Methods
Research design
We combined a structured observation of board meetings and a cross-sectional sample survey of board members. This paper concentrates on the former. (Details of the survey are available on request from the authors.) We observed the meetings for each of eight boards, categorising the behaviours that we saw board members use by applying categories which we had developed from those used in existing empirical studies [
31,
34] and from the theory of speech acts. In applying these categories, and refining them by doing so, we formed some initial conclusions about board members’ modes of behaviour, the topics of board discussion, and which board members tended to take the lead on particular topics.
Sample and settings
A mix of PCTs, acute FTs and acute SGTs were included in both parts of the study. We selected a sample of eight English NHS trust boards for observation, in order to collect data suitable for qualitative analysis. This was a theoretically-based selection. We assumed that boards with different functions within the NHS might discuss different topics, and that relationships between ED and non-ED members, and the ways in which meetings were conducted, might correspondingly differ. Of the eight boards, four (PCTs) were predominantly commissioners, and four providers of care. (The latter were acute care trusts, two of them SGTs and two FTs.) We were able to observe both the open (part 1) and private (part 2) part of the board meetings in five organisations. In the remaining three trusts, part 1 only was observed; two provider trusts refused access to part 2 and one commissioning trust had not decided by the time the study ended. Table
1 characterises the eight trusts whose board meetings we observed.
Table 1
Characteristics of trusts whose board meetings were observed
Commissioner | PCT 1 | Inner-city, deprived area, high ethnic minority population | N |
PCT 2 | Rural area serving a large area and population | Y |
PCT 3 | Mixed rural and urban, largely affluent area | Y |
PCT 4 | Inner city, deprived area, high ethnic minority population | Y |
Provider | SGT 1 | Large teaching hospital, city setting | N |
SGT 2 | Teaching hospital, mixed urban and rural setting | N |
FT 1 | District general hospital, largely rural population | Y |
FT 2 | District general hospital in small city, mixed urban and rural population | Y |
All types of trust were undergoing transition at the time of the study (2008–9). PCTs had recently undergone mergers and become essentially commissioning organisations, not providers. The SGTs were considering applying to become FTs, and the FTs were still in the early stages of adjusting to their new status and of being accountable to both a board of directors and a board of governors. We used a survey (not reported here) to assess whether findings from the sites described in Table
1 were likely to have external validity, which they were. In brief, the ratio of EDs to NEDs in the observational sample was similar to the ratio among all NHS Board members [
23].
Data collection
Three consecutive meetings were observed in each of the eight NHS trust boards i.e., 24 observations totalling over 80 h. Methods of designing the observation, to include construction of the observation schedule, have been previously reported [
34]. Briefly, the observation schedule recorded the ‘presenting problem’ (taken to include any practical proposals or action points) and who raised it. Besides directors’ behaviours, we recorded the main points of the debate, who responded, and how, to the ‘presenting problem’ raised by a NED, and what decision the board finally made. There were also sections for other qualitative observational notes and quotations. The schedule and its coding sheet were pilot tested for reliability before use. From publicly available biographical information on NHS trust websites we also ascertained the occupational background of the board members we observed.
Analyses
We analysed the observational data inductively. We classified directors’ behaviour according to the perlocution [
35] of their questions and statements in board meetings, i.e., in terms of what type of practical response that the speaker (NED) was apparently trying to elicit from the board members who were being addressed (e.g., getting an ED to agree to alter a proposed course of action). We took this approach because a perlocutionary categorisation tells us:
1.
the range of practices (e.g., option assessment, seeking information etc.) through which NEDs tried to influence EDs’ managerial work; and
2.
which behaviours within this repertiore NEDs most heavily relied upon at Board meetings
Also a perlocutionary classification offers a framework for:
3.
systematically comparing how NEDs’ use of these behaviours varied between different organisational types; and
4.
imputing what the NEDs assumed were legitimate practical demands to make of the EDs; hence describe what, at minimum, NEDs thought their role involved.
