Memorandum by the NHS Alliance (PAP 63)
1. The NHS Alliance welcomes the opportunity
to provide evidence to the Public Administration Committee's enquiry
into patronage and public appointments, focusing particularly
upon the reforms recently introduced in the system of appointments
to the NHS Primary Care bodies.
2. The NHS Alliance is the independent body
that represents NHS primary care. Some 90% of Primary Care Trusts
(PCTs) are members, together with individuals who work in primary
care. It brings together the combined force of clinicians (including
GPs, nurses and allied professionals), managers and the lay people
who serve on Primary Care Trust boards. It is concerned to encourage
and enable a genuine partnership between these three groups within
the NHS, and between the NHS and the public. The Alliance is widely
recognised as the major independent voice of primary care. It
has strong links with government and the Department of Health.
3. The National Association of Lay People
in Primary Care voted earlier this year to amalgamate with the
NHS Alliance. Many members of the NALPPC were also members of
the NHS Alliance, either as individuals or through the membership
of their PCT. That group of former NALPPC members now forms the
NHS Alliance Lay Members' Reference Group, sitting alongside other
special interest reference groups.
4. The NHS Alliance supports the system
for making appointments to the Boards of NHS Primary Care Trusts
put in place by the NHS Appointments Commission (NHSAC). It has
introduced reforms that have brought much needed transparency
and fairness into the process. The system now has much in common
with that generally used in human resources recruitment and so
is easily understood and accepted by applicants and the public.
The advertising of all posts, although costly, is valuable in
reaching out to the broadest possible range of candidates. In
particular, the Alliance applauds the decision to abandon the
previous generic lists and to introduce a system of appointing
to specific roles.
5. There are proposals to change the current
criteria from a knowledge and skills base to a competencies base.
That too, is a move the NHS Alliance supports. We believe it will
assist in broadening the diversity of applicants to positions
on Primary Care Trust Boards.
6. Nevertheless, the Alliance has identified
tensions between Primary Care Trusts and the NHS Appointments
Commission. There are some concerns about the practical operation
of the reforms to the appointments system. We would wish to highlight
the following key issues.
Primary Care Trust chairs and non-executives
strongly oppose NHS Appointments Commission proposals to reduce
the time commitment required of PCT non-executives. They advise
that it would not be feasible to carry out the tasks required
of non-executives if these proposals were implemented. In particular,
the role of non-executives in challenging as well as supporting
management and clinicians is valuable and would be put at risk
if the NHSAC proposal were adopted.
Associated with this proposal, the
NHSAC has stated that PCT non-executives are "executised".
To the best of our knowledge, the Commission has no evidence to
support this contention.
It would not be acceptable to reduce
the official time commitment required of non-executives but then
expect them to "volunteer" to give more time, as NHSAC
Chair Sir William Wells suggested at the Alliance conference (18
October 2002) and, we understand, on other occasions.
More work needs to be done to establish
the best means of improving the diversity of applicants and appointments.
There are concerns about accountability
and the roles of the NHS Appointments Commission and Strategic
Health Authorities in the performance management of non-executives.
There are concerns about the quality
of training provided by the NHS Appointments Commission.
There are concerns about the efficiency
of the appointments process.
OF PCT BOARD
7. In October 2002, the NHS Alliance carried
out a survey of Primary Care Trust chairs and non-executives.
The full survey report is annexed to this document.
8. Briefly, the survey found widespread
disagreement with the NHS Appointments Commission proposal to
reduce the time commitment required of PCT non- executives. Almost
one in four (78%) said they would not be able to maintain their
roles and responsibilities within the proposed 2.5 days per month.
Nine out of 10 (90%) also said it was wrong to claim non-executives
had become "executised" and 95% said there should be
full consultation before reaching a decision on any proposed changes
to PCT management arrangements. Chairs and non-executives also
said that their role was not similar either to that of company
directors or charity trustees: 80% said they have a new role that
includes challenging orthodoxies.
