Healthy NHS Board: a review of - NHS Leadership Academy

7.2 Size
Recent guidance has not recommended any changes
in the size of NHS provider boards. As in our original
review, research-based recommendations on board
size still vary (Bennington, 2010). There is limited
evidence suggesting that smaller boards may be more
effective. However, a review of the evidence on board
performance indicates it is likely that the number of
directors on a board is rather less important than what
directors do (Chambers et al., 2013).
7.3 Composition
Research evidence indicates that there may exist
a connection between board composition and
organisational strengths. However, a contingency
perspective is emphasised: certain board compositions
may better suit different challenges. For example, boards
with a higher proportion of independent directors may
support minimisation of risk in an organisation; smaller
boards with more ‘insiders’ may support more innovation;
while a larger proportion of ‘boundary spanners’ may
support legitimisation of a new organisation with partner
organisations (Chambers et al., 2013).
Our original review noted the potential value to
healthcare boards of ‘insider expertise’. This is reflected
in the Francis Report’s support for a stronger nursing
voice, for example recommending that boards obtain
and record the Director of Nursing’s advice on how
nursing staffing arrangements might impact on quality
of care, and that boards should be encouraged to recruit
nurses as Non-Executive Directors (Francis, 2013). In
terms of research, a recent study indicates that a higher
proportion of doctors (but not other clinicians) on
boards is significantly associated with improved patient
satisfaction and reduced mortality (Chambers et al.,
2013, Veronesi et al., 2012). Also, research suggests that
CEO characteristics may be important, with background
as a doctor associated with better levels of quality in US
hospitals (Goodall, 2011) and CEO tenure supporting
prioritisation of patient safety in UK hospitals (McKee
et al., 2010). The tendency to select doctors for a board
role based on their clinical, rather than governance,
expertise is noted (Bennington, 2010). Given doctors’
potential contribution to board and organisational
effectiveness, this suggests that induction and training is
particularly important with this staff group.
There is some research evidence on the benefits of
diversity. Reviews of the evidence indicate that greater
gender and race diversity at board level is positively
associated with greater innovation (Bennington, 2010).
Research indicates that training in equality and diversity
is associated with lower staff absenteeism (West et
al., 2010). Boards may benefit from featuring more
women. A recent study found that ‘high performing’
healthcare organisations were more likely than ‘low
performing’ organisations to have a board featuring at
least 50% female membership (Chambers et al., 2011).
Research suggests boards featuring a higher proportion
of women may perform more effectively: identified
benefits include better decision making, sensitivity to
other perspectives, greater transparency, and higher
quality governance processes (Alimo-Metcalfe, 2012,
Chambers et al., 2013, Bennington, 2010).
7.4 Skills
As described in our original review, and reflected in
previous sections of the current review, boards must
draw together a wide range of skills to carry out their
duties (National Quality Board, 2011, Storey et al.,
2010a). Many of these relate to topics under discussion
in board meetings, reflecting such priorities as finance,
productivity and most importantly quality (Storey
et al., 2010a, National Leadership Council, 2010).
Wider skills to ensure effective working of the board
include decision making, people management (based
on emotional intelligence), and managing numerous
complex issues simultaneously (Storey et al., 2010b,
Deffenbaugh, 2012, Storey et al., 2010a).
Corporate guidance recommends that Executive
Directors consider taking on a non-executive role in
another organisation: this may help ensure they possess
a suitably wide range of board governance skills, and
contribute to board dynamics by providing them with
a clearer appreciation of the contributions and needs
of their current non-executive colleagues (Financial
Reporting Council, 2011).
32 The Healthy NHS Board, 2013: Principles for Good Governance