Details of the government's quality drive are emerging, but managers are concerned at the lack of funding for the new initiatives and worried that they may be lost among other demands. Pat Healy reports

Managers may have had to wait several months for the full details of the government's quality agenda, but publication of the consultation paper A First Class Service heralds a positive shoal of related documents.

Between now and spring 2000, there will be at least 16 'milestones for quality improvement', starting with the new NHS human resources strategy this summer and ending with the first clinical governance reports from trusts.

In between, there is the promised publication of the NHS information technology strategy, guidance on the implementation of clinical governance and on lifelong learning, plus the first national survey of patient and user experience.

Early next year, the National Institute for Clinical Excellence will be set up as a special health authority, to be followed in 1999-2000 by a sister body, the trouble-shooting Commission for Health Improvement.

All of which suggests there is a steely determination behind ministers' rhetoric about placing quality at the heart of the NHS.

Health secretary Frank Dobson acknowledges that change will not happen overnight, but the consultation paper makes it clear that he wants to achieve a fundamental shift in the culture of the service.

NHS Confederation chief executive Stephen Thornton sees the document as confirming that the government 'is really trying to restore public confidence' after the Bristol heart babies tragedy.

But he is concerned at the lack of new funds for the quality agenda - existing resources are to be switched around to pay for it.

'It will involve a great deal of management time, particularly at local level, ' he says. 'Funding may be available at national level, but not at local level. I do not believe it can be done on the cheap.'

But Mr Thornton broadly welcomes the document, particularly because it recognises that quality requires a long term programme and that there can be no instant solutions.

He is also concerned that health authorities and trusts may find themselves unable to introduce a particular drug or treatment backed by NICE.

'What is going to happen when patients demand a particular treatment because it has been endorsed by NICE, but financial pressures mean they can't afford to introduce it?' he asks.

This is not a question answered by the document. It says that national standards, to be set through the new system of national service frameworks and NICE, are intended to 'guide local decisions by managers and clinicians, not tie their hands'.

But CHI will be checking on the implementation of standards through its rolling programme of trust visits and will step in where there are serious or persistent clinical problems.

It will be able to tackle management issues where they are the cause of clinical problems.

It is also expected to work closely with the Audit Commission to agree a joint programme of national work and to conduct both local and national reviews to make best use of each body's expertise and resources.

CHI is expected to develop effective working relationships with other bodies that already have a role in the quality field. For example, it will need to build links with health service commissioner Michael Buckley, the professional regulatory bodies - including the General Medical Council and the UKCC - the royal colleges, the Health and Safety Executive and social services bodies.

The potential for such links has clearly already occurred to MPs. When Mr Buckley appeared before the Commons public administration committee last week, the chair, Rhodri Morgan, asked how his office would interact with the CHI 'to ensure a tragedy like that at Bristol Royal Infirmary never happened again'.

Mr Buckley said he welcomed indications in the white paper that CHI would co-operate with other health service bodies, including his own office.

A lot of quality work is already carried out in the NHS. Doctors' leaders have reminded health ministers of their involvement by sending them a document detailing how medical organisations can make self-regulation work.

Joint consultants' committee chair Sir Norman Browse comments that standards of care in the NHS and the role of professional self-regulation are under 'severe scrutiny'.

'It is important for the government and the public to realise, however, that the medical profession already has in place a number of mechanisms for ensuring the safety of the public, ' he says.

But ministers believe there is a lack of co-ordination and coherence about the present arrangements and are looking to NICE and CHI to provide a national focus with stronger enforcement powers.

Some existing bodies will be subsumed and their resources channelled to the new ones.

For example, CHI will take over the review work of the Clinical Standards Advisory Group, which will be abolished under a bill expected early in the next parliament.

This is part of what Institute of Health Services Management director Karen Caines describes as a 'huge and complex' agenda which she thinks should command support. But she says it is time for the various initiatives from the centre to be carefully paced in order to identify immediate priorities.

'Otherwise, there is a risk that the vital drive on quality will come second to the demands of setting up primary care groups, restructuring acute services and reducing waiting lists, sorting the millennium bug, developing partnerships and managing the money.'