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The process for appointing senior roles in NHS hospitals and trusts in England should be reviewed, after figures showed boards have become less diverse.

Appointments of black, Asian and minority ethnic candidates (BAME) to non-executive positions have fallen over eight years, a report found.

The NHS Confederation, who published the report, called it 'a wake-up call'.

NHS England said the number of trusts with more than one BAME board member had increased.

The report found that the proportion of board chairs and non-executives from a BAME background recruited, or re-appointed, in 2017 was 8% of a total of 1,603, down from 12% of 1,190 in 2009.

The number of BAME appointments fell from 139 to 128 over the same period.

Joan Saddler, director of partnerships and equality at the NHS Confederation, said: "This report must be a wake-up call for a health service which is heading in the wrong direction and becoming less diverse at board level.

"That is not right for patients and staff working in NHS organisations."

Dame Donna Kinnair, chief executive of the Royal College of Nursing (RCN), said: "Nursing professionals bring skills, talents and experience from all backgrounds and walks of life - but many are starting to believe that equality of opportunity in the NHS is a myth.

"We still hear from our members that they are not consulted on clinical decisions or are passed over for promotion, and the only explanation appears to be their race or gender," she said.

"The way to prove to hard-working NHS staff that things are changing is to make way at the top and diversify the health service's boardrooms.

Ms Kinnair added: "As long as minority voices are grossly underrepresented in senior management positions, NHS leaders will struggle to convince staff that, like the RCN, they deplore all forms of sexism and discrimination."

The report argues there were two factors behind the slight fall in BAME appointments.

Firstly, the growth in the number of foundation trusts where non-executive appointments are not subject to the same level of official public scrutiny as before. These trusts were introduced in England in 2004.

Secondly, the abolition in 2012 of the NHS Appointments Commission - which used to oversee recruitment to a range of NHS public bodies - was a factor.

The Confederation has stated that the commission brought "a degree of rigour and consistency to the recruitment of senior leaders" and was never replaced, though NHS Improvement does "have some limited influence" over chair appointments.

Danielle Oum, chair of Walsall Healthcare NHS Trust and co-chair of the NHS Confederation's BME leadership network, said: "Diversity on boards is important for diversity of thought - it's particularly key for the NHS due to the make-up of its workforce and the population it serves."

The report comes at an awkward time for NHS England, which launched its long-term plan in January, including a pledge that "action will be taken to support diversity and a culture of respect and fair treatment".

But Yvonne Coghill, director of workforce race equality standard implementation at NHS England, said there had been an increase in the number of trusts with more than one BAME board member.

"A new model employer strategy is providing further intensive support to improve diversity at all levels of local NHS organisations," she added.