The government's presentational handling of massive extra cash for the NHS has engendered wariness - and weariness - about its real intentions. Lyn Whitfield reports

The government's manipulation of the media has become a phenomenon in its own right.

But its apparent inability to stop 'spinning' every story for a quick headline now seems to be doing real harm within the NHS.

Stephen Thornton, chief executive of the NHS Confederation, was incandescent that briefings ahead of the first allocation of Budget cash last week gave it an 'anti-bureaucrat' spin.

Briefings by 'sources close to the minister' left newspapers reporting that health secretary Alan Milburn planned to cut out health authorities and take 'unprecedented' control of how the£660m was spent. The money will go to HAs, but with instructions to pass it on to trusts and primary care groups.

Mr Thornton is not alone. Ken Jarrold, chief executive of County Durham HA, says: 'I am very happy about the new money. I am not happy about spin-doctoring.

'This government is right to demand modernisation, but we also need partnership with the service. Last week the spin doctors were allowed to undermine the government's own policy on HAs. They should not be allowed to do this again.'

Elsewhere, the government's habit of talking tough for the papers and softly to representative organisations and magazines - including HSJ - has engendered a degree of wariness about its real intentions.

A trust chief executive says: 'My initial reaction to the Budget was 'this money is amazing''. But after living through the past 18 months it is impossible not to be cynical.

'I will believe it when I get it, and when I find out whether we are doing the performing seal routine again, with money held out like fish for us to write essays for.

'There is a real feeling of sadness that it is as bad as ever: managers are bashed, doctors are bashed, now it seems as if Mr Blair wants to do it all with a few nurses over a cup of tea in Downing Street.'

Ros Lowe, chief executive of Hounslow and Spelthorne Community and Mental Health trust, says: 'I welcome the extra money, but I have yet to see how it will play out in this organisation.

'It sounds absolutely fantastic. But then one day you read that it will be given straight to doctors and nurses because they are the best people to spend it and the following day you read that is denied. I am holding my breath.'

Mr Jarrold says the Budget's 6.1 per cent over inflation increase for the NHS over four years is the sort of money he hoped for when, as president of the Institute of Health Services Management, he launched a campaign for more resources with the British Medical Association in 1985.

He argues the£660m in itself - 'if it really is without strings' - will 'sort out' pressure on the service.

And he is 'very encouraged' by the themes of the five challenges set by Mr Blair, as he is by the people drafted on to the six modernisation action teams that will address them and produce a four-year 'national health plan' by July.

But the former NHS Executive human resources director says: 'You cannot run the NHS from Whitehall.

You must leave it to the chief executives, the people on the ground, to get on with the job.'

This is what few managers believe they will be allowed to do. But this does not seem to worry Mike Waterland, chief executive of Birmingham HA. By last Friday he had 'secured' targets with local trusts for their share of the£660m and agreed to 'roll over' some money to primary care groups.

'Of course, the money will come from targets, but you do not have to be a rocket scientist to work out what they will be, ' he says. 'You can forecast the labels. And what is wrong with dealing with cancer or waiting lists? They can spin things as much as they like. What I want is the cheque.'

Peter Reeves, chief executive of West Surrey HA, which is dealing with a large underlying deficit, says he is 'unclear' about whether the£7.5m his HA should receive from the£660m will come without new targets - but quite clear that his 'choice' would be to deal with 'legitimate cost pressures'.

In the longer term, he says, NHS organisations need clarity about who they are accountable to - 'we have the regional office, czars for all sorts of things and now Downing Street is getting involved as well'. And how much of the above-inflation increases will they get in the three years from 2001-02 to 2003-04?

'We know what is pencilled in for the NHS, but that does not increase our planning visibility, ' he says. 'We can work out roughly what we are likely to get, but we might be wrong, and every percentage point is£4m-£5m for the average HA.'

Mike Fry, chief executive of Christie Hospital trust in Manchester, says money needs to be spent on the infrastructure to cope with older, sicker patients - which means beds, nurses and neglected services like radiography.

Alan Randall, chief executive of Eastbourne Hospitals trust, also believes that money needs to ease pressure on beds and with it pressure on staff.

'Only last night I was called after a long day at work because no beds were available, ' he says. 'That cannot be right. It is not even the middle of winter.'

In common with many community and mental health managers, Ms Lowe would like to see resources channelled into the gap between community and social services and the national service framework for mental health.

But she believes the money will be 'badged' for nationally driven initiatives, rather than underlying cost pressures. 'And that is an issue because by next year the public will want something pretty slick and so will government.'

This is also a concern for Mr Randall, who says of the Budget: 'I had an initial sense of elation. Over many, many years of working in the health service I never thought there would be this sort of support and backing for the NHS.

'But that changed into a sense of foreboding due to the very high expectations of the public and politicians of how this is going to make an immediate difference.

'This is a feeling I have not had since I was a child and wanted my first bicycle and then got it and thought: 'Oh dear, now I will have to ride the thing''.

'The service will deliver, but I do not think politicians or the public will see results overnight - and that is what they want.'

In the Opposition corner

In the run-up to the statement, the Conservatives were stressing their policies to increase private healthcare provision.

Yet as soon as Chancellor Gordon Brown had sat down, Opposition leader William Hague 'unambiguously' welcomed new money for schools and hospitals, and promised his party would match the commitments.

In an interview with HSJ, shadow health secretary Dr Liam Fox claims that there is no contradiction. 'We want to see an expansion of the private sector as well as the NHS, ' he says. 'We need both if we are to increase health spending to the level of other countries.

'Labour are one-club golfers. Every other country in the world manages to do this.

We should be looking at the expertise of other countries to see how to combine an excellent NHS with the voluntary private sector.'

In a parliamentary debate on the first£660m that will be handed down to the NHS, Dr Fox repeated the Opposition's commitment to meet Labour's cash for health, but said it would spend the money 'better'.

Asked how, Dr Fox said the money needed to be handed down 'without strings' to 'clinicians' - quickly amended to 'trusts' - and without distractions such as the waiting list initiative.

'I have a letter from a consultant saying that to meet the waiting-list commitments, his hospital is paying people to work at weekends, which costs more than getting people in through the normal channels, ' he says.

'The government's emphasis on waiting lists is distorting clinical priorities - and costing money as well. What we need is an emphasis on waiting times.'

Liberal Democrat health spokesman Dr Peter Brand said the cash injection was 'way overdue'. He also called for new resources 'to be invested in increasing the capacity and quality of the NHS and not simply thrown at the dubious waiting-list targets that distort clinical priorities'.