Dysfunctional boards, power games and cover-ups - there were as many issues as opinions at a seminar on performance, writes Paul Stephenson

When it comes to success and failure in the NHS, it seems that managers are much better at defining what went wrong, and why it went wrong, than defining what constitutes achievement.

When the question, 'what is success?' was put to a seminar of leading managers from the NHS and the private sector last week, it was met with a resounding silence. The seminar, the second in phase two of the Bristol Royal Infirmary inquiry to look at the performance of organisations, seemed to reach a good deal of consensus, despite problems over basic issues such as who runs the NHS and what sort of organisation it is.

NHS Confederation chief executive Stephen Thornton asked: 'I don't think we have even clarified what business we are in - are we in the healthcare business?'

Participants were reluctant to debate that point. Instead there was a great deal of discussion about whether it is politicians, chief executives or clinicians who run the organisation, and a lot of consensus around the important role of the chief executive and the board. Few participants even mentioned patients.

The medical director of Birmingham Heartlands and Solihull trust, Dr Rowland Hopkinson, said that it was clear from visiting trusts in the West Midlands that the 'quality of the chief executive is important'.

Professor Andrew Pettigrew of Warwick University's business school said it was also clear that 'problems start at the board', just as 'a fish starts rotting from the head'. He said:

'In a study of 500 boards, the critical point was, does the board want to give legitimacy to nonexecutive directors?'

Mr Thornton said one of the problems was that nonexecutive directors were not trained. He said that although for boards 'a critical role is to take the wider community into account', many 'have a reluctance to engage in some issues'. He said they would tend to say something was all right if doctors said it was all right.

Dorset health authority chief executive Ian Carruthers agreed: 'Boards take the view that they are there to placate professional groups. The person who stands out is often perceived as a problem.'

East Sussex, Brighton and Hove health authority chief executive Alan Bedford pointed out: 'Nobody monitors or supervises boards. If they become dysfunctional, nobody knows.'

Although leadership from the top was seen as a priority, delegates agreed that close collaboration between managers and clinical staff and effective teamwork were also important.

Aston University business school's Professor Michael West said: 'The people who work in the NHS are under profoundly more stress than in other public sector organisations.' But simple answers like 'getting doctors and managers to meet' made a big difference, while people who worked in teams 'have much better mental health'.

Bob Ricketts, director of performance management at the NHS Executive South East regional office, said that when there was talk of clinicians meeting managers, that ' needs to include nurses'.

Professor Peter Smith of York University's centre for health economics said that while junior doctors did not have much to say about their work, and seemed to take their lead from more senior doctors, frontline nurses had an acute awareness of problems. He added: 'If we are talking about teamwork, there is a long way to go.'

The unique nature of the NHS was also discussed at length. Mr Bedford identified three areas as special. 'One is the incredible complexity. Second is the way that leaders have to operate in an extremely political atmosphere. Third is the existence of very powerful tribes - for example, clinicians.'

The issue of being able to raise problems without fear of being attacked, and of accepting information, no matter where it came from, was also a serious matter.

Mr Thornton described how a scribbled letter had once hurriedly been handed to him in a car park, which, it later turned out, contained details about a scandal involving nurses' overtime. At the time, he had ignored it, because he hadn't taken it seriously.

Woolwich plc executive director Julie Baddeley said: 'If there is one single thing we need to change, it is the fear of punishment for failure.'

The limitations of league tables were described by Professor Ian Sinclair, codirector of York University's social work research and development unit. He said that a study of the top and bottom ends of a league table of maternity units had shown that those at the high end of performance had nice accommodation and were in good areas, while those at the bottom were in deprived areas, had poor facilities and the managers had changed.

Professor Smith said a York University study of eight trusts had found that 'the trusts perceived to be performing well were those with a good relationship' with their NHS Executive regional office. They were 'deemed to be performing well because they were not causing trouble'.

King's Fund research fellow Dr Jennifer Dixon described how she toured the NHS 18 months ago asking for possible solutions.

She found that managers wanted to know how they could find out where good work had been done, and how problems had been cracked.

As a result, the King's Fund had set up an NHS learning fund to access such information, and some clinical team swapping had been arranged, including 'buddying' a failing trust.

The inquiry is set to hold five more seminars on management performance over the next three months, before drawing up its recommendations for health secretary Alan Milburn.