The Health and Social Care Bill in England has passed into law after months of bitter debate. Medically qualified critics of the Bill never gained sufficient access to the media to communicate effectively with the public. While most professional bodies in the UK eventually set their face against health secretary Lansley's ideas, the proposed changes were so complex and far-reaching that many organisations lacked sufficient understanding to crystalise their opposition. At least, not until it was far too late to influence the politicians. It is a measure of the scale of this piece of legislation that it absorbed 2000 amendments before passing into law, without becoming any more attractive to the majority of its critics outside parliament.

Readers beyond these shores may wish to know the essence of what Lansley terms healthcare reforms, but which others have identified as the end of our National Health Service (NHS) in England. It is difficult to state simply with any degree of objectivity, but we are discussing a major structural reorganisation that entails ditching the local commissioners of secondary care services as well as the regional bodies responsible for strategic planning and surveillance. In place of these two layers, a national commissioning board and locality commissioning groups, mostly made up of general practitioners with all the administrative support of the previous commissioners, are expected to commission services from ‘any qualified provider’.1 That means established NHS hospitals, and not-for-profit non-governmental organisations and commercial organisations, large or small.

In the sense used here, commissioning has a specific meaning in the UK semimarketised health system. It involves negotiations with providers, setting out the units of healthcare to be purchased, the tariff for the units of care and the quantity to be undertaken before different pricing structures are enforced. Effective commissioning delineates the responsibilities of secondary …