'Treatment for those who will benefit' was Alan Milburn's spin on the r-word at NICE's first conference. Kaye McIntosh joined the queues

Queuing is said to be Britain's top hobby. Which must be why the National Institute for Clinical Excellence gave delegates at its first conference last week so much practice.

The organisers certainly weren't meeting their waiting-list target - with more than 2,000 delegates, they were struggling to find standing room at the back of the seminars.

'I've seen faster-moving hearses, ' commented one woman, still standing in line to register after 30 minutes and realising she was missing NICE chair Sir Michael Rawlins' opening remarks.

And it ended in appropriate style, with a message that the building was being evacuated. British to the last, people filed slowly out of the main exit - using the fire doors might have given the impression they were a little overexcitable. One false alarm later they were allowed back in, but many had given up and headed off before chief executive Andrew Dillon's closing speech.

At least the queues had earlier ensured a full house for health secretary Alan Milburn's set piece denunciation of what his boss has described as 'the forces of conservatism'. He warned delegates that the Daily Mail and the Conservative Party 'believe that only emergency and urgent treatment should be provided on the NHS'.

'Elective and chronic care should be left to an expanded private sector.'

Instead Labour was committed to a modernised, public sector NHS.

He said he was 'breaking with convention' by using the 'r-word'. But only to insist that rationing does not exist in the NHS. 'We are not in a system where each patient only gets a fixed ration of healthcare.' But 'just like any other healthcare system in the world' the NHS had to set priorities. This didn't include charging patients. 'That ignores the fact that healthcare is disproportionately used by the very young and the very old.'

More charges or top-up private insurance were 'not effective solutions to the challenges we face'.

Strange, then, that the next day the British Medical Association said it would be looking at introducing more patient charges as part of 'a wideranging review of healthcare funding in the UK'.

In a move that might be interpreted as a snub to Mr Milburn, BMA chair Dr Ian Bogle said it was the BMA's duty to look at the 'large and widening gap between the resources available for healthcare and the demands and needs of patients'. Mr Milburn may have a reputation for doctor-bashing, but the BMA obviously intends to give as good as it gets.

The health secretary said NICE would be part of his own solution to meeting the rising cost of healthcare.

'The government sees the role that NICE will play as a key to the sustainability of the health service. It will have to sort out the wheat from the chaff of both old and new technologies.'

In an upbeat assessment, Mr Milburn said: 'It is precisely because NICE will point out which treatments are less clinically cost-effective that it will free up financial headroom for faster uptake of more clinically cost effective treatments. That's how patients will get the drugs they need, while being protected from those they don't.'

NICE chair Sir Michael Rawlins thought this was being slightly optimistic. He told HSJ: 'It would be too little money if you relied purely on disinvestment.'

Adam Oliver, from the Office of Health Economics, said: 'I am not sure whether they have completely thought through where the money for new treatments will come from.' Any extra benefit from cost-effective drugs would still drive up costs - and there probably weren't enough widely used and obsolescent treatments to make huge savings.

Mr Milburn said NICE guidelines would not replace clinical decisions.

But 'health service organisations had systematically and consistently to take account of NICE's approved guidelines'.

And - in a warning to managers - he said the quality reforms, including NICE, would mean 'pressing down on unexplained variations in the costs of care in NHS trusts'.

At the same time, Mr Milburn tried to reassure the pharmaceutical industry that NICE was not an attempt to control it.

'I see no reason why in future new drug treatments should not comprise a much higher share of the growing NHS budget - which is precisely why we have taken the arbitrary cap off drug spending by developing unified budgets.'

But any hopes he had of heading off criticism of NICE may be short-lived.

In what looked like a fit of pique, Glaxo Wellcome hadn't taken an exhibition stand at the conference. The unlucky manufacturer of Relenza, the first drug to be refused NICE approval, had spent its money on advertisements reminding doctors they can still prescribe the drug on the NHS instead.

Cultural change 'more important' than structural change Leeds Teaching Hospitals trust medical director Dr Hugo Mascie Taylor said NICE was an example of 'changing the structure instead of the culture'. There was 'an over reliance on structural change when what matters is cultural change'.

General Medical Council president Sir Donald Irvine said what was written about clinical governance was 'all about structure and hardly any of it is about better care and how we practice'.

The public wanted doctors with good communications skills, who respected patients and wanted to gain their consent - better behaviour, not organisational change.