The non-executive asked a simple question; “Why can’t we just say no?” In the world of business they inhabit, this is a rational question.

We were on one of our regular board development sessions. I had been endeavouring to explain why we were pursuing a particular course of action. Reasonably, but with a modicum of exasperation, one of the non-executives was trying to understand the logic behind why we were choosing that particular course of action. All they wanted was a rational and logical explanation.

Fortunately, for me, we were also studying a new National Leadership Council document; The Healthy NHS Board- Principles for Good Governance.

I referred my fellow board member to paragraph 142 on page 33, which sits underneath the heading “Where is power and authority really vested in the NHS system?” 

Formally, NHS boards are both sovereign and accountable; the reality is inevitably less tidy.  The Department of Health at central and regional level, major regulators and NHS boards share accountability, power and authority. And the balance of power ebbs and flows over time and in response to circumstances.

There is a further bullet point which can only be described as a rhetorical question (to save you the time looking for an answer):

How do board members retain a sense of their purpose and value in a context that may, at times, feel highly constrained?

To be frank, I marvelled at the honesty of the whole section in which this paragraph sits. For anyone who wants to understand the challenge of working at board level in the NHS, this document sets it out.  Leading and managing in this context requires skill and judgement, insight and understanding and a great deal of patience and resilience.

The NHS is a system where the balance of power ebbs and flows over time and in response to circumstances: it is not always rational and logical. It is, perhaps, best described as “contextual and consequential”.

That does mean, sometimes, it is vital for board members to say ‘no, this is not right’ for the sake of patients – they have a duty to get the context right or others will suffer unacceptable consequences.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.