NEWS FOCUS: The new directors of health and social care in England have a pivotal role in the latest NHS upheaval as the regional offices disappear.They know what is being demanded of them, but can they deliver? Alison Moore reports

April fool's day 2003 may sound a long time away, but there is a good chance that it is already marked in the diaries of Ruth Carnall, John Bacon, Peter Garland and David Nicholson.

That is the day when the four new directors of health and social care in England are expected to take up their new posts on an official basis. And - like every other April 1 - it marks yet another reorganisation of the NHS, as the old regional offices disappear and the distinction between the NHS Executive and the Department of Health becomes even more blurred.

In reality, the foursome will be immensely powerful figures in the NHS from now on, even if they are not officially in post.

So will the four - many of whom have only been in their present jobs a short while - represent new brooms sweeping clean the NHS?

Ruth Carnall, current director of South East region, is quick to quash that idea. 'You can't feel like a new broom when you have been around the NHS for 25 years. I think there is a need for continuity and stability.'Nor does she feel her finance background was important in her selection. 'I was a hopeless finance director. . . it was a big relief for everyone when I moved into general management.'

Ms Carnall is keen to stress that her appointment - and that of her colleagues - does not indicate a switch in emphasis towards finance and performance management.

Given that the role of regional offices has been performance management for the last few years, it is not surprising that that is where the candidates' strength lies.

John Bacon - who will continue to cover London region - suggests their role in performance management will be more distant than that of current regional directors, as strategic health authorities take on much of the role of monitoring performance.

Alan Maynard, professor of health economics at York University, feels that their role will be as catalysts, fighting against what ministers see as torpor within the NHS. But he adds that although there will be tremendous pressure on chief executives to perform, this will be counterweighted by emphasis on the human resources agenda and the need to train, support and develop managers.

So what do the four have in common? One source says: 'If there is a strand, it is that they are not just beat-them-up rent-a-thugs. They all seem to have some interest in the development agenda, as well as performance management.

'They do all appreciate that producing good performance is more than shouting and waving a finger.'

However, another describes them as 'all essentially toughies. . .

these guys seem to be the gauleiters of the minister. They will be pressing down through the strategic health authorities and into the trusts and the primary care trusts.'

'In order to get the kind of performance improvements we need, we have to energise and support the frontline, ' says David Nicholson, current director of Trent region who will oversee the Midlands.

'Being bureaucratic will not do it.

The jobs are much more about being nurturing and supportive.

'Obviously, all managers have to be tough - we have performance improvements to deliver.'

Defining how their role will work may be their first task - Mr Nicholson admits there are still issues to be talked through. But he sees the jobs as firmly rooted in the DoH, rather than the halfway house between department and NHS which the current regional offices are. 'A key thing for us is how we can mobilise the expertise within the Department of Health to help the NHS, ' he says.

Peter Garland agrees: 'There are some real opportunities - the first one is about influencing the national agenda. . . the new directors will be national directors, more fully integrated with headquarters, and that is very important.'

So to what extent will they be responsible for problems in their regions? 'Shifting the Balance of Power does identify trouble shooting as one of our roles. I think there will be a level of responsibility for sorting some of these things out but I do not see us as being involved in troubleshooting routinely unless it is affecting the system as a whole.'

NHS Confederation policy director Nigel Edwards suggests that the job needs to be done in such a way that the four directors are not second-guessing SHAs.

He points out that the geographic size of their new responsibilities is such that a new style of management may be needed. In Southern region, for example, Ms Carnall expects to work in London and have bases in Guildford and Bristol.

But even Bristol will be three hours' drive from the south western corner of her empire.David Nicholson will have to keep his eye on a ball which could be anywhere from Southend to the Welsh borders.

And there will be the question of management costs: the abolition of regional offices and the setting up of strategic health authorities is meant to save£100m a year.

How will the new directors play their part in achieving that?

They will have to manage 18 months of change as regional offices run down. Key personnel - including some of the remaining regional directors - may leave for jobs elsewhere in the health service. Staff may be demoralised.

The transfer of power is likely to be continuous rather than happening on the morning of 1 April 2003. Mr Bacon says: 'We will evolve our role relatively rapidly. It would be odd if we hung onto the whole performance-management role throughout 2002-03 when the SHAs want to develop it.'

No one doubts that keeping all this on track is a big task, but many have lived through similar upheavals.

In London, Mr Bacon is perhaps facing less structural change - unlike the other directors, he will not be taking on responsibility for additional regions - but more practical ones. Continuing good relations with other pan-London bodies, such as the Greater London Authority and the mayor, using the NHS's role as the biggest employer in London to assist the capital's regeneration, and providing seamless health and social care are ones which he swiftly lists.

Waiting times, emergency care access and hitting targets loom large in Ms Carnall's mind. She highlights delayed discharges as a problem in the South East.

Mr Nicholson puts setting up the SHAs, getting his own staff sorted out and dealing with the service and financial framework process as three priorities for his early days in the post.

The four directors will eventually take on national policy areas as well as their regional remits.

But no one knows what or when.

'The intention is that we become more main board directors than we currently are, ' says Mr Bacon.

'We would expect to be much more engaged in national policy than currently, but Nigel [Crisp] and his colleagues will want to determine that as things progress.'

Stuck in: who's who

Southern - Ruth Carnall,45 Former chief executive of West Kent health authority 'kicked upstairs'to become regional director for the South East in March.Previous jobs include finance director at Hastings HA.A hard worker who nevertheless insists she is not a workaholic, she tries to protect family time.

London - John Bacon,50 Appointed regional director for London in March after acting up following Nigel Crisp's promotion.Before that, he was finance and performance management director for the region.Even his best friends would not call him colourful, but he is known as a straight-talker who grasps details easily.

Northern - Peter Garland,54 Director of Northern and Yorkshire region since 1999.

Many years working in social services before moving to the Executive as deputy director of finance and performance management.Has worked on developing fundholding and preparing for the comprehensive spending review.Described as 'an unblinking mandarin' by one commentator, he has a reputation for being tough.

Midlands - David Nicholson,44 Long career in the NHS has included six years running Doncaster Royal Infirmary and Montagu Hospital trust before moving to Trent region as director of performance in 1997.He was appointed regional director in November 1999.

Tenacious and determined.