Health secretary Alan Milburn believes the NHS must be the best, as well as the biggest, employer in the land. 'Don't wait for advice: start now' was the message to the Institute of Healthcare Management. Lyn Whitfield and Tash Shifrin report

Keep up the momentum on delivering the NHS plan. That was the message delivered by the centre to NHS managers attending the Institute of Healthcare Management's annual conference in Harrogate last week.

The message was given extra bite by the Conservative Party's decision to call for a major expansion of private healthcare. Health secretary Alan Milburn warned that sections of the media wanted to see the end of the NHS and that public confidence in the NHS was 'fragile'- particularly among young people.

The NHS, he said, needed to modernise to secure the confidence of the new generation.

And the process needed to start 'now' with 'discussion about how to make it happen in every corner of the health service. '

Mr Milburn gave trusts until April next year to start showing 'tangible improvements' to people's working lives. And he announced that every trust would be given£25,000 immediately which staff could spend on improving their work place.

By April 2003, trusts will also have to show how they will meet a new 'improved working lives standard' set out in a human resources framework document published by the Department of Health. Mr Milburn said the initiative meant that for the first time NHS employers would be measured by the way they treated their staff, with cash linked to their behaviour. The DoH has put aside almost£21. 4m for training, with most going to qualified nurses wishing to specialise - including 600 places in critical care,175 in infection control,25 in cancer,100 health visitors, and 50 community psychiatric nurses. There will also be an additional 200 scientists and technicians, 100 radiographers, 100 operating department practitioners, 50 speech and language therapists and 40 clinical psychologists, due to extra investment in pre-registration training.

Mr Milburn told the conference: 'Overworked and under-trained staff do not deliver high quality patient care. The NHS is already the biggest employer in the land. Now it must become the best.

'Good human resources management is part and parcel of good general management. That is why, for the first time, human resources in the NHS will be performance-managed as energetically as other objectives and targets. '

Mr Milburn said the improved working lives standard 'encapsulates the commitment I expect you to make to staff '. It meant creating well managed, flexible environments, promoting staff welfare and development, and respecting the need to manage a healthy and productive balance between work and home.

The measures include the immediate allocation of£9m -£25,000 for every trust - for 'tangible, practical improvements to the working environment of staff '. Staff would be able to determine how the money was spent.

Acting NHS chief executive Neil McKay, reiterated the point. He wanted to see 'restless managers who do not accept the status quo. '

'Do not wait to be told what to do to improve patient care, ' he said. '. . . do what needs to be done. '

Managers had not to wait for advice on implementation of the plan but to start making changes on the ground. ' Do not feel you have to ask for advice - although if you do ask you will get it by the bucketful, 'he said. 'Please feel free to get on and do something now. '

Mr McKay echoed Mr Milburn in describing the plan as a 'tremendous opportunity' for the NHS. And he said he was convinced it would be delivered because it had enormous support - unlike the internal market reforms 'which were only supported by about 5,000 people in the health service'- and because it came with new money.

Delivering the 'vision' would be tough. 'The health secretary cannot deliver the plan, I cannot do it, regional offices cannot do it. Only 'you can deliver it, 'he concluded.

But he insisted that 'in future years we will see this as the start of a movement to transform the NHS and make it fit for the 21st century. '

Concerns remain Managers attending a 'meet the NHS xecutive'breakfast session at the IHM conference were more sceptical than their leaders. Key concerns were whether the money was there to deliver the plan's promises and the 'tension' between central control and local delivery.

Professor Brian Edwards, a former regional general manager, warmly welcomed the NHS cancer plan, unveiled by Mr Milburn at the Labour Party conference last week.

But he asked whether the money was really there and whether the local networks needed to deliver it could be developed. 'What are the chances of that happening?' he asked, 'particularly when the people who need to do it are very busy. It is not as if they are sitting around trained up and ready to go. '

In response, NHS finance director Colin Reeves said: 'Trust me, the NHS plan is affordable over the three year spending review period. 'He said the NHS Executive had 'done its sums very carefully'- a view echoed by Mr McKay.

Chief medical officer Professor Liam Donaldson said he was 'more optimistic' about the cancer plan than Professor Edwards, because it would build on five to six years'experience with the Calman-Hine framework.

But NHS human resources director Hugh Taylor acknowledged there were 'tensions'between central and local control.

He said it would be 'mad' for the centre to try and run everything - but equally 'mad' for 400 trusts to try and reinvent the wheel on every issue.