Too many new policies, a lack of coherent strategy and invasive performance management are creating 'pathological' levels of stress among NHS middle managers, an NHS Confederation report has warned.

Too many new policies, a lack of coherent strategy and invasive performance management are creating 'pathological' levels of stress among NHS middle managers, an NHS Confederation report has warned.

The study, produced after six months of group discussions and interviews with members working at all levels, says managers have fallen victim to 'a plethora of plans, but a shortage of strategy'.

While all the policies are important, they are no substitute for a strategy that sets a direction and addresses how clinical services will change and develop, it warns.

The current regime encourages boards and managers to spend time 'firefighting and chasing targets rather than developing long-term plans', the report claims. 'Scarce managers are pulled in multiple directions by all the unconnected demands placed upon them. This can lead to some of the governance problems witnessed recently, as well as to a level of reported stress in middle managers that is pathological'.

The report's findings were supported by a separate poll of 200 chief executives, which said the development of high-quality strategies for the development of clinical services was the most important challenge for the coming year, with the need to strengthen commissioning a close second.

Report author Nigel Edwards said managers needed to be given room to produce coherent strategies, as well as to push forward clinical development: 'Both are necessary; one won't do without the other,' he said. 'It's not that no-one is doing either at the moment, but managers have not been able to do enough of both because they are too busy looking upwards.'

The report identifies the 'conundrum of competition versus collaboration' as the largest unresolved policy question, and cautions against leaving decisions to market forces.

It goes on: 'In many health communities, if there is not a shared approach to the development of strategy and each organisation pursues what appears to be its own best interest the results could be disastrous.

'The only solution to some of the hardest challenges will be through reconfiguration that cannot be achieved through the operation of market forces. A plan will be required, along with some very mature behaviour and significant courage at every level, including the political.'

Mr Edwards warned that large parts of the service could slip into 'chaos and meltdown' if competition was allowed to run unchecked.

The report urges strategic health authorities and the Department of Health to to find new ways of working which allow trusts and PCTs to operate independently and with confidence. Loosening the grip from the centre is vital for the success of strengthened commissioning, via practice-based commissioning, it says.

'Managers need support from the centre - &Quot;political air cover&Quot; - rather than an atmosphere in which one mistake can spell the end of a career,' said South Staffordshire Health foundation trust chief executive Mike Cooke in the report.

One PCT finance director with a history of 15 years of break-even or surplus budgets said: 'We have to stop the culture of bullying, performance management by shouting and telling people to just do it. Some hard questions need to be asked about where this sort of behaviour comes from and why it is tolerated.'