This is a good, practical argument. It makes sense to people who intuitively know that in their own lives when they are halfway through something – even if they know it was a mistake to have started it – that sometimes it’s better to finish it – and then have a think about what to do next.

Those arguing for the passing of the Bill do so for this very pragmatic, common sense reason.

The only problem with this argument is that in this context it completely undermines the sovereignty of Parliament.

The Bill to abolish PCTs has yet to pass through Parliament, but they have already been abolished.

The Bill to set up the National Commissioning Board is yet to pass through Parliament, but this illegal body already has a Chief Executive and Chair – and last week outlined its structure, where the staff are going to sit, and what they will do.

The Bill that will move public health functions to local authorities has not passed through Parliament, but most Directors of Public Health are already spending a lot of their time arguing about to whom within the local authority they should report.

I know there are all sorts of good reasons why the implementation of a Bill has to start before it is passed, but the speed with which these NHS reforms have been implemented – without legal certainty – is an exceptional example of the ‘need for speed’ that has characterised this Government.

But this is a very, very high risk argument to use. People have only to link the idea that we are half-way through implementation with the unfortunate fact that the Bill has not yet been passed and some will raise some constitutional issues.

The Government appear to be daring Parliament to assert itself against those who seem to see its agreement as a minor issue.

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Yesterday’s debate – caused by the letter from the editors of the Nursing Times, the Health Service Journal and the British Medical Journal – provoked the use of this metaphor on many occasions.

When I heard the discussion on Tuesday’s Today programme between Charles Alessi and the BMJ’s Dr Fiona Goodlee, what struck me more than anything else was that presenter John Humphrys kept on saying – to gales of his own laughter – that nobody knew what the changes actually were.

He said repeatedly that while he was used to there being disagreement about what reforms might actually achieve, the experience of having no-one able to persuade him what empirically they were was a new one for him. He thought it really funny that – there they were, on prime time radio, discussing a major set of changes – and no-one could tell him what they actually were!

So he asked the two doctors he had invited to debate the changes.

Charles Alessi said that the reforms will give clinicians the right to decide what should happen in their localities. And it’s true – this was an intention of the Bill.

Fiona Goodlee countered by saying that national organisations gain more power through the reform. And that’s true too – this was an intention of the Bill.

The reason John Humphrys finds this so funny is that the car crash between these opposing intentions is already embodied in the Bill. This is not a matter of intention -but actual fact.

As I mentioned earlier this week, CCGs are being set up in every locality. The NCB is set up to bring power to the centre.  More NHS commissioning will take place at a national level than ever before.

So the car crash is taking place already – with the system trying to achieve two contradictory things on everything.

Tomorrow I will explore what this means for public health.

Since September 2010 I have been pointing out that the Government has no narrative for these reforms. The fact is that we are – 16 months later  - hearing John Humphrys thinking it’s really funny that no-one can explain to him what the Government is trying to do with the biggest organisation in the country.

I have now discovered what an NHS reform car crash sounds like.

It’s John Humphrys chuckling on the Today programme that – as one of the best informed people in the country – he hasn’t a clue what they are.

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If you are a Tory MP you will look back to July 2010 and remember a White Paper which rang out loudly with some important truths about getting rid of bureaucracy in the NHS. At the time the Government was announcing its revolutionary plans to reform the NHS. Whilst no-one, including Tory MPs was too clear about what health care problem the reforms were meant to solve, they were at least clear that they wanted to remove layers of bureaucracy form the NHS.

As in the quote above – from the executive summary of the White Paper – there was much talk of decluttering the bureaucratic maze of the NHS.

The Bill enacting this White Paper has now been going through Parliament for a year. So if I were that same Tory MP looking at the architecture of NHS Commissioning from 2013 what would I see?

Let’s pretend that I am that MP, having a cup of coffee with Dr Smith the GP who is chairing his pathfinder Clinical Commissioning Group, and that I ask him what this simplified commissioning will look like.

