Irwin Brown of the Socialist Health Association signs off in the last of his series of guest editorials, looking at the skirmishes won in a lost war.

It has been a depressing time dealing with the hated H&SC Bill. We had the better arguments, better advice, and better lawyers - and at the end we had all the support - but it was never enough to overcome political expediency.

The LibDem sell-out was no surprise, but the efforts at collaboration and sharing ideas, amendments and information was still genuine on our part, if not on theirs. The big surprise is that they appear to believe the nonsense they have had to put out about the Bill being a welcome development.

Small improvements
It was a much longer fight than most predicted and the Bill has changed in some important but peripheral ways – like the recognition of the importance of things like education and training, integration and co-operation which were not in the original Bill.

Progress of a sort has been made on embedding public and involvement - at least, in theory. The enthusiasm for price competition and a strong economic regulator has been damped down at least for now; the issues are now better understood and the forces to oppose privatisation and market forces are now better-prepared and better-organised.

CCGs now have more participants than just GPs and some strange sort of governance - but the governance is ludicrously weak compared to that previously thought necessary for commissioners in charge of £60bn of public money. And nobody has a clue about how effective CCGs will be – there will probably be huge variation.

Trust in the NCB?
We now have a National Commissioning Board doing the most local kind of commissioning! It’s a huge unaccountable bureaucracy with outposts and silos that were not even in the Bill led by the Commissar Lansley and his gang of four. This mega-quango is both the greatest obstruction to any attempt to drive market reforms through the NHS and the best hope for the NHS to continue to function for patients through the turbulence.

That clash between the ideology of the markets and competition and the steady pragmatism of those who actually have to keep the NHS functioning offers the best hope for implementation of the worst parts of the “reforms” to be slowed and even stopped – by the activism of those on the inside, combined with continuing political pressure from the outside. A long road, yet to be travelled.

We have a pathetically weak role for the patients’ voice, neutered at the elevenh hour when everyone was too tired to put up more of a fight.

We have Health and Wellbeing Boards with no powers. We have Senates that exist only out in the mists somewhere.

We won’t have underfunded and undervalued public health parked on the sidelines.

Monitoring anti-competitive behaviour
We have a regulator torn by a massive conflict of interest and with a leadership that is openly ridiculed. In the power stakes, it is now subordinate to the NCB when it was supposed to be the other way round. Its competition-promoting role is hidden but still implicit – with no idea how it can be delivered.

Nobody outside the Ministerial group thinks the Bill was either necessary or worth the cost of forcing it through – both political and real money cost. The Bill is a mess of compromises and untested assumptions, and few understand it. It’s an experiment on a huge scale.

We needed brave radical reform of social care and a period of stability for the NHS – we got the opposite.

The Secretary of State for Health has given up most of the powers to direct and oversee a universal, comprehensive and national health service – and in time , all three of those pillars will be challenged – the N has probably already been sacrificed.

The NHS as the provider of the healthcare we need is gone. The idea of the NHS having a publicly accountable structure for strategy and planning and the distribution and oversight of our tax-paid money has gone.

The values of integration, collaboration and co-operation are acknowledged, but competition trumps them all – and the lawyers will make it so.

The NHS will not collapse; the more apocalyptic fears will not be justified - but we have seen the end of the NHS as we know it.

Nobody ever voted for that.