OF PCT CHIEF
9. A smaller sample (25% of PCTs) of chief
executives and Professional & Executive Committee chairs demonstrated
similar views. 86% said that the overall contribution of non-executives
was valuable (57% very valuable); 73% said their independence
was not compromised by involvement in committees, working groups
or functional areas (so-called "executisation"); 75%
said it would not benefit PCTs to reduce the time commitment of
non-executives to 2.5 days.
10. The NHS Alliance would welcome means
of improving the diversity of appointments to PCT Boards but does
not accept that reducing the time commitment required of non-executives
would achieve the desired result. Our survey found that 63% of
PCT chairs and non-executives believed reducing the time commitment
would not assist in recruiting more younger employed people and
people from ethnic minorities. Work (and often family) pressures
mean that public service is difficult for this group. A similar
experiment in the 1980s, linked with local government and supported
by the CBI, was not successful. Nor was a more recent attempt
to recruit younger employed people as lay magistrates (offering
a shorter working month). It is difficult to see the link between
reduced commitment and ethnic minorities.
11. The means adopted must take into account
the responsibilities and duties of the role. In fact, the duties
of non-executives are expanding rather than contracting, for example
under the National Service Framework for Older People, the Working
Lives Pledge and the Mental Health Act.
12. First steps in establishing means of
improving diversity must include consultation with relevant bodies
such as PCTs themselves and those concerned with disabled people,
carers, women and other groups, as well as with the CBI and Institute
of Directors, who have already been consulted. It is unlikely
that either diversity in appointments or the success of NHS modernisation
can be achieved by ignoring or riding roughshod over the groups
most closely concerned.
13. Increasing the remuneration paid to
non-executives so that it becomes a viable source of income would
probably assist in recruiting from poorly represented groups.
However, we understand that the Secretary of State for Health
does not intend to amend this. Nor is pay the principal motivating
factor. As one non-executive said: "We do this because the
NHS deserves it."
14. The NHS Alliance proposes two means
of improving the diversity of appointments. First is a relaxation
of the current criteria regarding previous experience in health.
We should be prepared to make more appointments based on potential
rather than actual experience. Secondly, there should be more
effort to improve public awareness and understanding of public
service in the NHS. For example, as well as the conventional press
advertising that already takes place, alternative media such as
bus, tube, local radio and cinema advertising should be considered.
That should be supported by a public information campaign that
might include literature made available at supermarkets and pubs
as well as the more conventional outlets such as health centres
and public libraries. In addition, local and regional news media
should be kept fully informed of the work carried out by PCT Boards
and other bodies. At present, public awareness is limited. It
is clearly unrealistic to expect improvements in the diversity
of appointments without improving public knowledge of the opportunities.
NHSAC IN THE
15. The NHS Appointments Commission has
the sole power to hire and fire NHS chairs and non-executives.
Yet Boards are accountable to the Secretary of State through Strategic
Health Authorities for the performance of their PCTs. The NHSAC
itself has no responsibility for the delivery of healthcare and
has limited understanding of the work undertaken by PCTs.
16. As a result, there is confusion and
a lack of clarity about the respective roles of the NHSAC and
the Strategic Health Authorities in the performance management
of PCT non-executives, and whether both are looking at the same
demands and evidence. The NHS Alliance detects some lack of confidence
among PCT chairs in the appraisal process. There is a need to
resolve these issues.
17. The new appointments system doubtless
brings with it many advantages. However it does vest considerable
power in unelected individuals who have no responsibility or accountability
for the work carried out by the public bodies to which they appoint.
That is bound to result in tensions. There may be a need to examine
the operation of the new system further.
18. There have also been questions about
the relationships between Strategic Health Authorities and PCTs.
These are to be addressed in a joint report currently being prepared
by the Prime Minister's Office for Public Sector Reform, the Department
of Health and the NHS Alliance. That report is due to be published
late December 2002.
