Editor's blog Monday 13 June 2011: The political NHS and the real NHS

There is the political NHS, and then there is the real NHS.

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The political NHS is intrinsic, and hugely important. It is the focus of much of what Health Policy Insight does; it has been the battlefield of who wins the reform of NHS reform, a battle we have chronicled in some detail and which is all over the media today.

The political NHS matters hugely: the politics and personalities that drive it. They write the policies (very badly, at points); they draw the map.

But a vital reality-check is to talk to people who work at the front line in the real NHS about their view and understanding of the political NHS.

And if you do so, you will quite often find they do not have a clue about the political NHS and its denizens.

Some years back, I was at a DH diabetes event in Slough (yes, my life rocks) at which the star attraction was then-health minister John Hutton. Hutton was fine: he popped around the various dignatries and local players, gripping and grinning and gurning in his unique way. And one of the local leaders (who was not being rude) said "yes, but who are you?"

This man genuinely didn't know who the minister was, nor why his appearance at a photocall mattered.

That local leader represents a lot of people in the NHS, whose discretionary effort is essential if The Nicholson Challenge of making £4 billion efficiency gains a year over the next four financial years running (which as far as anyone can tell, is unprecedented for any developed health system).

That is about the optional effort and engagement of local middle-managers and clinicians who quite often simply do not know or need to care who the minister is. The realpolitik of the Conservative political narrative of the past year, which has been calling management "empty bureaucracy", may have some intriguing consequences.

Because every single thing needed to make the reformed reforms work requires management.

I'm going to wait until reading the actual Future Forum reports and Government response are published before forming any conclusions on who has won or lost the reform of the NHS reforms.

I'm just mindful of a conversation with a very experienced nurse manager that I had over the weekend. This person is retired after an very good NHS career managing nursing staff and a specialised unit, and was talking about a request from their last trust to come back and help with some shifts and projects. "And I thought about all the changes, and what a mess they'll cause, and now it's back to RTT-18 after that was let go. And I said 'No thanks, I don't think I will'."

That is, of course, just the view of one person. But that's one person from the real NHS - the one on which the political NHS depends (it's not the other way around).

And I suspect there may be quite a few more like her.

And both the political NHS and the real NHS need those people. And there is more than a fair chance they may fail to get them.