91�ȱ�

No-one likes being in limbo - and the NHS is no different.

And that is why, within the health service in England, the concessions are being generally accepted as a reasonable way forward.

Not everyone got everything they wanted - that would have been virtually impossible - but most doctors, nurses and managers alike are ready to get going.

They recognise that the NHS is facing a real challenge in just standing still.

The reaction of the British Medical Association illustrates this. The union has been one of the most vocal critics of the plans and Dr Hamish Meldrum, its chairman, is still not convinced the reforms are the right ones.

But he says: "They may prove to be a distraction and we don't think the privatisation genie is back in the bottle, but we have to get on. There are big challenges ahead and that needs everyone to focus."

Factors like the ageing population, rising price of drugs and lifestyle issues such as obesity means costs are outstripping the small rises the health service is getting in its budget.

And so, despite the pause, changes have already been happening behind the scenes.

The establishment of consortia - or clinical commissioning groups as they are now being called - is already happening.

Meanwhile thousands of staff have already left the local management groups - primary care trusts - that they will replace.

Greater competition and choice, albeit more managed now after the listening exercise, is clearly the way forward.

In fact, this has probably been less of an issue in the wards, GP practices and community clinics across England than it has been elsewhere.

That is because it is already alive and kicking. Private health firms are already seeing NHS patients undergoing knee and hip operations and about a fifth of mental health care is delivered by private firms and charities.

Of course, it will not all be smooth sailing.

Many experts believe the government faces a tricky job in making amendments to their legislation so that the promises made this week are kept.

That could well mean there is more toing and froing in the coming months.

There are also bound to be a few controversies along the way. In an organisation the size and complexity of the NHS things will always go wrong.

Waiting lists may go up at times, standards at some providers - NHS, private or voluntary sector - could be found wanting and access to services may suffer.

Such problems will probably be blamed on the reforms. But in reality in many cases it will be hard to tell whether the changes have helped or hindered performance.

It will probably only be in time, perhaps a decade or more, that the success of the changes will be able to be judged accurately.