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One minute good cop, the next bad cop, NHS chief executive Nigel Crisp has decided it is time to get tough. But as Paul Smith discovers, the increasingly influential IHM is not afraid to bite back

If anyone still reeling from their star-rating results was looking for some comforting words, few were coming from the mouth of NHS chief executive Nigel Crisp last week.

His message at the Institute of Healthcare Management annual conference in Belfast was harsh - stop whining and get on with it.

'I am going to deliver several hard messages, ' he told delegates.

It was the first appearance of the word 'hard', which quickly became the major theme of the speech.

The public had a right to know if their local hospital was rubbish.

The NHS would be 'supportive' to managers intent on bringing their trust up to scratch. The help would be there. But there was no going back to an attitude that 'the NHS knows best'.

He also stressed that there was more to fear from next year's stars.

'Next year, we are going to measure trust performances in terms of what patients say about them.

That is a big change for us.'

So not just the two-penn'orth from the Commission for Health Improvement, doctors, consultants and the local community health council - but from the most vociferous, tenacious and irrational element in the NHS family - ordinary members of the public.

Some managers in the audience seemed to wince.

Amid the growing complaint about the pace of structural reform Mr Crisp also stood firm.

A question from the floor - which included the words 'radical' 'restructuring' and 'getting in the way' - was quickly dispatched - or ignored, depending on your view.

Mr Crisp told delegates: 'We are talking about delivery. We are talking about improvement and we are also talking about change, all at the same time.

'As one manager to others, we have to measure performance. At the moment, that is one of the real issues that is hard. When we measure performance we have to tell the public this. It is not just a secret to be kept within the NHS.

'I know one result of that is that we get the tabloid behaviour, but we get the tabloid behaviour anyway on lots of different issues.'

But he could play good cop too: 'For trusts without stars, I know these announcements were a blow to the people working within them. But I know there was recognition of the problems facing them. It is important our role in the centre and in the NHS is to support and develop people through these things. We want people to succeed.'

And back to bad cop: 'There are issues that need to be tackled and we cannot duck those performance issues.We can't duck them.'