Abstract

This study explores the purpose and role of public board meetings in the British National Health Service as an aftermath of public sector reforms. It deviates from the mainstream methodologies to study boards in action as it employs an ethnographic approach. Data has been collected through participant observation, in-depth semi-structured interviews from eighteen board members and members of the public, and documents in the form of board agenda and meeting minutes. Findings reveal that the purpose of the public board meetings is to manage their public image and to protect their reputation as rational actors and serve as a reporting function that excludes the public from active participation. Hence, this study asserts that public board meetings serve as a formal ritualized practice that performs board meetings. This study has practical implications as similar reforms have been introduced in other public organizations.

Key Words

Board Meetings, Public Sector, Ethnography, British NHS

Introduction

The National Health Service(NHS) organizations have undergone a major transformation as part of public sector reforms that have changed the role of the boards as well (Farrell, 2005). The previous role of public boards as mere rubber-stamping the government decisions have now been transformed into a more active role of decision making (Clatworthy, Mellett, & Peel, 2000; Peck, 1995). Another significant change in the NHS is the engagement of local communities in the planning and running of the NHS services. The NHS boards have become open to the general public as they hold part of their session of board meetings in public (Allen, 2006). Research shows that public engagement has become a dominant discourse on the public boards but has been rarely analyzed (Tracy & Durfy, 2007). Generally, public boards have been less researched in-depth as compared to the private sector boards. Though, there has been some research on the various roles of public boards in recent years but less is known about their role and purpose of their public session of board meetings (Freeman & Peck, 2007; Peck, 1995; Peck, Gulliver, & Towell, 2004; Veronesi & Keasey, 2012). The systematic review conducted by Mockford et al., (2012) demonstrates that there is less evidence of public involvement in the British NHS. Public meetings are important as they help to convey information to the officials influence and attract media attention, but they are considered to be a useless democratic ritual that fails to incorporate the public voice in board governance and strategy making (Adams, 2004). Also, it is argued that patient and public involvement in health care has become un-fragmented and unstable (Hogg, 2007). The introduction of board of governors in the NHS Foundation Trusts (FT), which are autonomous NHS hospitals, is one of the methods of incorporating public voice in the governance process since governors are elected members of the local communities and represent various constituencies. However, the effectiveness of the board of governors and their involvement in board governance and strategy making is yet another question mark to the effectiveness of NHS FT board governance (Bennett, 2002). 
To address this significant research gap that has both theoretical and practical contribution and implications, this study aims to explore the role and purpose of public board meetings and to investigate the extent of public involvement in the public session of the board of directors and board of governors’ meetings where key decisions concerning public health are made. Furthermore, this study is significant since the British NHS model has been implemented in several countries as 
a consequence of public sector reforms; therefore, this study could be of interest to the practitioners and researchers across the globe. 
This paper is structured as follows: it begins with a literature review followed by the context of the study. Afterward, the methodology of the paper is discussed. The next section presents the findings and the paper then closes with the discussion and conclusion of the study. 

Literature Review

Public participation in policymaking can be simply defined as “the ways in which ordinary citizens can or do take part in the formulation or implementation of policy decisions” that is a crucial policy of the British government (Richardson, 1983, p. 8). In the NHS, there have been two models of public participation – the consumerist model and a democratic model (Rowe & Shepherd, 2002). The former is more instrumental in nature that reflects that the services provided meet their needs whereas the latter values public empowerment to have a greater say in the design and the delivery of services (Rowe & Shepherd, 2002). Public meetings are a common practice of several public organizations that attempt to involve and empower the general public in shaping the health and social care services (Mockford et al., 2012). Research shows that in most of the public meetings, the public is allowed to ask questions for a very few minutes without engaging in a dialogue with other members of the public or with the board members (Adams, 2004). This infers that a consumerist model is applied in the public board meetings and the public has a limited say in the board meetings. However, in other kinds of boards, such as the school boards in the US, the public is more actively engaged in the decision-making process (Tracy & Durfy, 2007). Hence, different public organizations choose different methods of public participation in strategy and decision making.  

Research on NHS boards, in particular, has been studied from two main perspectives – the instrumental and the symbolic view (Freeman & Peck, 2007). The former looks at the structural and compositional aspects of boards whereas the latter addresses the more important work on boards that do not appear on the board agendas and could only be known through close observation (Peck et al., 2004). Inside observation of the board meetings in the NHS demonstrates that board meetings proceed as a ritual, with a particular emphasis on formality, rule governance and performance (Peck et al., 2004). Similarly, the annual general meetings of the NHS FTs are seen as a ritualized practice of creating accountability of the board members (Hodges, Macniven, & Mellett, 2004). The contribution of the public in these meetings has been hardly addressed despite the dominant discourses of public participation in the NHS. In nearly all the public meetings of the NHS organizations including the annual general meetings, the board members present a report to the general public, which in fact creates the impetus that the board members are somehow accountable to certain stakeholders. The findings of the study conducted by Hodges et al. (2004) demonstrate that the NHS trusts face problems in attracting substantial public in their annual general meetings and hardly understand what should be done to improve their attendance. 