THE NHS APPOINTMENTS
19. The NHSAC levies an annual charge on
PCTs for training. It has produced an excellent induction pack,
but its basic induction training is, at best, patchy. There has
been dissatisfaction with the quality of other training it has
provided and concern at the overlap with training provided by
Strategic Health Authorities and the Modernisation Agency. Some
PCT chairs have demanded action to improve co-ordination between
these different bodies. It is unclear what professional expertise
in training exists within the NHSAC. The role of the Appointments
Commission in training non-executives needs further examination.
20. While the Alliance has not undertaken
a study of the process, we have received reports of lengthy delays
and confusion in making appointments. We believe there is a need
to examine further the system's effectiveness and efficiency.
Survey of PCT non-executive directors
In his latest round of national Roadshows NHS
Appointments Commission Chair Sir William Wells told delegates
that he is considering significant changes to the time commitment
and role of Non-Executive Directors in Health Organisations. After
consulting the CBI and the Institute of Directors, although not
PCTs, he proposed to revise the time commitment from 5 days per
month to 2.5 days, so as to encourage the recruitment of younger
employed people and ethnic minorities. He also suggested NEDs
had become inappropriately "executivised" by involvement
in committees, working groups and functional areas.
A number of Primary Care Trust Chairs and Non-Executive
Directors (NEDs) contacted the NHS Alliance to say they were dismayed
by the implications of these statements. In view of the concerns
expressed, the Alliance carried out a rapid e-mail survey to establish
the opinions of PCT Chairs and NEDs on the issues Sir William
The Appointments Commission did not provide
any written material to support Sir William's speeches. Consequently
the Alliance has been obliged to rely on reports from members
of the messages he gave, in slightly different words, at fourteen
meetings called by the Appointments Commission and attended by
Chairs and Non-Executives across the country.
The survey consisted of a short questionnaire
e-mailed to Primary Care Trust chairs, with a request to forward
it to their non-executive colleagues.
308 PCT CHAIRS AND
Of these, 24% were PCT Board chairs
and 71% NEDs (5% unknown)
78% said NEDs could not maintain
their roles and responsibilities if their time commitment was
reduced from 5 days per month to 2.5 days.
14% agreed that they could
maintain their role if their time commitment was reduced.
95% believed that any proposed changes
to PCT management arrangements should be subject to full consultation.
63% said reducing the time commitment
would not be helpful in recruiting younger employed people and
representatives from ethnic minorities.
90% said NEDs were not compromised
in their independence and ability to challenge decisions by involvement
in functional areas, or by acting as chairs or leads of working
groups and/or committees (80% "not at all" and 9% "to
a small extent").
80% felt that PCT NEDs were not equivalent
to either non-executive directors of private sector companies
nor to charity trustees: they had a new role that includes challenging
In addition to completing the questionnaire,
76 respondents added comments. Many had attended the Appointments
Commission roadshows and had heard Sir William speak. Common themes
emerging from this correspondence are:
Deep hurt at what is seen as "trivialisation"
or "denigration" of NED's role and their level of commitment,
and complaints that Sir William's statements are "demoralising".
The proposal to revise the time commitment
of NEDs reveals a "lack of understanding" of the nature
of the role and the complexity of the tasks faced by PCT Boards.
Accountability requires thorough
knowledge and understanding of PCTs' obligations and activities:
this would be impossible to achieve with a time commitment of
2.5 days per month.
Warnings that the NHS should avoid
the mistakes made by ENRON and WorldCom.
A number of NEDs with professional
expertise in recruitment expressed disbelief that a revised time
commitment would impact on recruitment.
The rate of pay is more significant
However, others felt pay is not a
motivating factor: "We do this because the NHS deserves it".
The majority of NEDs are well aware
of the need for objectivity and avoidance of direct involvement
in day to day management.
There was a strong view that full
consultation on any proposed changes would be essential and that
no evidence had been presented to support the Commission's criticisms.
At best, these results suggest the Appointments
Commission and its PCT constituency are not entirely in tune with
one another. That must be a matter for concern. Primary Care Trusts
are young organisations, many less than a year old. They are still
evolving and these differences cannot assist their development.
