Published: 24/03/2005, Volume II5, No. 5947 Page 17

Everyone is knee deep in contract negotiations and budget trade-offs.

It is all rather tense. Yet most of us came into health service management through conviction. Of course, our ability to do good is more indirect than the individual clinician's. Our typical week involves fewer instant moral choices than in the typical ER episode. But the impact of effective management on patients' experience and clinical outcomes can be profound.

Ex-ICI boss Sir John Harvey-Jones once argued that the Victorians would have erected public statues of NHS managers to celebrate their civic commitment, a consoling thought as election-driven manager bashing hots up.

The flipside is that the power to act creates responsibility for not doing so. Of course, there are constraints: cash; time; inertia. But sometimes the job of the NHS manager is to cut through the crap and say enough is enough. To decide:

this situation in my hospital or my primary care trust has got to change, this year.

Take patient safety. We know that (thanks largely to chief medical officer Professor Sir Liam Donaldson) the NHS is doing more than most other countries. Yet the National Patient Safety Agency estimates that around 500,000 inpatients every year are victims of avoidable errors, to use the non-politically correct term.

Or another example: stroke services. There is now very clear evidence, from the stroke unit triallists collaboration and elsewhere, that patients are avoidably harmed if they are not treated in a specialist stroke unit - regardless of age, sex or stroke severity. So we can be pleased that 82-90 per cent of acute hospitals now have a stroke unit.

But according to the Royal College of Physicians, on a typical weekday only just over half of stroke inpatients are actually being cared for in a stroke unit. This despite the fact that stroke is not just 'another condition': one in four of us aged over 45 will have one. It is the third biggest killer.

As Ian Dalton, chief executive of Warrington Hospital, pointed out in relation to the battle for Margaret Dixon's shoulder, a correctly specified tariff has the potential under payment by results to reward hospitals for getting the clinically appropriate service models in place (news, page 9, 10 March). And rigorous oversight of clinical process standards by the Healthcare Commission will help.

In the meantime, the management challenge is, as always, to keep a double perspective: to think about populations, opportunity costs and lives measured by public health statistics.

But also to see our own service as others experience it, one patient at a time. And therefore always to ask - like US healthcare journalist and Pulitzer Prize winner Michael Millenson - why accept second best?

Does second best seem good enough, asks Millenson, 'because declaring that a specific hospital is dangerous would anger powerful interest groups?'.

'Is it because those who work in healthcare are caring people, so there is something unseemly about giving them an ultimatum? Is it because an ultimatum would impose a difficult financial burden?

'All of these factors are true today, were true last year, and will be true next year. Yet suppose that an airline's managers and pilots repeatedly resisted installing collision avoidance systems despite solid evidence of their worth.

Suppose, too, that they complained that the radar was not reimbursed adequately, required inconvenient retraining, provided no competitive advantage in attracting passengers... and was an insult to pilot judgement.

'No-one would blithely blame 'airline culture' for an ensuing disaster, and no-one would absolve individual pilots and managers of responsibility for that disaster simply because they never intended for passengers to be harmed.'

(Airlines now manage an amazingly low .0076 accidents per million miles flown. ) Perhaps Millenson is overly simplistic. But perhaps he also reminds us that the most visionary NHS managers have always sought to generate momentum for change, despite the reality of tight resources and awkward choices.

Interestingly, as Stephen Eames argued (Feedback, page 20, 10 March) mental health managers have often excelled at this. Certainly, I would class my former boss Dave Anderson, the retired former chief executive of the mental health services in North Tyneside and Northumberland, as one of the most user-focused NHS managers I have ever come across.

Dave - ex paratrooper as he was - first and foremost saw institutional psychiatric care from the perspective of service users, and did not like what he saw. With compassion and steel he used those insights to drive organisational improvement from the moral high ground.

What is it about mental health that has allowed some managers to set progressive agendas? Perhaps it is that the mental health user movement is stronger than in many other clinical areas.

Perhaps It is that psychiatrists are less powerful than medical consultants - or better team players.

Whatever the reason, this is what NHS management has to be about.

If clinical governance means anything, it means being willing - and able - to take a stand.

Over the next three years, NHS managers will direct increases in health service spending from£69bn to£92bn. Yet at this time of year It is easy to forget that managers' greatest potential impact comes from the power to mobilise staff commitment, and generate energy for change.

That is the role Roy Griffiths envisaged when he advocated general management across the NHS. Easy to say, harder to do.

Critical, nonetheless.

Simon Stevens is president of UnitedHealth Europe. From 19972004 he was the government's health policy adviser at 10 Downing Street and the Department of Health.