Dr Smith is assisted in answering this because just last Wednesday David Nicholson met all 50 CEOs of the PCT Clusters to discuss the formation of the NCB and Dr Smith has just been updated.

As an MP I have a real interest in this reform not only because I’m interested in health care for my constituents, but just as importantly from the point of view of  democratic representation I want to know where they will go with a constituency problem in the new dispensation.

This is what Dr Smith says,

“It’s a bit complicated. My colleagues and I plan to form a Clinical Commissioning Group that will commission a lot of the NHS care for your entire constituency. I will come back to how we will do that in a minute.

We will however not be commissioning all the NHS care for your constituents. Specialist care for those of them with rare diseases will be commissioned nationally by the National Commissioning Board. The NCB is a new national quango set up under the Bill going through Parliament.  The NCB will also be commissioning GP services in your constituency. So if you have a problem with either specialist care or the standard of GP service the body you need to complain to will be the NCB – run from Leeds.

The NCB will have a field force at our local level. Your old local PCT which had a local chair and non-executives has been abolished and formed into a cluster of PCTs. This PCT cluster will now become a part of the National Commissioning Board in our region.

Some NHS Public Health Services will be commissioned by the NCB and some by your local authority. Public Health England – a quango that has been set up under the Bill – will have a further role. Therefore if you have a complaint about the public health services commissioned for your constituent you can go to your local authority, the NCB or Public Health England.

I and my GP colleagues are forming a clinical commissioning group. But before we are allowed to commission any services we will have to be authorised by the National Commissioning Board. We don’t know yet what this authorisation will entail but are starting to plan for it. So if we gain authorisation you will be coming to us with any complaints about the NHS services that we have commissioned for your constituents.

It is however possible that we won’t be authorised by the NCB – in which case a manager from the NCB will be appointed to run commissioning services and you will probably have to take any complaints to the NCB.

As CCGs we will employ some staff ourselves. We are also being told that we have to employ ex-PCT staff that are being formed into Clinical Support Organisations.

If we are authorised we will be working with both our own staff and those from the CSO to develop our commissioning intentions. Before we will be allowed to publish these they will be agreed by another new body – the Health and Well-being Board formed by the local authority.

But before we take it to the Health and Well-being Board we will have to consult the clinical senates that will have been set up by the National Commissioning Board.

So if you don’t like the CCGs commissioning intentions you can complain to the Health and Well-being Board and the Clinical Senate as well as the NCB.”

Whatever else the Bill achieves – no one can see this as simplified.

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Of course not. The core business of all of this debate and discussion is to relieve pain and distress through the application of the basic principles of the NHS within a limited budget. For me the reforms and the politics are an important part of that process, but they are not its purpose.

Last Thursday we had a glimpse of what this is all for when a comprehensive study of heart attacks in England was published. The outcomes of 840,000 people who had had 861,000 heart attacks between 2002 and 2010 had been studied and had found that death rates had fallen by 50% for men and 53% for women.

I remember that the 2001 Labour government had, as one of its dreaded targets, the aim to reduce the death rate from heart attacks by 50%. When I started as a special adviser in 2001 I was hoping that someone had done some detailed work on how to achieve this – and it looks like they had. Someone had carried out an analysis and shown that if best practice was applied quickly across the NHS this many lives could be saved.

The researchers found that half of the drop in death rates resulted from changes in lifestyle so that our hearts were stronger and the attacks were less severe. But 50% of the reduction is due to the much better organisation of services within the NHS.

Much of this is caused by the earlier application of thrombolytic drugs to the patient as soon as possible after they have had a heart attack.

Some of the rest is caused by angioplasty and stents having become a much more routine and safer operation and the third major reason is the much, much better rehabilitation advice and activity that makes a second heart attack less likely.

