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NHS changes: The key questions The pitfalls facing the government's NHS shake-up
(5 days later)
By Nick Triggle Health correspondent, BBC NewsBy Nick Triggle Health correspondent, BBC News
The government has given the clearest indication yet about the changes it is prepared to make to its overhaul of the NHS in England. The wait is almost over. In the coming days, the government will set out how it plans to reshape its reform programme for the NHS in England.
In April, amid mounting criticisms, ministers announced there would be a pause in the roll-out of the plans. Here is a look at the pitfalls that lie ahead and how the government could navigate them.
Now David Cameron has announced several concessions he is prepared to make. The government's proposal for changes to the NHS were put on hold at the start of April to allow ministers to carry out a "listening exercise".
These include relaxing the deadline for the new system to be up-and-running, and getting hospital doctors and nurses involved in managing the budget alongside GPs. A panel of experts - known as the NHS Future Forum - was set up to carry out the review.
But his intervention has raised as many questions as it has answered. Last week the prime minister gave an indication of the concessions that could be made.

class="section-header" id="heading-1">Too many cooks?

 But the full details will emerge this week with the publication of the NHS Future Forum report on Monday, which will be followed by a government response on Tuesday.
In recent months, much of the criticism about the plans has focused on the risk of privatisation. But when the changes were first unveiled last summer it was the decision to put family doctors in charge of the budget through GP consortia that attracted most of the attention. After months of criticisms from MPs, health unions and academics, ministers face a tricky challenge in getting its programme back on track.
The prime minister now says GPs will be joined by hospital doctors and nurses to create clinical commissioning. This was something the House of Commons' health committee had called for.

class="section-header" id="heading-1">Too many cooks

But there is now concern among those who originally supported the plans. The NHS Alliance, which represents staff working in the community - including many of the GPs who were piloting the changes - says involving other NHS staff too heavily could be damaging. Much of the criticism about the plans has focused on the risk of privatisation. But when the changes were first unveiled last summer it was the decision to put family doctors in charge of the budget through GP consortia that attracted most of the attention.
The prime minister has now indicated GPs will be joined by hospital doctors and nurses to create clinical commissioning. This was something the House of Commons' health committee had called for.
But there is now concern among those who originally supported the plans.
The NHS Alliance, which represents staff working in the community - including many of the GPs who were piloting the changes - says involving other NHS staff too heavily could be damaging.
It says hospital doctors may have an interest in promoting the profitability of their hospital - even though it may not be in the best interests of patients. It also warns that decision-making and accountability could be diluted.It says hospital doctors may have an interest in promoting the profitability of their hospital - even though it may not be in the best interests of patients. It also warns that decision-making and accountability could be diluted.

class="section-header" id="heading-2">A two-tier system?

 One way round this would be for the government to involve other staff, but not put them on the board of the consortia, allowing GPs to be take the ultimate decisions.

From big bang to a whimper

The NHS has been working on a deadline of 2013 for the creation of the consortia, but it now seems those areas that are not ready will not be compelled into adopting the new structures.The NHS has been working on a deadline of 2013 for the creation of the consortia, but it now seems those areas that are not ready will not be compelled into adopting the new structures.
It remains to be seen whether this opt-out will be a temporary position or if areas will be allowed to pull out altogether.
Health Secretary Andrew Lansley has warned that if some parts of the country are allowed to opt out - even for a short-time - there is a risk that a two-tier system will be created.Health Secretary Andrew Lansley has warned that if some parts of the country are allowed to opt out - even for a short-time - there is a risk that a two-tier system will be created.
This happened in the 1990s, when half of GPs were given more responsibility under a system known as GP fundholding. It led to different standards of care in different areas.This happened in the 1990s, when half of GPs were given more responsibility under a system known as GP fundholding. It led to different standards of care in different areas.
Plans had already been sketched out to allow the national board - to be headed by current NHS chief executive Sir David Nicholson - to support those consortia that needed help. More detail on this could provide a way round the issue, although that would mean the opt-out would only be a short-term measure.
A more radical option would be to allow primary care trusts in some slimmed down form - they have already started merging into clusters - to remain in charge.

