Jeremy Laurance: This compromise may offer the worst of all worlds

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Andrew Lansley's Bill has been emasculated. The effect of the Coalition's "reform of the reforms" will be delay, less competition, more bureaucracy, less power for GPs, more for hospital doctors. It will mean a less efficient, less effective, less innovative NHS.

The vested interests who defended the status quo have triumphed. The result will be a two-tier service, with extra layers of management, fewer new providers and less change. The most bizarre consequence is that we may end up with an NHS less market-driven and with less competition under the Tory-led Coalition than under the previous Labour administration.

One of Mr Lansley's targets was bureaucracy. He wanted to sweep away strategic health authorities and primary care trusts and pass control of the bulk of the NHS budget to family doctors.

But now we are to have a National Commissioning Board with regional outposts, clinical senates, health and wellbeing boards, clinical commissioning groups – perhaps a couple of hundred of them – which will dispense the loot, and will each include GPs, nurses and hospital doctors. The worry is these new layers of management will have conflicting priorities which will make the delivery of more effective care to patients unachievable. The NHS's historic problem has been its resistance to change. There is no lack of innovation – the problem has been spreading innovative ideas around the service. Competition has been an effective lever, driving up quality and saving lives (when limited to quality, not price).

But competition and the opening-up of NHS services to "any willing provider" is being de-emphasised in the revised reforms, in order to head off accusations of privatisation. So the grit necessary for the oyster to produce the pearl of innovation may be lost.

David Cameron insisted yesterday that the most important of his Health Secretary's reforms remained. We will soon learn the truth of this. But on one score – Mr Lansley's aim of taking the NHS out of day-to-day politics – he has abjectly failed. There is now fiercer political debate about how to run the NHS than there has been at any time for a generation.

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