The quality of managers is the biggest potential barrier to creating a world-leading health service, the chief executive of the NHS has warned.

David Nicholson proposed a Royal College of Medical Management to prepare more clinical leaders for management posts.

Speaking at the NHS Employers conference in Birmingham last week, Mr Nicholson said the NHS had to nurture managers' talent and increase their diversity.

A 'significant number of big chief executive posts' in the past few years had failed to attract a single applicant, Mr Nicholson told an audience largely consisting of workforce directors and human resources staff.

He said more training was needed to support NHS staff considering taking on senior positions. 'The biggest obstacle to driving changes forward will be the quality of people in leadership and management positions,' he said.

'It's increasingly difficult to fill the top jobs. People don't feel equipped to do them. Leaving it open to markets simply won't happen. With a much more diverse group of people taking the most senior positions the quality of our work and services will improve.'

More clinical leaders would bring Britain into line with the rest of the developed world. Setting up a Royal College of Medical Management could help to bring this about, he said.

But union Managers in Partnership chief executive Jon Restell said if Mr Nicholson wanted more people to go for senior management jobs he needed to make it worth their while. 'The most talented medical managers are looking at director-level jobs and saying: "Is it worth it?"'

He said boards were encouraged to pin the blame on senior managers when things went wrong. 'People are keeping their heads below the parapet. We need open and robust procedures to deal with perceptions of poor performance.' Mr Restell called on the government to review how directors are accountable to boards for poor performance.

He agreed that better diversity practices would widen the talent pool and warned against the use of headhunter firms, whose diversity policies might not be as robust.

Health secretary Alan Johnson took up the theme of talent-spotting in the NHS in his speech to the conference.

Strategic health authorities had a role to play in making sure that the best staff were recruited and retained, he said.

The latest staff survey had shown that 'job satisfaction and morale are a real concern', he added.