The latest annual health check ratings raise some important and difficult questions. It is time to think again about performance management.

I was working at national level in 1997 when Alan Milburn strode into the Department of Health and established his reputation fast. I always give him as an example when I share my six ingredients in performance management.

Do health service organisations command the confidence of those they serve - patients and carers?

First, he was absolutely clear about his objectives - above all waiting times would be reduced. Second, he had commitment to delivery and the will to do it. Third, he drove the development of good quality information as evidence of progress. Fourth, he insisted on rigorous and effective monitoring and fifth, he had resilience and staying power.

The sixth ingredient is, of course, people - getting the best from our most important resource is the great task for leadership and management.

In the last 12 years waiting lists have been reduced and there has been progress in other areas that have been the focus of the performance management system.

When I share my six ingredients I talk most about the sixth. I have always believed that without it success would not be sustainable, and so it has proved.

Clarity, commitment, evidence, rigour and resilience will never be enough. To sustain performance improvement we must allow ourselves to think again about how we manage the managers and how we attempt to lead the leaders. Those who manage and aspire to lead need autonomy and control over how they deliver. They need to be appreciated and supported. They need to be listened to and valued.

Nothing is more disheartening than being bullied and harangued by people who may not have any idea how to do the job they are trying to performance manage.

I have no difficulty with the hard question management experts Warren Bennis and James O’Toole set for would-be leaders. It is right to ask “do you hold people accountable for their performance and promises?”

Everyone in a senior position in the public sector should be held accountable in this way. However, they also need to be managed and led in a way that motivates them to take control of their destinies and they need the freedom to serve their local population as they think best within the frameworks set by ministers.

It is also time to review the nature and extent of the targets for which the managers and leaders are held accountable. Would it be possible to reduce the performance regime to three simple questions?

First, is the health status of the people improving? This needs to be judged on a long term and interagency basis. Second, do health service organisations command the confidence of those they serve - patients and carers? Third, do they command the confidence of the people who work in them - the staff?

If we ask the right questions and think about the sixth ingredient there is a real chance that long term success will be within our grasp.