Guidance
FIGURE 8
- At least seven in ten (70%) respondents found each of these pieces of guidance very or somewhat helpful.
- Respondents were most likely to say they found the fit and proper person test framework for board members helpful (81%). Two fifths of respondents said this guidance was very helpful (41%).
- Respondents were least likely to find the framework for conducting annual appraisals of chairs helpful (72%), and most likely to find this guidance unhelpful (18%).
- No respondents found the insightful providers board guidance unhelpful.
FIGURE 9
- Governance leads were more likely to find this framework helpful (82%) compared to chairs (56%). Over a third (35%) of chairs said this framework was unhelpful compared to 7% of governance leads.
- Over half (55%) of respondents from acute specialist trusts said that they found this guidance unhelpful, the highest proportion of all trust types by some way and in contrast only a fifth (20%) of acute trusts found this guidance unhelpful. All (100%) of respondents from mental health/learning disability trusts and ambulance trusts found it helpful.
NHS leadership competency framework for board members
- Chairs were less likely to find this framework helpful than governance leads (chairs: 67%, governance leads: 84%). 14% of chairs found this framework unhelpful compared to no (0%) governance leads.
- A third (33%) of respondents from acute specialist trusts found this framework neither helpful nor unhelpful, higher than the survey average of (15%). Nearly a tenth (11%) of acute specialist trusts and combined mental health / learning disability and community trusts found this framework it unhelpful.
If you did not find any one of these pieces of guidance helpful, please explain why:
- Respondents identified several reasons why certain pieces of guidance were not useful. Members noted that some guidance is overly complicated, time-consuming and unclear. The most commonly cited piece of guidance was the chairs appraisal framework, which members said was time-consuming, complex and superfluous, as well as lacking in understanding of the NED role and having more relevance to an executive role.
- Some members said that the fit and proper persons guidance is overly time-consuming and bureaucratic, detracting from their ability to focus on governance and strategy. Some also noted that the requirements were ambiguous and they felt that aspects had not been properly thought through.
- Some also felt the leadership competency framework was too detailed, subjective and unclear, particularly regarding the distinction between executive and NED roles.
- The insightful board guidance was less likely to be mentioned, with some respondents highlighting that it was too soon to comment on its value.
“The principles of the guidance are helpful but for some they are too extensive and have lost their impact as they have added additional bureaucracy and lack of clarity (e.g. there are too many
questions in the chairs appraisal questions are not easy for stakeholders to answer including governors; the leadership competency framework has a lot of good information but
a risk it will be a 'tick box').”
Company Secretary, Acute Trust
“I find some of the guidance contradictory. For example, emphasising the need for boards to operate at a strategic level and then overloading them with very operationally focused
requirements. I get the sense that guidance has been written by individuals who have never worked at a board level.”
Chair, Combined Acute and Community Trust
Policy
Following recent national announcements from the chief executive of NHS England and the Secretary of State for Health and Social Care, to what extent do you agree with the following statements:
There was an error in the survey response categories for this question and the 'disagree' option was unavailable to respondents. Respondents wishing to select disagree may have selected either strongly disagree or neither agree nor disagree. Due to this, we focus here on the agree and strongly agree responses and do not include a table/figure, which may be misleading.
It makes sense to withhold annual pay increases from executive directors and other VSMs where trust performance is poor
- Half (50%) of respondents from mental health/learning disability trusts agreed or strongly agreed with this statement, higher than the survey average (22%) and any other trust type. The next highest was community trusts, of which a third (33%) agreed with this statement.
League tables for trusts will support us to improve performance
- Over two in five (44%) community trusts agreed with this statement, double the survey average (20%) and all other trust types.
The announced change in the role of ICBs (from performance managers of trusts to strategic commissioners) is a welcome step towards clarifying roles and responsibilities in the system
- Seven in ten (71%) respondents agreed, compared to two in ten respondents in agreement with the
other statements.
Please tell us more about any of these topics (proposals about league tables, the ICB role, and/or VSM pay):
- Most respondents expressed concern about league tables, seeing them as potentially demoralising, demotivating and counterproductive to collaborative efforts. Concerns were raised that league tables could lead to trusts focusing on improving certain metrics at the expense of others or masking underperformance. Members emphasised that league tables often lack the nuance needed to account for differences between trusts, leading to unfair comparisons and potentially harmful consequences. A few acknowledged that while benchmarks can be useful for identifying areas of improvement and showcasing good performance, members felt they needed to reflect local challenges to be beneficial.
- Regarding Very Senior Manager (VSM) pay, members highlighted the importance of transparency and fairness. Many were opposed to punitive approaches, suggesting that poor outcomes often stem from systemic challenges rather than individual leadership failures. They emphasised that good leaders need to feel encouraged to take on challenging roles without fear of penalties in the form of pay cuts. Many members welcomed being held to account; however, they call for an approach to accountability that is fair and constructive rather than penalising.