A perlocutionary classification captures the practical content (locution) of a speech act, in this case what the EDs were being asked to do. It tells us how, within Board meetings, NEDs exercised their role through speech acts. It does not necessarily capture NEDs’ tone of voice, attitudes, whether an NED was trying to persuade, intimidate, cajole etc., nor impute to the speaker any implicit, unspoken perlocution behind the overtly stated one. Insofar as they reflected hidden interpersonal agendas, We observed whether those being addressed appeared to understand, and whether they appeared to comply or made counter-responses.
Two researchers categorised the directors’ behaviours from field notes made during the 24 periods of non-participant observation of board meetings, devising new categories until saturation (no more appeared necessary for classifying the data), then de-duplicating this initial set of categories to yield an irreducible set of six. Each category was defined, and differentiated, in terms of what practical response the director appeared to be seeking from the board and managers, i.e., to:
1.
encourage existing activities and decisions (‘supportive’ behaviour).
2.
suggest practical steps to prevent the recurrence of past problems (‘drawing [practical] lessons’).
3.
analyse what had caused such problems or, conversely, successes (‘diagnostic’ behaviour):
4.
evaluate which strategy was preferable (‘option assessment’)
5.
elicit suggestions about how to develop the organisation’s future work (‘strategy-seeking’)
6.
initiate the production of information about the organisation’s current or recent activities (‘seeking fuller reports’).
Items (3) and (6) respectively concerned explanations and factual information about the current and recent past activity. Items (2) and (5) elicited proposals for action (responding to past events and shaping the organisation’s future activity), and items (1) and (4) elicited normative judgements (respectively about the present and future). The empirical distribution of behaviours across these categories therefore reveals whether directors attended more in practice to retrospective (e.g., monitoring) or prospective (e.g., strategy) issues, and more to descriptive, analytic (e.g., diagnostic) or normative (e.g., legitimating past or choosing future activity) questions.
Some utterances might be interpreted as having more than one of the perlocutions listed above (e.g., an ostensibly supportive comment such as ‘How have the Outpatient clinics coped with the increase in activity?’ might also be a veiled request to diagnose the trust’s current activity to assess whether the increase was sustainable). In such cases we coded each utterance according to what the researchers agreed appeared to be its primary perlocution, given its context and the practical implications that those at the board meeting took to follow from it. By ignoring what might be called secondary perlocutions, this approach tended to under-record the number of perlocutionary acts occurring in board meetings, so in that sense be incomplete.
What would it mean for a Board, even an organisation, if its NEDs tended especially to use certain of these perlocutions rather than others? Above we noted that, agenda-setting apart, the two main approaches by which NEDs might influence other Board members and through them the rest of their organisation were:
1.
proposing strategies for their organisation’s future work; and
2.
holding EDs and other staff to account for its current and past work.
To see NEDs relying heavily on seeking practical lessons, option assessment and strategy-seeking would suggest a predilection for the first of these. To see them rely heavily on diagnosis of past failures or successes, seeking further reports and, if applicable, supportive behaviour would suggest they preferred the second approach, emphasising the monitoring of what their organisation did. Passive, ‘rubber-stamping’ NEDs would themselves make little use of diagnostic behaviour and option-appraisal but they, and NEDs who wished to avoid discord, would make much use of supportive behaviours. NEDs who focused on risky strategic decisions would rely most upon diagnostic behaviour, lesson-seeking and option appraisal. In short, different selections of perlocutions would constitute different strategies by which NEDs exercised governance through their Board, with correspondingly different balances of emphasis on recent, current or future activity. Insofar as NEDs’ influence extended beyond the Board, one would expect the wider management style of the organisation then to display similar patterns.
Research ethics and governance
The NHS Research Ethics Service (reference number 08/H0104/5) and the Plymouth University Faculty of Health Research Ethics Committee granted approval; approval was also gained from individual trust research and development officers under the NHS research governance framework. We obtained written consent for the observations from members of NHS Trusts. As a condition of ethical approval, informants and study sites are pseudonymised.
Results
The observational analysis suggested that NEDs used six main types of questioning tactic. Table
2 gives examples.
