More health cash? It's a nightmare

We have high expectations of how the Health Secretary and his working parties will spend the new NHS

Spare a thought for Alan Milburn. The Health Secretary is to oversee the extra spending of £19.4bn pledged by Tony Blair last month to improve the National Health Service. In so doing, he must beware of stepping on the PM's toes: Blair has assumed "personal responsibility" for the NHS, and indeed presented the government's health strategy himself, while a bravely smiling Milburn sat quiescently in the background.

The stakes are high indeed. No longer will the NHS have penury to blame for visible failure. Should the largesse fail to deliver tangible improvements, many think the NHS will have no second such chance to reform. As the president of the General Medical Council, Sir Donald Irvine, says: "This is not a short-term fix."

It is an unenviable predicament for any ambitious 42-year-old to find himself in. As Norman Blackwell, the former head of the No 10 Policy Unit, says, Milburn risks "being the person that Blair gets to do the backtracking - and then ditches". The former health secretary Kenneth Clarke has described the departmental job as "the most politically dangerous" in western Europe. And George Alberti, the president of the Royal College of Physicians, describes Milburn's plight as "very difficult shoes to be in".

Still, there are some who keep faith in Milburn's ability to cure the NHS headache. The former minister Doug Henderson says that, "if one of the young lads is going to do it", it is Milburn - "He's got conviction." From primeval CND days come tales of how young Milburn would throw himself into the melee of early 1980s anti-nuclear idealism. He would then, says one co-campaigner, leave the pub meetings "to go and plot his future career on flow diagrams".

Certainly, Milburn has been busy. By April he'd appointed what one report described as "dozens" of health professionals and lay personnel (including Crimewatch's Nick Ross) to form working parties, officially named Modernisation Action Teams. The plan is for each team, having gathered on 12 April, to aim by early July to report on how the NHS billions should flow.

There are reservations about the summoning of the great and the good to a smattering of confabs. For one, the method reminds some of the Wilsonite 1960s Whitehall-knows-best corporatism. (Indeed, the department describes the initiative as a "National Plan".) Some also fear an old-fashioned medical establishment takeover and that the very size of working groups - around 20 each - will hamper their efficiency.

The breakneck July deadline prompts most concern. The participants are largely part-timers with heavy, often senior, responsibilities elsewhere. Alberti says the timescale is "so short" that he doesn't feel that "real well-developed" long-term thinking can emerge from it. Dismay arose when it became clear that some had been invited to the initial meetings with only five days to spare. One was notified by a solitary fax - and was not asked to confirm acceptance. Given such difficulties, alongside the complexity and profound importance of the task, one health official believes that "the schedule is impossible".

The prospect of No 10 involvement casts its shadow. One target is Blair's health policy adviser Robert Hill, accused by an observer of waiting for documents to appear and then "adding fairly vociferous comments". But Blackwell says the PM's involvement can be beneficial, although Downing Street staffers have "no detailed knowledge" to match that of traditional departments. Since 1997, the Policy Unit has "totally underestimated the difficulties of trying to drive policy".

Scenting the likely fallout from failure - in the form of the next winter epidemic or other, as yet unforeseen, mishap - perspicacious Whitehall high-flyers are keeping their distance. A likely future permanent secretary commented that the Blair- Milburn project resembled the most dishevelled kind of dog's policy-making breakfast. "Sounds like a nightmare," breathed one canny operator, sheltering behind a sheepishly grasped beer mug. "You won't catch me near that one."

One Milburn initiative of particular note has been the formation of a strategy unit of health professionals, who will each sit on one of the working groups. The unit is described by the Whitehall expert Peter Hennessy as both "hybrid" and "unusual".

It is chaired by the special adviser Simon Stevens, a former NHS manager turned local health authority official, recruited by Frank Dobson in 1997. There will also be a steering group to "co-ordinate" the far larger working parties - and attempt the fiendish task of arbitrating in the many expected cases of policy overlap between them. It may be that the working parties will fulfil the deadlines set and formulate well-informed, enlightened policies. The temptation to prefer headlines over long-run wisdom may be resisted. It may even be that Milburn's unit will be capable of throwing open the debate on the limits of public healthcare - this, the experts agree, is essential to bring realism to the debate among voters, as patients and taxpayers alike.

But at present, for Milburn, the threat of failure looms. The weeks until July will pass swiftly. His hitherto stellar career could be effectively over in a few, short, life-transforming days. He will certainly need a fair wind to escape a fate similar to that of John Moore, the last rising star responsible for health to head such a review in 1988 under an equally dominant leader. He lost his career over it.

As midsummer approaches, there will be headlines. There will be spin. There will be consistent overdoses of targets, crackdowns, announcements, initiatives and, above all, photo ops. For the sake of the NHS, wish Milburn, Blair and everyone else good luck. They are going to need it.