This chapter explores three main sets of issues pertaining to the experiences of being a healthcare manager: the nature of managerial roles and responsibilities in the context of local operational pressures and wider institutional change; the challenges faced by managers on the ground in overcoming the clinical-managerial divide; and how exhortations to exercise leadership translated into the aspirations and actions of managers. Understanding the nature of managerial work in healthcare and the skills required is an essential first step in understanding the types of knowledge that managers require and mobilize. Management as a technical practice has long been seen as at odds with the interests of other professional groups who tend to dominate the 'professional bureaucracies' in which they both work. A good deal of attention was focused in the interviews on how managers interpreted their own roles and responsibilities in their organizations.