Laura Donnelly on primary care leaders

Are you sitting comfortably?

Or are you one of dozens of primary care trust chief executives coming to terms with their failure to get a job running the new PCTs, while arguing over pay-offs and alternative employment?

As I write, about half the new PCT top jobs have been filled from existing stocks, with estimates suggesting that, of 70 new jobs, about 45 are likely to go to current PCT leaders. Considering the pool began with about 170 chief executives, what does this say about NHS management?

One argument is that new strategic health authority chief executives, keen to assert authority and be seen to do so, are indulging in an exercise otherwise known as 'don't think much of yours'. That is, having been sent off to new parts of the country, their default setting is to 'out-macho' each other via 'clearing out' the maximum number of people. By that theory chief executive Mark Britnell is winning, with just two of six top PCT jobs in South Central going to existing leaders.

Then there is a second, overlapping thesis. That is that the same SHA chief executives, buoyed by a spirit of competition, are determined to speed through 'internal recruitment' so they can pick the cream of the crop via national advertisement. By this token, Mike Farrar in the North East ? who had the first advertisement in before the successful candidates even had a patch to call their own (let alone before anyone had anything in writing) nudges ahead.

Both of these arguments may be excessively cynical. If new SHA chiefs don't think much of the PCT chief execs on their patch, they certainly shouldn't appoint them. And, if there are several slots to fill, getting to national recruitment ahead of the pack makes sense.

What of the also-rans?

But what becomes of the PCT leaders who get left behind? They can't all go into turnaround consultancy. And whose fault is it if fewer than one in three of them have the potential to match the demands of the new organisations?

New SHA chief executives will be measured by the success of their new territories, whether that's financial success, drastic reconfiguration plans achieved without blood on the streets, or even improving the health of their populations. Will anyone hold them to account for how far they develop the leaders in their territory? On current performance, it seems reasonable to assume not.

But the low numbers of new PCT chief executives emerging through pooled recruitment must be seen as a poor reflection of the tier above them, in failing to develop sufficient leaders for the future.

Now, thanks to the restructuring of SHAs, surviving leaders have been moved to unfamiliar parts of the country, adding to the perception that they have been absolved from any responsibility for the primary care leaders within their old territories. This might help when it comes to clear-eyed decision-making; it also leaves others to clear up their mess.

Sadly, lack of long-term accountability is the pattern sewn in to the fabric of the ever restructuring NHS.

Thanks to what the late and legendary Department of Health head of press Romola Christopherson described as the habit of political leaders, including Thatcher and Blair, 'to kick the fridge when things went wrong', the NHS will always be vulnerable to medding at the first sign of trouble.

Political fiddling

And if there is one interventionist tendency which overrides all others, it is the politician's urge to opt for structural change over more subtle and deep-seated reform.

With every reorganisation, talented people are thrown away. Not only that, but the inability to plan ahead leaves the service with a habit of expensively recycling formerly redundant managers.

At SHA level, the process will lose the NHS well-respected former North East London SHA chief executive Carolyn Regan, who decided to leave the service after 25 years when she failed to get the (now vacant) job running London. Meanwhile, highly rated former regional director Ruth Carnall re-enters the NHS fray to look after London on an interim basis some two years after being made redundant after a quarter century on the state payroll. Both have made a huge contribution to the service over the years; wouldn't it be sensible for the service to repay loyalty with a tempting career, rather than a pay-off?

There are probably two main ways to protect the service from meddling politicians. The first and most ambitious, mooted most weeks by opposition parties, academics, and backbench MPs, would be to remove from government the power to use the NHS as a political football.

What no-one has quite worked out is how exactly ministers would be barred from the pitch; as Blair's former health adviser and HSJ columnist Simon Stevens acknowledged earlier this year, foundation trusts have only acted as a partial circuit breaker. Simon suggests other routes to giving the NHS a more permanent and transparent footing, including regulating anti-competitive behaviour and creating an independent tariff-setter for payment by results. I wouldn't disagree. But radical as those changes might be, they would still leave politicians with plenty of scope for a kickabout.

Now may be the time to vest some hope in a second, less ambitious, route, already underway. If it works, the restructure at the top of the DoH, and most specifically, the division of the 'top job' back into that of permanent secretary and chief executive, ought to create a buffer zone which more effectively protects the NHS from politicians.

At the moment the zone is policed by acting permanent secretary Hugh Taylor, a highly respected diplomat who many would wish to see retain the job.

Incoming NHS chief executive David Nicholson is already talking tough: he may yet be glad of a firm buffer behind him when ministers come knocking.

Laura Donnelly is news editor of HSJ.