Published: 03/11/2005 Volume 115 No. 5980 Page 10

I saw in the weekend papers that a new academic study reveals that up to half of patients do not follow the advice of their doctor in following prescribed courses of treatment, often with fatal results.

The problem? Poor communication skills and a lack of effective bedside manner on the part of the medic.

'Satisfaction depends upon the patient's perception of the doctor's sensitivity, concern, respect and competence, ' wrote a couple of psychologists in the trade press.

Naturally it made me think of health secretary Patricia Hewitt, still recovering from what must have been the most bruising political week of her four years in Cabinet. A lot of nonsense is routinely spouted by backbench MPs on all sides, and one Cabinet minister I spoke to (not Ms Hewitt) said they could not bear to read the Sunday papers because they were 'such rubbish'.

But even allowing for media hype and malevolence, there is no doubt that a three-way test of wills is under way between Tony Blair, his ministers and MPs on the speed and direction of public service reform.

Backbenchers smell blood: his.

In this column last week I predicted correctly that the health secretary would retreat over primary care trust staffing (she did so at Commons question time), but wrongly that she would prevail on the less important but sexier issue of the public smoking ban in England.

As everyone now knows, she didn't. What happened? Last summer Ms Hewitt opened up a consultation process on smoking. She wanted to 'unpick' the manifesto compromise crafted by then-health secretary John Reid with the agreement (this bit is important) of Tessa Jowell, the Cabinet's anti-smoking Taliban.

Instead of allowing smoking in pubs with no food and stopping it in 80 per cent of outlets, the health secretary wanted to create sealed 'smoking carriages'. Apparently Mr Reid was happy with that, provided she left private clubs alone, working men's pints 'n' fags clubs, not the cigar-and-brandy kind. Nowadays, as the defence secretary, Mr Reid protects soldiers' smokey dens too.

As I noted here last week, Ms Hewitt was 'confident of being able to persuade Cabinet colleagues'.

That is where it went wrong, in the Cabinet's domestic affairs (DA) committee. Normally chaired by deputy PM John Prescott, who was abroad, its chair that day was the ever-busy, generally tolerant foreign secretary Jack Straw who has other things to worry about.

What happened was that Ms Hewitt was seen to have briefed some reporters in advance that a) she would win and b) her revised policy was tougher.

Apparently Taliban Tess, a former public health minister, thought it just the opposite. Why? Because all pubs and restaurants in England would be able to have smoking carriages, not just the non-food minority.

Tess duly prevailed over Trish and the DA committee ended up back where it started with ex-smoker Reid's compromise. It was rooted in gradualism and the argument that these days pubs make their real money from food, so the deal works with the grain of public opinion and profit. Ms Hewitt was left to put a brave face on it, predicting a total public smoking ban, Irish-style, eventually. She's right.

What both rows- fags and PCTs- underline is the lack of inter-personal skills, of tough or tender variety. Did Ms Hewitt ring enough backbench MPs over the summer to schmooze? I doubt it. For instance, was antismoking MP Kevin Barron, admirable new chair of the health select committee, squared on fags or PCTs?

I do not think the row proves that Mr Blair is yet on a terminal slide, though a few Brownites say so.

The PM is routinely described as a dictator; all of a sudden he's a wimp.

Both versions are caricature.

The row highlights the difficult role of press officers and those politically appointed special advisers (spads) across Whitehall. The main task for a minority of them is handling the press, as distinct from policy. In its running war with the media, the NHS needs facts and counter-spin.

It must have been a hard week for Ms Hewitt's new spad, Paul Richards, caught in the middle doing his best for the boss in a maelstrom of rival briefings. He is the author of Be Your Own Spin Doctor, a lively book I still recommend.

This week Mr Richards did not return my call. I do not blame him. .

Michael White is political editor of The Guardian