One in four NHS managers believes underperformance is tolerated in their organisation, according to data seen by HSJ.

The figure is drawn from detailed work carried out by the Hay Group consultancy with 670 public sector leaders, including 134 from the NHS.

Hay Group director of public sector practice Phil Kenmore said NHS managers did not feel sufficiently empowered to confront poor performers, compared with other parts of the public sector.

Better training was needed, but organisational cultures also needed to change.

He said: “The NHS has a top-down culture…that makes people feel they haven’t got the power to take on poor performance.”

Chief executives and boards often felt they were closely scrutinised by the Department of Health and strategic health authorities, but performance management was weaker further down the organisation.

Mr Kenmore said: “The NHS has got quite a unique set of professional boundaries. Performance managing across those boundaries can be hard.”

Clinical leaders were rarely given sufficient training on how to manage other doctors. While they were comfortable pointing out clinical errors, they found it more difficult to deal with challenging behaviour.

The figures also reveal just 51 per cent of managers find their ability to deliver results is hampered by a lack of organisation and planning, compared with 44 per cent across the public sector.

In addition, 40 per cent did not think they had enough autonomy to use their initiative, 38 per cent felt that the risk-taking required to innovate was not rewarded and 24 per cent felt they were not free to experiment.