Why a dearth of board-level nurses is bad for patients

More nurses should sit on boards to help avoid 'strategic missteps'

More nurses should sit on boards to help avoid 'strategic missteps'

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Only 40% of the 15 NHS organisations running England’s health services have nurses sitting on their decision-making boards, according to a new investigation by Nursing Standard.

This is in contrast to the rest of the UK, where nursing is better represented at board level.

The Health Research Authority, NHS Digital, and the Care Quality Commission (CQC) are examples of the nine English organisations that do not have nurses as a voting board member.

Across the Department of Health and Social Care's 15 agencies and partner organisations in England, there are only eight nurses sitting on six boards, compared to 31 doctors sitting on 13 boards.

In 2016, the government in England scrapped its Nursing, Midwifery and Allied Health Professions Policy Unit, which had a team of nurse advisers liaising with ministers.

The dearth of nurses at the most senior levels of NHS governance is symptomatic of a wider problem of how nursing is valued, say the profession’s leaders.


RCN director of nursing, policy and practice Dame Donna Kinnair says: ‘It is foolhardy to ignore the role of nursing leadership in devising, implementing and delivering national strategies.'

Professor Kinnair says: ‘These individuals lead the largest workforce in the health service, which delivers 70% of care and treatment and is closest to the voice of patients.

‘It is disheartening to learn that there are four times as many doctors as nurses on the boards of the NHS bodies Nursing Standard has examined. All NHS organisations should have senior nurses at the heart of their governance, playing a full part in the decisions they take.’

Queen’s Nursing Institute (QNI) chief executive Crystal Oldman says the relative scarcity of nurses at board level is both surprising and disappointing.

Dr Oldman adds: ‘As nurses lead on so many aspects of service delivery, performance management and improvement, that experience should be represented at board level. The nursing voice can make a real difference to the quality of patient care – not just on the frontline but also at the strategic, system level.’

QNI surveys of community nurses indicate that systems are sometimes introduced – such as IT systems taken from hospital to the community – without a full understanding of the unique complexities of community healthcare, she adds.

‘If there were more nurses at board level, more strategic missteps might be avoided.’

Vital role

Dr Oldman also warns that a lack of community nurse representation at senior levels can mean the vital role of community health teams is underappreciated.

‘The rhetoric about moving more healthcare into the community is often not delivered in practice, because it is repeatedly overlooked at the strategic planning stage,' she says.

When questioned about the lack of nurses on their boards, organisations were keen to highlight the input nurses made to their senior governance team.

A CQC spokesperson says: ‘Our board is designed to enable the organisation to function effectively, rather than to represent all the professionals who work in the services across health and social care that we regulate.’

She adds there are ‘a number’ of nurses among the organisation’s senior team, including two deputy chief inspectors who share the role of lead nurse and communicate with the board.

NHS Digital clinical director Martin Severs says his deputy, chief nurse Anne Cooper, and senior nurse Caron Swinscoe both have ‘great influence’ in decision making across the organisation and regularly provide advice to the board.

'We do no discriminate'

Professor Severs says: ‘We do not discriminate between different types of clinicians, whether they be doctors, nurses, pharmacists, physiotherapists, dentists or any other clinical expert. At present it happens that two non-executive posts are held by doctors.’

Despite there being no nurses on the board of NHS Blood and Transplant (NHSBT), chief executive Ian Trenholm says nurses play a crucial role in the organisation and it invests in the development of nurses’ leadership skills and creates career opportunities.

Mr Trenholm says NHSBT has three ‘very experienced’ nurses leading on blood donation, organ donation and transplantation, and diagnostic and therapeutic services.

‘Together they lead our nursing council and developed our nursing strategy agreed with the board and covering 2016-2020,' he says.


Similarly, a Medicines and Healthcare products Regulatory Agency (MHRA) spokesperson says: ‘While we do not presently have a nurse on our board, [nurses] play crucial roles in both our wider staff and as expert members of our advisory committees.

'At MHRA we highly value the perspective nurses bring to our work. From 2003 to 2013, our deputy chair of the board was Shelley Dolan, who at the time was chief nurse at the Royal Marsden Hospital NHS Foundation Trust.’

A Human Fertilisation and Embryology Authority (HFEA) spokesperson says the organisation is restricted to having four professional board posts from across the fertility sector: ‘In the past [these] have included nurses, but currently comprise gynaecology, genetics and counselling.

‘We consult widely with nurses across our sector and beyond, through the Senior Infertility Nurses Group and the RCN's fertility nursing forum, and involve nurses in all our public policy and stakeholder work, for example on donation and the prevention of multiple births.

‘As further board opportunities become available, we encourage anyone – lay or professional – who feels they can contribute to the good governance of the HFEA to apply.’

Organisations with nurses on the board are keen to point out the advantages.

Strong nursing voice

Health Education England (HEE) has three nurses on its board – the only organisation to have more than one.

HEE chief nurse Lisa Bayliss-Pratt says it is critical to have a strong nursing voice in key policy and decision making in organisations.

Professor Bayliss-Pratt says: ‘My extensive and diverse portfolio covers a wide range of areas from mental health to nurse education reform, which has led to the creation of a regulated nursing associate role.

