'Middle managers need more support to survive in the treacherous terrain between their bosses and clinicians'

This week the NHS Confederation takes the lid off health service management and finds standards lacking in many areas.

Its study The Challenge of Leadership in the NHS, published today, is a litany of weaknesses. For example, there is a culture of bullying, decision-making takes too long, there is a lack of evidence about what works, and training is often poor or non-existent.

The report offers disturbing insights into the often-dysfunctional relationship between managers and clinicians.

Engagement between the two frequently falls short at every level in an organisation, while middle managers need more support to survive in the treacherous terrain between their bosses and the medics.

And, from the managers' point of view, the entrenched power of clinicians is exacerbated by the fact that they tend to work in the same hospital for many years; managers are often in and out of the door in just two or three.

Key messages

Overall, the confederation concludes, there are simply not enough good leaders. Commissioning organisations in particular need higher-calibre staff, with more capacity building and training.

But the report also drives home important messages for policy-makers, just days before Gordon Brown reveals his ministerial team.

Despite moves to push power down the NHS bureaucracy, managers still feel compelled to focus upwards on the Department of Health rather than on the priorities driven by their patients and staff, while the long-standing malaise of too many targets driving short-term thinking is still skewing management priorities.

Our survey of HSJ readers' expectations of Gordon Brown's government reveals deep unease over whether the new prime minister will continue the devolutionary drive in the NHS (See 'Exclusive survey: winning over NHS staff could be Brown's first big challenge').

The confederation's report provides compelling evidence that slowing or reversing this trend would severely hamper managers' ability to deliver demanding targets such as the 18-week treatment cycle.