The NHS is undergoing continual and rapid change, which must be reflected in the maintenance of professional performance for all career grade medical staff, especially consultants. In 2004 we undertook an audit of the current status across 39 of 40 secondary care organisations, of a number of domains used in guiding the development and support of career grade staff. These included methods of appointment, induction, appraisal, mentoring, CPD (medical and generic) and structures and process in place 'when things go wrong'. The main findings were many examples of good practice across London, yet overall great variability in delivery and systematic implementation. Where good practice has been developed, it requires continual enthusiasm and input, which may be lost as individuals move from jobs or as mergers and other organisational changes occur. Trusts need to recognise that new consultants, in particular, are not the finished product. All need nurturing, supporting and developing into the roles to which they have been appointed. Failure to manage this resource actively has undoubtedly led to some of the current problems in the NHS. However, the needs of medical staff must not be considered alone, but as part of the total needs of senior staff within each healthcare organisation.