As the Modernisation Agency tours the no-star trusts and conducts dozens of other programmes of change, Laura Donnelly battles her way through the organisation's complex structure in an attempt to pin down its role

'I am thoroughly enjoying it. I think some people think I am bonkers.'

David Fillingham, Modernisation Agency director It is seven months since the creation of the NHS Modernisation Agency, and a handful of critics would like to know what difference it has made (see panel). But so far, no-one has questioned the sanity of David Fillingham, the agency's director, in embracing a role which means his toothbrush is always on stand-by.

'I think on a personal basis, I've got used to having the mobile phone on, and moving from place to place, ' he laughs. 'I like to understand what's going on, and it is also a great opportunity to visit lots of places where great work is going on. It still feels good.

There is a lot going on.'

So far, the agency has had a limited impact on the public. Its launch, on 25 April, was overshadowed by health secretary Alan Milburn's announcement at the same event of a wholesale restructuring of the NHS.

And if the agency's remit is not stamped on the public consciousness, perhaps That is not surprising.

Finding one's way about its corporate structure and discovering what it actually does is incredibly difficult. The agency runs some 60 programmes - most of which were inherited from the bodies which the agency subsumed. It is difficult to work out how many bodies the agency did take in, given the multitude of groupings and subsections within the body.And from the outside, the labyrinthine structure makes it hard to work out the lines of accountability which lead from each programme to the agency.

On the agency's website, it would appear that it brings together six key groupings: the National Patients' Access Team, the Clinical Governance Support Team, the National Primary Care Development Team, the learning network team (which includes the collaborative, beacons and national awards programmes), the orthopaedic services collaborative and the leadership programme.Not included on that list are the National Institute for Mental Health and the changing workforce programme, which also come under the auspices of the agency. A further site map breaks the agency into two main areas: service modernisation and leadership development. This time, the changing workforce programme gets a look-in.NIMH is still hard to track down.

Whichever route one chooses, It is a painstaking job to work out where each of the 60 programmes sits. The amount of work the agency is involved in can't be denied though. A total of 1,200 teams across the country are working on its collaboratives for cancer, coronary heart disease and primary care alone. Nor can one deny the enthusiasm with which its 280 staff are tackling the modernisation agenda. Yet getting to grips with its role remains difficult and for those outside the agency, this is probably another reason for its lack of profile.

The agency's involvement with no-star trusts may be about to change all this. In September, Mr Milburn spelt out the agency's role supporting trusts in producing action plans and working with trusts to tailor a franchise specification.

All no-star trusts get a visit from the agency's 'visits team', part of the service improvement division of the agency.Depending on what problem is found, a further team may be sent in, whether it be the clinical governance support team or one dedicated to trolley waits.

So far the team, led by deputy director of service development Deborah Jones, has visited five of the 'dirty dozen' trusts.

But Mr Fillingham insists the modernisation agenda is challenging 'for everybody - whether they have zero or one star, or whatever'.

He insists the agency takes a hands-on approach: 'It is about being practical, rather than making high-flown statements about changing the culture, that you actually bring about change. We try to root ourselves very much in practical steps.'

And he says there is no question of the agency thrusting itself on reluctant trusts. 'The overwhelming majority of trusts come to us and say they want our advice. They are hungry for it. Often they are very good people who have just not had time to reflect in this way.

'What the agency does is to hold a mirror up to the organisation. It is not supposed to be a one-off, It is about a continuing dialogue. It is very much an interactive process - It is about incremental changes.'

The theme of hunger reappears in conversation with Professor Aidan Halligan, director of the CGST. His Leicester-based organisation has involved 360 NHS teams in its clinical governance programme, which involved groups of about five people being sent away for five days over nine months.

How does the team convince trust staff who are not persuaded of the benefits of change? Professor Halligan says It is important to have a time to be open to questions and 'get it all out, all the cynicism and the scepticism. You can get the emotional resistance. You can understand fear. People are often fearful of change. But there is a stronger emotion than fear - and that is ownership.'

Once teams are signed up to change, says Professor Halligan, 'they become hungry for it'.

But what evidence is there that the programme has made a tangible improvement to clinical governance in the NHS?