Table 2
Types of NED perlocution observed in board meetings
Type 1 Supportive |
I am impressed with this report and the extent of working with partners. (Site D, PCT). |
Are you happy with the 4 h target? [Board setting criteria for pilot work in the new Minor Injuries Unit] (Site A, PCT). |
How are the problems with the NHS IT system affecting the staff at grass-roots level? (Site E, FT). |
Are you content with the length of time between an incident and the report; is it good enough? (Site F, FT). |
Type 2 Lesson-seeking |
How have we managed to reduce both long term and short-term sickness? (Site H, SGT). |
Do we know why our C. Diff rates have improved so much? (Site E, FT) |
The success of the sexual health model is to be applauded; is there a model here that we can also use for immunisation? (Site C, PCT). |
Type 3 Diagnostic |
Why are we not achieving targets for out of hours diabetes services; is the target unrealistic? (Site B, PCT). |
Why is COPD not included in the top ten [World Class Commissioning] priorities? (Site D, PCT). |
It says here that we’re running at 148 % capacity: how? (Site G, SGT). |
Why are almost 50 % patients waiting more than 31 days? (Site A, PCT) |
Why are we focusing on hips and knees [in reducing waiting lists]? (Site E, FT). |
Communication [with patients whose appointments were cancelled] is a weak area and needs improving. (Site G, SGT) |
Type 4 Option Assessment |
Will the new informatics strategy improve co-ordination of diabetes management? (Site B, PCT). |
What are the complaints about? We’re far more interested in the nature of the complaints; we need more detail on this rather than the process to resolve them. (Trust G, SGT). |
What are the additional costs for pre-op screening of all patients [for MRSA]? (Site H, SGT). |
The risks and staffing are quite different for home and hospital births; are the tariffs [i.e., payments to the hospital] different? (Site E, FT). |
Type 5 Seeking Strategy |
How will we know that changes [resulting from a Health Care Commission report on one of the provider trusts] are being sustained? (Site B, PCT) |
Who are we consulting with [about regionalisation of stroke and trauma services]? (Site C, PCT). |
How will we review this [Health Care Commission] rating during the year to ensure we’re not in the same situation again? (Site F, FT). |
How can we take this [problem with inpatient and outpatient waiting times] forward in relation to our Foundation Trust application? (Site H, SGT). |
When will we see improvement in the privacy and dignity performance indicators? (Trust D, PCT). |
Type 6 Requesting Fuller Reports |
We can’t see what the targets are and what the current baseline is; this needs different presentation. (Site A, PCT). |
Can you please provide a separate report on orthopaedics each time and add it to the exception reporting. (Site F, FT). |
Supportive comments (see Table
2) acknowledged - in one case to the extent of being congratulatory, and in others by means of leading questions – that the organisation was functioning as the board desired
(e.g., I am impressed with this report and the extent of working with partners.), endorsing them, encouraging them to continue and re-asserting that board decisions, or the actions taken to implement them, had been sound. Lesson-seeking consisted of assertions or questions about the underlying reasons for the kinds of events that might be the subject of the supportive comments
(e.g., do we know why CDiff [Clostridium Difficile infection]
rates have improved so much?). Diagnostic comments and questions
(e.g., ‘Why are we focusing on hips and knees?’) were used to explain or question why apparent problems, failures or unforeseen events had occurred, and so challenge EDs to account for their decisions. NEDs used strategy-seeking questions to challenge EDs to explain and substantiate how they would achieve objectives set by, or externally imposed on, the board (e.g.,
How will you get up to target?). The focus or content of strategy seeking questions therefore depended on the type of trust. NEDs’ strategy-seeking questions (e.g.,
What is the average length of stay for all patients?) were typically seeking to discover:
1.
how patient pathways were working or might be expected to change if the board took a particular decision,
2.
the extent of compliance with standards of care,
3.
the cost implications of clinical practices.
Unlike supportive comments or questions, strategy seeking questions challenged EDs to justify their assertions or decisions. Requests for further reports (e.g., Can you examine why we have an increase in DNAs [patients who missed outpatient appointments]?) usually supported the board’s scrutiny role. Their content reflected the type of trust. NEDs on PCT boards were more likely to ask questions about the PCT’s commissioning activities whereas NEDs for the provider trusts were more focused on clinical outcomes. Categories (1) to (6) each related a director’s behaviour to a local context, although what that context was, hence the substance of each suggestion, demand etc., obviously depended on each organisation’s particular circumstances at the time and the meeting agenda.
