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Health systems have elected to devolve management to semi-autonomous clinical subunits, known as 'clinical directorates'. This has placed responsibility for managing diminishing healthcare resources primarily in the hands of those who use them the most, notably medical practitioners. This research examines and presents a framework that describes the dimensions of efficient and effective clinical directorship in the context of a devolved management structure. A qualitative research design was employed to explore the perceptions of those involved in the operation of clinical directorates some 10 years after their implementation at three public teaching hospitals in Western Australia. The research found that the clinical insights that medical practitioners bring to the role of clinical director were perceived to be the grounding for clinical directorate effectiveness. Clinical knowledge combined with contextual knowledge, understanding of the politics of healthcare and ability to influence medical peers, were seen as critical. However, having business skills, commitment and good communication skills were perceived to be important to achieve both effectiveness and efficiency. The paper describes the dimensions of clinical director competence as well as the competencies, skills and knowledge perceived to require further development. It highlights the problems and issues that can arise for clinical directors from the perspectives of directors and their management teams. [ABSTRACT FROM AUTHOR]