Thus, one of the major roles of the public sector boards is responsibility and accountability to the concerned stakeholders including members of the public (Adams, 2004; Farrell, 2005; Ferlie, FitzGerald, & Ashburner, 1996). However, the role of the board and the NHS boards, in particular, has become a ritualized practice that somehow raises the question of public involvement in the boarding process (Peck et al., 2004). Some researchers have taken a performative view of the board and hence have used the dramaturgical approach to study board meetings in the public organizations (e.g. Freeman, Millar, Mannion, & Davies, 2016; Freeman & Peck, 2007) and in policymaking (Hajer, 2005). Under this notion, the board meetings resemble a stage of a theatre whereas the board members are actors on stage that perform the board meetings where the public voice during the meetings is seen as an intrusion (Manzoor, 2012). Often, the purpose of the public board meetings appears to be about sharing information rather than including their voice in strategy and decision making (Peck, 1995; Peck et al., 2004). Hence, the purpose of the public board meetings is rather symbolic as it progresses with the set agenda item and progress in a formalized manner where most of the discussion is predetermined (Bell, 1997).

 

Context of the Study

This study has been conducted in the British NHS organizations, including three NHS FTs and two NHS organizations. The organizational structure of the NHS FT is different from the NHS trusts in a way that the NHS FTs have a board of directors and a board of governors whereas other NHS organizations have a board of directors only. The board of governors has elected members who represent various constituencies. The board of governors attends board of directors meetings as members of the public and vice versa. The board of governors is a requirement for all other NHS trusts to achieve the status of the NHS FT. The NHS FTs are more decentralized and have greater autonomy of decision making and less governmental influence. The British government encourages all the NHS trusts to ultimately achieve the status of the NHS FTs. 

All the NHS organizations, including the NHS FTs, have two hours of board meetings a month. Usually, an hour is dedicated to the private meeting where the public is not allowed to attend these meetings. The next hour is a public session where the public is allowed to attend the meetings. The public could be governors in the case of NHS FTs, members of the staff or community, members of the press, or any other public member who might be interested to attend the meeting. Similarly, the board of governors also has a one-hour private session and a one-hour public session in the NHS FTs. 

The normal practice for the public to attend the board meetings is to inform the board secretary beforehand so that they can take the attendance as who would attend the meeting. Observations show that the public is not allowed to intrude the board meetings. They may ask questions either at the beginning or at the end of the board meeting subject to the permission of the chairperson. In some NHS organizations excluding the NHS FTs, the public is not even allowed to ask questions. Also, the NHS FTs hold an annual general meeting where members of the local communities are invited to attend the public meeting similar to the corporations.

Methodology

This study adopts an ethnographic approach to study board meetings in situ. ‘Ethnography is an eclectic methodological choice which privileges an engaged, contextually rich and nuanced type of qualitative social research, in which fine-grained daily interactions constitute the lifeblood of the data produced’ (Falzon,2009). It helps to gain access to the tacit and implicit knowledge and feelings embedded in social settings, objects, and interactions (Hansen, 2006). Hence, an ethnographic approach was used as a methodology to gain nuances understanding of the purpose and role of public boards in public meetings. Also, ethnography allows the free movement of the researcher in different spaces that help to understand an individual’s connections, associations, and relationships across space (Hammersley& Atkinson, 1983; Falzon, 2009). 

Hence, data were collected through participant observation of the public board meetings as a member of the public from two NHS organizations – a partnership trust and two NHS FTs. Also, two annual general meetings of the NHS FTs were attended that lasted for two hours each. Detailed diary notes were taken with an aim to note down the conversation and dialogue among the board members and the members of the public since the researcher was not allowed to record the board meetings. Memos were also prepared, and interpretations of the board meetings were recorded separately soon after attending the board meetings. 

The ethnographic data was complemented by in-depth semi-structured interviews that were taken from eighteen board members, including director and governors, and several ethnographic interviews were taken from the members of the public who attended the board meetings. The main questions asked were: why there is a lack of public participation in board meetings? Why there is a lack of public interest in attending public meetings? These interviews were tape-recorded with permission and immediately transcribed with the assistance of the software – Express Scribe. Hence, the data were triangulated through participant observation, agenda and minutes of board meetings that provided a useful context, and semi-structured interviews that increased validity and rigor of the ethnographic research. 

The data generated through participant observations was quite messy as it is the tradition of ethnographic research. Thematic analysis was applied to the entire corpus to understand the role and purpose of public board meetings and the extent to which the public voice is included in strategy and decision making. The thematic analysis generated two main thematic categories: managing reputation to protect face and exclusion of public voice in public board meetings as shown in figure 1. 

