and care excellence sections 232 to 249 expand the role of the national institute for health and clinical excellence to include social care, re-establishing the body on 1 april 2013 as the national institute for health and care excellence (known as nice). this non-departmental public body publishes guidance in areas such as the use of new and existing medicines, treatments and procedures, taking into account cost-effectiveness; its scope is nhs services, public health services, and (in england only) social care. part 10, abolition of public bodies sections 278 to 283 abolished the alcohol education and research council, the appointments commission, the national information governance board for health and social care, the national patient safety agency, the nhs institute for innovation and improvement and the standing advisory committees. parts 11 and 12, miscellaneous sections 284 to 309 contained various other provisions. public reactions general on 19 january 2012 two major unions of healthcare professionals that had previously tried to work with the government on the bill, the royal college of nursing and the royal college of midwives, decided instead to join with the british medical association in "outright opposition" to the bill. on 3 february 2012 the royal college of general practitioners also called on the prime minister to withdraw the bill. the confederation of british industry supported the bill, declaring that "allowing the best provider to deliver healthcare services, whether they are a private company or a charity, will spur innovation and choice." in may 2011, a number of doctors from gp consortia wrote a letter to the daily telegraph in which they expressed their support for the bill, calling its plans "a natural conclusion of the gp commissioning role that began with fundholding in the 1990s and, more recently, of the previous government's agenda of gp polysystems and practice-based commissioning". on 14 may 2011, the guardian published an article reporting that the gp appointed to head the nhs "listening exercise" has unilaterally condemned the bill. the article said that steve field had "dismissed" the plans "as unworkable" and that these statements were "provisional conclusions that could fatally undermine the plans". the royal college of general practitioners (rcgp) also denounced the bill. the royal college of physicians and royal college of surgeons welcomed in principle the idea of medical professionals determining the direction of nhs services, but questioned the bill's implementation of the principle, particularly in regard to the approach of making gp consortia the primary commissioning deciders, and also in regard to requiring competition. the british medical association said similarly. neither of these organisations supported the bill. in february 2011 david bennett, newly appointed chair of monitor, said the nhs could become like other privatised utilities, so that monitor would potentially be a regulator like ofcom, ofgem and ofwat: "we, in the uk, have done this in other sectors before. we did it in gas, we did it in power, we did it in telecoms we've done it in rail, we've done it in water, so there's actually 20 years of experience in taking monopolistic, monolithic markets and providers and exposing them to economic regulation." the house of commons select committee on health condemned the comparison as not "accurate or helpful." gps as commissioners the bill intended to make general practitioners the direct overseers of nhs funds, rather than having those funds channelled through neighbourhood- and region-based primary care trusts, as was previously done. there were concerns about fragmentation of the nhs and a loss of coordination and planning. the royal college of general practitioners said it was "concerned that some of the types of choice outlined in the government's proposals run a risk of destabilising the nhs and causing long-term harm to patient outcomes, particularly in cases of children with disabilities, those with multiple comorbidities and the frail and elderly." the royal college of physicians said that "whilst we welcome the broad provision in the bill to seek professional expertise, the rcp is concerned that the bill does not require that specialists are at the heart of the commissioning process." the royal college of psychiatrists said it "would be dismayed if psychiatrists were not closely involved with local consortia of gps in the development of mental health services." the royal college of surgeons said that "the legislation leaves the question of regional level commissioning unanswered with no intermediary structure put in place." and there were concerns about management expertise, particularly by looking at the us. the bmj wrote that "no matter how many gp consortiums eventually emerge, their number will probably greatly exceed the 152 primary care trusts they are replacing, which brings a set of new challenges. smaller populations increase the chances that a few very expensive patients will blow a hole in budgets. more consortiums mean that commissioning skills, already in short supply nationally, will be spread even more thinly. denied economies of scale, smaller consortiums may be tempted to cut corners on high quality