The chief executive of one of the six no-star trusts put on three months 'probation' in late September remains off sick since taking leave six days after the ratings were announced.

Dartford and Gravesham trust's Anne-Marie Dean has been absent since 1 October. HSJ sources say a combination of 'intense and quite outrageous' anti-management coverage from some local media - including a local newspaper's ballot on whether Ms Dean should resign - followed by the publication of the star-ratings, may have heaped too much pressure on the chief executive.

The trust was awarded no stars because it missed core targets on financial performance and outpatient waiting. It also missed targets on deaths in hospital, outpatient waiting times, consultant vacancies and sickness rates.

Half of the no-star trusts have been given three months to turn around services - a period due to end on Christmas day - after which, if action plans are deemed unacceptable, chief executives will be removed.

NHS Confederation policy director Nigel Edwards said performance management should be part of a 'continuous process' and suggested the trust should have received earlier support from external bodies.

He said the current threat hanging over chief executives on probation was a long way from good employment practice.

'If you treated members of staff the way they are treating senior managers they would take you to the cleaners at a tribunal, ' he said, suggesting that if managers were thought to be failing, good employment practice would mean earlier interventions and support.

Mr Edwards said public sector management did not offer rewards to match the pressure on chief executives: 'The rewards in relation to the risk are not great compared to the rest of the industry, where they would also have great compensation payouts for chief executives who ended up in a similar situation.'

Ms Dean, who has worked for the NHS in Dartford for 24 years, saw through the flagship Darent Valley Hospital, which opened last year.

The private finance initiative scheme was the subject of a National Audit Office report which expressed concern over a£12m miscalculation in savings. The closure of three hospitals and the movement of services into the new building, which had 50 fewer beds, all happened during the period covered by the star-ratings.

Trust chair Sarah Dunnett said trust managers were working hard in conjunction with those in the rest of the health economy, and had already made good progress on a number of key targets, including outpatients, where they expected to meet performance criteria.

Refusing to comment on Ms Dean's absence, she said there was a lot of loyalty within the trust to the chief executive: 'She has been here 24 years. She has done a fantastic job in completing the hospital building, and she is held here with high regard and with fondness.'

Local sources said media speculation on Ms Dean's future could only have increased the pressure on management. Interviewed by HSJ on the week the ratings came out, Ms Dean admitted she had considered her position.

A South East region spokesperson said the trust was planning a visit from the Winter Emergency Strategic Team 'in the near future, ' had been subject to regular visits from regional office, with a visit from the National Patients Access Team and the Modernisation Agency yet to be scheduled.