The long-awaited consultation document on the NHS in Wales, catchily titled Proposals to Change the Structure of the NHS in Wales, finally arrived on 2 April.

It covers five key issues: the end of the internal market, the potential transfer of community services from the current integrated trusts to local health boards, the reduction in the number of local health boards from 22 to eight, the introduction of a national planning forum, and the new governance arrangements that might be introduced for trusts and local health boards.

The focus to date, as it was in the period leading up to publication, has been on the issues surrounding community services. I will return to this in a while. The issue I want to explore first is the impact that ending the internal market will have on our ability to describe the NHS as a national entity.

Yes, publicly funded health services in each of the four home countries continue to share the common principle of being free at the point of delivery and equally available on the basis of need. The extent to which this is the case is for another debate, but the principle remains. Sitting below that principle are some fundamental differences between the four countries of the UK that have emerged since devolution in 1999.

National divisions

Scotland has a fully integrated healthcare system with no purchaser-provider split, Northern Ireland has a fully integrated healthcare and social services system while retaining a commissioning function, England has commissioning and any willing provider, and Wales is, at the moment, moving towards a two-tier system but without any commissioning.

Is this difference significant enough to call into question the continued use of the term NHS? Probably not, given the universality of the overarching principle, but as England moves towards a plurality of provision secured through commissioning and contracting and the other countries further develop their planned and/or integrated approach, the fissures between us will become more and more stark.

Nowhere is this better illustrated than on the front page of a recent Western Mail. The newspaper got hold of a North Bristol trust internal memo instructing receptionists in their hospitals not to book in Welsh patients. Now, the detail behind the headline will be, as ever, complex. The impression left, however, on both sides of the border is that although Wales' first minister's clear red water flows through the Bristol Channel, patients no longer flow across it.

Structural questions

The suggested transfer of services from one body, the current trusts, to another, a slimmed-down number of local health boards, will, as is always the case in these matters, generate a considerable amount of debate and at times more heat than light. But through the heat, there is visible a beacon of sweet reasonableness.

The trusts in Wales, very crudely paraphrased, will respond along the following lines: put the patient at the heart of any reforms, recognise that the greatest degree possible of integration is in the best interests of the patient, get rid of us and the local health boards, and, in a planned system no longer based on commissioning and contracting, create a single integrated tier of health service organisation that plans and delivers all services and contracts with primary care.

Two warnings: first, I chair a trust and have been part of the process that has come to this conclusion, so I am biased, and second, this is by no means a new or innovative suggestion. Scotland currently operates such a system. Anyone with any length of NHS memory will recognise the model.

It will be interesting to see how local health boards respond to this. Equally interesting but more significant will be how the health minister reacts to a response that goes one significant step further than the proposals set out in her consultation document.