‘The role will sit alongside the registered nursing workforce to help meet ever-changing needs of patients in the communities where they live.’

She adds that, as a leader who is passionate about nursing, it is fantastic to work for HEE, ‘an organisation that recognises the importance of the nurse's voice. This is underlined by involvement that I have on the board level alongside eminent non-executive nurse leaders Jacynth Ivey and Sir Stephen Moss.’

Chief nursing officer for England Jane Cummings agrees it is vital that the voices of nurses and midwives are heard across the NHS at all levels.

'World-class care'

Professor Cummings says: ‘They have an extensive range of skills, knowledge and experience that must contribute to the planning and delivery of world-class care.

‘In my view it is important that they bring this invaluable experience to executive and non-executive roles across the health and care system.’

So, why is there such a marked disparity between the numbers of nurses and the numbers of doctors on these most senior NHS bodies?

University of Southampton faculty of health sciences principal research fellow Jane Ball believes the issue lies with attitudes towards nursing, ‘despite much rhetoric and the best of intentions’.

Dr Ball says: ‘It all symbolises that, at the very highest level, we still don’t get treated with the same regard as others.’

She cites the lack of nursing presence on the HRA board as one example of how fraught with difficulty and problematic it is to improve attitudes to the nursing profession.


The National Institute for Health Research (NIHR), although not a DH partner organisation, has a complex management system, which does not include a nurse at the very top of its management and decision-making hierarchy.

However, the organisation's clinical research network does include a director of nursing, learning and organisational development, Susan Hamer.

‘So often when it comes to research, we talk about wanting to improve and increase quality nursing research,’ Dr Ball says.

‘Yet how do we do that, if the people commissioning and regulating research don’t have insight into nursing research, and what that quality might be and look like? How do we raise the standards and make sure nursing has the right kind of evidence base?’

Dr Ball says there is a problem with policy-makers, politicians – even wider society – not understanding what nurses do, or what nursing is, which she says has a knock-on effect on healthcare decisions at all levels around research, strategic thinking and policy.

‘For example, if nursing is not understood and valued, then the nursing workforce is not planned properly,' she says.

'Symptom of failure'

‘This is a symptom of a failure to really understand the value of nursing and that is hard to challenge.’

The key to improving the situation does not lie solely in the profession, says Dr Ball, who says the nursing profession is arguably like a disadvantaged group.

She points out that the onus would not be put on other disadvantaged groups – such as women fighting the gender pay gap, or black and minority ethnic people striving for equality – to fix things for themselves.

'This is not just up to the profession to speak louder and demand far more, it is up to each of these bodies to change, and think again about whether they are making the most of valuable members of the team.

'It is not just us, other people have to be part of the solution too.'

The Department of Health and Social Care declined to comment.

The picture elsewhere in the UK

Northern Ireland (NI) has nurses on the boards of 11 of the 18 public bodies for which the Department of Health takes responsibility.

This includes five health and social care trusts, the Patient and Client Council, the Health and Social Care Board and the Safeguarding Board for NI among others.

Wales has executive nurses in place in 11 out of 14 bodies, including Public Health Wales, the Velindre Trust, Welsh Ambulance Services, seven local health boards and the Welsh Health Specialised Services Committee.

The new body Health Education and Inspection Wales will also have an executive nurse director, a post that is due to be advertised shortly.

A Scottish Government spokesperson says NHS 24 Scotland, NHS Education for Scotland, the State Hospitals Board for Scotland and 14 health boards all have directors of nursing.

Chief nursing officer for Wales Jean White says: 'It is essential that there is a strong nursing voice wherever strategic decisions and policies for health services are being considered.

'This view is consistent with that set out by the World Health Organization, in numerous declarations, recognising the importance of nursing involvement in shaping health services.

'Nurses make up the largest proportion of the health workforce in any health system and provide the widest spectrum of care.

This gives nurses a significant insight into patients, carers and families' needs as well as having an important role in ensuring delivery of safe, high-quality, person-centred care, which they can bring to the table.'

Scotland's chief nurse Fiona McQueen says: 'I have no doubt that the quality of services is enhanced by the executive nurse director contribution.'

The nurse board member

Nurse Elaine Inglesby-Burke says there are numerous advantages to having a member of the profession on an organisation's boards.

She joined the National Institute for Health and Care Excellence (NICE) as a non-executive board member, two years ago.

Ms Inglesby-Burke says: ‘I am privileged to represent the nursing community, making sure our voice is heard where it needs to be.

‘If we are to drive high-quality, person-centred care we must develop nurse-accessible guidance and draw on the expertise of nurses alongside other health and social care professionals.’

She adds: ‘The increasing demand in different care settings, a drive for productivity and the impact of shortages on the nursing workforce make it essential that senior leadership positions reflect this demographic and incorporate the value of nursing and the professions view at all levels.’


Fast facts

  • Four times as many doctors than nurses sit on the most senior NHS boards in England
  • Six boards out of 15 running England's health services have nurse executive or non-executive members
  • Three nurses sit on the board of Health Education England, making it the only organisation to have more than one nurse board member

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