- On the role of ICBs, members generally approve of the clarification, but many expressed the need for greater clarity still regarding responsibilities and accountability structures and the need for NHSE and ICBs to have more of a strategic focus as opposed to performance management. There were isolated concerns that ICBs would not accept the change in role as well as some uncertainty around what these changes will mean in practice.
“League tables brings back competition which we are trying to replace with collaboration. I don't think the role of our ICB will change and they have said as much. Who will work for challenged
organisations if they then don't get a pay rise – certainly not our most talented managers.”
Chair, Combined Acute and Community Trust
“League tables will provide news stories, rather than supporting NHS providers to improve in the way they need to.”
Company Secretary, Acute Trust
“Poor performance does not happen overnight and is never straightforward to fix. It would be unwise to penalise a new management team for previous mistakes or performance. Funding and investment, as well as demand needs to be considered as a driver and enabler of good performance. League
tables can drive perverse behaviour and create unintended consequences. If introduced should focus on patient outcomes and system wide indicators.”
Company Secretary
“Poor trust performance is a very nuanced issue and withholding annual pay increases is a blunt tool. There ought to be a distinction between cost-of-living increases and pay increases as the former should be applied in the same way as for other pay arrangements.”
Company Secretary, Acute Trust
What is the main thing you would like NHS England's revised oversight and assessment framework to achieve?
- Members emphasised the importance of clear and transparent processes, along with ways to ensure accountability at all levels - particularly with the trust board. There was again a focus on greater clarity around the roles and responsibilities of NHSE, ICBs and other stakeholders.
- Clarity was a main theme, with some mentioning a need for clear criteria for transitions between oversight levels and a better understanding of consequences and expectations from NHSE. Others said that the framework should be consistently applied across organisations, avoiding duplication or overlap and maintaining objectivity in assessments.
- Some respondents said that NHSE should give high-performing trusts more autonomy, while focusing oversight efforts on trusts needing additional support.
- Others stated that the framework should prioritise collaboration across organisations, as well as prioritising supportive measures, rather than solely focusing on compliance. Members also raised concerns over the amount of bureaucracy, asking that simplicity of implementation is prioritised.
“Improvement in the quality of care for service users.”
Company Secretary, Mental Health/Learning Disability Trust
“Currently the framework does not bring the support which is described in the framework. Going forward the framework should be objective in its assessment, descriptive of the
support which will be made available and adhered to.”
Company Secretary, Acute Trust
“Greater clarity about what can be achieved by each trust so that expectations are clear.”
Chair, Acute Trust
“I welcome rigorous oversight, but would like it to be twinned with support to change performance... I am concerned that a desire to balance the books and drive productivity may squash creative efforts to transform services because there will be little risk appetite for short term instability (in performance or finances). I would like planning to move to a two to three year cycle as the focus on in-year performance is ridiculous.”
Chair, Mental Health/Learning Disability Trust
NHS England regional teams currently (as set out in NHSE's operating framework 2022) have a remit that includes: developing leadership within ICBs and providers, collating and sharing best practice and lessons learnt, and facilitating supportive interventions to improve performance and outcomes. If the role of the regional teams was to change as part of the revision of the operating framework...
…What would you wish to see retained:
- Most members said that they would like the current remit as described in the question to be retained. Many specifically mentioned that developing leadership within ICBs and providers, and collating and sharing best practice and lessons learnt, were most important in their view. A few said that facilitating supportive interventions to improve performance and outcomes was important
“Leadership that is positive and encouraging that enables and empowers. Focus on patient and staff experience”
Chair, Acute Specialist Trust
“Focus on true collaboration across organisational boundaries and enabling provider collaboratives to work more seamlessly”
Company Secretary, Mental Health/Learning Disability Trust
…What would you wish to see changed:
- Many members emphasised the need for a clearer delineation of responsibilities between regional teams, ICBs, and trusts, particularly regarding performance oversight, regulation and strategic direction. Others mentioned wanted to see a reduction in the duplication of efforts between NHSE, regional teams and ICBs – with some mentioning a need for proper delegation of responsibilities from NHSE to regional teams to reduce overlaps.
- Others would like to see greater transparency in NHSE's reporting structures and clearer accountability. A number of respondents also mentioned a need for interventions that genuinely support improvement, as well as a more active role in leadership development and simplified performance targets.
“Clarity about their role in terms of the strategic directions of each ICB and of the region as a whole.”
Chair, Acute Trust
“Ensuring supportive interventions are supportive rather than blame shifting.”
Chair, Acute Trust
“Culture of directive intervention on trusts, sometimes without
understanding of the real day to challenges we experience.”
Chair, Combined Mental Health/ Learning Disability and Community Trust