In the observed meetings, drawing lessons was NEDs’ least frequent intervention, strategy-seeking the most frequent NED contribution to board meetings (Table
3).
Table 3
Types and numbers (percentage) of Non-Executive Director intervention observed during board meetings
Supportive comments | 5(11 %) | 0(0 %) | 0(0 %) | 6(25 %) | 7(16 %) | 1(4 %) | 3(8 %) | 1(3 %) | 23(9 %) |
Lessons learnt | 2(4 %) | 0(0 %) | 3(9 %) | 1(3 %) | 3(7 %) | 0(0 %) | 0(0 %) | 2(6 %) | 11(4 %) |
Contextual comments, Questions | 8(18 %) | 7(27 %) | 3(9 %) | 4(17 %) | 10(23 %) | 5(20 %) | 7(18 %) | 6(18 %) | 50(19 %) |
Option assessment | 14(32 %) | 8(31 %) | 7(23 %) | 5(21 %) | 15(36 %) | 8(32 %) | 7(18 %) | 9(27 %) | 73(27 %) |
Strategy seeking | 11(24 %) | 7(27 %) | 10(31 %) | 4(17 %) | 7(16 %) | 10(40 %) | 9(24 %) | 4(12 %) | 62(23 %) |
Requesting further work | 5(11 %) | 4(15 %) | 9(28 %) | 4(17 %) | 1(2 %) | 1(4 %) | 12(32 %) | 11(34 %) | 47(18 %) |
TOTALS (100 %) | 45 | 26 | 32 | 24 | 43 | 25 | 38 | 33 | 266 |
Table
3 shows that NEDs’ behaviour was on balance more suggestive of the approach of exercising governance by proposing strategies for their organisation’s future work than that of attributing responsibilities to executives for its current and past work. The former (option appraisal, strategy-seeking) accounted for half of the NEDs’ interventions. The general qualitative pattern was that NEDs saw their roles in meetings as being to interrogate what the organisation’s managers (including the EDs, but not only they) were doing, to make feedback about organisational (but not usually personal) performance, and to select the main directions for future activity. EDs saw their roles in meetings partly as responding to the feedback and requests for practical proposals, also as helping to frame the range of strategies and feedback issues that NEDs would interrogate. However, we observed variations in this general pattern. Some NEDs contributed little to meetings and asked few questions, whilst others frequently asked questions and asked EDs to explain further or undertake further work in a variety of areas. In particular the extent of discussion of clinical matters depended on the ways in which NEDs questioned EDs. The lengths of meetings varied considerably (45 min to 5 h, mean 3 h 20 min) and were generally longer where NEDs used a variety of questioning tactics that generated discussion and debate. The level of debate and discussion in board meetings varied according to the questioning tactics and willingness of the NEDs to question EDs and Chief Executives.
We observed three dimensions to this dynamic. One was how the NED role was set up at organisational level, for example what part the NEDs played in governance structures outside the Board itself. NEDs’ ability and freedom to question the EDs appeared to depend on what further roles, besides board membership, the NED had in the organisational structure and upon the NED’s personal ability and willingness to question EDs. NEDs’ precise roles varied across trusts. Thirty-four of the 135 NEDs identified further roles that they held. Nineteen were chair and eight vice chair of the board, and seven were chair of the audit committee. Most were chairing committees, for example the clinical governance committee or audit committee, depending on their skills. At one trust NEDs regularly visited wards and other clinical areas and had a regular agenda slot to feed back what they found. Whilst we limited our observations to the board meetings, it was evident, and not surprising, that NEDs with these additional roles played a more active role in discussions related to their governance role. Nevertheless these NEDs still retained a ‘non-executive’ attitude in these discussions in that they did not become defensive of Trust actions in their discussions at the board. There was no obvious relationship between the extent and type of board meeting contribution and the occupational background of the NED. Neither did the length of time served on the board (or, in the case of newly merged trusts, predecessor bodies) appear to influence the contribution made by individual NEDs.
