Scotland's health minister Susan Deacon is hardly popular among NHS insiders. But it doesn't look as if she's allowing that to throw her off her stride. Last week she moved to tighten central control over the health service and sent a clear signal that she was going to get tough with those who failed to meet government targets.
Delegates at the NHS in Scotland annual conference in Peebles listened warily as Ms Deacon outlined her vision for 'a new relationship between government and the NHS'.
She started on a conciliatory note: 'I believe today marks an opportunity for all of us to both reflect on - and redefine - the relationship between central government and the NHS in Scotland.
'Too often this relationship has been based on diktat and demand - with acknowledged faults on both sides. I see no sides. Like the vast majority of patients, I see only a single corporate NHS providing much-needed care.
'No individual making a serious commitment to improvements in patient care - at any level - has anything to fear.
But equally no-one should doubt our determination. . . to make those improvements as quickly as possible.'
There had already been two strong measures to ensure all senior managers in the NHS were listening. First, Ms Deacon had announced that£60m of the additional£173m announced for the NHS following the Budget would be distributed to health boards 'with strings attached'. As she explained: 'Health boards will have to demonstrate how it will be used before they can spend it.'
She continued: 'Performance will be closely monitored throughout the year.
A new team, drawn from the NHS and the health department, will review what the extra money is providing and advise me on progress.'
Just in case there were still some people who weren't paying attention, this was followed by news of the transfer of control of future pay increases for around 1,000 senior managers to the Scottish Executive. The new arrangements cover chief executives, executive directors (excluding medical directors) and other senior managers.
Ms Deacon said: 'Managers will no longer receive pay increases as a matter of course without identifiable improvements to patient care. They will be set tough performance criteria linked to the Executive's ambitious modernisation programme.'
There will be performance-related increases of 6 per cent for senior managers who perform exceptionally, while managers who fail to achieve improvements in patient care will get nothing.
Most of those attending the conference said - on the record - that this was a good thing. Off the record several expressed doubts both about how it would work and the motivations behind the changes. One chief executive said: 'You would have to question how it is to be implemented given the diversity of trusts in Scotland. Some have almost no problem with waiting lists, so should their chief executive get his bonus when he overcomes a problem that wasn't there to begin with?'
Dr John Garner, chair of the British Medical Association's Scottish committee, believes the minister is returning to a 'command and control system' that could be 'demoralising'.
He said: 'There must be some doubt as to how individuals can be judged in their performance given the number of outside influences which can affect the way a trust operates.'
Dick Manson, general manager of Carstairs State Hospital, thinks that '6 per cent is not enough' to motivate anyone. 'They're going to do a good job because they want to, not because they are being motivated by financial rewards.'
The performance element in the£60m allocation was more broadly welcomed. Chris Spry, chief executive of Greater Glasgow health board, believes that 'sums of this magnitude should be justified by boards, particularly on issues which the public feels strongly about. It is quite right to expect some additional level of services for this money.'
Ms Deacon also announced the creation of an NHS modernisation board with membership drawn from the Executive, the NHS and social care. It will work with the NHS to plan investment and spread good managerial practice.
The first move will be a report from Robert Calderwood, chief executive of South Glasgow University Hospitals trust, and Barry Sealey, chair of Lothian University Hospitals trust, on better ways to deliver value for money in procurement and in capital purchasing.
Mr Calderwood explained: 'We will be looking at how the NHS can learn from best practice in procurement and investment, and also at the balance of net capital priorities, and seek to advise trusts accordingly.'
Trevor Jones, chief executive of Lothian health board, believes 'there has been considerable pressure on capital spending in recent years and anything which produces best practice in purchasing must be a good thing' .
Dr Garner agreed: 'This makes good sense since purchasing centrally large capital items is likely to be the best use of funds, and this should also involve the Scottish Health Technology Advisory Centre which will be able to advise nationally on procurement.'
Ms Deacon is also to consult widely over board appointments and, in particular, their timing, 'to provide greater continuity within the service'.
The conference made clear that the pace of change, the demands placed on senior managers, and their personal liability for implementing that change, are set to increase considerably.
Whether this is a 'challenge', as Ms Deacon believes, or a recipe for disaster, remains to be seen.