Poor Mr Cameron. Up till now, he must have thought that if only the Health and Social Care Bill survives the House of Lords and its return to the Commons, everything will be all right. Then, when it gets the Royal Assent, the sceptics will see the light, hail Andrew Lansley as the new Bevan, and recognise his blueprint as the new Jerusalem.

But now it seems clear that even if the Bill is passed, it will be only the beginning – the beginning of warfare between branches of the service, disappointment among public health doctors and GPs, and legal challenges from patients.

Many GPs who previously supported the Bill now seem to think that the commissioning consortia will be under the thumb of the National Commissioning Board. Several prominent members of the NHS Alliance, which has consistently supported the Bill, signed the letter to the Daily Telegraph asking for the Bill to be withdrawn. So GPs will be fighting the National Commissioning Board.
And some public health doctors think they will be fighting the local authorities into which they are being parachuted. One told the BMJ that he is dreading the day of his transfer. “Our councillors have said they have no interest in public health, and will get rid of it as soon as they can, yet we are being forced to join them ‘like lambs to the slaughter’.”

But most worrying of all must be the opening of a legal case in the High Court this week. A retired railway worker from Slough is taking a primary care trust to the High Court in a case starting today (Wed, 8 Feb) alleging that the awarding of a multi-million contract to a private body is unlawful and will be detrimental to the long-term interests of patients.

Mr Michael Lloyd, a retired railway man from Stroud, will claim in a judicial review hearing at the High Court that a contract worth between £240m – £400m has been awarded to a specially created Community Interest Company (CIC) by Gloucestershire Primary Care Trust on an unlawful basis.

Law firm Leigh Day & Co will argue during the two day hearing that the effect of these arrangements will be to outsource NHS funded community health services to a company, Gloucestershire Care Services CIC (GCS), which operates outside the NHS, with services delivered by staff who are not NHS employees and that such an arrangement is likely to be detrimental to the long-term interest of patients in Gloucestershire.

The services include the operation of community hospitals, district nursing, community physiotherapy services, out of hours medical and pharmacy services, community dental services and sexual health services. The value of these services is estimated to be in the region of £80m per year, or £240-400m over the period of the contract.

Government policy seeks to separate NHS commissioners from NHS providers by requesting PCTs to transfer their provider services to other organisations. Lawyers argue that the proposal by NHS Gloucestershire to enter into a contract with a company such as GCS for the provision of their NHS community services, without undergoing a fair and transparent process, is unlawful for domestic public law reasons and for EU law/public procurement reasons.

This should send a cold shiver down the spines of everyone in the NHS. One can foresee a time when the whole NHS budget is taken up in the cost of legal disputes. If the reforms do not have the public behind them, and most surveys show that they don’t, patients, as well as private health companies, are likely to challenge all the decisions of the new Jerusalem.

The Royal Assent might solve one problem for the Government, only to create another, much bigger one, for the future.

Annabel Ferriman is the news editor, BMJ.