgeon"). Dave Stewart was frequently quoted in the local press, usually in his role as Operational Division Chair. He had previously held this post as an appointed member of the Board and had also appeared in the local press as an appointee. Local newspapers did refer to him specifically as an "elected member". One unusually high-profile appearance after the pilot began related to some potentially inflammatory comments made in the December Board (reported in the Courier of 22nd December 2010) about the Board's relationship with Fife Council. Similarly, new elected member John Winton had enjoyed a high profile as a campaigner for services at Queen Margaret Hospital before the pilots began and continued to be quoted by journalists from time to time after he was elected. Some of this coverage suggested disagreements with the Board's policies, although our interviews suggested that the press coverage might have exaggerated disagreements. Neither members nor the Board can control the manner in which journalists report comments made during public Board meetings.
5.32 Similarly, in Dumfries and Galloway most elected members received very little media coverage besides announcement of their election. Those who did typically had some media profile before their election. For example, Alf Hannay was quoted in the Annandale Herald a few months after being elected (18th December 2011) and his criticism of the recruitment of a Public Health Consultant in one of the higher pay bands made the local BBC news on 11th May 2011. Mr Hannay was also willing to brief the press directly on the constraints imposed on the Health Board by government spending restraint (Dumfries and Galloway Standard 6th October 2010). However, it is worth bearing in mind that he had a local media profile as a Unison official (and indeed as a councillor several years earlier) before being elected (quoted in, for example, the Dumfries and Galloway Standard of 2nd June 2010).
5.33 A relatively high level of media interest in the elected members began with an article in the Dumfries and Galloway Standard on the 2nd of July 2010 reporting that anonymous new members had told journalists that they were unclear on their roles. The elected member who attracted most publicity in 2010 and early 2011 was Alis Ballance, who actively wrote to local newspapers disagreeing with collective decisions. Of all the elected members she had campaigned most explicitly on a platform of saving the region's community hospitals, and in office she maintained her commitments. Media coverage of Ms Ballance's role on the Health Board began when local press picked up on a disagreement in the Board between elected members who wished to hold one-to-one surgeries with members of the public (Ms Ballance and Tommy Sloan), in the same way as local councillors do, and other members (reported, for example, in the Dumfries and Galloway Standard of 3rd November 2010). She continued to write to newspapers both in her role as Convener of the local Green Party (Dumfries and Galloway Standard 17th September 2010) and as an elected member of the Health Board. She called for community hospitals to be kept open in a letter to the Dumfries and Galloway Standard (15th October 2010) and arranged for a public lecture in her local community on how a Health Board decision to close community hospitals in Cumbria had been overturned (Dumfries and Galloway Standard 13th October 2010). Following a collective decision that Board Members should not hold one-to-one consultations with members of the public, but should instead participate in collective public engagement sessions of which she was highly critical, Ms Ballance felt obligated to hold individual surgeries. She was criticised for this by the Chief Executive in the press (Dumfries and Galloway Standard 11th February 2011).
5.34 Ms Ballance was obliged to stand down from Dumfries and Galloway Board when she decided to contest the 2011 Scottish Parliament election; in her resignation letter to local newspapers she cited "conflict" with the other members of the Board and accused Dumfries and Galloway of having "abused" the pilot elections (Galloway Gazette, 9th March 2011).
5.35 In both Boards, non-executives who previously had high profiles in the media seem to have retained media interest. This created both risks and potential opportunities for the Boards' communication with the media and, indirectly, the public. However, it is important not to overstate the increased media interest in non-executives. Even in the elected Boards, the members who were most commonly quoted in the media continued to be the Chairmen and the Executive Directors, along with other senior NHS staff.
Removal of executives' board status
5.36 Board members who remained in place over the course of the pilot typically portrayed the removal of two executives from Board-member Director status as either causing no appreciable change (as those Directors continued to attend meetings as before) or having a mildly negative effect on Board efficiency and transparency. There was concern at a lack of advance consultation, and the short notice given to the Boards when they were asked to reduce the number of Executive Directors also caused some complaint.
Assessing overall impact on pilot boards; understanding scale and context.
5.37 Elections to NHS Dumfries and Galloway were held against the background of major service redesign. This led to significant changes in the Board dynamic, particularly in the first twelve months of the pilot. Some elected members had explicitly campaigned on issues that were part of the Clinical Services Strategy regarding the future locations of secondary care in the region. In the first twelve months decision-making became noticeably less consensual and disagreements, which might previously have been discussed privately, were debated in public meetings. In this period the Board was far more likely to take a formal vote on decisions than has been the case hitherto: many of these votes related to issues of Board procedure rather than substantive Board business. After the initial twelve months, and coinciding with the departure of Ms Ballance and a period of Board development work with an external consultant, Board meetings became less contentious.
5.38 In Fife, the impact was more subtle. Successful candidates had not stood on platforms that were at odds with the Board's existing strategy. There were some changes, including more extended Board meetings with more time devoted to discussion. Some new members did clearly develop personal interests in particular aspects of the service to which they were particularly keen to draw attention. The new members did seem to produce a greater diversity of views. There was disagreement among our interviewees as to how far this was a consequence of their being elected or whether appointing a large number of new non-executives could have changed the Board dynamic in similar ways. Decision-making remained more consensual than in Dumfries and Galloway. Only one formal vote was tabled in the course of our observation, and while several elected members voted against the decision that was eventually taken they adhered to the decision thereafter. Very few members of the public attempted to influence the Board by contacting elected members directly, and most of the non-executives who were approached referred members of the public who contacted them to NHS Fife's communications team, as had been standard practice before the elections.
5.39 The alternative pilots have shown that when Health Boards are given some latitude in advertising non-executive vacancies they can attract large and diverse bodies of applicants. The individuals selected in this way seem to have impressed both the selectors and their new colleagues. However, while they did see themselves as having a distinctive relationship to public opinion, there was only a subtle difference between their perception of their role and that of other appointed non-executives, who also saw themselves as fulfilling the role of an informed member of the public.
5.40 While the elections removed the Scottish Government and OCPAS from the selection process, the alternative pilots retained this element of selection. This means that the distinctive appointments process remained, possibly making some applicants uncomfortable. It also meant that while applicants were somewhat different, the appointments process remained the same except for the lack of specific skills as an objective in recruitment.
5.41 It is important to stress that the scale of the intervention in the boards with election pilots was greater than the scale of the intervention in the boards with alternative pilots. In both Grampian and Lothian, the pilot involved two non-executive directors on established, large, boards. In Dumfries and Galloway and Fife, the elections pilots changed half the board. It is to be expected that even without elections, such turnover might affect a board.
Email: Fiona Hodgkiss
There is a problem
Thanks for your feedback