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My Trust claims to be clinically lead but in many ways we have the worst of all worlds. We have unclear accountability ( the managers are still the only whipping boys for budget and CIP failure), most clinicians don't want to be engaged other than where it directly affects their reputation or pay packet, Medics don't see a wider Trust responsibility to manage scarce resources, clinical leaders are asked to run a division on a couple of PAs and the consultant job plan is still regarded as the one staff resource area which cannot be openly challenged. Despite the fact that clinical directors have the authority to lead the business units and the services, they do not generally have the top level general management or people skills required to negotiate, compromise, communicate and understand financial or HR issues. I have built up these skills over many years practicing as a career general manager across a number of sectors. Why would we assume that a medic - however bright - can pick all this up on a quick course and then run a multi million pound business in financial difficulty? Does this smack of medical arrogance? The best clinical leaders tend to have a long career behind them with the experience at least of leading a clinical team. They work cooperatively with a profesional manager who actually takes responsibility in effect for the overall management. However, these experienced clinicians often lack the enthusiasm to take on the very difficult management tasks in today's environment and don't want to end their careers with a reputation for fighting the entrenched interests of their peers, BMA and nursing managers- all of which are part of the job description. Our younger clinicians are often very bright and motivated but lack the management skills and the attitude for inspiring people and effectively resolving conflict. They quickly discover that peer conflict can limit their clinical careers. Some of them see the clinical director role as a chore which is passed to them for a few years after which they will return to more clinical roles among their peers. Unsuprisingly they show little courage and aptitude to challenge among the group they are planning to return to. Pathway change is often blocked or delayed by clinicians squabbling between themselves with failure of top level clinical intervention. Resource decisions are botched where quality general managers are not involved. Of course we have to work together as to survive in this climate but beware the assumption that putting medics right at the helm is usually the answer. We need the right leadershiop qualities at the helm and the courage to swiftly replace those who are not performing - whatever their background.