news focus: Is the Health Reform Bill a case of ill-conceived legislation catching up with ministerial initiatives? And will what is there pull together the loose ends? Tash Shifrin reports

For health ministers who have been slaving over promises to reform the NHS, the publication of the Health Reform Bill could be seen as the equivalent of a domestic spring-clean. A clear out, if you like, catching up with all those niggling chores they have been meaning to do for absolutely ages (tidying away health authorities, putting some elbow grease into the Commission for Health improvement).

In the paperchase of recent health legislation, the new bill looks like a rather bitty accumulation of clauses to fill the gaps left by the previous acts, and to allow the statute book to catch up with ministerial initiatives.

So what is new? In response to the Kennedy report on Bristol Royal Infirmary, the bill offers a dramatic extension of the Commission for Health Improvement's remit.More familiar is the creation of a Council for the Regulation of Healthcare Professionals and a second attempt at abolishing community health councils, both originally promised in the NHS plan.

And - the most eagerly anticipated part - a legal framework for the Shifting the Balance of Power in the NHS reorganisation.

And even the proposals to increase the scope of CHI leave several key issues to be resolved after legislation is passed.

For example, what are 'special measures', exactly? The bill says CHI can recommend these where healthcare is 'unacceptably poor' or 'there are significant failings in the way the body or service provider is being run'.

And CHI communications director Matt Tee says 'a menu of special measures' will be discussed with the Department of Health.

NHS Confederation policy manager Alastair Henderson says:

'In practical terms, We are not sure what this will mean.'

The confederation is cautious about CHI's takeover of the starrating system. 'I think they are aligning the CHI process with the star process - it does make sense because there were some oddish things this time round, ' Mr Henderson says diplomatically.

'But there is a concern that It is mixing and confusing the qualityimprovement agenda with the performance-management agenda.

CHI's purpose is about looking at quality, looking at ways to develop and improve.

'Performance management doesn't always come from that approach.'

Dr Walshe says CHI's wider remit is 'really welcome'. He had expected the DoH's response to Kennedy to be 'much dustier'.

But he asks how far the changes will really go. 'A CHI power to say a trust has to cease to operate in a certain area would be much more useful, ' he says. 'I hope it will translate into CHI having significantly more power.'

But Durham University's Professor David Hunter is less happy at the 'mushrooming of CHI', which he says is 'moving towards a very developed regulatory state model'.

Professor Hunter points out:

'That wasn't the original model under which CHI was set up, or the model [its chief executive] Dr Peter Homa originally articulated. The notion of an Ofsted for health will be a complete turn-off for professionals and people in the service, unless It is handled very carefully.'

The changes give 'tremendous power to a new organisation That is still developing', bringing 'rapid growth when we ought to be evaluating whether It is the best model'.

And he warns that CHI's organisational growth will mean 'taking talent from the service', draining it of managerial capacity already in short supply.

The real losers would seem to be those other inspectors at the Audit Commission, which will now have to consult CHI on its own value -for-money inspection programme. An Audit Commission spokesperson insists it 'really welcomes' the change. 'We formally offered this sort of relationship with CHI some time back.

'CHI's brilliant on clinical governance, whereas we look after corporate governance and value for money, ' she says.

But CHI's role in identifying failings in the way NHS bodies are being run looks like a move into corporate governance that could see the Audit Commission pushed to the margins.

Perhaps one of the interesting issues is not what's in the bill - but what is left out - particularly on the vexed question of patient and public involvement, where glaring gaps are to be filled later by health secretary Alan Milburn in regulations.

The bill contains scant detail of the new system, outlining only trust-level patient forums and a new national body, the Commission for Patient and Public Involvement in Healthcare.

The staff-only Voice organisations, derided by opponents as too remote - at strategic health authority level - and lacking lay member involvement, do not appear in the bill. But they do appear, minus the name, in DoH briefing material.

The bill says: 'The commission is, so far as practicable, to exercise its functions by reference to the areas of primary care trusts.' The briefing material explains that this will be done through 'a network of specialists'.

'It is likely that there will be one team of specialists per SHA area' - to be set up by the health secretary's regulations, presumably.

