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Towards a framework for enhancing the performance of NHS boards: a synthesis of the evidence about board governance, board effectiveness and board development N Chambers,1* G Harvey,1 R Mannion,2 J Bond1 and J Marshall1 1Manchester Business School, University of Manchester, Manchester, UK 2Health Services Management Centre, University of Birmingham, Birmingham, UK *Corresponding author Background: There is a need to reduce the variation in organisational performance across the NHS for which boards hold ultimate responsibility. By exploring how boards can add value, we hope that this research will benefit patients and improve service efficiency and effectiveness. Objectives: We know that there are knowledge gaps in relation to the composition and characteristics of effective boards in the NHS, their impact and the range of tools and techniques available for developing effective boards. This realist synthesis study, therefore, aims to add to existing knowledge by (1) providing a theoretical contribution to board governance and relating it to the NHS context, (2) offering fresh insights into effective board composition, structures, processes and behaviours in the NHS, (3) furthering an understanding of how NHS boards can affect organisational performance and (4) summarising and analysing the range of board assessment tools and development interventions available for the NHS. Method: The study adopted a realist approach to an evidence synthesis of a diffuse literature. In line with realist review principles, we tested, honed and refined the research questions and emerging findings with a joint expert advisory and stakeholder group of 23 people. A search was conducted across relevant library and external sources including ABI/INFORM (ProQuest, Ann Arbor, MI, USA), SciVerse ScienceDirect (Elsevier, Amsterdam, the Netherlands), MEDLINE, EMBASE and the Social Science Research Network, from 1968 to 2011. A total of 618 general articles, 209 health-care-related articles, 252 textbooks and 54 reports were identified. Results: Frameworks that have developed from theory and from practice were categorised into the three elements of composition (board structure), focus (what the board does) and dynamics (the behavioural dimension), and the potential conjunction between board theories and practices was explored. We found some important distinguishing characteristics in the public, non-profit and health-care sectors. In relation to the impact of boards on organisational performance, the importance of contingency factors was highlighted and there is positive empirical support for the role of physicians on the board. Other than self-reports, we could not find any significant studies on the impact of board development on board effectiveness. Limitations: The study is dependent on the diverse nature of the sources of evidence and the relative infancy of the realist synthesis method. The literature is fragmented, equivocal and, at times, contradictory. We believe, nevertheless, that the study offers insights in terms of developing middle-range theories for effective health-care boards. v © Queen's Printer and Controller of HMSO 2013. This work was produced by Chambers et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

health services and delivery research

Towards a framework for enhancing the performance of NHS boards: a synthesis of the evidence about board governance, board effectiveness and board development