NEWS FOCUS: Labour's back with a vengeance. What did the Queen's speech reveal about its ambitions for health in the second term? Paul Smith reads between the lines

Perhaps Chairman Mao would have frowned upon the style - Britain's head of state dressed up in all the trimmings of regal symbolism. But the substance of the Queen's speech last week, with its continued commitment to permanent revolution within the NHS, would certainly have met his approval.

Whatever health secretary Alan Milburn says about letting the NHS get on with delivering the much-needed improvements to frontline services, last week he reminded everyone that it does not mean the process of major structural change will be brought to a halt.

It seems we are about to witness that much-vaunted shift of emphasis from the acute sector to primary care.

That was no real surprise in itself - the health secretary had said it all before the election. Ever growing numbers of primary care trusts will soak up the budgets of doomed health authorities.

Seventy-five per cent of funding will be given directly to 300 or so PCTS by 2004.

It means extra responsibilities again for GPs, as well as for dentists, opticians and pharmacists, though the full timetable for the reforms is not expected to emerge until the autumn.

But the questions and worries have already begun. NHS Confederation policy director Nigel Edwards said the culling of HAs and the birth of slimmer, apparently more efficient strategic HAs could end up in mass redundancy payouts and the loss of experienced managers.

He also fears such upheavals mean greater workload on already over-stretched managers battling to deliver the frontline service improvements which the prime minister has insisted are so fundamental to his government's success.

'We have a lot of good staff, but they are going to have to deal with delivering the improvements to the service as well as dealing with reorganisation. That is going to be difficult because it seems unrelenting. We also need a clear indication of what the reform of primary care services is for. The arguments so far are good as a guide, but managers need more about the government's specific aims. '

The NHS Alliance, which welcomes the direction of primary care policy, is already concerned about whether the politicians can genuinely relinquish control and trust the new PCTs to carry out their work without excessive meddling.

Chair Dr Michael Dixon said:

'Yes, devolving more powers to PCTs is welcome. But if they are swamped by directives from the Department of Health, that is going to make their work more difficult. They can set the targets and the ends that need to be achieved. But PCTs have got to be allowed to run the services in the way they think best so they can meet not only the national imperatives but local ones too. '

He also stressed that the size of PCTs would also be an issue:

'Already there are a number of PCTs who have moved responsibility for the development of primary care from chief executives to other managers. The worry is that chief executives will take on an abstract role, disconnected with service provision creating a 'them' and 'us' culture with GPs.

They will lose the touchy-feely aspect of their work which is so necessary. '

Other health legislation over the next 18 months will centre on clinical negligence. Growing litigation is a painful boil on the rear of the NHS. It currently faces claims totalling some£3. 9bn, and with fears that the country is following the US in its obsession with court action the government has signalled that it wants to stop fattening the lawyers' pockets with scarce NHS cash by clamping down on the cost of claims.

There are suggestions that the DoH is examining a tariff system whereby patients who have suffered at the hands of the service will be offered compensation according to circumstances without liability having to be proved. The thinking - no court hearings, and no lawyers - equals cuts in costs.

However, as former Conservative home secretary Michael Howard found, messing with the law is an easy route to a bloody nose. Many legal experts believe any change in the system undermining patients' access to the criminal justice system to settle their claims could end up on a collision course with the Human Rights Act.

The Queen's scripted silence last week on private sector links to provide public services may have been unsurprising - little formal legislation is needed to foster the 'greater partnership' so close to the government's heart. And the fact that a ban on tobacco advertising - given Labour's flirtation with Bernie Ecclestone - was also absent may have raised an eyebrow on the leasy worldly-wise.

But the lack of any mention of the much-debated reforms to the Mental Health Act did give rise to concern, with some in the service suggesting that mental health's persistent 'Cinderella' profile has allowed ministers to push it onto the back burner.

So far pressure groups, including the Mental Health Alliance, have given the government the benefit of the doubt and avoided strongly worded comments in the press. They see the lack of action as allowing the government to use the time - it will be 18 months before the next Queen's speech - for a rethink.

Mind - one of the organisations which make up the alliance - says:

'We are concerned that it is being put back, but we want the government to use the time to ensure any new Mental Health Act will help those suffering from mental illness.

'We have been calling for new legal rights - rights to treatment and rights to assessment - and hopefully these are the things that will be included. '

Finally, there remains the saga over community health councils.

They have survived into the Blair second term despite the best efforts of government.

Again little came from the Queen's speech to soothe the nerves of those who have fought so hard on their behalf. And a big majority in the Commons may mean little chance of a policy Uturn.

The DoH promises to ensure the public has a greater say in 'decisions which affect their care and that of the local community'.

Democratically elected local bodies will scrutinise the local health services and have the exclusive right to refer contested local service changes to the new national reconfiguration panel.

A spokesman for the Association of Community Health Councils for England and Wales says: 'The devil will be in the detail and we are anxious to know what will happen as far as patient representation is concerned.

'We hope that there is wide consultation and that we can have a say in the shape that it could eventually take. But at the minute it is a question of waiting to find out what it is exactly they want to do. '

All go: NHS Reform Bill Decentralise power and put 75 per cent of spending power into the hands of PCTs.

Reform of the General Medical Council and creation of a new body given powers to regulate doctors to ensure they are safe to practise.

Scrap CHCs and create democratically elected committees to scrutinise local health services - a bid to give patients more influence on the way they are run.