NurturingTom, Dick and Harry

We talked about crisis teams, since he had come to the UK to set up and lead such a service.He believed in it, understood every detail, and converted me.His life and career are committed to delivering crisis services, and he enjoys travelling around the world to show how they work.

This contrasted starkly with a friend I had a drink with recently after ten years without contact.

Harry is a nurse I worked with.

He was then in his late twenties, and transformed a rambling collection of individuals into a cohesive and motivated team.His talent was recognised, so he was promoted to become a manager, first of community services, where he did well, and about two years ago to borough manager.

He is now bogged down in sorting out bed pressures, budgets and performance management. Apologetically, he told me he never received any management training.Harry would like to get back into clinical practice, but would have to spend a year on a revalidation course and lose at least£15,000 a year in salary. It is not always about glass ceilings: sometimes concrete floors are the problem.

Of course, there are different stories to tell.Another nurse friend of mine, Bill, remained in clinical practice despite alternative opportunities.He is now a team leader in his late forties, burnt out, hoping to attend a full-time course - not of much use to him - simply to get a year out.

These are sad examples of waste, personal and professional, and I believe avoidable.

I wonder why so many people believe that growth and promotion means leaving clinical practice behind and becoming a manager. This is accentuated by a hierarchy of management, invariably higher seniority and status associated with shedding specialist skills. It is even more perverse.Many charismatic leaders with unique expertise are appointed to jobs that require mainly transactional management, probably because they were the most interesting candidates.Yes, many can do the job, a few very well - but the loss to clinical care can be so much greater and, without adequate training, as with Harry, a waste.

Why people from a clinical background become managers is obvious: money and status.Very few clinicians earn£50,000, the lower end of a borough manager position. If one is a young clinician, ambitious and wanting a London house, the only way to go is into management.

Medics are the exception that proves the rule. They are reluctant to move into management, but then, they already earn more and enjoy a high status.Many doctors are respected clinical specialists, enjoying opportunities to develop clinical and academic interests internationally.How many nurses have been abroad for a conference, or have a contract allowing them a day a week for their academic interests?

I think that Bill, the burnt-out nurse, would have benefited from such opportunities.

If we want to establish effective specialist services - and mental healthcare, like healthcare as a whole, is increasingly specialising - we need to foster expertise.

Roles need to be created that encourage charismatic leaders to stay. I believed for a long time that such leaders were liabilities, since they tended to leave and services would collapse.

I am now convinced that the problem is not the charisma, but rather the services that cannot sustain their interest. The challenge is to identify, foster and inspire such people.Without them we will achieve little sparkle.

The Australian nurse is the example of a person seeding excellence and able to sustain it.

No need to become a general manager, he is esteemed for his experience, but I doubt he will stay for long in the UK unless we create further incentives.

The nurse consultant or modern matron might have been a way forward. But those positions seem to have become unfocused and part of the management ladder.

Maybe this can be reversed, so we can proffer status and a decent salary to the people on whom the service so heavily relies.

How can we nurture motivation and modernisation? Clinical networks could be crucial.

Networks drawing in the change agents from services such as crisis resolution or hospital care, possibly at strategic health authority level, could achieve a spiral of improvement.

Transformational leadership must be at the heart of it. Such jobs would be challenging, comparable in complexity to middlemanagement positions, and would require support and training.

This might be an ideal level of operation for the Modernisation Agency and the Leadership Centre, targeting the Harrys and Bills of this world and transforming them into the modernisers we so desperately need and they so desperately want to become.