westminster diary

One of the hardest tasks NHS managers face in the course of their jobs is dealing with politicians, says Baroness Cumberlege, who has sat on both sides of this fence and suggests that politicians are, well, misunderstood.

'Managers need to understand how politics works,' she says. 'Politicians are weak on understanding how policy translates into management. Very few of them realise the consequences of their decisions until they hit the NHS. They all want to make a difference and improve the NHS, but it's a very purist ideal.'

The baroness - formerly a regional health authority chair and a health minister under John Major - is now making her living as a consultant, including teaching managers to come to terms with their often capricious, vain, and temperamental political overlords.

'The Red Indian brave says you have never known another brave until you have hunted in his moccasins. It is only when you get into government you really understand the difficulties of managing a complex organisation like the NHS from Westminster and Whitehall.'

She doesn't reveal too much about the content of her 'Westminster experience' away-days, although she drops hints that it can be, at times, an authentically gruelling experience for her 'pupils'.

Look at it from a minister's point of view, she says. They are desperate to make their mark, and yet the pressures of the health brief, coupled with the vagaries of the electoral timetable, means that they have very little time to make changes. 'In the first year the administration is thinking what to do and in the last year they do not want to make heavy decisions. As a result it is difficult to bed policy down.'

She should know, having overseen five years of the Tory internal market reforms, a programme which she suggests was cut off in its prime. 'The NHS needed another eight years or so to get the full benefit of the reforms.'

She is magnanimous about Labour's New NHS reforms, and is probably too much of an NHS devotee - and canny consultant - to be too harshly critical.

'It beholdens all of us to make sure primary care groups work.'

But her work with PCGs makes her suspect they are heralding a 'four- tier service'. She wonders if the salaries on offer can attract managers of a sufficient calibre and worries that many GPs are unprepared for the very public scrutiny - and press attention - that will come with PCGs.

She also questions if GPs are genuinely committed to sharing power with nurses and other board members. 'Some GPs are finding it difficult to accept that nurses are there on equal merit, and I suspect that is true of lay members and council members.'

The baroness was offered jobs at both social security and National Heritage during her five years in government, but turned them both down because she says she loved the NHS too much. The champion of Changing Childbirth and nurse prescribing is still, she says, 'passionate about the NHS'.