The NHS Alliance and its Lay Reference Group
believe immediate steps are necessary to resolve the concerns
highlighted by this survey and have sought an early meeting with
Sir William to consider the matter further. They have also called
A moratorium on any changes or announcements
on non-executive roles prior to full consultation and further
The publication of any evidence on
which the Commission has based its views.
An independent report, perhaps along
the lines of the recent HMSC report on clinician involvement,
exploring the role, responsibilities, and the value to the NHS
and its patients, of the lay members (non executives) of PCTs.
Appendix 1 provides tables giving the full survey
results. A selection of respondents' comments is attached at Appendix
2. As near as possible, these reflect the overall views expressed.
As in all NHS Alliance surveys, respondents were guaranteed anonymity.
Neither individuals nor their organisations are identified.
NHS ALLIANCE SURVEY OF PCT CHAIRS AND NON-EXECUTIVE
BOARD MEMBERS: RESULTS
|1. In your opinion, would non-executive directors (NEDs) be able to maintain their roles and responsibilities if the time commitment was revised from its present 5 days per month down to 2.5 days per month?
|2. The reason given for reducing the time commitment of NEDs is that it would allow the recruitment of more younger, employed people and more people from ethnic minorities. In your opinion, how helpful in practice would this move be in recruiting from those groups?
Not very helpful
Not helpful at all
|3. In your own PCT, are functional areas allocated to NEDs, and/or do NEDs lead or chair working groups or committees?
||Functional areas allocated to NEDs|
NEDs lead/chair groups or committees
None of these
|4. In your experience, do these roles in any way compromise the independence and ability to challenge decisions required of PCT non-executive directors?
Compromised to some extent
Compromised to a small extent
Not compromised at all
|5. In your opinion, which of the following descriptions best applies to the role of PCT NEDs?
||Equivalent to NEDs of private companies|
Equivalent to charity trustees
New role: includes challenging orthodoxies
|6. How important is it that any proposed changes to PCT management arrangements should be subject to full consultation?
Not very important
Not important at all
|7. e-mail: PCT chair ||75
Total number of replies received: 308.
Number of respondents who provided additional comments: 76.
Comments from PCT Chairs and non-executive directors
All the NEDs that I work with in my PCT, and the NEDs from
other Trusts in the local health economy, feel passionately about
their role and are totally committed to the NHS and to improving
services for patients. To suggest that 2.5 days per month is adequate
to fulfil the requirements of a NED's job description is ill judged
and trivialises the work that NEDs undertake with commitment and
Most non-execs do far more than they are paid to do, and
to reduce them to less paid time would be an insult. Nor does
this mean, as Sir William has suggested, that they have become
"executivised". I would argueand did, at the
meeting with himthat they can be knowledgeable and well
informed without losing their ability to challenge and take an
The role of NEDs in the corporate world has been brought
seriously into question following ENRON and WorldCom. The NHS
should steer very clear of the dangers of going down the same
route of NEDs giving insufficient time to bring genuine questioning
to bear on the Executive.
I suggest he [Sir William Wells] recognises that to advertise
the task as being capable of being performed in what is probably
50% of the present commitment will be not only misleading but
in the longer term counter-productive.
Sir William claimed that a re-focus of Non-Executive priorities
is required to curb the growing tendency for the Non-Exec role
to become "executivised", and the independence and ability
to challenge therefore compromised. Sir William cited no evidence
other than hear-say and his proposals do not have the weight of
a study or consultation behind them.
There appears to be considerable tension in reducing the
time spent by non execs in their role and the ever increasing
Government expectations on them. Two examples:
Under the NSF for Older People there is a requirement
to appoint a non-executive champion and that a non-executive director
is involved in the role of Local Scrutiny Groups in Rooting out
Age Discrimination (Standard 1). To do any justice to this role
The Improving Working Lives Pledge also requires
the nomination of a non-executive (as indeed do many other areas,
such as the role of Complaints Convenor).
