National Institute of Health Research

HS&DR - 10/1012/03: Towards a framework for enhancing the performance of NHS boards: a synthesis of the evidence about board governance, board effectiveness and board development

Project title Towards a framework for enhancing the performance of NHS boards: a synthesis of the evidence about board governance, board effectiveness and board development
Research type Evidence Synthesis
Status Project complete
Start date July 2011
Publication date

October 2013

Link to journal publication
Cost £ 46,467.16
Chief Investigator Professor Naomi Chambers
Co-investigators Dr Gill Harvey (The University of Manchester), Professor Russell Mannion (University of Birmingham)
Contractor The University of Manchester
Plain English summary This study will provide a better understanding of the composition of effective boards, how high performing boards work, how boards can be developed and what impact they can have on their organisation including the quality of care provided to patients. It will provide a guide (framework) based on ideas and on evidence for managers and boards to work from. It starts with a review of what is known about how boards operate across all sectors and in different countries, and a follow-up review which focusses on boards in healthcare in the UK and elsewhere. This review is then brought together in a summary (synthesis) of both the ideas (theories) and the practice of board working. This synthesis will take the form of a main story and will explain the main ideas rather than judge them. The study then focuses on the relevance of this 'main story' for healthcare and for the NHS in particular. One of the challenges is that, to some extent, the desirable form of boards, the focus of effort and outcomes will differ from place to place according to local circumstances. So we have chosen a research method ( 'realist review') that will elicit what works in what circumstances, in what respects and why, which will be more useful than findings which describe the key tasks, processes and impact of an 'average' board in an 'average' situation. The research method also depends on linking with other researchers and with practitioners who are experts in their field. In this case, these are NHS board members, and those who advise and support them. We intend to convene a group representing these practitioners so that we can test and check whether the questions that we are pursuing and the storylines that we are developing make sense, are relevant and accord with the challenges and priorities faced by NHS boards. The success of the research can be judged according to how robust and compelling the resulting framework is for developing effective NHS boards, as viewed by both academics and by practitioners, and how well and easily it can be translated into new practical evidence-based tools for board development
Scientific summary The study is an evidence synthesis of a diffuse literature in relation to boards and organisation performance with particular reference to healthcare boards and with special emphasis on the NHS. The terrain is characterised by complexity both in terms of the multiple locations of the evidence and by weakness and ambiguity in terms of association and causation. The meta-narrative mapping approach to synthesising the evidence is attractive because it acknowledges different disciplinary traditions and changes to dominant narratives over time (Greenhalgh, 2004). Board governance is a good example of where the dominant narrative has changed, with a shift away from the discourse of agency theory within the political science discipline to a more hybridised one in which, inter alia, board dynamics within the organisational behaviour discipline is now playing a significant contribution. A realist angle emphasises the contingent nature of the evidence and addresses questions about what works in which settings and resulting in what outcomes ( Pawson et al, 2005). A realist review also emphasises an iterative approach between programme theory and predicted theory (ibid). We therefore propose incorporating a meta-narrative mapping exercise particularly in relation to the first objective within an overarching realist approach. In relation to managing the potential volume of papers, from diverse sources, the purposive sampling strategy will set strict boundaries in relation to relevance, allowing for iteration. Data extraction, and inclusion/exclusion is less linear than in traditional systematic reviews and decisions here will call for pre-existing knowledge of the subject area and the exercise of judgement on what to include/exclude from the review (drawing on advice from the research team and stakeholder group as required). One of the key tests for SDO funded studies is that the research questions and subsequent research findings are relevant and usable for the target audience who are responsible for the organisation and delivery of healthcare. In accordance also with realist review principles, we propose that the research questions are so far provisional as we would plan to hone and refine these with an expert advisory and stakeholder group. We would plan to convene this group once on a face-to-face basis and to run a facilitated workshop early on in the study to check out programme theories about board structures, processes, dynamics, development and impact on organisation performance and to guide the development of the research questions. Contact would be maintained electronically during the study with members of the reference group and in particular the provisional findings would be tested with them. We would anticipate that group members would include at least one board chair, one chief executive, one executive director, one opinion leader with a national-level interest and role in board development, a contact each from the NHS Confederation, Monitor, the Foundation Trust Network ,the NHS Appointments Commission and the board development team at the NHS Institute for Innovation and Improvement, and two 'ordinary' non executive directors. The responsibilities of the research team will be in general divided as follows: NC ( principal investigator),who has the most extensive subject knowledge, will take overall charge and lead on project management, the convening and facilitation of the reference group workshop, carrying out the review and subsequent communications. GH (co-applicant) will advise on and support the technical aspects of realist review and synthesis. RM (co-applicant) will provide advice, particularly in relation to research on boards and organistional culture and will help to draft the report. The specialist librarian will provide support in literature searching and extraction.

Protocol (PDF File - 342.6 KB)

Commissioning Brief (PDF File - 59.5 KB)

Addendum This project was commissioned by the NIHR Service Delivery and Organisation (NIHR SDO) programme under the management of the National Institute for Health Research Evaluations, Trials and Studies Coordinating Centre (NETSCC) based at the University of Southampton.


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