If one national intervention made the most impact upon these improvements it was the creation of the National Framework for Coronary Disease with its powerful National Director Roger Boyle. Both the Framework and its director spent most of its time out in the country arguing with medical practitioners about the way they organised their services.

The National Framework had a method which it believed was the best and it was the job of the National Director to have and win arguments with those that delivered services across the country.

Clinician to clinician argument, combined with change supplemented by extra resources, has made this enormous difference.

I grew up in the 1950s. Older men had heart attacks and died.

Many more of them now don’t – and a good part of that is down to mprovements in the NHS.

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This man, Shivinder Mohan Singh, unlike the others, is not a doctor. But like the others he is developing some very straightforward organisational principles and driving them into creating much more efficient hospitals. In fact he concluded his talk with the phrase “Keep it Simple” – all the time trying to apply very simple improvement techniques to what we all know are complex organisations.

During the Q and A it became clear that both he and the audience recognised that it would not be possible to simply apply what he was achieving in India in this country. In fact I recall that last year when a doctor who had revolutionised access to heart care through his hospital was asked if he would come and replicate what he was doing in this country he said that he would be mad to do so.

So at the end of the evening I was left with some complex thoughts.

First, entrepreneurs have a set of skills and capacities which would be immensely useful for the development of the NHS. What they do is bring very different approaches to the way in which value is achieved and those skills can help the NHS deal with the very hard tasks it is facing.

I don’t think they are the answer, but I do think they can add to our stock of answers. The main place I see that happening within the NHS at the moment is through the experiences of a number of non-executive directors (NEDs) in FTs. Increasingly the boards with which I work are trying to understand how they can develop new business models to provide better services. Frequently NEDs recognise they have a wide range of experiences which have achieved better value in previous worlds in which they have worked. Often the insights, precisely because they are from outside the NHS, point to a clear way forward. Sometimes their experience can’t be translated to the NHS.

Over the last 5 months or so I am hearing these voices make a bigger and bigger contribution to sustaining the NHS.

My second thought was a bit more depressing. There are thousands of people who care deeply about the NHS who see entrepreneurs such as Mr Singh as being not just outside of the NHS – but its enemy. The anger and alarm about the private sector and its involvement in the NHS that has swept through the debate about its reform over the last year has been the clearest example of the Government’s lack of narrative.

The debate has now settled into a common set of assumptions about the bad impact that the private sector would have on the NHS. This means that Mr Singh is experienced by some in the debate as an enemy.

This is very sad. The NHS cannot afford to turn its back on skills and processes which will help it deliver the much better value health care needed in the future.

This Government has completely failed to make that case.

But it still needs to be made.

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The Government replied by saying that on the contrary the reforms were necessary in order to drive those improvements in value.

The argument is simple. Do the reforms get in the way of creating better value for money – or are they an essential step to that new value creation?

There is another argument that revolves around timing – which says that the creation of the new system will be a distraction for the next few years, but that when the new system is up and working it will save more money.

It’s worth examining this argument in more detail.

Some of the sessions in which I have been working with the NHS over the last few weeks have touched on this issue – with regard to the role of commissioning. Since this lies at the core of the reforms that may have an impact on improving value for money it is a good starting point.

Commissioners buy NHS health care on an annual basis. So it is interesting to look at the commissioning years 2011/12, 2012/13, 2013/14 and 2014/2015 to see if the reforms have disrupted them.

The commissioning year should be well under way by the October of the year before the start of the financial year (in April). I make that point because the commissioning year 2011/12 started in October 2010 just as many PCTs were being reorganised into clusters. They were beginning to shed senior and junior staff between the July 2010 White Paper and the publication of the Health and Social Care Bill in December 2011. Therefore the commissioning year 2011/12 was disrupted from its very beginning as people were being made redundant and contracts were being developed for the following year.

As the year 2011/12 progressed commissioners found it difficult to carry out their monitoring role as, over the year, their numbers were cut by between a third and a half.

