Chief executives have become a 'socially excluded minority', frozen out of policy-making and subject to rigid command and control from the centre.
Two hundred of them from trusts and health authorities met in York last week for the second NHS chief executives' annual forum, and the first since the government launched its reforms in The New NHS white paper.
They were eager to explore ways to re-assert their influence. And they were struck by the irony that though they shared this government's values and aspirations far more than the previous one's, they felt ministers distrusted them.
'Policy-makers at the centre see particularly early-wave trust chief executives as the problem, not the solution,' said one.
They were suspected of having 'internal market mindsets'. As a result, they were left out of policy-making - and so was the NHS Executive.
'The Tories knew a lot of senior people in the NHS. The new government must have had doubts whether we would perform the same way for them. If they had thought deeply and logically, they would realise people would try even harder for a Labour government,' another observed.
Because of this distrust, politics was now overtly driving management through command-and-control performance management which curtailed managers' initiative and overloaded them with guidance: in the 13 weeks before Christmas, 13 major pieces of guidance were scheduled to be sent to chief executives.
'We're being told how to do it and how to behave in a way we haven't before. It's very patronising.'
The waiting list initiative was a 'classic example'. Managers knew that cutting lists was the wrong target, but had to obey 'an absolute diktat that we must achieve it or else'. A minister had even admitted the target was wrong, 'but it was in the manifesto'.
One chief executive argued: 'Waiting lists are a testing zone for managers. If we deliver this they will begin to trust us.'
Despite their support for the government's vision for the service, the sense of being distrusted was contributing to inertia and lack of enthusiasm for the reforms. 'It's not grabbing us.'
The pace and scale of change was partly to blame - and it was impossible to see how the vision and the policies joined up.
'We're fighting on too many fronts, so our efforts are weak and inadequate in many areas.'
Some were angry that health secretary Frank Dobson chose to write to each member of staff as part of the policy of involving them in the way the NHS develops, instead of accepting that managers can deliver the message.
One said: 'I see politicians speaking values that I share, but actually implementing it in ways I despise. The way they are going about it is totally wrong.'
This was such a common theme that one chief executive said he thought he had come to 'depression city' and was thinking of leaving. 'I can get that at our house,' he said.
Some contrasted this with the elation they had initially felt with the internal market reforms. But others warned that they should not be seen as Cassandras, 'moaning and whinging and hankering after a past age of independence.'
They had to find a way to win ministers' confidence and be part of the change rather than simply be told how to do it. 'We need a clear idea how we can put ourselves in a position to talk to ministers more coherently than we have done so far'. Currently, managers did not 'figure in ministerial thinking'.
Someone suggested drawing up a 'York statement' since a quarter of the senior managers in the NHS were gathered there, declaring to Mr Dobson something on the lines of 'we want to help you but we don't know how to and we want to be part of the process'.
Founding a new organisation for chief executives failed to gather much support. But so too did the existing representative organisations.
The Institute of Health Services Management had 'the wrong image with the current regime and can't influence them'. It was 'dead in the water' despite its merger plans.
The NHS Confederation was 'spineless and sycophantic' and had not influenced the government 'one jot or tittle in the last year'.
Meanwhile the professions - particularly general practice were striding ahead. Yet the NHS was becoming 'increasingly a managed service', so managers themselves were becoming 'absolutely pivotal to it'.
Not everyone shared the general gloom. An older chief executive with a clinical background said as individuals they exerted enormous power if only they used it.
And a younger one wanted to know what the problem was when chief executives have exciting, well paid jobs that they have chosen to do.
Give and take
Chief executives confessed they were still struggling to get to grips with joint working.
It meant 'giving up something' which could cause problems, particularly when local authority representatives did not have the same freedom to make decisions because they have to return to their political bosses.
'You have to be careful about not giving away too much and not getting something back,' one chief executive said. 'Sometimes they come back and say they can't deliver something they said they would do.'
A health authority chief executive observed 'It is hard not to be in charge of everything.'
But he admitted that NHS managers 'are not as tuned as we might be to the political process', partly because their exposure to it is limited until they find themselves in the top jobs.
But it could be a positive experience. One chief executive said political changes over the last 12 to 18 months had led to 'a massive upsurge of action with a commitment to make it work'.