Second, NEDs’ interests in particular areas of questioning tended to wax and wane depending on the context in which they were discussed. For example a patient complaint could suddenly evoke high levels of interest if it reflected poorly on the organisation. Similarly, if there were a staffing crisis affecting care-giving or achievement of targets, interest in human resources moved up the scale. Clinical ethics and governance attracted more interest if there was an ethical dilemma (such as balancing the costs and efficacy of medications) or issue with the implementation of evidence-based practice. Also the agenda usually constrained what NEDs would ask about.
Third, we observed variations in how actively or passively EDs responded to NED requests, questions and comments. At one pole, ED responses were passively compliant, for instance in minuting the NED’s request (e.g., to amend board minutes to record difficulties as well as successes in meeting control of infection targets) or in agreeing with what the NED had said (e.g., about the financial situation, staff morale). More actively, EDs agreed to chase up promised actions which had not taken place or bring the matter forward to a subsequent board meeting. In a few cases, EDs provided then and there missing information whose absence an NED had pointed out. EDs also undertook to hold further discussions outside the board meeting (e.g., to correct alleged inaccuracies in reports about capital grants) and to guarantee NED involvement in board sub-committees (e.g., for audit, remuneration). This was the nearest that EDs came to making counter-responses to what the NEDs said. We did not observe any occasion on which an ED overtly challenged the NED’s intervention or showed any outward sign of non-compliance. NEDs were prepared to press EDs to substantiate what the EDs were stating or proposing, and sometimes insisted on being kept informed of (even involved in) work directly arising from Board decisions. We observed no occasions on which NEDs simply over-ruled the EDs.
The main substantive foci of board discussion were the overall performance and competence of the management of the trust (‘corporate governance’), the management of clinical quality (‘clinical governance’) and finance. In the SGTs, which were preparing their applications for FT status, NEDs were more likely to request further reports in the Part 1 (public) meetings. Much of the discussion in the private part of PCT board meetings related to their dual role at that time of commissioner and provider and, in particular, to the purpose of NED participation in managerial sub-committees. There was also considerable discussion of the NEDs’ role during the Part 2 (i.e., private) component of board meetings:
The non-executive directors are being used in too operational a manner; the NED role should be to challenge the executive directors (NED, PCT 1).
We need maximum engagement between the Non-Executive Directors and the Executive Directors (Chair, PCT 4)
We need to ensure that the Non-Executive Directors are kept in the loop [regarding media interest in a serious untoward incident] (Chief Executive Officer, FT 2)
The NED should ensure that appropriate advice has been taken (Chair, PCT 1)
NEDs’ ability, willingness and freedom to question EDs and hold them to account appeared to vary across organisations, depending on both NEDs’ personal characteristics and the manner in which the role was established by the chair.
We also observed that EDs intervened more often to discuss concrete, practical aspects of service provision: service design, evidence base for practice and referral rates and volumes, i.e., what might be described as the more technical aspects of management, both financial and ‘real side’ (e.g., activity rates), than NEDs. NED interventions gave weight to broader service outcomes such as patient feedback and complaints, relationships with stakeholders, clinical ethics and clinical outcomes. Otherwise NED and ED patterns of intervention did not appear to differ much. Taken together, NEDS and EDs showed more interest in retrospective (outcome monitoring) and diagnostic issues than NHS policy agendas, although service design was often discussed. EDs were more likely to contribute about topics that were subject to national performance targets, especially those which combined clinical and policy issues, for example, service design and standards. These topics have potential implications for risk management (hence managers’ accountability or hospital liability), but for other target-driven topics - clinical outcomes, referral rates and activity levels - EDs and NEDs equally contributed to board discussions and decisions. We observed that NEDs did nevertheless contribute actively to finance-related discussions. This suggests that NEDs saw financial questioning as a key component of their role (regardless of whether they were personally interested in the subject [
34]).
Competing interests
The authors declare they have no competing interests.
Authors’ contributions
All authors contributed to study design, overall analysis and writing-up. Data collection was carried out by RE and VW. All authors read and approved the final manuscript.