Jon Restell on keeping managers in the NHS

It's also a good way to let your Darzoid tendencies slip neatly into public view. But when you're not showing off, it also gives rise to an interesting exercise: looking into the futures of people who have just started work in the NHS.

I recently spent some time with a group of management trainees coming to the end of their time on the human resources and finance programmes. These are people who self-consciously describe themselves as bright-eyed and bushy-tailed. (After talking to them, I realise I can't recall feeling like that myself. I think I must have maintained the same brand of cheerful pessimism from my teens to my - very - early middle age of today.)

Anyway, I liked the trainees a lot. What's not to like? They were anxious not to put the interests of managers over those of the service as a whole. Intolerant of how things have been done, annoyed with the old guard - who of course they wish to replace as soon as possible - they want to change the world. They don't - yet - feel rejected and despised. They are developing a vocation for dignified and effective healthcare.

So the question is: what is the outlook for all this gilded youth in 10 years' time?

Some will of course leave early after securing one of the best management educations in the UK. For most, thankfully, the health service will get under their skin and they will stay, thrive and move into ever more senior leadership jobs.

Future executives

In 10 years, some of them will be thinking about securing board-level positions - some will already have them - and a smaller band will have been identified as future chief executives. But unfortunately some will be thinking along very different lines. Talk to quite a few directors and chief executives and they will complain about the number of talented and energetic managers who have decided to keep themselves just below the radar.

These assistant directors have seen what happens to colleagues at board level and they consider the risks or the rewards or both as simply not worth it. These people are not just serving time. Quite the contrary; they are good at and passionate about their jobs. Rather, they are rational, normal people who want an interesting and worthwhile career in reasonable balance with the rest of their lives.

As an example we have a situation where at least two strategic health authorities are believed to have recently struggled to appoint to key directorships. These are jobs at the top of the tree - people should be queuing up for them. And although it's in the mix of reasons, this is not just about salary.

Culture management

The wider truth points at the poor culture for management in the NHS. A very thoughtful chief executive from the private sector recently gave me his analysis. There is often nothing wrong with the quality of managers in the NHS. (This is not always the case - he would argue that the worst of NHS management is very bad indeed.) Rather the core problem is the extent of top-down targets and centralised control. Real management autonomy and a culture of businesslike continuous local improvement are impossible to achieve in spite of the wider system. This man does not want to become an NHS chief executive any time soon, which is a pity because I think he would make a good one.

The lack of stability at the top end, either through our failure regime or regular reorganisation, is not simply a problem for post holders. Services, patients and staff suffer from our casual attitudes to management and managers and the development of both. Studies from Sweden (that great mine of evidence to support most debating positions in healthcare) show how important long-term stability in leadership is for the overall and continuing success of services. One high-performing county council has had the same chief executive for nearly 20 years. How unlike our own "hire 'em, fire 'em" approach. We'd almost certainly complain about such low turnover.

One of the concrete measures proposed in the next stage review, the process to stop poor managers getting re-employed in the service, is only a tiny step. And if you're wondering, the bad, the sad and the useless must always be fairly but squarely guided to the exit. This has never seemed to me strange for trade unionists to believe. But it is the sort of sentiment that always leaves centre-right pals aghast - as it doesn't fit the common management fantasy that requires trade unions to have a vested interest in the incompetent delivery of the employer's business, against which managers must heroically and individually battle.

Mismatched commitment

The real problem does not rest with this handful of allegedly disastrous managers. It is with the majority of managers whose career-long commitment to the service is never quite matched by the service's commitment to develop and support their skills or to provide a positive enough framework in which to manage for the continuous improvement of patient care.

There is now an opportunity opening up around the next stage review which every manager should want to seize. Several top leaders, including NHS chief executive David Nicholson, are clearly prepared to take action to address some of the barriers. The emphasis on leadership, including the commitment to develop clinical and managerial staff in leadership roles, is therefore great.

There is plenty to debate. For example, the idea of a royal college of management, which has a growing number of cheerleaders. Personally, I think we should be careful what we wish for. But at least these questions of leadership and management look as though they might be about to get the attention they deserve. I'll be keeping those trainees in mind.

Is there a poor culture for management in the NHS? Email hsj.feedback@emap.com