WALKING TALL: 'Ministers are clearly frustrated by the NHS absorbing increased funding without seeing any sea change in how it operates'

What should one write on the day of a general election?

Should I assume readers are yet to go to the polling station or are reading this several days later when the results are already passe?

Perhaps the best way is to identify the health issues politicians have to address in order to get my vote - though they may not be the ones you feel are important.

Four years after New Labour raised so many expectations in so many quarters, the NHS finds itself in a complex situation.

Few of those people looking for significant alterations have been disappointed: they happened in both the organisation of the NHS and in the more subtle areas of change management and political development.

The organisation has seen the demise of the internal market and all its by-products.Moves to restore public perceptions of equity and co-operation came in the shape of primary care groups, health improvement programmes, the duty of partnership, clinical governance, the National Institute for Clinical Excellence and the Commission for Health Improvement.

There was also the reconfiguration of many institutions, including community trusts, mental health trusts and now health authorities.

These mechanical changes have a certain internal logic to them.

First, keep the service as locally sensitive as possible to develop a stronger sense of 'our'NHS, and a proxy for consumerism in a system without excess capacity to give consumers real choice.

Second, they harness economies of scale so that technical expertise, capital expense and rare workforce skills may be concentrated in large, efficient warehouses (or should I say temples? ) of specialised services.

Third, they make the system as transparent and accountable as possible to allay public misgivings about professional misbehaviour.

Fourth, the government centralises the principles underpinning clinical services, but avoids becoming embroiled in the mechanisms of delivery.

Local sensitivity has been increased by user involvement, and by scrutiny models influenced by local authority members. Clinical principles have begun to emerge in national service frameworks. Clinicians have been encouraged to provide a more standardised model of care, offering predictable and consistent standards.And professional accountability has increased.

It is difficult to argue with the rhetoric of these developments, but one wonders whether the electorate will allow the government to continue driving the NHS in its current direction.

We should be clear about the messages we want to give politicians.

For many people, most problems lie in the gaps between rhetoric and reality, where the government's approach to change and people management may have been naive and simplistic.

One can sympathise with its motives; ministers are clearly frustrated by the NHS absorbing increased funding without seeing any sea change in how it operates.

In the scenario that plays out as 'managers can't run the NHS, the only way we'll get a decent service is to run it ourselves', politicians end up trying to run probably the most complex managed organisation in the world.

Policy-makers with (at best) a mechanical knowledge of clinical issues, who are attempting to run such services directly from Whitehall (even if they have included some clinicians) are likely to have an uphill struggle persuading clinicians at the coalface that Ministers Know Best.

As long as the community psychiatric nurses, GPs and consultants are putting their dedication, effort and knowledge into patient care, frameworks may be a helpful adjunct, providing support and rigour. But guidelines, protocols and instructions will not improve patient care if the professionals feel alienated, disenfranchised or undervalued.And much of the impact of the last four years has resulted in all three.

The 'Respect' campaign by GPs, the British Medical Association's ballot on industrial action, the recruitment and retention issues that are beginning to beset many areas of the service are all signs that ministers' 'hands-on' approach can have perverse effects.

I like the principles underlying politicians' policies, but find the translation into practice unpalatable. If politicians recognise that clinical leadership and inclusion are keystones of the new NHS, they should allow leadership to emerge and flourish.

If they do not believe it, they should stop talking about it, because what is worse than overt disempowerment is disingenuousness. Leadership - yes please. But above all, consistency in language, policy and delivery.

All I need now is a way of expressing that in a single X.