Commons health select committee chair David Hinchliffe is surprised that his proposal for patients' councils - umbrella groups of local patients' forums to work across a local health economy - appears to have been dumped.

'What I am concerned about is It is almost back to where we were last time round, ' he says. 'What I would like to see is something written into the bill that specifically ensures clear procedures for drawing together patients' forums. The big weakness is There is no mechanism, so far, for following patients [through the healthcare system].'

Mr Hinchliffe was set to quiz ministers at the bill's second reading last Tuesday. 'I want a lot more detail than is in the bill, ' he emphasises.

Lack of detail on the face of the bill sets the scene for a complete rehash of last term's parliamentary debate, as opposition MPs and worried Labour backbenchers try to ensure that their concerns are met on the statute books.

Little gaps and anomalies pop up all the time. For example, measures to allow patients' forums to elect a member onto trust and primary care trust boards seem to be missing from the bill.

This was promised in the NHS plan, widely publicised by ministers and announced again in briefing material.

If it does not require primary legislation this time, it seems strange that the measure was included in the Health and Social Care bill - before the patient and public involvement clauses were dropped - last time around.

Then there is Shifting the Balance. And the British Medical Association's views on the clauses which will bring in structural change to the NHS, oddly enough, for once echo the pleas of NHS managers.

GP committee chair Dr John Chisholm notes the 'challenging agenda' for PCTs, and adds: 'It is essential that adequate resources are provided to ensure these responsibilities can be discharged, and it is also essential that PCTs have high-quality management, professional input and leadership.'

This is what Professor Hunter calls 'the high risk around PCTs - 75 per cent of the budget going to a completely unproven quantity'.He is scathing about ministers' claims that this is devolution, which 'seems slightly disingenuous'.

It is more like 'pretty fierce central command and control', he says.

The government will allow devolution to trusts and PCTs 'only if they meet defined criteria and do the centre's bidding'. But 'devolution means you define your own agenda', he says.

With four regional offices more closely integrated into the DoH and few enough SHAs to 'get them all round a table in [DoH HQ] Richmond House', this is centralisation, not devolution, he argues.

Dr Walshe has slightly different misgivings about the money going straight from the health secretary to PCTs.

'It potentially makes life harder for SHAs, because if they can't control the money, what do they control?

'It remains to be seen how they will be able to act as the broker in the local health economy.'

Professor Hunter also voices a fear that NHS managers might share on the quiet.

The NHS plan promises major service improvements, and ministers will expect to see this before the next election. 'But the reorganisation is derailing the timetable. People are just worried about where they will be. Some of these PCTs are clearly unsustainable in terms of size, capacity and geography, ' he says. 'I think the whole thing's going to go bang. l Open doors: how the prison service will benefit Prison healthcare is set to benefit from measures that will allow pooled budgets and devolved responsibilities between the NHS and the prison service, similar to those covering joint working with local authorities.

NHS Confederation policy manager Janice Miles says the need is there, particularly for mental health services.

The changes will encourage the NHS to factor prisoners into their planning.Ms Miles notes that most prisoners are inside for between six months and a year, 'so these people are coming back out into the community and will need those services to continue'.

Behind the move, she says: 'It is the prison service recognising that the quality of service they're offering is not very good and they need to work with health to improve that.'

Half-way step: regulating the regulators The proposed Council for the Regulation of Healthcare Professionals could be the cause of scuffles in the Lords, Dr Walshe believes.There are one or two ex-General Medical Council types in the upper house, he says.

The NHS Confederation's Alastair Henderson is pleased with the move because of the 'need to ensure consistency in the way regulators deal with different professions'.The move was 'a half-way step', given that ministers could have gone for a single giant regulatory body, but he adds:

'Everyone recognises that the GMC has been responding to change.'

The GMC, in its 'guarded welcome', expressed concern that 'the independence of regulators could be compromised'because the council had 'a built-in majority appointed by ministers'.

But Mr Henderson - in a view that may better reflect both ministers and the public on a body to 'regulate the regulators'- turns the question around.'I do not see anything sinister in there not necessarily being a majority from the regulatory bodies themselves.'