GPs
Dr Clare Gerada, chair of the Royal College of GPs, is pleased ministers have performed what she calls "a monumental U-turn" and says "the prime minister is heading in the right direction". But she wants to see the exact wording of the amendments to the health and social care bill to ensure it does follow through on Cameron's pledges to honour all 16 recommendations of Steve Field's NHS Future Forum report.
The GPs helped secure one important concession: that the health secretary would continue to be responsible for providing a comprehensive health service in England. But the government's response also makes clear that in future ministers' responsibility will be "not for direct operational management [of the NHS], but for overseeing and holding to account the national bodies – in particular the NHS Commissioning Board and the regulators – backed by extensive powers of intervention in the event of significant failure". MPs may seek to amend that plan when they scrutinise the bill afresh.
Gerada is concerned that the importance of patient choice is being exaggerated, and could cause problems. "Choice is good but what patients want and need is good local providers. And how do you map choice into a cash-limited NHS, and how do you avoid duplication of services?"
NHS managers
The 40,000 managers in the NHS are pleased that Professor Steve Field forcibly urged ministers to stop denigrating them as pen-pushers and bureaucrats, which he said had prompted some managers to quit the service just when their expertise is needed to help it through the coming upheaval.
Some also see the restructuring as a distraction from the real challenges they face at the NHS frontline: contributing towards the £20bn efficiency savings target and reducing the sometimes wide variation in the quality of many forms of care that health experts agree is a major problem.
The NHS Confederation, which represents the NHS's employers, is pleased that the Field process has brought "a more intelligent approach to the issue of choice and competition", but says it remains unclear exactly how the twin aims of competition and integration of services can be made to work on the ground.
Chief executive Mike Farrar said he wants ministers to recognise that, while integration is important "for some services, the use of choice and competition is also an essential route to deliver the best patient care".
The confederation also wants the new clinical commissioning groups to get power pushed to them as soon as possible after some of them get up and running in April 2013.
Hospital doctors
The abandonment of Andrew Lansley's original plan for the regulator to promote competition between hospitals pleased the Royal College of Physicians, which represents hospital doctors.
It now wants to help the NHS Commissioning Board and Monitor to develop guidance on how choice and competition can be applied on the ground in hospitals, GPs surgeries and elsewhere.
But Sir Richard Thompson, the college's president also warned that "without fundamental review the government's current proposals for reforming medical education and training will put the next generation of doctors' training at risk and could jeopardise patient safety."
The mandatory inclusion of a specialist hospital doctor on the board of each clinical commissioning group is a significant success for the college. It is suggesting that, as a reciprocal gesture, a local GPs' representative could sit on the board of every local hospital.
Unusually among key medical bodies the Royal College of Surgeons broadly supported Lansley's original plans. Now it wants the changes to happen as fast as possible. "The best thing for the future of the NHS is to get on with making these plans a reality without delay", said John Black, its president. Removing the need for all the new groups of clinicians to be operational by 2013 could see the NHS ending up with "a mixed economy of commissioning" with some freshly-formed groups co-existing with some remaining GPs practices which, he warned, could "create wasteful duplication of how NHS money is spent."
Nurses
The Royal College of Nursing, which represents the UK's 400,000 nurses, scored a victory by ensuring that "at least one registered nurse" will be on the board of each new clinical commissioning group, rather than just local GPs.
"Nurses have an unparalleled range of skills and experience to enable them to improve healthcare at every level [and can] help build a service which can manage long-term conditions, keep people out of hospital and improve the health of the public", said RCN chief executive Dr Peter Carter.
But, Carter adds: "The government needs to get a grip and put some more details on these reforms with the utmost urgency. PCTs are collapsing around the country and many staff have already been made redundant. There are still real risks with the architecture of the health service in these reforms in the eyes of practioners and, more importantly, for patients and their care. It's quite shocking that a year into this process we still don't know
important details about governance, commissioning and reporting regimes. What happens if one of these commissioning bodies fails? There is still no proper failure regime in place. It is irresponsible of the government not to provide these details."
He doubts NHS staff are preparing to strike "yet", but added: "there is certainly the possibility of more marches, particularly if patient care is affected. NHS staff have already proven they will come out to demonstrate, and I'm sure they will do so again if their concerns are not met."
Private and not-for-profit healthcare firms
David Cameron's explicit rejection of further private sector involvement in the NHS has appeased the Bill's many critics and helped neutralise its most sensitive issue. But it has left both private and not-for-profit providers of healthcare frustrated and warning that the NHS will be poorer if they are squeezed out.
"The independent sector continues to believe that the NHS needs more innovation, diversity and robust, fair competition if it is to meet the challenges it faces, including achieving better integration, which we support and which can be strengthened by a competitive market", said David Worskett, director of the NHS Partners Network, which represents both sectors.
"The commitment to patient choice rings hollow when there is so little real encouragement of diversity or providers to make it meaningful. Overall the process of reforming the provider side of the NHS so that it better meets patients' needs has been set back by several years", he added.
"Providers who have worked immensely hard to integrate with and support the NHS are disappointed at the Government's failure to recognise this or provide wholehearted commitment to the independent sector for the future", said Worskett.
Health policy experts
Professor Chris Ham, chief executive of the King's Fund health think-tank and a member of the Downing Street health 'kitchen cabinet', sees the updated reforms as "a more promising approach to meeting the health challenges of the future than the proposals originally set out in the Health and Social Care Bill."
But he warned that: "The confirmation of the Prime Minister's pledge to keep waiting times low, and the emphasis placed on the 18-week maximum wait for hospital treatment enshrined in the NHS Constitution, leaves
the NHS with a very significant challenge. With the spending squeeze beginning to bite, the number of hospital inpatients waiting more than 18 weeks for treatment is already at its highest level for more than three years and waiting times for A&E and diagnostic services have also risen. As the government has said that it is opposed to targets, it now needs to be clear about how this pledge will be measured and enforced."
Failure to honour that pledge could have political ramifications for Cameron.
Financial pressures are more important than reorganisation for NHS leaders just now, Ham added. "The Future Forum won't address the problems of the health service in itself. Waiting times and access are commitments that are increasingly being made by the prime minister and the pressures to meet those are being compounded by financial pressures. We're all going to be much more focused on the Nicholson challenge [to save £20bn by 2015] and there is a real question about whether care will be compromised as we face the toughest period in the health service."
In addition, "the sheer number of changes being made to the structure of the NHS risks creating confusion and additional bureaucracy" through the creation of an array of new bodies in the NHS -- such as clinical commissioning groups and regional arms of the National Commissioning Board -- he warned.
