The summer conference season may be drawing to a close, but ministers show little sign of letting up on the carrot and stick approach in their annual messages to NHS staff groups.
This week it was the turn of the ambulance services to be exhorted through a mix of flattery and criticism to meet the government's modernisation agenda.
Health minister Baroness Hayman was serenaded by the Scottish Ambulance Services pipe band as she arrived at the Ambulance Services Association conference in Harrogate, but she showed no sign of softening her message.
'There should be no doubt on the government's interest in, or commitment to, improving pre-hospital care. This is not a time for resting on laurels,' she insisted.
But before waving a big stick, Baroness Hayman produced the carrot. Emergency services in Cleveland, Wiltshire and Gloucestershire will each get£2.6m over the next three years to pilot joint control rooms.
Closer co-operation with the police and fire service would be a key principle underlining the government's agenda, she told delegates. 'The aim of the joint control room project is to create a cost-effective and efficient control room function. We shall be supporting and monitoring the projects, and we expect, in the meantime, the wider scope for joint working to be examined by the three emergency services everywhere.'
Emergency demand was now 50 per cent higher than a decade ago, and the minister acknowledged the difficulties facing the service.
'Ambulance staff are facing an ever-increasing workload - last year there were 270,000 more 999 calls and an extra 140,000 emergency journeys compared with the previous year.
'The growing demand had an adverse effect on response-time performances, which were generally disappointing.'
Baroness Hayman did not accept that spiralling demand was a good enough excuse. 'Far too many services are struggling to meet Patient's Charter standards.
'Of course, we have to recognise that 80,000 more responses were within the charter standards than the previous year, but that achievement is quite simply not enough.
'Everyone has the right to expect the highest standards irrespective of where they live.
'The national response-time targets are challenging, but the emphasis placed on meeting them is not so we can produce better statistical rates or better press releases but a better service.'
NHS chief executive Sir Alan Langlands was more conciliatory. He, too, acknowledged that rising demand had affected response times. Ambulance trusts face tough performance standards, to be met by March 2001.
Progress towards the targets, which include an eight-minute response time for at least 75 per cent of all critical cases, should have been presented to regional offices by the end of June.
Sir Alan insisted he would look at these returns 'sensibly'.
'I will think about them carefully and about the way we are facing up to some of the difficulties we may have towards progressing with some of them.'
He added: 'We are not going to be taken in by figures. If there are real obstacles to progress we will try to help you get around them or knock them down.'
On speeding up response times, Baroness Hayman said that the early use of defibrillators was delayed in some cases because they were simply too heavy or too awkward to carry from the ambulance. She announced a further£500,000 this year to equip ambulances with lightweight devices. This would complement moves to place defibrillators in public places, due to be announced in the public health white paper.
Ambulance services would play an important role in the national service framework on coronary heart disease, she added.
Tom Quinn, coronary heart disease co-ordinator for West Midlands regional office, has worked on the framework and hinted that it would include response times and treatment within 60 minutes of a call for help. 'I would say that as a matter of policy, services should routinely upgrade suspected heart attack calls from urgent to priority,' he said. This would save lives because, on average, patients wait an hour from the onset of classic heart attack symptoms before dialling 999.
The government's reforms, particularly the formation of primary care groups, concerned delegates.
One said that if PCGs were given control of commissioning ambulance services they might divert funds elsewhere.
Baroness Hayman replied that the Department of Health wanted to place commissioning powers at the appropriate levels.
Later, she told HSJ: 'We don't believe that PCGs want to take responsibility for commissioning emergency ambulance services. It is not sensible to devolve them down to that level.'
But she added that PCGs could take on the commissioning of patient transport services.
Ambulance services are coming to terms with April's upheavals, but there will be little time for rest. Sir Alan warned that the NHS needed short- term victories in order to create the breathing space needed to make long- term changes.
He added: 'One of the best management quotes I have heard in recent weeks was from Sir Alex Ferguson. 'He said: 'Control is everything in management, but the only thing that gives you control is time, and the only thing that buys you time is success'.'