Figure 1

The Analysis Process Developing Thematic Codes and Thematic Categories



Findings

Findings demonstrated that the public meetings served two main purposes: to manage the reputation of the board members and the Trust by presenting an image and reputation of being a responsible and a rational actor, and to report information to the public which is usually not present in the public board meetings. 




Managing Reputation to Protect ‘Face’

The NHS organizations are concerned about their public image and the way they would be presented in the media and press. The term protecting ‘face’ refers to the management of impression that one forms on others (Goffman, 1955; 2017). Here, this term means managing the reputation of self and of the organization among the audience. Findings demonstrate that there were two aspects of protecting reputations that were both at the individual and at the collective level. At the individual level, board members themselves were cautious of their own impression in the public board meetings that determined the extent of their participation in discussion in the board meetings. The board members are concerned about whistleblowing that affects their engagement in meetings. 

Staff governor: “There is a feeling that whistleblowing the rest of it offers problems. And I am sure certain governors have that… One only has to read some of the reports on the hospital on whistleblowing. So, I think more and more individuals don’t have much enthusiasm for turning up for meetings”

Most of the times, board members, both the directors and the governors, felt embarrassed when they were singled out during the board meetings held in public that affected the quality of discussion in board meetings. 

Non-executive director: “I have always asked the stupid question usually that’s one question. Nobody else was asking and it is important to ask. So, yeah! (I feel) unacceptably…but these questions have to be asked, you know”.

At the collective level, board members were concerned on the impression that they would produce as a board on the general public that included members of the press. For example, the CEO of an NHS trust was concerned on the way they were projected in the media regarding the closure of some services and tried to give an explanation to the board and to the public.  

CEO: ‘Our colleagues were besieged by the media. Most of the debate was very heated and political...it’s important for things like that to calm people that we are not planning to take any closure. The media portrayed as if there was some secret financial analysis. 

Director of Finance (looking at the CEO and then turned towards the public): ‘We were very keen to release financial analysis. It was already in the public domain. It got an aura (in the media) as if it was a secret and it is not’.

Hence, the board was usually cautious of the manner in which they would be presented in the media. Similarly, in another NHS FT public board meeting, the chairperson appreciated the press on presenting a positive image of the trust. 

Chairperson: “I was very impressed with the press release that came out. That has been very helpful. Thank you!”

(The member of the press who had given this report was there. everyone looked at her and smiled with a gesture of gratitude. The member of the press smiled as well). 

Thus, the presentation of self as an individual and as a board is crucial for the NHS organizations as they fear the manner in which they would be presented in the press and media. 




Role of Disseminating Information in Public Meetings

The extent to which the public is allowed to participate in the board meetings and the extent to which what information could be disclosed to the public depends upon the chairperson and the CEO. For example, in one of the NHS board meetings, the chairperson clearly stated before and after the public meeting that the public is not allowed to ask questions. However, a member of the public ignored the chairperson and started praising the board regarding their financial plan which is always a matter of concern for everyone. It is worthwhile to state here that the management of finances and the financial plan constitutes the main discussion in the public board meetings. The following dialogue demonstrates that the public may be allowed to speak if they praise the board. 

Chairperson: ‘we don’t invite questions from the public. That’s all for the public session’. 

There was restlessness among the public and one person said: ‘can we ask a question’. 

Chairperson: No! 

(He sat back on his chair. The posture was changed from leaning on the table to sitting back. The member of the public ignored the chairperson) 

Member of the public: ‘I thought it was very wise to mention typographical changes and financial risks, and all that submitted for annual report…on behalf of the public, I thank you for everything that you have done. We notice that you did a good job’. 

The chairperson became more excited and emphasized: ‘I think people are doing fantastic job…we are going to raise hundreds of millions of pounds. We all worked very hard. This was not a top-down plan. It was a bottom-up plan…’ 

The members of the public were then asked to leave so we all came out. 

In the NHS FT public board meetings, the chairpersons usually allow the public to either ask a question at the end or at the beginning of the board meetings and are not allowed to ‘intrude’ during the board meetings. For instance, in one of the NHS FT public board meetings, the chairperson used to announce: “this is not a public board meeting, but a meeting held in public/ you will be allowed to ask questions at the end of the meeting”. It conveyed a strong message that the purpose of the public’s presence is to watch the board meeting. However, this particular chairperson was generous as he allowed the public to ask a question at the end of the board meeting. As a consequence, the public presence in the board meetings was almost negligible. The lack of interest and trust on the board of directors is reflected from the following quote of a member of the public: 

Member of the public: “it is good that after retirement you sit behind those tables and do nothing’ (ironic laughter). 

In another public board meeting, a governor became surprised when he realized that there were no members of the public in the board meeting. 

