A little on structure

The concept of the Chief Executive is still relatively new in the 60-yearold NHS. Arguably, the role is merely another stage in how services are developed, led and delivered as it has evolved from different types of management systems.

The first model was the medical control of services through medical superintendents supported by matrons. This changed with the establishment of co-equal ‘hospital management teams’ – comprised of a doctor, a nurse and an administrator. This was followed by general management, with the implementation of the Griffiths (1983) report. Finally, for the moment at least, the development of the concept of corporate management through the Boards of Directors of NHS trusts and primary care trusts. The emergence of NHS foundation trusts has seen, alongside Boards of Directors, the requirement of foundation trusts to have a membership drawn from the communities they serve. Foundation trusts also have a Board of Governors, the majority of whom are elected from the membership. The Board of Governors, among other things, hire (or fire) the non-executive directors of the Board of Directors. Foundation trusts are set up as ‘mutual’ organisations such as those in the cooperative movement. They receive their ‘terms of authorisation’ from Monitor, an independent regulator of foundation trusts set up by Parliament. The terms of authorisation describe each foundation trust as a public benefit corporation. Foundation trusts are outwith the control of the Department of Health and their local strategic health authority. They report quarterly to Monitor against a number of indicators. If these indicators indicate good organisational performance, foundation trusts are left alone to manage their own affairs.

The wider landscape

All NHS Chief Executives are the ‘accountable officer’ of the organisation in which they work (Monitor, 2008). To this effect, a memorandum is signed by each Chief Executive describing their personal responsibilities and obligations. Chief Executives are therefore responsible for the overall performance of their organisation. Things can go wrong, sometimes suddenly. In extreme circumstances, the Chief Executive is the first to walk the plank, often followed by the rest of the Board of Directors. When this happens, it is rare for others such as senior clinicians to get a P45 as quickly.