With chief executives running around in circles trying to meet the demands of the modernisation agenda, no wonder so many posts go unfilled. Laura Donnelly takes a reading of the top people's gloomometer

'Who'd be a trust chief exec?

It is a really tough job, and getting harder. The government is placing more and more personal responsibility on them to meet a massive range of targets.'

This rather depressing description of life at the top of a trust came from one source who - not surprisingly - asked not to be named. He went on: 'Health authorities have a much lower profile, but then the future is uncertain: the smart money is on primary care trusts.'

HSJ surveyed the field to test the mood of senior managers, six months on from the launch of the NHS plan. Most were slightly more optimistic.

But tense relations with chairs and non-executive directors were the least of the worries described by chief executives beginning to feel the weight of demands placed on them by the modernisation agenda.

The wave of enthusiasm that greeted the plan appears to have passed. Managers are still happy with the principles enshrined in it, the government's commitment to the NHS and increasing spend.

But there are reports that trust chief executives are increasingly fearful of a performance agenda that means 'we are being held to account more than ever'.

A recent incident reflected this growing mistrust. The NHS plan promised an end to national demands for efficiency targets imposed 'without adequate analysis of what is sensible or achievable locally' - something that was greeted with relief by cash-strapped trusts. But the release of the NHS implementation programme on 20 December muddied the water. It said that 'nationally we expect efficiency gains to equate to approximately 2 per cent'.

The NHS Confederation responded by expressing alarm that such targets could hinder attempts to improve support services such as cleaning.

Last week NHS chief executive Nigel Crisp rushed out a rebuttal, insisting that he was calling for increased activity - not reduced spend.

In a statement, he stressed: 'During the 1990s, efficiency in the NHS meant cash-releasing savings which cut patient services.

The NHS plan. . . brings that definition of efficiency to an end. . .

Higher efficiency is now to be measured through a broader range of indicators based on better experiences for patients.'

Tactfully enough, the NHS Confederation expressed relief, with policy director Nigel Edwards describing 'this clarification of the guidance on efficiency' as 'very helpful'.

But the incident reflects a growing perception of increased pressures. One flagged up a recent strategic and financial framework document with 'nearly 300 headings which made demands on managers'.

And Mr Edwards told HSJ that with trusts becoming increasingly large 'these jobs have probably become much more demanding'.

'It is a question of this increasing emphasis on central direction and the speed of the pace of change.'

He urges the government to move quickly to invest in skills development and succession planning.

'We are hoping the leadership centre will get going quickly and pay attention to the needs of middle and top management, ' he says.

Other sources point to problems recruiting senior managers as evidence that the heavy workload was deterring the best applicants, forcing trusts to re-advertise posts.

Last week's HSJ flagged up the fact that four of Birmingham's trusts were without chief executives in post.

The same issue held a record number of job advertisements - evidence both of the proliferation of new opportunities for senior executives under the modernisation agenda as well as possible difficulties finding the right people for these jobs.

And one senior manager working at a HA shrugs off suggestions that he is taking the easy option: 'I think life is tough at every level of the NHS. The system is under considerable pressure. I think a lot of people feel absolutely knackered.

'People at the top do need to think very carefully about the sustainability of all these targets they are piling on.

You have to take people with you, and managers have to have some kind of life left of their own.'

He also highlights the difficulties for those at HAs to work in a climate of uncertainty.

'People I talk to in the field are predicting that the number of health authorities will drop very sharply from the 100 or so there are now, to 35 or perhaps 40 in the next couple of years. That will mean a lot more changes yet.'