NHS overhaul: What next?
The NHS listening exercise is drawing to a close, but still the criticisms keep coming.
Despite David Cameron's insistence that there will be "real changes" to the proposed reforms for the NHS in England, doctors' leaders doubt it.
The British Medical Association's chairman says the Prime Minister's renewed pledges are "not a game-changer".
The government has spent the last two months trying to get critics on board.
After more than 200 listening events with thousands of doctors, nurses and patients, the consultation is now ready for publication next week.
Mr Cameron has said he will support a number of important changes to the proposals, including more say for hospital doctors and nurses and limits on competition.
So, what next?
Officially, the government is saying no decisions will be made until the report of the NHS Future Forum, the group which led the listening exercise, is published.
But Mr Cameron has outlined a few key changes in the meantime:
- Doctors and nurses will be involved in new consortia planning and buying care, not just GPs
- These groups will only take responsibility when they are ready not by April 2013 as previously envisaged
- New "clinical senates" consisting of senior medical professionals will oversee integration of NHS services across local areas
- NHS economic watchdog, Monitor, will have a duty to promote integration of care across an area
- Greater competition will only be introduced when it benefits patient care and choice
The detail will not come until next week. But it is expected to make a wide range of recommendations about how the plans need to be altered.
The forum has been chaired by Professor Steve Field, the former leader of the Royal College of GPs.
Professor Field has already made it clear greater clarification is needed over the issue of competition. Under the current proposals, there is a duty on the economic regulator, Monitor, to promote competition.
Professor Field is also known to be looking at whether primary care trusts - the management bodies Mr Lansley wants to scrap - should stay on in some form to support GP consortia.
Smooth over the tensions
A combination of poor election results and the fall-out from the tuition fees row has meant the Lib Dems have come out fighting on the NHS.
Nick Clegg has made it clear he wants to see changes, particularly to the role of Monitor.
His positioning has meant clear divisions have begun to open up in the coalition for arguably the first time.
He has talked about being a moderating influence in the government, much to the annoyance of many in the Tory party.
In many ways, the listening event has changed the nature of the coalition - and both parties need to adjust to that. And quickly.
Get the profession on side
It seems whatever concessions are made need to answer the criticisms of the NHS staff, who will be the ones working in the new system.
Mr Lansley faced perhaps his more difficult day of the past two months when he visited the Royal College of Nursing conference in Liverpool before Easter.
On the morning of his visit delegates gave him a vote of no confidence. He then faced a meeting of more than 60 nurses amid claims he was running scared of the full conference hall.
And, of course, the BMA set out its concerns.
Without warmer words from groups such as the BMA and RCN in the coming months, it will be difficult for the government to get the reforms back on track.
Produce a coherent set of proposals
Almost all those involved in the NHS believe change is necessary to deal with the demands of the ageing population, cost of new drugs and lifestyle changes, such as obesity.
If there is not a clear vision for the future, the NHS could find itself struggling to just maintain standards never mind improve them.
The prime minister, deputy prime minister and health secretary have all talked about substantial changes.
The challenge is making them in a coordinated way that convinces those working in the health service and the public that relies on it that the government has got it right this time. It promises to be a tricky balancing act.