In October 2011 a reclustering of PCTs was taking place with the move towards the creation of local arms of the National Commissioning Board. The commissioning year 2012/13 is probably the most disrupted because in many places whilst the new CCGs are not yet there, the old organisations (of PCTs) have been abolished.

Some commissioning staff are looking to transfer to the NCB.

Some are helping to write the prospectus for the 85 Commissioning Support Organisations that are being developed.

Some are looking to work with the CCGs.

Not many are actually commissioning.

Therefore what I have heard over the last few weeks is that in many places there is no one on the end of the phone to talk to about commissioning. Providers have to develop their own approaches to 2012/13 and then seek someone out to whom to talk about it. This is not real commissioning.

By November 2012 – for the commissioning year 2013/2014 – some of the CCGs will be authorised and in place and will probably will be picking up what to do. But others will be completing the authorisation process and they will not be sure whether they should be preparing contracts for 2013/14 or whether this should be done by the National Commissioning Board.

By November 2013 – for the year 2014/15 – there will be some who are still unsure whether commissioning is to be carried out by authorised CCGs or whether the NCB maintains its grip.

It is clear that in some parts of the country commissioning will be disrupted – perhaps severely disrupted – for 4 years. In those places the Select Committee must have been right to say that the NHS has been distracted from developing better value for money.

There are some places where CCGs have virtually taken over now for the year 2012/2013. Here I would expect good commissioning to take place which will develop rapidly to become great commissioning.

Judging on the past performance of PCTs this will probably happen in about a quarter of the country.

But even here there is a problem. What is the engine that will be used to develop good commissioners into great ones? I am not at all starry-eyed about the ability of PCTs to carry out great commissioning, but by the spring of 2010 between 20 and 30 % were ‘very good’ at the commissioning cycle.

The development programme of World Class Commissioning was levering up the skill base for these organisations. I was working with a PCT on May 22^nd  2010 when the coalition programme and the abolition of PCTs was announced. That PCT had spent 2 years moving from the bottom 20% of the PCTs to the top 20%. In those PCTs they were more than capable of picking up the challenge of creating greater value.

If the PCTs had been left alone it is certain that by this commissioning round – 2 years later – another tranche would have become good commissioners.

Therefore we have had at least 4 years of very considerable disruption of one of the main ways – commissioning – that the NHS can develop better value.

Will CCGs be better at creating better value through commissioning when they are settled in? I think the best will and after 5 years of development they will be very good indeed.

But that’s 10 years after the destruction process started.

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But the Government seems eerily confident of getting the Bill passed when it returns to the Lords for 6 days between February and March.

They can’t both be right.

Let me offer an explanation for how the politics of protest could be defeated by the politics of raw power.

At some time this week there will be a summit to discuss tactics and strategies that NHS organisations may use to either change or stop the Bill. Last week we saw the royal nursing colleges come out against the Bill and call for it to be stopped.

Organisations will be looking for ways of gaining enough votes to beat the Government – either in a series of crucial votes on amendments – or finishing off the Bill completely. This will involve some of the most modern tactics and strategy of lobbying with members of the Lords receiving carefully tailored letters arguing for them to vote against the Bill.

NHS organisations opposed to the Bill will be looking at some of last week’s victories in the House of Lords on welfare benefits. They will be thinking that all they have to do is get the same numbers who have been voting against the welfare measures to vote against the Government Health and Social Care Bill and it will be defeated.

All of which looks quite logical.

But the real raw politics of power has another logic which changes these terms of political trade.

The Government has the right to increase the number of people in the House of Lords whenever it chooses.

Everyone knows that lists of new peers are announced at New Year and in June for the Queen’s Birthday honours.

But the Government can nominate new peers at any time – and it is up to them who they nominate.

So let’s pretend that this week the Government is anxious about getting the Bill passed. One piece of naked power that the Government could use is to create 50 new peers – this week. Now of course it would have to create more than just Tory peers. One way to determine how many of each there should be would be to look at the proportion of votes at the last election and divide up the new peers in that way.

