One overarching conclusion can be reached from the changes to the government’s reforms: there will be a continuation of the planning blight that has afflicted the health service since the decision to scrap primary care trusts without thinking through the implications.

The changes will all have to be considered and revised as unintended consequences emerge. Issues such as the strengthening of “commissioners’ duty to promote choice” will have the British Medical Association sounding the alarm. While those closest to the reforms – not just politicians – who believe the changes are “keyhole surgery, not amputation”, will battle to maintain the thrust of the original reforms.

This blight will distract and confuse. Quality will suffer, as will efficiency – despite the efforts of NHS staff, including HSJ readers, to compensate.

Some will argue that health secretary Andrew Lansley should pay the price for getting reform so wrong. We disagree. He should stay and help sort out the mess and answer for any consequences that emerge.

So, as far as it is possible to tell, have the reforms been improved enough to make a longer period of uncertainty a price worth paying?

A stronger role for the NHS Commissioning Board, the arrival of clinical senates and the greater role of networks should mean a surer hand on the tiller. However, as HSJ warned last week, many of the more go-ahead GP consortia will feel shackled. In short, fewer car crashes are likely as the new system develops, but we are also likely to get fewer breakthroughs. 

Compromise, not innovation, will rule.

This more evolutionary approach is underlined by the extended timetable for reform. The government declares its intention not to let a two tier commissioning system develop, but by not setting a drop-dead date for change they are guaranteeing it. As with foundation trusts, there will always by areas which struggle to meet required standards. The willingness to take the hard decisions required is likely to be in short supply. Spooking the horses once was bad enough.

Expect the NHS to arrive at the next election with perhaps 10-20 per cent of non-specialist commissioning still being effectively handled by the local arms of the NHS Commissioning Board.

The goal to make every NHS trust a foundation will also not be delivered by the next election. Scrapping the April 2014 deadline removes a key driver to tackling the financial and structural barriers preventing some trusts from making the grade. Each trust will have its own deadline, but readers will know how easily these can be shifted as circumstances change.

The same slackening off in the perceived need to tackle difficult issues will also be experienced in the drive to reconfigure services. The decision to drop the system of “designating” essential services means there will be no pre-agreement about which services are open for reconfiguration.

None of this, of course, means the efficiency challenge is going away or will reduce in scale or urgency.

The changes effectively mean a wider group now have a greater say in how efficiency will be delivered. A good thing in principle, but as HSJ readers know, everybody having responsibility can mean no one taking ownership. NHS chief executive Sir David Nicholson will have to tighten his grip further.

The reform changes also signal the energy draining away from the desire to encourage greater private sector input in provision or commissioning support.

Overall, the effect of the changes is to push the most difficult decisions back towards the end of this parliament, where it will be most difficult to make them. The changes to the health secretary’s responsibilities are largely cosmetic – but they will have the very real impact of increasing the expectation that it his job to fix local problems.