Governor: ‘surprisingly there are no members of the public in the meeting’. 

On other occasions, the governors as members of the public stated that it could be the timings of the board meetings which does not allow the public to attend the public board meetings or it could be the lack of interest of the public as well. However, this was a matter of concern for several boards. 

Governor: I just think, really may be the time…I mean they are held during the day. Obviously, those people at work and business are not able to attend, but (ahem) I think even at different times, I am not sure people that anyone will attend. It’s just (ah), doesn’t seem to grab the public interest. When I was in the forum we had meetings in public. If there was a burning issue, we would get a large number of people to turn up. Other time hardly anybody…and I think it’s the same.

This also infers that the public was seldom interested to attend public board meetings due to their simple function of reporting and because they did not think that the boards discuss important issues as such. 

Also, some of the NHS FT board meetings conversed in a low tone which created problems in understanding what they were discussing. It was interpreted as the public was excluded from the board meetings and the purpose of the public meeting was to report to the public, which became the main cause why the members of the public showed lack of interest in attending the board meetings.

Discussion and Conclusion

This study contributes to the current literature on public boards by providing an inside view of the purpose of public board meetings. It asserts that public meetings serve two important purposes: management of the reputation of the board members themselves and of the organization and disseminating information or reporting to the public, which questions the effectiveness of public involvement in the NHS public board meetings. However, despite the public’s interest in the NHS in the UK, the public seldom attends the board meetings. On the contrary, the public is usually interested in the Annual General Meetings, but this varies among trusts. Extant research shows that reputational risk is considered to be a major threat to the organizations (Murray, 2004). In business organizations, reputation is considered to be an intangible asset (Rokka, Karlsson, & Tienari, 2014). Managing the organization’s reputation ultimately lies on the board of directors, specifically the CEO of the organization, but is often put to risk in the corporate sector (Dowling, 2006). Similarly, the findings demonstrate that the board of directors in the NHS, specifically the CEO and the chairperson, were very keen and cautious about their public representation both at the individual and at the collective level as a board. 

The second finding shows that the public board meetings are formalized which excludes the public from active participation. The purpose of these meetings is merely reporting to the general public and the board members are engaged in impression management tactics to present an image of a rational and responsible actor.  Thus, the practice of board meetings is congruent to what Peck et al. (2004) and Hodges et al. (2004) suggests that board meetings are a ritualized practice that is followed by all the board meetings in all the NHS trusts that were studied. Future research should explore in-depth the way public voice is included in the board process as they are not allowed to engage in public board meetings.  

This study has practical implications both for the British NHS and all public organizations that have either undergone or are under the process of reforms. One main concern of reforms is to improve the public voice in the governance processes. This study can provide useful insights to all such public organizations all over the world on the challenges of including public voice in the governance process, the mechanism of incorporating these voices and the way it can influence board effectiveness. 

References

• Adams, B. (2004). Public Meetings and the Democratic Process. Public Administration Review, 64(1), 43-54.
• Allen, P. (2006). New localism in the English National Health Service: What is it for?Health policy, 79(2-3), 244- 252.
• Bell, C. 1997. Ritual: Perspectives and Dimensions. New York: Oxford University Press
• Bennett, B. (2002). The New Style Boards of Governors - Are They Working? Higher Education Quarterly, 56(3), 287-302.
• Clatworthy, M., Mellett, H., & Peel, M. (2000). Corporate Governance under 'New Public Management': an exemplification. Corporate Governance: An International Review, 8(2), 166-176.
• Dowling, G. (2006). Reputation risk: it is the board's ultimate responsibility. Journal of Business Strategy, 27(2), 59-68.
• Falzon, Mark-Anthony (2009) Multi-Sited Ethnography: Theory, Praxis and Locality in Contemporary Research. England: Ashgate Publishing Ltd
• Farrell, C. M. (2005). Governance in the UK Public Sector: the Involvement of the Governing Board. Public Administration, 83(1), 89-110
• Ferlie, E., FitzGerald, L., & Ashburner, L. (1996). Corporate governance in the post-1990 NHS: The role of the board. Public Money & Management, 16(2), 15-21.
• Freeman, T., & Peck, E. (2007). Performing governance: a partnership board dramaturgy. Public Administration, 85(4), 907-929.
• Freeman, T., Millar, R., Mannion, R., & Davies, H. (2016). Enacting corporate governance of healthcare safety and quality: a dramaturgy of hospital boards in England. Sociology of Health & Illness, 38(2), 233-251.
• Goffman, E. (1955). On Face-Work. Psychiatry, 18(3), 213-231.
• Goffman, E. (2017). Interaction ritual: Essays in face-to-face behavior. Routledge.
• Hajer, M. A. (2005). Setting the Stage:A Dramaturgy of Policy Deliberation. Administration & Society, 36(6), 624- 647.