Published: 14/04/2005, Volume II5, No. 5951 Page 38

If some Moroccan shepherds and farmers were wondering about the competency of this particular NHS manager, I had no such doubts about them.

Having emerged from what seemed like nowhere, they first tried to dig out and then successfully towed my desertunsuitable car from a ditch on a half-built track. Fortunately, one of them took on the manager's role to organise these saviours and put my holiday back on track.

The Battle of Margaret's Shoulder has brought into sharp focus the debate about the commitment and quality of frontline staff in the NHS. Both parties - and the patient herself - have declared that all frontline staff are, in fact, fantastic, dedicated, hard-working and skilled.

But the battle has also refreshed longstanding perceptions about the value and competency of managers. Antagonism towards us unites every Question Time audience. Loud applause endorses anyone declaring the end to those enemies of patient care: managers and bureaucrats.

This is quite some change from the days when investment in frontline pay - and even maintaining staffing levels - were considered by many to be at the expense of patient care.

Annual public sector staffing levels dropped for seven years from 1991. But since the late 1990s they have increased by 600,000, and with that the pressure on middle managers has grown.

They have to contend with a conundrum. The top of the organisation expects them to deliver speed and compliance on all corporate objectives with pinpoint accuracy. However, frontline staff see their managers as there to do battle solely on their behalf. This paradox is essential experience for all future corporate leaders.

Matters are made worse by the widely held public view that operations would not be cancelled, even the 31 per cent cancelled by patients themselves, if only managers and bureaucrats would get out of the way.

Forests have been felled in analysing how best to reduce the level of bureaucracy. National organisations are disappearing, merging and integrating in pursuit of this goal. Widely welcomed, except by the middle managers squeezed out in the squash.

NHS employers must identify their leaders - from ward sister to human resources manager to chief executive - as a key development group. The leadership of my trust is made up of 400 such line managers, many with substantial clinical commitments. It is up to this group to show how they can benefit patient care and improve the reputation of managers in the face of all this criticism. After all, without managers the NHS would collectively be stuck in a ditch.

David Amos is director of workforce at University College London Hospitals foundation trust and former Department of Health deputy director of HR.