The 'nurse consultants' bombshell dropped by prime minister Tony Blair may have shattered the illusion of both health service managers and unions that they are being treated as partners by the government.
Andrew Foster, chair of the NHS Confederation's human resources committee, told HSJ through gritted teeth that the announcement caught him on the hop.
Certainly, the idea has not cropped up once in months of discussions with ministers and civil servants over the Department of Health's new NHS human resources strategy, the proposed pay and reward system, or even over next year's award.
Indeed, insiders say that health secretary Frank Dobson himself was not aware of the new scheme until a couple of days before the annnouncement. That may not have given enough notice for the idea to be included in the Depart-ment of Health's evidence to the pay review bodies, due last Friday.
Confederation chief executive Stephen Thornton is now demanding that the government should involve health authorities and trusts 'as the employers of nurses' on the practical implementation of Mr Blair's proposal.
NHS employers are already concerned about the impact of the new discretionary awards for senior nurses and professions allied to medicine, as their evidence makes clear.
The awards, which were formally agreed last week, will be a 'new charge on the system', the evidence says. They are also one of the unavoidable national service pressures which, the confederation says, will eat up much of the growth money from the government's comprehensive spending review.
Health service unions, of course, see it differently, arguing that the results of the spending review will provide enough for a substantial pay award next year.
But if the new nurse consultant posts prove to be yet another extra drain on resources, that would also limit what employers can afford to pay.
On the other hand, if the new posts do reward nurses at the top of their profession there may not be many contenders. The assumption is that Mr Blair was speaking about I grade nurses, an increasingly rare creature on the wards.
Apart from the lack of consultation on the issue, the confederation's main concern is that the idea of nurse consultants could complicate the already agonisingly slow progress towards a new pay system.
Its evidence insists that 'any changes in the current system should be limited' until the new system is implemented.
Until that happens, the confederation rules out the idea of a three-year settlement in line with the spending review. For next year, it wants a pay award that 'modestly exceeds inflation', which it estimates might be slightly more than 2.6 per cent, a figure likely to be revised by the time employers are called to give oral evidence to the pay review bodies.
The confederation is also arguing for an identical pay award for all staff, and stresses that there should be no staging next year.
The evidence warns that staging could be one of the 'major adverse consequences' of 'a pay increase beyond what is affordable'. Other options could be cuts to services, leading to fewer staff.
Staging or service cuts would be highly unpopular options, the confederation warns. It would also aggravate recruitment and retention problems, which the confederation believes are the key issues.
Unlike doctors, nurses and professions allied to medicine, the confederation does not see pay as the solution.
It wants a national recruitment and retention strategy linked to the emerging new human resources strategies for England, Scotland and Wales. But evidence from the health service occupational groups forecasts that even more staff will leave the NHS if pay is not tackled.
The British Medical Association - which says that it is totally unacceptable to tie doctors' pay to DoH spending targets - wants a 10 per cent increase next year specifically to tackle recruitment and retention problems.
The BMA sees the rise as the first stage of a five-year plan to restore doctors' pay to the 'appropriate level', both in relation to other professional groups and to compensate for past staging of awards.
PAMs organisations say substantial pay rises are vital to stop the exodus of skilled staff, and are seeking a 22 per cent increase over three years to bring them into line with comparable professions.
Their evidence says that the recruitment and retention crisis is worse among PAMs than any other occupational group in the NHS, and cites a survey of recently qualified staff as showing that pay is the main reason for staff leaving the NHS.
Similar points are made by the nurses, midwives and health visitors staff side in evidence to be published next month.
Even Royal College of Nursing general secretary Christine Hancock, while welcoming the nurse consultant idea, made a point of saying: 'We must ensure that all nurses are valued properly in terms of pay, conditions and support.'
Institute of Health Services Management director Karen Caines thinks making the nurse consultant idea a reality will require delicate negotiations between the government and the professions.
'Modernisation of nursing is welcome, but the government has still not promised to resolve the profession's major gripe about the basic pay settlement,' she says.
Some indication of whether that nettle will be grasped may emerge this week, when the DoH is expected to publish its evidence and Mr Blair faces his critics at the Trades Union Congress.
But the signs are that the government intends to keep public sector pay awards down, and in that context perhaps nurse consultants will prove to be simply a sop to divert attention from the main issue.
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