The whole thing, as a result, is a complete mess. It is doubtful that primary legislation is really needed to make the changes now planned. It is sensible, as this blog has argued for months, to make GP commissioning voluntary. But it is absurd to turn Monitor from a guardian of fair competition into a cuddly promoter of both competition and collaboration. It can't be both - and do its job. As amended, the accountability mechanisms are in severe danger of embedding huge conflicts of interest.
But, as today's Populus poll for the Times shows, the public's big concerns are not addressed. Waiting time targets - like floor standards in schools - are an essential guarantor of minimum patient requirements. Ben Goldacre in Saturday's Guardian showed how excessive A and E waits cost lives: for many, that experience is a key part of how they will judge the NHS too. Moving from 18 month to 18 week maximum waits for treatment was one of Labour's great successes. These absolute figures are getting worse (regardless of median waits) and will continue to worsen unless languid Lansley indicates that he cares about them. Together with the quality of care people receive in hospital, these are the issues people care about most and unless ministers get them right, their reforms, such as they are, will be judged a failure.
That is not to say that structural issues don't matter. GP commissioning, with willing participants, and private or voluntary providers can improve efficiency; but so can a strong NICE and a willingness to move from general to specialist hospitals, both cynically opposed by Lansley in opposition. By failing to grasp such nettles, and focusing on surprise but ill-thought through reforms, the health secretary has set back NHS reform by at least a decade. And by being asleep on the job as he was doing so, David Cameron and Nick Clegg must take the blame too.