One element missing from current discussions of the Health and Social Care Bill is a straightforward account of what will happen if it becomes law. From a detailed study of the Bill and the academic and policy literature about it, plus many discussions with experts, I have distilled this simple scenario of England a few years after the Bill’s enactment.

If the Health and Social Care Bill is passed and fully implemented, the NHS will no longer be a provider of services, as GPs, hospitals and community health services will all be outside the public sector. The NHS will simply be a publicly funded budget and a brand name for a subcontracting operation for competing private organisations, subject to European competition laws which will allow private companies to predominate over other (eg third sector) providers.

Since competition and collaboration are incompatible and in any case, cooperation between providers will be punishable by law as anti-competitive, coordinated services for people with chronic or complex conditions will break down and disappear except within the restricted framework of tied providers under the so-called “integrated care” model developed by the US health insurance industry.

Because the post-credit-crash health service has a more or less fixed budget it will increasingly be the case that services judged to be ‘of lower clinical priority’ will no longer be provided free and will be charged for (or alternatively people will go private). These increasingly common NHS charges will create a demand (i.e. a market) for health insurance, which will mainly be affordable by the most affluent and which will also drive up costs because of administration fees and private profits.

The trigger for the roll-out of top-up insurance will be the impending introduction of personal health budgets, which represent a first step towards user charges.

Clinical commissioning groups will operate on an individual basis so as to be compatible with the insurance companies, unlike the traditional GP service which is population-based and pools risk across the whole country. Illness will begin to cause bankruptcy as is common in the US. Inequalities will increase enormously. Large amounts of public funds raised through taxation will be redirected as profits for the private companies which will provide NHS services and NHS commissioning support, and direct NHS charges (or health insurance payments to cover these) will become a normal item of household expenditure.

This letter first appeared in The Guardian.

The health secretary and his Health and Social Care Bill are in real trouble.

Andrew Lansley had every chance of weathering the storm of professional opposition with a few, carefully chosen compromises but, with cabinet opposition growing, he and it are now vulnerable.

I think the BMA has done a pretty good job in highlighting the weaknesses in the Bill, and other unions have done their tub-thumping bit, but the real driver for change is now coming from the deputy prime minister and his attempt to save both his party and his political career.

Don’t get me wrong - there will be legislation creating GP consortia, more foundation trusts, and more competition in healthcare delivery, but the time lines are going to change and so will the strength of some of the proposals. And, following the recent health select committee report, consultants will be ‘encouraged’ to be involved in GP consortia along with other health professionals.

How much change depends on the quality of the ideas of the assorted bright sparks the Prime Minister is consulting.

First he got directly involved and announced the ‘listening exercise’. An eclectic but largely sympathetic crew were assembled, under the guidance of Prof Steve ‘the fan’ Field to feed back on the reforms. At this stage, all talk was about refinement rather than fundamental change.

But then the real meetings started happening behind closed doors. Cameron rolled in the big beasts of health policy for private consultation. This included Nicolaus Henke of consultancy firm McKinsey, former DH commissioning chief Mark Britnell, now global head of health at KPMG, and former executive chairman of Monitor Bill Moyes (not a doctor, nor a health secretary in sight).

Their challenge - how can these reforms be re-packaged, become less disruptive but still introduce strong competition as the driver of change?

The best case scenario for the government now is that they offer Lansley as a sacrifice, lengthen the implementation period and tone down the requirement for competition. Less speed, and a bit less compulsion will probably be enough for the Lib Dems.

But, it won’t pacify professional opposition. This is very much focused on the obligation for competition and its potential effects on integrated, cooperative services.

The new role of Monitor, in regulating and promoting competition, is a huge target for opponents. And its chairman has done little to convince the doubters that it will contribute to anything other than the fragmentation of the NHS.

A couple of months ago, I thought the Health and Social Care Bill would just be steamrollered in. But, I’m not so sure any more. The public are more aware of the issues and, I think, feel they should have had the chance to vote on them. The Lib Dem leader has to differentiate his policies from those of the Tories.

Lansley, the man entrusted to inspire confidence in the Conservative’s handling of the NHS, has failed to inspire.

And while there’s been an absence of effective opposition from the Labour Party, others have provided it - such as the unions, the health select committee, Tory MP Sarah Wollaston, and now the Lib Dems.

Whether you agree with the Health Bill or not (and I, like a lot of people, like some bits and distrust others), it’s easy to see that opposition is only going to grow until the main tenet of ‘any willing provider’ is watered down enough to give public sector healthcare providers some level of protection.

Read a light hearted take on it.