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Raised blood sugar levels turned out to be the key to success for the winners of the HSJ Management Challenge simulation. Laura Donnelly lived through a day of intellectual and emotional exhaustion

Some came armed with in-trays and vision statements. Others brought bumper packs of sweets. But for those who hadn't planned tactics, the series of crises which followed may have come as a bit of a shock.

A spiralling deficit; a non-executive with wandering hands; a psychiatric ward ablaze; 'alarming results' on millennium compliance; demands for an investigation into poor quality of care; local GPs determined to get their hands on Viagra. All this and it wasn't yet lunch time at the HSJ Management Challenge, a one-day simulation run with Birmingham University's health services management centre aimed at enabling rising management stars to try their hands at running the NHS.

The one-day event saw 36 teams battle to develop strategies for their local health economies - one health authority, one recently merged acute trust, one primary care group (complete with tensions) and a community trust.

From the din and laughter in a packed room at Birmingham's botanical gardens, an observer could have been forgiven for thinking the teams of six - five players and one observer - were enjoying themselves. They were. But laughter can be misleading.

It was hard to distinguish between the nervous titters as teams took their first shaky steps, the dull groan following the latest knock-back from regional office, and the hint of hysteria when a hefty deficit turned up 'out of the blue'.

Players' abilities to work together, prioritise, develop strategy, manage change, work collaboratively and manage communi- cations and public relations were all under examination.

And by the end of the day, assessors - who had taken on a dual role as regional office directors - were impressed by the innovation, collaboration and robust thinking they had witnessed.

Claire Perry, chief executive of Bromley HA, assessed a cluster of four teams - which included 'outstanding performance' winners West Hertfordshire HA.

She praised the 'absolutely radical solutions' put forward by the cluster, which included plans to hand over the management of all paediatric services to a primary care trust created from a merger of PCGs with the community trust.

Ms Perry said: 'They have been coming up with ideas which haven't been tried, and they have got robust financial strategies to back them up.'

Anne Walker, West Hertfordshire director of commissioning (acute services), suggested one of the key lessons of the day was the value of perseverance.

She said: 'Partnership can be hard work. You have to be prepared to work at difference paces with different people. And you have got to work all the time at fostering relationships.'

So what gave West Hertfordshire the edge?

Ms Walker came clean on rumours that the team's performance had been chemically enhanced. 'We had to keep our sugar levels up. One member of our team brought copious amounts of sweets and chocolates,' she confessed.

Ms Walker suggested the team may have had another advantage in taking on the role of an acute trust - its members' HA background 'with experience of looking at the whole picture'.

The converse problem - the difficulties faced by teams taking on the role of a HA - was a key issue picked out by many assessors. Ms Perry described feedback on the subject as 'absolutely astonishing'.

'They told me - 'We hadn't realised what a difficult job HAs do.''

Ken Jarrold, chief executive of County Durham HA, was another assessor who believed the simulation flagged up a 'lack of understanding about what an HA actually does', and this echoed a 'real problem across the NHS'.

He suggested that the internal market's emphasis on fundholders and trusts had created a 'lack of strategic leadership' among HAs, now struggling to redefine their role.

And he urged a 'higher priority to be given to the role of HAs' in real life, and increased efforts to attract the best managers into them.

'We have got some good HAs - but there are not enough of them,' he added, stressing that the salaries paid to HA chief executives did not match those of their trust colleagues.

North Staffordshire Hospital trust chief executive David Fillingham said the day demonstrated the need for broader management career development across the health economy.

'Just as in medical training, where doctors are rostered to work in different places, managers should have experience of working in PCGs and HAs, as well as trusts,' he said.

Watching managers take on the role of the HA was 'a fascinating process', though sometimes 'there was a tendency to enter the realms of caricature,' he added.

Pam Charlwood, chief executive of Avon HA, was impressed by the collaboration within the cluster of teams she assessed. 'They began working together almost immediately - operating as one local health economy.

'What we found interesting was the discussions that followed - why was it so easy this time - and what are the things that make it so much more difficult in the real world?'

Ms Charlwood said the 'apolitical environment' of a simulation flagged up real life obstacles such as 'the attitude of the public whose views may not be so pristine and rational and pure as ours.

'It's that kind of political awareness that makes the difference between a very good manager and a top manager.'

She suggested 'bringing in a few awkward blighters - pressure groups and local councillors' could up the ante and make future simulations more realistic.

Like many assessors, Ms Charlwood was impressed by the ability of teams to distinguish between the 'urgent and the transient', refusing to be distracted from their strategic aims by the latest scare. But she stressed that life's not always like that.

'In real life, when you get the call from regional office, who have just had a call from Downing Street, sometimes you just have to deal with it, regardless of its place in the wider scheme,' she said.

That apart, it was the authenticity of the simulation that struck teams and assessors alike.

Peter Homa, assessor, waiting- list buster and president of the Institute of Health Services Management, praised the balance between strategy and everyday operational pressures in the situations thrust on the teams.

One team member described the simulation as 'horribly realistic'. But strides made over the course of a few hours gave 'a real sense of optimism' about tackling similar pressures back home.

One 'tired but happy' manager confided: 'We knew this was going to be hard work - but nobody said it would be fun.'