But the Government doesn’t have to be fair at all. If it is worried about its legislation it could create – for example – 50 new peers. That fifty could be split between 30 Conservative 15 Lib Dem and 5 Labour. This would – in one day – increase the Government’s majority in the House of Lords by 40.

Of course if the Government were to do this it would be extremely unfair on all those NHS organisations who were lobbying against the Bill. It would make their task almost impossible. NHS staff would be very angry. They would feel that this was extremely unfair.

They would be right.

But it would get the Bill through.

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I received a number of comments from people who felt that the reforms in which as special adviser to Alan Milburn, John Reid and Tony Blair I was involved from 2001 – 2007 had laid the ground for the current reforms and that I should take some of the blame for the current Government.

So I thought it important to finish my analysis by examining the current Bill and its reforms in the context of the Blair reforms of the NHS.

The first thing to note about the continuity between the Blair and Cameron reforms is that since the election Lansley and Cameron have – on most occasions – said that what they are doing is different from what Blair did, and that there is no continuity.

On coming into power the new Government could have looked at past reforms and compared them with their own and said theirs were a continuation. They consciously chose not to.

In this area of policy – along with all the others – they declared May 2010 to be ‘year zero’ and said that what they were doing as a Government was new. In the summer of 2010 this looked like a strategic error for two big political reasons.
First there was strong evidence that both at the election and over the months since the public had demonstrated record support for the NHS. Public experience of the NHS was better than ever before.

Therefore if as a Government you are going to say that the last lot messed up the NHS and we are going to do something different, you need to understand that you are taking on the public and their expressed satisfaction with the NHS.
You have to find a delicate way of saying that the public are wrong. You need to persuade them that they are wrong to be satisfied with the NHS. That in fact there are these things (a, b, and c) wrong with it – and our reforms (x, y, and z) will impact upon a, b, and c in this way – and make them better.

So in saying that their reforms were brand new this Government were saying that the public and their satisfaction with the NHS were wrong.

It’s not impossible to develop a political position which starts off by saying that the public are wrong, but you need to be a much better and steadier communicator than this Government has proved to be.

So the Coalition Government chose to say that their reforms were very different and that they needed their own Bill (the biggest in the history of the NHS) to carry out their own reforms.

The second reason (apart from that of not deliberately disagreeing with the public) that it might have been a better strategy not to portray these reforms as departures from Blair’s is that the Conservatives are always going to be seen by the public as having a problematic attitude to the NHS.

A couple of weeks’ ago I posted on the political explanation of how certain formations of the left and right are better positioned to make some reforms and not others precisely because they are left or right wing. (The example I used was Nixon’s recognition of Chairman Mao’s China rather even though he was right wing).

This is also true of the Tories and the NHS. A wise Tory Party would have said we are simply continuing Labour’s reforms and going with the grain of the NHS. They would have hidden behind the Labour Party and its reforms.

But they have not done this. They have said the reforms are clearly theirs and that they take responsibility for their reforms.

So claims made by some of my readers – that these reforms are simply a continuation of the Blair reforms – are not shared by the Government.

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My immediate thought was – why is this news? It’s been pretty obvious that this was going to be their position for some time, so is it news when something you know is going to happen actually happens? But my second thought is that my first thought is probably an insider’s thought. Most of the people who heard that news item will not have not spent years of their lives steeped in the ways of various professions wanting to stop various reforms.

For nearly everyone in the country it is news that the nursing colleges want to completely stop Government reforms. So my third thought (please bear with me on this – for 7 years of my life I heard these stories not as an interested bystander but as someone who worked on these sort of issues in Government, so I tend to have a rush of immediate thoughts when this sort of thing happens) is how will the Secretary of State deal with this. What will he say and how will he say it?

