What motivates people to join the NHS, sometimes taking a 50 per cent pay cut in the process? Five years ago HSJ talked to a group of new entrants about their aspirations. Joanna Lyall finds out how three of them have fared

Dr Rupert Morrall Age:29 Job: House officer, Royal Cornwall Hospital, Treliske Salary:£17,260

Rupert Morrall had a first degree in biological sciences and was assistant manager of a sports shop when he decided to go to St Mary's Hospital medical school at the age of 24.

'I enjoyed the clinical part of the medical school course. Being on the wards was much better than book work. But I didn't realise how completely at the bottom of the heap you are once you qualify.

Nobody has time for you.

'I found the last year quite tough; I went to a missionary hospital in Northern India for an eight-week elective. I learnt so much about all specialties and being on call.

'I came back in November and after Christmas I only went out one night a week.

In June it was nothing but exams; but I did run across the park to the hospital.

'In the first two years of the course I worked in a sports shop to earn money, but there was not time after that. I did have days when I thought why am I doing this; but I never got disillusioned. There were 120 in our year and about 10 dropped out. I want to do general practice in the West Country. I like the idea of getting to know families and doing preventive medicine. Now I have moved to Cornwall I never want to go back to London. I love being able to get to the beach for a couple of hours' windsurfing.

'I don't think about the money much; I live in the hospital and life is definitely cheaper than in London. I have a two-bedroom flat provided by the hospital that costs£60 a week to rent. I am still finding my feet but am amazed at how much there is to do. It's such a big jump from student to doctor. In my first week I couldn't believe that I'd done five years and am still at the bottom of the pile.

'Everyone seems to know more than me; even the healthcare assistants know where the blood bottles are. But I can see I will start to enjoy the job. I like being on call and the challenge of trying to work out what's wrong with a patient.

'The nursing staff are mainly permanent, so the place is much better looked after and there is team work. They know the wards. I feel that I am lucky that I have a job where I can continue to travel. I am planning to spend next year in Australia and New Zealand.

'If I had gone through medicine five years earlier I would have found relating to patients much more difficult. I wanted a job that was going to interest me for the rest of my life.'

Hanif Wazir Age:32 Job: Directorate manager of anaesthetics and A&E, Bedford Hospital Number of staff in directorate:350 Directorate budget:£8.5m Salary: 'Less than£40,000'

Before he joined the NHS management training scheme in 1994, at the age of 26, Hanif Wazir had completed a degree in computer science and philosophy and a master's in business administration. He had spent time working with an overseas aid agency in India and a medical agency in Afghanistan. He was earning£26,000 a year as a management consultant when he joined the scheme, on£13,000 a year.

The inspiration to join the NHS was provided by a chief executive who gave a presentation as part of the recruitment 'milk round'when he was an undergraduate.He liked the idea of working in the public sector and having responsibility very early on in his career.

After completing the training scheme he took a job as general manager (corporate affairs) and trust board secretary at Greater Manchester Ambulance Service trust.He worked there for 13 months and initiated an IT project which involved 14 acute trusts predicting emergency workload, and centralised bed management.

In September 1997 he resigned to go backpacking around the world on a 14-month honeymoon, going to India, Nepal, South East Asia, Australia, New Zealand, the US and the Pacific Islands. On his return in 1998 he took a short-term post at Walsgrave Hospital as a project manager in cardiac services before landing his current job in April 1999. He has since completed a further master's degree in managing healthcare organisations.

He has overseen the refurbishment of all the operating theatres and changing rooms for staff, and initiated flexible working in anaesthetics so that anaesthetists are no longer attached to a single consultant. He has also introduced multi-skilling of theatre nurses and strengthened management arrangements within his directorates.

But he was surprised by the level of responsibility the job involved. 'I hadn't envisaged that so many senior people would be relying on me to make a decision.'He believes that attitudes towards managers have improved over the past five years. 'I think there is a realisation that a£38bn service needs professional managers, and that teamwork is better than professional fiefdoms.'

He finds consultants happy to work on improvements. 'Their attitude seems to be, 'How can we work on this together'. Obviously there are barriers to change but we keep on chipping away.' His biggest headache is what he believes to be mounting paperwork. And the NHS's biggest challenge, in his view, is improving equity of outcomes.

Five years ago his ambition was to become chief executive of a provider unit. Now he envisages more of a portfolio career, split between the NHS and international organisations such as the World Health Organisation (where he did a two-month placement while on the management training scheme), Oxfam and the High Commission for Refugeees. 'I think I could make a bigger impact working that way.' But he would like the next move to be to the Department of Health, or a regional office, where he would have more responsibility for strategy. 'The only permanent thing in the NHS is change and that suits me down to the ground. I like change.'

Claire Molloy Age:37 Job: Locality development manager, Oldbury and Smethwick primary care group. No of staff :3 Budget:£27m Salary:£35-£40,000

Claire Molloy became an NHS management trainee at the age of 29 having completed a four-year business studies course and worked in marketing for East Midlands Electricity Board, as well as for a private company manufacturing textiles and at Birmingham city council. She was drawn to the NHS by public sector values and is now certain she will spend the whole of her career there.

Her first job after leaving the training scheme in 1995 was associate manager for surgery at Walsgrave Hospitals trust in Coventry, where she had responsibility for all its theatres. She stayed there until August 1997 when she negotiated a six month secondment in commissioning mental health services at Coventry health authority. After two years in an acute trust she wanted a chance to work with different organisations and to have more contact with the wider community.

Studying for a two-year MSc at Birmingham University in health and social policy heightened her interest in social inclusion and working in partnership with other organisations. In March 1998 she took a job as locality commissioning manager at Sandwell HA and moved to her current position in July last year. As deputy to the chief officer, much of the past year has been spent setting up the PCG board.

The biggest satisfaction, she says, has been working with the chief officer and gradually building up a small management team that are working well together. And she has enjoyed establishing relationships with GPs, a group she had not worked with before. At Walsgrave she managed a staff of 200, compared with three now.

But she doesn't miss the headaches of day-to-day operational management. 'There it was 80 per cent firefighting and 20 per cent service development.

There is time to do a lot more planning here, although you still have to deal with every day queries, such as requests for additional staffing.'

Smethwick, which is the locality she covers within the PCG, has received a grant of£10m from the single regeneration budget and her job involves considerable liaison with housing organisations, education providers and local authorities.

Colleagues who have been in the NHS for 20 years and more tell her the change in the past 10 years has been unprecedented. 'But I don't mind that because I have known nothing else. But as a manager I can see that dealing with organisational change can divert you from your main business of improving health and reducing inequality.'

She has never had a strict 10-year plan for her career, or one ambition, but her next move will probably be to a primary care trust. She believes attitudes have shifted about the length of time managers should stay in post. 'There used to be a feeling that you needed five years somewhere to really be effective, but I have friends who have spent two years, or less, in a job, and then gone on to higher things. I think it is now more about the quality of the experience rather than simply length of time served. For my part I want to stay in a job long enough to see I have had an impact. I love working in the NHS, which continues to reflect my personal values, and have a level of responsibility I don't think I would get elsewhere.'