Being a T-shaped director

The advent of advanced foundation trusts reminds principal consultant Joanna Watson of a useful concept for any board. 

In November 2025 the Health and Social Care Secretary announced the new advanced foundation trust (AFT) designation, giving trusts greater autonomy and financial flexibility. 

NHS England has published a guide for applicants, and much has been written about AFTs since then, including here at GGi - such as this article by our CEO Professor Andrew Corbett-Nolan.

AFTs are an evolution of foundation trusts, which were themselves first announced by the then Health Secretary, Alan Milburn, in 2002, with the first ten authorised in 2004. Reading the 2025 AFT guidance has reminded me of the process for being authorised as an NHS Foundation Trust back in the 2000s, which included the Department of Health, independent due diligence and an assessment process by Monitor. 

Much has changed in the past 20 years, not least the increased focus on the importance of quality governance. One part of the process which is common to both AFTs and the original FT authorisation process is the need for a board-to-board, which for AFTs is described as a “‘board-to-board’ meeting between applicant board and senior NHS England and Department of Health and Social Care (DHSC) leadership.”

Back in the 2000s, briefings for NHS boards applying to become foundation trusts included referring to the need to be ‘T-shaped directors’. I’ve used this illustration many times since – it’s relevant not just to unitary boards, but to any board member, on any board, in any sector.

In the NHS it’s clearly set out in the insightful provider board guidance:

‘All board members should have sufficient understanding of issues and risks across all aspects of the trust’s operations to make decisions and ensure there is a culture which supports open debate.’

That’s about being T-shaped. 

Stem and arm

In typography, the vertical of a capital T is called the stem. In being a T-shaped director, each director brings their professional expertise and their experience to the organisation. So it is likely that a non-executive director with a background in HR will chair a people committee, and it’s expected that there is at least one member of the audit committee who has ‘recent and relevant financial experience’ (HM Treasury audit and risk assurance committee handbook and also in the NHS audit committee handbook published by HFMA). In discussion at the board about a cost improvement programme, the clinicians on the board are likely to be asking questions about the impact of cost reduction on the quality of patient care and the safety of patients. Every member of a board brings their expertise to the discussion, debate and decision-making. 

The other part of a capital T is the horizontal line at the top, which is called the arm. It stretches the full width of the letter, and in the same way all directors – executive and non-executive – need to stretch across the organisation. 

This is about being professionally curious, not just in board meetings but outside them, so as to have a broad understanding across the whole of the organisation. Developing this understanding includes seeking opportunities to engage with the organisation in different ways – joining ward/site visits, attending events, and meeting with senior leaders outside formal meetings – so that directors come to board and committee meetings with insight that they can use to triangulate with what they read in papers and hear in presentations and discussion at meetings.

Boards made up of T‑shaped directors are generally more resilient, more insightful and better equipped to steward organisations.

Practical application

What does this mean in practice? It means that a director who has a clinical background is comfortable talking about the trust’s financial performance and that a qualified accountant on the board knows what the main challenges are in delivering safe care. It’s only to be expected that this is easier for the executive directors, who work full-time in the organisation and will meet regularly as a group. While it is more of a challenge for non-executive directors, it is important that they have an interest in all areas of the trust, not just the one where they have expertise and experience.

I have focused here on the NHS, but the concept of a T-shaped director applies on any board. Board members need to bring not just their professional skills and experience to the table, but also their professional curiosity – asking questions, listening carefully, triangulating information, and using supportive challenge – so that there is high-quality debate in meetings and sound decision-making.

How do you know if you’re successful? Here are some ways in which you can get feedback, either as an individual or as a board:

• Reflection at the end of each meeting, which could include sharing views on the quality of the discussion
• Individual board member appraisal, including the extent of individual directors' engagement outside meetings, and the extent to which they contribute at meetings on all topics – not just their own areas of expertise
• Independent observation of the board and its committees, as part of a developmental well-led review (in the NHS) or a board effectiveness or governance review, will provide expert insight as to the depth and breadth of directors’ contributions.

And last but not least, it’s a helpful tool to use in self-reflection after a meeting – why not ask yourself after a meeting you’ve attended, have I been a T-shaped director today?