More bureaucracy?

More bureaucracy?

The plans were originally hailed as a way of getting rid of NHS bureaucrats. Facing the chop were two tiers of management - 151 primary care trusts and the 10 strategic authorities that keep an eye on them.The plans were originally hailed as a way of getting rid of NHS bureaucrats. Facing the chop were two tiers of management - 151 primary care trusts and the 10 strategic authorities that keep an eye on them.
But if anything, the prime minister's speech has opened the door to more layers of bureaucracy. At the top of the tree will be the national board to which consortia will be answerable. But if anything the concessions in the pipeline may actually lead to additional layers of bureaucracy.
However, with no fixed deadline for consortia to take responsibility for the budget, it is possible that primary care trusts in some slimmed-down form will remain in certain areas. At the top of the tree will be the national board to which consortia will be answerable.
On top of that, there is now talk of "clinical senates". As yet it is uncertain exactly what they will do and how they will work. The best bet is that they may take charge of complex care that can not be done locally by individual consortia, such as cancer or heart surgery. But below that there could be multiple layers of management if primary care trusts are kept in some form in some areas and consortia take the lead in others.
So in theory all this could mean there will be as many as four levels of NHS management. On top of that, there is now talk of "clinical senates". As yet it is uncertain exactly what they will do and how they will work.
The best bet is that they may take charge of complex care that cannot be done locally by individual consortia, such as cancer or heart surgery.
So in theory all this could mean there will be as many as four levels of NHS management - a muddle that would need some explaining.

The end of competition?

The end of competition?

Hardly. The independent regulator of NHS foundation trusts, Monitor, could now have the twin role of promoting competition as well as the integration of care to ensure the best interests of patients are served. Hardly. Monitor, which is pencilled in to become the NHS economic regulator, could now have the twin role of promoting competition as well as the integration of care to ensure the best interests of patients are served.
However, the British Medical Association has been quick to point out that the two things can sometimes be contradictory. BMA leader Dr Hamish Meldrum described the prime minister's speech as "not a game-changer", and added the situation was "muddy". However, the British Medical Association has been quick to point out that the two things can sometimes be contradictory.
Others were more positive. The NHS Confederation, which represents managers, said it was pleased with the clarification, pointing out that while competition should not trump all else, it was important in tackling poor practices.Others were more positive. The NHS Confederation, which represents managers, said it was pleased with the clarification, pointing out that while competition should not trump all else, it was important in tackling poor practices.
How the regulator manages to balance the two - and what direction it is given - will undoubtedly be one of the key issues.How the regulator manages to balance the two - and what direction it is given - will undoubtedly be one of the key issues.

id="heading-5">What about listening?

id="heading-5">Making everyone happy

When Mr Cameron, Nick Clegg and Mr Lansley stood side-by-side at a hospital in April to announce the pause they all said they wanted to listen and reflect on their proposals. When the government announced its listening exercise it was in effect an admission that ministers had to work harder to get different parties on board.
To do this, they set up a panel of experts - known as the NHS Future Forum - to take a lead. More than 200 events were organised as the views of doctors, nurses and patients were sought. Critics included everyone from Lib Dem MPs and think-tanks to health unions and the medical royal colleges.
The events have now finished, but the forum has yet to hand in its report, due to be given to the Cabinet next week. For many, the report's conclusions will be the true test of whether they can support the plans. It will be virtually impossible to please everyone. The question is, can they get enough on board?
Peter Carter, general secretary of the Royal College of Nursing -one of the most vocal critics of the NHS changes - simply said: "We have to reserve judgement until we see more detail." Academic groups like the King's Fund and NHS bodies including the confederation, which represents managers, have started being more positive in recent weeks.
There are also signs the Lib Dems are happier. The big question mark hangs over influential unions, such as the British Medical Association and Royal College of Nursing.
The government does not have to have them completely signed-up, but some warmer words would go a long way to allowing ministers to get its plans through parliament.
Do you work in the NHS? What is your reaction to the government's planned reforms? You can send us your views using the form below.