Healthcare board governance

PURPOSE: In the light of failings of the board highlighted by the mid Staffordshire NHS Foundation Trust public inquiry, this paper seeks to offer insights about how boards in general might develop in order to discharge their responsibilities for quality and safety in health care more consistently in the future. The paper also proposes to examine wider questions about the role, purpose, and impact of boards on organisations. DESIGN/METHODOLOGY/APPROACH: The paper draws on literature from across the social sciences to assess the evidence for effective board working using a contingency and realist approach. FINDINGS: The examination leads to the identification of three key issues surrounding the construction and the development of boards. First, there is no evidence or consensus about an "ideal" board form. The rationale and evidence-base, for example for the 1991 model for NHS boards in the English NHS, has never been set out in an adequate manner. Second, the evidence about effective board working suggests that there are some key principles but also that local circumstances are really important in steering the focus and behaviours of effective boards. Third, there is an emerging proposition that boards, including in healthcare, need to embody a culture of high trust across the executive and non executive divide, together with robust challenge, and a tight grip on the business of delivering high quality patient care in a financially sustainable way (high trust - high challenge - high engagement). ORIGINALITY/VALUE: The paper argues that it is advisable to move away from a tendency to faith-based and exhortative approaches to guidance, training and development of boards and that it is time for a root-and-branch inquiry into the composition, structure, processes and dynamics of healthcare boards in the interests of assuring patient safety.