Changes to the way in which nurses, midwives and PAMs are regulated could have a profound effect on the running of the NHS.Andrew Cole reports

Over the coming months MPs and civil servants will be putting the finishing touches to a relatively obscure piece of legislation that could nevertheless change forever the relationship between health professions and the public.

Draft legislation, out last month, outlines the creation of new slimmed-down professional bodies for both nurses and midwives as well as the professions supplementary to medicine. But after consultation finishes at the end of this month, the reverberations may also be felt by doctors, support workers and managers.

The most significant difference between the new bodies and their predecessors is the degree of public accountability. For the first time it is explicitly stated that the primary purpose of the new professional bodies is the protection of the public.

And where membership of the old UK Central Council for Nursing, Midwifery and Health Visiting contained just four lay members out of 60, the new council will be almost equally divided between lay and professional representatives. In theory, the president of the new body need not be a nurse. In reality, Jonathan Asbridge, director of nursing at Barts and the London trust, has just been appointed to the role.

At the same time there will be a broader definition of unfitness to practise, enabling the new council to deal with rogue nurses more effectively, together with a tougher armoury of sanctions, ranging from striking off to suspension or caution.

Although generally welcoming the changes, nursing organisations have expressed concerns about some aspects, particularly the prospect of registration fees rising sharply.

But this is merely a dress rehearsal for the battles to come.

First in line are likely to be the estimated 100,000 support workers currently in the public and private healthcare sectors.

There is concern that these staff remain unregulated despite giving as much direct hands-on care as the nurses and others who supervise them. Indeed, at the moment a nurse who is struck off the register could, theoretically, return to work as a care assistant without facing any scrutiny.

It seems the government is now prepared to bite the bullet and introduce some form of regulation. The long-awaited report by De Montfort University into the role and scope of support-worker regulation is to be published shortly and ministers will then develop proposals 'for the effective regulation of health support workers across all disciplines'.

Once they have put these forward, the arguments will begin in earnest. The Royal College of Nursing, which has just decided to open its doors to healthcare assistants, favours regulation by the new Nursing and Midwifery Council, while Unison, which represents the vast majority, plumps for a separate 'one-stop' regulatory body.

Most support workers strongly favour some form of regulation, says Unison national officer Paul Chapman - so long as registration fees are reasonably modest. But even more important is public protection.

'At the end of the day We are talking about people giving hands-on care to vulnerable people. They have as much opportunity to physically, sexually or financially abuse patients as anyone.'

But the biggest battle over regulation looks set to be with the group the government has had in its sights all along - the doctors.

The hostile reaction of the British Medical Association to the relatively modest reforms of disciplinary procedures proposed by the General Medical Council does not suggest much accommodation at the moment.

Ministers have made veiled threats that if the professions cannot act to reform themselves they could take away many of their self-regulating powers and hand them over to the new coordinating body, the UK Council of Health Regulators.

But many suspect this is bluff.

'I think it suits the state to reform but not take over professional regulation, ' says Stephen Dewar, fellow in the healthcare policy programme at the King's Fund.

'What secretary of state wants to be responsible for a future Ledward or Shipman? On the other hand, the threat to take away the perceived freedom and status of professional self regulation is an important lever.'

He believes there is still a strong case for self-regulation but it must be combined with greater public accountability. 'This doesn't necessarily spell the end of professional self-regulation. It just ushers in an era where it means something different.'

One of the few groups so far untouched by this push for greater regulation are managers.

The Institute of Healthcare Management has been pressing for some time for a compulsory code of conduct and fitness to practise certificates for its members, arguing that managers cannot demand accountability from other professions while remaining unaccountable themselves.

There remain a number of practical difficulties, but IHM chief executive Stuart Marples insists some form of regulation is inevitable. 'The only question is whether we do it ourselves or have it forced on us.'

How the council will work The new council starts business in April 2002.

The council will consist of 23 members, made up of 12 professionals and 11 lay representatives.

Interest in the lay jobs - which could involve 30-50 days a year at a daily attendance fee of£250 - has been huge.Over 1,000 people have inquired about the seven shadow posts.