What happens next is a return to the Government’s real long term problem. This rejection of the Government’s reforms by nursing colleges takes place against the backdrop of the Government not having established a compelling narrative of what they are trying to do with the reforms. If they had such a narrative Government reaction to everything, including this opposition, would fit in with it.

So when I come to look at the BBC news I am interested in how Andrew Lansley is going to explain this important opposition.

Andrew Lansley chose to do something really odd. He began his explanation for why the RCN and RCM were against his reforms by treating the BBC news watcher to an explanation of what Royal Colleges are.

He explained that actually they have two functions. On the one hand they have professional interests including the important improvement of patient care. On the other hand they acted as trade unions for nurses and were looking after issues such as nurses’ pay and pensions. When the nursing colleges announce that they are opposed to the Government’s reforms it is, so he said, the second of these concerns – nurses supporting their own interests – that is overcoming the first – their professional concern.

They wanted to give the Government a bit of a kicking because of concerns about their own pay and pensions. So they are using the attack on the reform programme to better negotiate their pay and pensions.

Let’s pause for a moment and think about the average person watching this at 7.05 in the morning. The Secretary of State chooses this moment to explain the conflation that exists within the nursing profession of guild organisations that grew in other professions in the 18^th century with trades unions that grew up in the late 19^th century.

Is this the right time to engage in what is admittedly an interesting disquisition on the nature of nursing organisations?

If people don’t ‘get’ this they will be very confused about what Andrew Lansley is going on about. This of course will add to the general feeling that they have about these reforms – which is that Andrew Lansley can’t really explain what he is doing. So another opportunity to explain what is going on drifts past the Secretary of State – like all the others.

But there will have been a few people watching the TV who know the difference between the nursing colleges defending nurses’ own rights and their professional concerns for patients. Those people will have been the nurses who are preparing for work or just coming back off shift.

They will see the Secretary of State telling the world that nurses are much more concerned about their pay and pensions than about patient care. That they are not really concerned in their own right about NHS reform but it is their concerns about pay and pension that override their concerns about NHS reforms.

This is patronising your opponents. The fact is the nurses are against the Government Bill for a whole range of reasons that are coherent within their world view. They are not opposing the Bill for underhand personal reasons. They are against it because they disagree with it.

So by 7.10 yesterday morning the Secretary of State had confused most people by treating them to a history lesson on the British Constitution and had made a lot of nurses angry by saying that they weren’t really against his reforms for professional reasons but because they were concerned about their pay and their pensions.

More of the same there then.

So what could he have said on the BBC news?

“I am really sorry that the nursing colleges are against the Government reforms. This is partly my fault because I have failed to successfully explain to the nursing profession why the NHS needs these reforms to improve our care for patients.

I have seriously failed in this communication task because I am convinced that these reforms will empower nurses to have a greater say over how the NHS works with the patients whose welfare concerns us all.

When the reforms are passed there will be real opportunities for nurses to take much more power in directing the NHS in patients’ interests. When nurses are actually offered these increased powers I am convinced that what are serious disagreements between us at the moment will disappear. They will take up the new powers being offered and help create a better NHS.

So what do I learn from this? That I must do much better in explaining what we are trying to do and how much better these reforms will be for nurses and patients.”

The reason for taking this line is that it is not a good idea to concentrate on the passage of the Bill as if that is the totality of reform. As I have posted this week, the Bill will come and go. Then it will be a matter of the partnership between the Government and its reforms and professionals in the NHS and their organisations to develop a better way forward. The more time thinking about that and the less on lobbying for and against the abstraction of the Bill, the better.

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That was why they were supporting the Bill.

Given that before that debate (and actually for most of the year after it) nobody really knew what the Bill was, it was the first – and only – time that a group of MPs could find an explanation of the purpose of the Bill and use it to explain their support for it.

At last a bit of a narrative!

