Health minister John Denham was spared the embarrassment of a slow handclap at the British Association of Medical Managers' conference, but the drive for reform has stirred up dissension among the ranks. Alison Moore reports

Health minister John Denham could have been excused for feeling a bit nervous as he made his first speech since prime minister Tony Blair was heckled by the Women's Institute.

But the medical directors who dominated the British Association of Medical Managers' conference were not the types to catcall and heard Mr Denham out, even if some of them seemed lukewarm about what he had to say.

In line with the conference's focus on 'leading clinical services in a new NHS', Mr Denham stressed that medical managers were crucial to the modernisation programme.

'I want you to be the sort of leaders who are always asking how to make things better. I know with your help we can take on the challenge of modernisation, we can retain public confidence in the NHS and we can provide staff with the support they deserve, 'he said.

'We have the best ever chance to define the NHS for the 21st century. We are now at the time when we have a debate about the future of the service and one that is focused on reform rather than resources. Professionals are at the heart of our reform.'

Mr Denham stressed the progress that has been made on consultant expansion. But his reference to the services as consultant-led and departmentally delivered was interpreted by some in the audience as acknowledgement that doctors' numbers are unlikely to increase dramatically.

Although there was praise for the work of doctors, and of medical managers in particular, it was obvious issues such as differences in productivity and quality were still high on the government's agenda.

'There are variations in productivity that translate into inefficiencies of care, ' said Mr Denham. 'I want you to use appraisal as a powerful vehicle in investigating variations in productivity in the clinical team.'

But Professor Jack Sanger, who has helped devise one of the few consultant appraisal systems already up and running - at Norfolk and Norwich trust - foresaw problems with the scheme the government is drawing up.

'Given the way the government is going and some of the statements from the British Medical Association, we will end up with a process where the consultant is in a loop and no real energy can be released. You end up with a ritualistic, habitual exercise which has no effect on practice because there is no engagement of the human being who is central to that practice.

'God help the government who devises an appraisal system that ignores the personal. We need to appeal to the personal in order to provoke change.'

But Professor Sanger, director of the centre for organisational research at Anglia Polytechnic University, said appraisal could be a 'valve for the stress that many healthcare professionals feel'.

Former BAMM president Sir Cyril Chantler offered his vision of the future. He anticipated the growth of intermediate care centres, where some hospital doctors would work, and new possibilities for GP-led hospitals. High-tech care could be concentrated in a smaller number of acute hospitals. Specialist training might have to change with doctors moving between specialisms far later in their careers than at present.

'Maybe the time has come to stop talking about GPs and consultants, 'he said. 'We might begin to talk about generalists and specialists and start to embrace the idea that in one career you can move from one to another.'

While many of the doctors at the conference supported fundamental change in NHS and doctors' working practices, some felt making these changes was limited by practicalities.

Rabbi Julia Neuberger, chief executive of the King's Fund, summed it up as feeling 'exhausted, fed up, got at and beaten up'.

Multidisciplinary team working was mentioned many times as a laudable aim. But away from the main auditorium, doctors spoke of the problems of dealing with colleagues who did not want to be team players and of the difficulty of getting protected time for team development.

The difficulties of bringing about change while running a service were also highlighted. 'How the hell do you get off the treadmill?' asked one delegate. 'The 18 months' priority does not go away, the 30 people queuing in A&E do not go away. These things conspire to throw me off track.'