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How much will the NHS reforms be watered down?

A slowdown and a consultation have been promised. But how strong is opposition to the bill, and will amendments be substantial? Alisdair Stirling investigates.

His image became intrinsically linked to the NHS. During the general election campaign, David Cameron's face appeared larger than life on billboards next to the Conservatives' manifesto pledge not to cut NHS expenditure. Now the PM is understood to be growing fearful of the political backlash to the health reforms and wants to slow the pace of change. So has opposition been so strong that number 10 is having a major rethink?

History lesson

The last time there was an outcry over health reforms was in 1989, when the Thatcher government was introducing market forces into the NHS via GP fundholding. There was a major falling out with the BMA. Health secretary Ken Clarke angered doctors with his famous after-dinner quip: ‘Why is it every time that I mention the word reform, GPs reach nervously for their wallets?'

A hard-hitting BMA poster and leaflet campaign ensued. One included a picture of a steamroller captioned ‘Mrs Thatcher's plans for the NHS' while another simply said: ‘What do you call a man who ignores medical advice? Mr Clarke.' Although ultimately unsuccessful, the BMA's campaign forced the row into the public domain. For some, this lack of large public engagement over the reforms is missing from the opposition camp this time around.

Dr Geoffrey Rivett, a senior DH civil servant from 1972 to 1992, witnessed a far more radical streak in the BMA: ‘In terms of a public protest, the motions getting passed now are quite muted. Then again, GPs' and consultants' salaries have at least doubled since then. I don't think the doctors are really ready for a fight this time.'

In spite of the scale of the 1989 protests, he says, ministers just pressed on regardless: ‘There's a certain amount of making it up as you go along with any set of reforms. We knew certain things were wrong and so did the BMA. But while the shouting is going on, the quieter heads are negotiating the rough edges. In 1989, there was a lot of public acrimony – but even then, both sides knew the pros and cons. Doctors are always revolting, but where are they going to go?'

Dr Clive Peedell, co-chair of the NHS Consultants' Association and BMA Council member, is a fierce critic of the reforms and despairs of the BMA's failure to capitalise on the momentum that built up before the BMA's Special Representative Meeting last month. ‘The BMA – especially the GPC – is frightened of losing control of the negotiations. But its policy of critical engagement allowed pathfinder consortia to be established. If the plans get dropped now, it will leave a lot of GPs in the schtum.'

But for Roy Lilley, an NHS trust manager in the fundholding years, clouds are only just beginning to gather for the Government, not least with the recent no confidence vote by the Royal College of Nursing in Andrew Lansley's management of the NHS reforms: ‘Opposition is much broader this time, and coming from all quarters. When you've got the Social Market Foundation and Civitas objecting, it's broad-based. This set of reforms is a different kettle of fish, and they're compulsory.'

Mr Lilley believes party political opposition to the reforms could be the most potent of all. ‘You've got a large part of the Lib Dems against this, as witnessed by their recent conference. This is going to have an impact on the bill's third reading, and there could be serious opposition led by Shirley Williams in the House of Lords. I think we're likely to see changes to section five of the bill on Monitor's role. If the coalition is going to satisfy the Lib Dems, it will have to back down.'

Second thoughts?

Critics of the reforms focus not only on the substance of the bill – particularly its potential to fragment care and make integration more difficult – but also the rushed way the reforms are being introduced as the NHS tries to make £20bn efficiency savings by 2014. The dual purpose the reforms now serve because of the financial crisis makes them increasingly controversial.

The BMA's emergency meeting motions last month sent out a mixed message – supporting clinical commissioning while opposing the bill – reflecting the uncertain and contradictory feelings within general practice. There are strong signs the Government has already entered the jitter stage. Earlier this month, former RCGP chair Professor Steve Field joined the PM and deputy PM to launch a new listening exercise after a Commons health committee report called for ‘significant changes' to the planned legislation. The bill has already been delayed for a month.

The recent Royal College of Nursing's no confidence motion in Mr Lansley is hugely symbolic of the way many NHS staff are not on board with the reforms and there are doubts over whether the listening exercise will be enough to win them round.

An inevitable rumour mill has started about whether Mr Lansley will remain health secretary. Interestingly, this might not be because he is asked to go by a nervous PM but because, if sources are correct, he will not stand by while significant changes are made to the bill.

David Cameron was the face of the NHS in the election. The question now is whether Mr Lansley is to remain the face of the NHS reforms.

David Cameron has repeatedly pledged to protect the NHS from frontline spending cuts David Cameron has repeatedly pledged to protect the NHS from frontline spending cuts