NHS chief executives should play dirty and learn political advocacy so that they could manage upwards as well as downwards, said Labour peer Baroness Young, chair of English Nature and former IHSM president.

'You need a collective voice in the quiet corridors of power. It doesn't need to be public, but it needs to be constantly there and respected where decisions are made,' she told the forum.

'You might have to play games every now and then. Negotiate some space. Deliver enough of the national agenda so they think you're OK while abandoning a lot of what doesn't chime locally. Don't let anyone else determine your agenda.'

NHS chief executives were the 'market leaders in UK management'. If you decide something is going to happen, it will happen. Not them. The power is with you.'

NHS Confederation chief executive Stephen Thornton pleaded for chief executives to support his organisation in return for representing their interests to government.

He wanted them to persuade their chairs and non-executives that the membership fee was a 'legitimate use of NHS resources'.

Competition to influence health policy was intense, he said, with the British Medical Association and Royal College of Nursing 'way ahead of us - we will struggle if we're going to catch up.'