It's hard to know whether to laugh or cry. In a list of key "barriers to change" in the health service, produced by Alan Milburn's modernisation action teams, one observation is incontrovertible and - in this context - full of irony. "Staff feel overwhelmed by the number of new initiatives," warns the draft report of the team working out how to improve patients' speed of access to healthcare. How true. After years of permanent revolution in the structure of the service, this reaction is not surprising. But when the professionals get to grips with the national plan for health, to be published towards the end of next month, they will realise that, as far as changes in working practices are concerned, they ain't seen nothing yet.
Health managers and non-executives, assembling today for the NHS Confederation's annual conference in Glasgow, are aware of the scale of impending reform - but not yet the detail. Chancellor Gordon Brown's budget speech in March promised that NHS spending would increase by more than 6% a year in real terms over the next four years -double the historic trend. In return, the prime minister demanded modernisation. Health service leaders, initially overwhelmed by the scale of resourcing, said they would do their best to oblige.
Since then, the NHS ideas factory has been working at full stretch. To energise the process in England, Milburn appointed six action teams to think through different aspects of the modernisation programme.
From the teams' confidential draft reports, written a fortnight ago, it is possible to work out many of the key features of the eventual reform package.
To achieve a phased programme of sharply reduced waiting times and improved service for patient, for example, the government wants a complete overhaul of traditional clinical boundaries.
As the action team on reforming the professions puts it: "Many patients experience delays because of unnecessarily rigid rules about which health professionals can assess patients, make decisions about their further care, or about discharge."
New protocols are envisaged to extend the responsibilities of nurses, midwives, therapists, scientists and support staff. Consultants will be expected to agree job plans, monitored by their trusts and linked to the delivery of targets. This will amount to "a major change of culture in the NHS".
The quality of the leaked draft reports looks patchy. They differ in format and style. Some seem to be engaging in blue-sky thinking, while others try to be extraordinarily precise about short-term targets with out mentioning the costs. Greater consistency will be engineered over the next few days as the teams finalise their reports before a meeting with ministers next Wednesday.
Issues that remain to be resolved include performance incentives. The action teams are distinctly cautious about linking pay to results, arguing that any scheme would have to be carefully piloted to eliminate perverse effects. Health staff are unlikely to be landed with anything like the performance-related pay being introduced for teachers. Ministers are still keen, however, on offering team bonuses to reward the groups who work the hardest.
Parallel work in the devolved health services in Scotland, Wales and Northern Ireland will be discussed in a joint ministerial group before the national plan for England is published, probably in the last week of July.
The plan will not be a compendium of action team conclusions. It will be ministers' own work. But from their speeches and from assorted leaks, the direction is clear -and so are some of the problems.
Stephen Thornton, the confederation's chief executive, is enthusiastic about the government's commitment to reform. "At the start none of us realised how radical this exercise was going to be," he says. "The teams have come to realise we cannot find answers by tinkering around the edge. We need really radical change in the way doctors are trained, managed, judged, hired and fired."
How resistant will the NHS be to this intensification of change? The problem for ministers is how to persuade the professionals that the status quo is not an option, without making the public even more discontented with the service they are receiving. For example, the action team on reforming the profession says the care patients receive is often characterised by waiting, lack of information, poor communication skills on the part of frontline staff, lack of continuity in care, poor environment and inadequate standards of personal care, including food and other facilities.
Change may be essential, but it will take time to introduce new systems and train extra staff. If the government tries to mobilise reform by trumpeting too loudly the deficiencies of the present system, it runs two risks.
The first is a collapse in professional morale. The second is the likelihood that everything ministers say now to criticise the service will be thrown back at them at the next general election. Inevitably, however good these reforms may be, the pain of implementation will come before patients and voters are likely to notice the benefits.