What they were saying (hoping?) was that hospital reconfiguration would be slowed down (and stopped?) by the provisions in the Bill. The two sets of innovations – placing commissioning in the hands of GPs and the creation of local Health and Weill Being Boards – would, in their analysis, take the drive for hospital reconfiguration out of the hands of the ‘NHS bureaucrats’ and slow down changes to their hospitals.

At the time this struck me as a little naive. The belief was that since the NHS bureaucrats were the people who were organising the reconfiguration of their local hospitals and, in the experience of these MPs, were the cause of the reconfiguration then if they were taken out of the picture – and the Bill did appear to abolish them as PCTs and SHAs – then the pressure to reconfigure their hospitals would go with them.

This has proved to be wrong for three reasons.

First, over the last year as the Bill has passed through its Parliamentary stages many of the hospital services that these MPs were hoping that the Bill and their new Government would defend have been finally closed.  GPs as commissioners – rather than springing to the defence of their local hospital services that other clinicians have found were unsafe and uneconomic – have agreed that the services need reconfiguring. This has been a bit of a shock since the drive to reconfiguration was thought to be simply bureaucratic and not clinical. So it has been a surprise to see the readiness of GPs, as shadow commissioners, to continue reconfiguration.

Surprise number two will have been that whilst a number of the dreaded NHS bureaucrats at PCT and SHA level will have gone, many of the people who were leading reconfiguration from within the NHS – at PCT and SHA level – are still there. Now they are in clustered PCTs and clustered SHAS but it has become clear as the Bill has progressed they will not be abolished but will become a part of a new organisation – the National Commissioning Board.

As the Board has developed it has become clear that the vast majority of its staff will be drawn from the management of existing PCTs and SHAs. The Bill, rather than getting rid of many of the NHS bureaucrats, will entrench them in a new and powerful organisation,

Even more oddly for the anti-bureaucrat argument for the Bill, these bureaucrats will no longer be under the control of the Secretary of State. The NCB is what these MPs might call an ‘unaccountable quango’. The bureaucrats that work for it will have more power with less control by MPs and Parliament.

This wasn’t how it was meant to be.

But the third set of changes that the MPs will have realised is that not only are GPs as keen as PCTs on hospital reconfiguration, not only are NHS managers back in new and more powerful roles, but the drive for hospital reconfiguration seems to have picked up speed. The pressure for change in the configuration of NHS hospital services looks greater in January 2012 than it did as the Bill was introduced into Parliament a year ago.

One of the reasons for this was contained in the White Paper and the Bill. The Government laid down a timetable for the move of all NHS provider services into Foundation Trusts by 2014, and then there will be a lot more change. Because the Government reforms set such a target it is inevitable that hospitals and other provider trusts would begin the plans to become FTs straight away. Those hospitals that have been coasting have recognised they can only become FTs with a lot of change.

Therefore the last year has seen many plans for the closure of services and for moving them to a smaller number of sites than ever before. It has seen a record number of plans to merge hospitals and for some to be taken over by others.

Those MPs expecting the Bill to quiet down the changes in NHS hospital services and take them off of their troubling local political agenda haven been confronted with more change and with even more arguments for change further into the future..

Some of this is caused by the Government reforms arguing for a quickening of the pace to move to FT status, and some is caused by provider trusts looking closely at the economics of the next few years.

There will be more pressure for the reconfiguration of hospital services as more of those services move into FT status. FT status gives Boards the clear responsibility for their services with a new necessity for clinical and financial governance. This has led to many more organisations looking for allies or takeover and recognising that change is inevitable for the services they provide.

I have posted on this process on many previous occasions over the last year. What I want to note here – a year on from the Bill entering the House – is that for those MPs that expected the Bill to stop the reconfiguration of hospital services the Bill must be a disappointment. The pace of change in the last year, rather than being stopped by the Bill, has quickened whilst the Bill has been going through Parliament.

And if it passes, it will quicken again.

For some enthusiastic supporters of the Bill from last year this must be very puzzling indeed.

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