'We are getting a sense that we are making a substantial difference, ' says Professor Halligan, with some caution. The Judge Institute, Cambridge, began an evaluation of the programme in January last year. Its findings are due towards the end of next year.

But proof is the niggling issue that dogs the agency. Richard Green, director of communications, insists that evaluation is 'built in' to each of the agency's 60-plus programmes.

A few external assessments have been carried out. Birmingham University's health services management centre showed that in 20 pilots on the first wave of NPAT's booked-admission scheme, the proportion of outpatients waiting who had an admission date rose by over 22 per cent, compared to a rise of 1 per cent for those outside the pilots between March 1999 and March 2000. The centre also looked at the work done by the cancer services collaboratives.

Mr Fillingham says: 'It is still very early days, but we are finding a lot of good work going on.

We are seeing the fruit of some of our collaboratives; some of the work done on emergency admissions is showing results.'

Indeed, earlier this year, a project Improving the Flow of Emergency Admissions, by director of emergency service programmes Karen Castille, showed some dramatic cuts in waiting times.

One of the more high-profile parts of the agency is the leadership centre, created in April, since when it has been headed by director Barbara Harris. It has established new programmes on mental health, citizen leadership, inductions for newcomers to the NHS, inductions for chairs and a leadership programme for doctors. Last week, it announced plans to co-ordinate a management programme to fast-track nurses into leadership posts.

But the outcome of these schemes has yet to be seen, and so far the centre has received far more attention over the publication of a Commission for Health Improvement report into Royal United Hospital Bath trust - where Ms Harris was previously chief executive - earlier this month. CHI criticised a management culture centred on an 'inner circle', disconnected from the rest of the organisation.

So what does the agency do that makes it more than the sum of its parts? 'People are already seeing the benefits' in the 'great synergy' between schemes such as the coronary heart disease collaborative and the primary care collaborative, or between the CGST and support and development team on visits to no-star trusts, insists Mr Green.

Synergy is, of course, somewhat difficult to measure. l Modernisation: It is only words To those unschooled in the language of modernisation, it can sound like white noise. It is about transformation, and a drive for radical change. It is about implementing improvement.Building a culture of innovation.Challenging traditional boundaries.Spreading good practice.Championing change.

Enhancing the prevention of ill-health. Investment and reform.And, cynics might add, It is about short sentences which lack the conventional tools of grammar.

Readers who fear that HSJ's own appetite for scepticism has got the better of it may be interested to know that all of the above phrases are used in the introduction of the Modernisation Agency's own guide to its work.Does it matter? Perhaps.The enthusiasm with which the agency tackles its work is hard to deny.But It is very hard to measure the performance of a body whose guiding principles are akin to motherhood and apple pie.

Birmingham University's health services management centre senior research fellow Dr Kieran Walshe suggests that the agency's progress risks being stymied by the limited powers it was given on its creation.'The problem is It is not an agency at all.People think that it is some sort of separate agency but in fact It is just a branch of the Department of Health.'

He believes the status of the agency should not be brushed aside.'This is not just a nerdy structural thing, 'he insists.'I think it is a sign of how much the DoH wants to control it.'

One source suggests that ministers took the decision to offer the agency limited powers because of initial difficulties in its relationship with the Commission for Health Improvement.He reckons 'ministers got their fingers burned when they set up CHI.They set it up as an agency and gave it a set of non-executive directors and it wouldn't do what it was told.Originally the agency was going to be a special health authority, but by the time it was set up, ministers had learnt their lesson'.

Dr Walshe says the fact that director David Fillingham is held in 'very high regard'as an 'extraordinary manager'has opened doors for the agency.But he shares the view of a number of anonymous sources who say the agency has yet to prove it brings added value to its constituent bodies.'One of the issues is It is such a heterogeneous organisation.When you have outfits like the leadership centre plus the teams sorting out access in trusts, it is a very perplexing combination of things, rather than an agency with a corporate mission.'

A senior NHS source agrees: 'I think at the moment when you try to find out what the agency is actually doing you get a lot of information about what NPAT is doing, and what the clinical governance support team is doing, but nothing about what the agency actually brings that wasn't already there. It doesn't feel like a coherent whole.What extra value does the agency bring?'