Karen Caines had everything you might look for in an IHSM director: a razor-sharp intellect, inside knowledge of the workings of government at its highest levels from her time as a Department of Health civil servant and experience as a senior NHS manager.

On paper, the only qualification she appeared to lack was membership of the IHSM itself. Certainly, its famously optimistic published membership lists for 1994 and 1995 do not include the former trust chief executive's name.

Appointed in April 1996, she set to work with gusto, continuing a process which started when the extent of the IHSM's financial problems became clear, by cutting back on staff and contracting out what had been core work.

Under Ms Caines, the IHSM was to shed the quasi-trade union approach it had developed under Ray Rowden and concentrate on policy, professional development and professional standards.

But Ms Caines was a controversial figure - perhaps inevitably as a strong-minded character in a high-profile job.

Few members knew that her contract allowed some weeks away from the job on top of her annual leave to continue consultancy work she had with the Brazilian government.

When they found out, there were murmurings. And what had once looked like assets in her background came to be seen, especially after the change of government, as liabilities.

In a Commons debate last March, health secretary Frank Dobson declared that she and Eric Caines 'were the principal architects of the lunatic system for organising the NHS that we inherited from the Tories'. Ms Caines also had a penchant for calling on friends from the early days of the Tory reforms to help out at the IHSM. The same people tended to be 'associates' at the academic centre run by her husband.

And there was criticism of the IHSM council's decision to bump up her£66,950 basic salary for 1997 with a performance-related bonus of£13,390 just as the institute was once again in financial difficulties.

Ms Caines has been stoutly defended by successive chairs and presidents, but is sensitive to criticism from members and what she describes as 'the steady, drip, drip of poison, week after week' about her and the IHSM.

If she has done nothing else, she has at least ensured debate about the long-hours culture of NHS management. Having left Heatherwood and Wexham Park Hospitals trust citing the difficulty of fitting in the 'modest pleasures' of life with an 80-hour week, she now leaves the IHSM in similar fashion.