In a moment of heat the other week, a ministerial adviser told me, 'Remember, Mike, a successful spin exercise isn't always one which results in favourable publicity. Sometimes it results in little or no publicity at all.'

One such example might be health minister John Denham's discreet announcement, in a written parliamentary answer, that 'we have no plans to set targets to reduce the number of management posts in the NHS'. In other words, a five-year cycle of manager bashing was drawing peacefully to a close.

At the time I thought I'd stumbled on a mini-scoop.

But my eagle-eyed colleagues at HSJ spotted it too, and beat me to the keyboard. In the event, Mr Denham has little or nothing to add: the NHS has responded magnificently to the challenge for greater efficiency, and health secretary Frank Dobson is well on target to save£1bn on management costs by the end of this parliament. Er, that's it.

Two stories in successive days illustrate the fickle nature of publicity. On one day the papers rightly trumpeted the decision by Mr Justice Johnson to overrule that 15-year-old girl's declared wish to die rather than see her life's chances cruelly curtailed by a heart transplant operation.

The next day they reported the 'victory for civilisation' achieved by Pamela Coughlan's Appeal Court verdict over long-term nursing care. Both fascinating, but one is personal - the ethical issue of medical coercion.

Unlike the Jaymee Bowen case, where the issue was the health authority's refusal to fund what it judged to be costly, ineffectual treatment, the heart case has little or no implication for the Dobsonian budget.

Ms Coughlan's case had huge implications -£220m a year if the Court of Appeal had upheld Mr Justice Hidden's ruling in December that all nursing care is 'health' care not 'social' care - ie not subject to means testing. As you will have read, it ruled instead that the NHS should pay where a patient's need in a local authority nursing home is primarily one of health.

Dobbo was 'delighted' because it upheld the status quo.

But so was the Royal College of Nursing, which had backed Ms Coughlan. It believes the ruling will tilt individual decisions away from means-testing. Hence those confusing headlines like 'Woman's nursing home victory saves NHS millions' (Guardian /Telegraph ) and the gloomier 'Ruling forces the elderly to pay for care' (Independent ). Personally, I thought the usefully short word 'chaos' should have got more prominence.

The devil will be in the detail, as NHS lawyers unpick the text.

Meanwhile, ministers are saying nowt. All the same, one aspect of the affair seemed worth immediate note. Ms Coughlan, paralysed in a 1971 car crash and now 55, did have one victory. The Appeal Court ruled that North and East Devon health authority had been wrong to close Mardon House, the purpose-built residential home to which she was moved in 1994, the second such rationalisation to which she was victim.

I was sensitive to this point because I had just been reading about Tory MP John Wilkinson's complaint that NHS rationalisation is endangering another of what Edmund Burke used to call the 'little platoons': a small, worthy hospital, St Vincent's in his Ruislip constituency, the sprawling outer suburbs of west London.

Opened in 1906 as the Eastcote Cripples Home (not much consumer sensitivity in 1906), it built up a useful orthopaedic role as a private, charitable hospital of the pre-NHS type, with mostly (98 per cent) NHS customers.

No longer. The NHS Executive's September 1997 circular which prepared us all for the end of GP fundholding and the internal market also told trusts to make 'maximum cost-effective use of local NHS capacity before contemplating recourse to private sector hospitals'. In an adjournment joust with the prickly but tenacious Mr Wilkinson, Minister Denham told the Commons that St Vincent's subsequent decision to abandon orthopaedic work (and sack 48 staff ) reflected the 'prohibitive cost' of maintaining surgical facilities.

MP Wilkinson is having none of it, and complained that the 1997 circular had encouraged nearby Mount Vernon (about whose future I seem to remember him protesting, too) to squeeze St Vincent's, though (Mr Denham countered) it is still getting almost£800,000 worth of NHS contracts a year. Huge PFI projects in the area may prove the kiss of death, the MP said. All local decisions, the minister told him. Talks are underway.

Don't hold your breath.