If middle managers don't manage and nurses are poorly motivated, no amount of money can solve the NHS's problems, says Michael White

My friend at the swimming pool Sue was on holiday when chancellor Alistair Darling made his pre-budget promise of more cash than expected for the NHS. But I know what this 40-year NHS veteran would have said. 'It's not about money any more.'

I fear Sue may not be far ahead of a shifting public consensus here. All this extra money is terrific but the cumulative effect is alibi-breaking. Obesity again? DIY dentistry? Hospital infections? Has no progress been made? Evidently not, judging by those 90 Clostridium difficile deaths in Kent. Better management skills? Not if Rose Gibb, the chief executive at the heart of Kent's outbreak is allowed to resign and pick up a large pay-off - with Comrade Alan Johnson almost certainly unable to stop it - instead of being fired. I know that these things are difficult and the private sector makes dodgy pay-offs too - but it's not taxpayers' money.

Shadow health secretary Andrew Lansley accidentally illustrated this when he attacked Comrade Alan for not sacking the 'killer bug trust' board and taking it over. I thought we now favour decentralised decision-making, Andy?

It is not all bad news. By coincidence Mrs White was in hospital (nothing serious) for a couple of days this month. I was thrilled to be confronted before entering the ward in this smart London hospital by a notice instructing me to rub my hands under the alcohol gel dispenser.

Well done, and about time, I told staff who happened to be cluttered around the ward desk. Did they spot that my clean hands were clapping them in a friendly but slightly ironical way? I hope so. Mrs W later told me they'd swabbed her for MRSA on arrival, another first.

Mrs W also reports that the food was excellent, although her taste is bland. Sue at the pool told me that when her late husband was in an equally swish NHS hospital for three months, he was refused the spicier West Indian menu on account of not being Afro-Caribbean.

Sue won that round. But it's a bad story and illustrates her main complaint: it's not about money, it's about attitude. Many middle managers don't manage, many nurses seem poorly motivated.

As it happens, Mrs White, herself an experienced manager, saw some excellent middle management on her ward. 'I told you the last time you must order more sheets as soon as stocks run low,' a nice-but-daft slip of a nurse was reminded when she feebly announced: 'We've run out of sheets.' The reproach was kindly done. The trouble is that we all have stories such as this ('the treatment was wonderful, but') and we all talk. That is why ministers are told NHS staff spread another lethal disease: demoralisation, which feeds its way into the polls.

Try this one. My gentle giant of a friend, Tom, refused to leave another of our great London hospitals until the woman in the bed next to his wife had been seen by a doctor. 'We'll call the police,' they told him on the ward. 'Call them,' he replied. When the doctor finally came he bawled out the nurses. ('You often have to tell them three times,' one medic tells me.) And Tom's wife was told that 'we don't put more paper in the toilets at weekend'. Argh!

Excuse the rant. But Mr Darling's extra 4 per cent (much of which comes from past capital underspending) will do nothing to restore government popularity if even patient patients give up. Nor will Comrade Alan's latest initiatives on the obesity crisis (surely not quite as serious as global warming?) on GP hours or on the new mantra - fair, personalised, innovative and safe care. Dirty sheets or loos can blot out all that (and where did 'choice' go?).

As Conservative leader David Cameron has unkindly taken to saying, 'stop treating the British people like fools' - even though they often behave like fools, getting fat and ill as a result, Dave tactfully fails to add.

Yes, Comrade Alan and Lord Darzi have got to take staff with them in the drive for better productivity and outcomes. But the service needs leadership and direction at a time when the Brown regime seems to lack both.

Sue thinks Darzi is right about hospital specialisation. Meanwhile, as we plough up and down the pool to avoid getting fat and decrepit, we're saving the NHS money.

For more analysis of the spending review, click here