If we are to perform the roles envisaged under SAGE, we need
to understand our organisation and be aware of what it is or is
not doing. Not only does this require our involvement at Board
Meetings, Audit &/or Remuneration Committeesbut considerable
reading to support our ability to have the necessary overview
which will enable us to contribute to the strategic direction
of the PCT. In my view 2.5 days is not sufficient.
I am dismayed at the lack of understanding of what non execs
are doing on the groundand any attempt to find out. The
reduction of time was to "solve" two problemsone
was recruitment of younger "thrusters" from industry
who were presumed thereby to improve their career profile. [There
is] no real evidence that CBI or IOD can deliverthey did
not with local government in the 1980s and times are tighter.
The second was the presumed executivisation of non execs.
On that, the assumption was unevidenced, but it was assumed that
non execs playing their current PCT role couldn't challenge effectively.
In my judgement they are not in general being "executivised",
but their new role actually enables them to challenge earlier
and more effectively
I strongly resented Sir William's attitude and profoundly
disagreed with his comments . . .[they were] at best demoralising
and at worst insulting. . . I came to that event prepared to be
inspired and motivated. I left dispirited and demoralised, and
with a realisation that that those who planned and executed the
seminar were unskilled and unprofessional. I am now determined
to do all I can to protect and support our national health service
from such people.
I am greatly perturbed at Sir William Well's proposed changes.
PCT's are in their infancy and need time to settle down before
any changes are considered.
I have looked at the amount of recorded time I have spent
over the last 15 months, and it comes to an average of 40 hours
a month if travel is taken into accountand there can be
quite a lot of travelling around the patch.
Far from reducing the amount of time expected (and remunerated?)
from NEDs, it should be increased. The notion that someone in
full time work but without the freedom to plan their own time
could undertake the job is not reasonable. Apart from meetings
in normal working time, things like sitting on appointments panels,
acting as complaints convener and performing the managerial functions
in relation to the Mental Health Act, all require one to be available
during the normal working day.
There is no evidence that the quality of Non Executives so
far appointed is insufficient for their task. Nor that reducing
the number of hours for the role will increase appointments from
poorly represented groups. The best way to achieve the latter
is probably to increase the remuneration for the role as a whole
so that it becomes a viable source of income.
I cannot understand the logic linking ethnic minorities with
As Sir William Wells presented this to the South West NEDs,
the purpose is to widen the diversity of NEDs. However the proposed
route was to enable employers to offer paid time . . . I can only
see the main impact of this as allowing more white middle class
employed men to apply . . . Where is the strategy to draw in more
women, more ethnic minorities, more disabled people, carers, people
at home with young families?
The policy is broadly welcome in my view, it might encourage
companies to allow staff do do this within their paid employment
or to allow time off for this role. However, the "pay"
is equally important, I believe. Another approach might be to
make the NED role into a really decent part time jobthis
would be particularly attractive to women who might be prepared
to sacrifice a larger salary and high flying job for more local,
rewarding work with child-friendly hours.
I feel there is very little hope that you can recruit employed
people in today's work climate and ethic. Unless Non-Execs are
only to be required at a Board Meeting which possibly could be
set at the same time every month in the evening, taking time off
work is almost an impossibility for most people, especially as
most of the meetings/committees that we are involved with can
be any time of the day.
I warmly applaud the statement that we should not be drawn
into the executive role and that we should be more strategic,
but feel . . . this is very difficult to achieve. No business
person would start a new business saddled with the debt we have
inherited. We were effectively bankrupt before we started, and
have continued to firefight ever since, thus taking our efforts
away from development of new or improved services. The prescribing
budget is proving to be a nightmare, and the more the Government
tell everyone they should get what they ask for, the more this
rises. We were effectively told to increase considerably the salaries
to our Chief Executives, at a level which meant we had to cut
back again on recruitment further down the line. . . SHA's have
been set up and appear to be growing like Topsy, and are recruiting
at inflated salaries, at our cost, both financially and ability
to get staff.