Longstanding readers will remember our Future Forum joke: Pinter The Coalition Health Policy Polar Bear, walks into a bar, approaches the barman, and says "I'd like a ........................................................................... Health And Social Care Bill cocktail, please".

The barman replies, "Why the big pause?"

Ah, the old jokes. They're still the oldest.

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Click here for details of 'The Buttle Of Britain - SOS accountability, meet the long grass', the new issue of subscription-based Health Policy Intelligence.

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Earl Howe has written a letter to Baroness Thornton regarding the Secretary of State's accountability, duty and responsibility. The text of the letter is available via Paul Waugh's Politics Home.

(We reported the existence of an inter-Coalition deal on the accountability and responsibility aspects of the Bill recently.)

Earl Howe's letter sets out his view of how the Upper House should seek to "reach an amendment, or a set of amendments, which reassures those who have been concerned that the Bill reduces the accountability of the Secretary of State for the health service". He proposes to address clauses 1 and 4.1 .

Howe naturally disagrees that the Bill reduces accountability, but is keen to "explore amendments which puts (sic) this beyond doubt".

Earl Howe's three aims are as follows: to clarify the SOS's accountability for the NHS; to make real the policy aim that the SOS should not be involved in the day-to-day running of the NHS; and to accurately describe the reality of what the SOS currently does and will do in the new system.

Howe proposes to meet with Lords as they wish, individually or in party groupings, and also plans to liaise with the Constitution committee, who scathingly noted, "We are concerned that the Bill, if enacted in its current form, may risk diluting the Government's constitutional responsibilities with regard to the NHS ... we consider that it may well be necessary to amend the Bill in order to put this matter 'beyond legal doubt'.".

These meetings would be followed by a session of (by implication) the whole house prior to Report stage.

The courteous tone of the letter is characteristic of the tenor of debate which is the Lords at its best. Nevertheless, this latest pause comes from a position of political weakness.

Howe is a hereditary peer, and recognises that the Constitution committee's concerns are not trivial. No punches were pulled during the making of their lines, "it is not clear whether the existing structures of political and legal accountability with regard to the NHS will continue to operate as they have done hitherto if the Bill is passed in its current form. As such, the House will wish carefully to consider whether these changes pose an undue risk either that individual ministerial responsibility to Parliament will be diluted or that legal accountability to the courts will be fragmented.

"Moreover, it is not self-evident that the proposed changes are a necessary component of the Government's reform package. Given the uncertainty as to the interpretation of the provisions proposed in the Bill, could not the relevant wording contained in the 2006 Act be retained?"

The coalition, and in particular the Conservative Party, are looking at a tide of pain in their NHS reforms. Grief will flow in (not all will be caused by this unpopular Bill, but all blame will be laid at its door); popularity will flow out.