infrastructure and management, thereby endangering their survival. these points emerge clearly from an examination of 20 years of us experience of handing the equivalent of commissioning budgets to groups of doctors. some groups had severely underestimated the importance of high quality professional management support in their early days and gone bankrupt as a result." the house of commons health committee has suggested the government let experts other than the consortia gps and their direct allies get involved in the running of the consortia, including hospital doctors, public health chiefs, social care staff, and councillors. that idea received some wider support and the government agreed to give it consideration. those close to health secretary andrew lansley have said that he is concerned adding too many people to consortia decision-making risks making them too unwieldy." in 2010 the same committee had gone so far as to declare that "if reliable figures for the costs of commissioning prove that it is uneconomic and if it does not begin to improve soon, after 20 years of costly failure, the purchaser/provider split may need to be abolished." accountability kieran walshe, professor of health policy and management and chris ham, chief executive of the king's fund, argued that "at a national level, it is difficult to see who, if anyone, will be in charge of the nhs. there will be five key national bodies: the department of health, the national institute for health and clinical excellence, the care quality commission, the nhs commissioning board, and the economic regulator monitor. although the remit of each is set out in legislation, it is not clear how these national bodies will interact or how they will provide coordinated and consistent governance of the nhs." clinical commissioning groups operate as statutory bodies, though it was suggested that up to third of ccgs are reluctant to do so. pace and timing of change the king's fund said that "the very real risk that the speed and scale of the reforms could destabilise the nhs and undermine care must be actively managed." the bmj said in january 2011 that "the bill promises that all general practices will be part of consortiums by april 2012, yet it took six years for 56% of general practices to become fundholders after the introduction of the internal market. nearly seven years after the first nhs trust was granted foundation status, there are still more than half to go—within two years. and there's more. the replacement for the 10 strategic health authorities—the nhs commissioning board—needs to be fully operational by next april. by then, gp consortiums should have developed relationships with local authorities, which will assume ultimate responsibility for public health via their new health and wellbeing boards, working alongside public health england, a completely new entity." the bma believes such targets to be either wholly impossible or, at best, able to be done only in a very roughshod manner, which could in turn have very serious on-the-ground consequences to nhs functioning. medical establishment reaction the british medical association opposed the bill, and held its first emergency meeting in 19 years, which asked the government to withdraw the bill and reconsider the reforms, although a motion of no confidence in andrew lansley by the bma failed. a later motion of no confidence in lansley at the royal college of nursing conference in 2011 succeeded, with 96% voting in favour of the motion, and several speeches thereafter condemning lansley threefold: the health and social care bill 2011 as written; lansley's decision not to address the entire conference with a speech, but instead to hold a separate meeting with 40 conference attendees in a separate space (taken as an insult to nurses, and leading to accusations of 'gutlessness'); and the current separate "efficiency savings" measures being undertaken across the nhs and those actions' material impact on frontline medical services, especially as contrasted with several prominent officials, including nhs leaders and lansley himself, repeatedly assuring that nhs frontline services are 'protected' at all times regardless of these "savings" measures. "people will die", richard horton, editor of the lancet, warned in march 2012, as he predicted "unprecedented chaos" as a result of the reforms, with a leaked draft risk-assessment claiming that emergencies could be less well managed and the increased use of the private sector could drive up costs. opposition groups a panorama of the 'block the bridge' anti-cuts protest on westminster bridge, in october 2011 various pressure groups opposed the bill, including the people's assembly, nhs direct action, keep our nhs public, 38 degrees, the socialist health association, many trades unions, including the chartered society of physiotherapy, unison, and unite. 38 degrees' petition against the reforms passed 250,000 signatures by 21 april 2011. in march 2011 a motion at the liberal democrat spring conference called for changes to the bill to ensure greater accountability and prevent cherry-picking by private providers, among other demands aimed at reducing marketisation of the nhs. unison sponsored rapper nxtgen to create an unflattering hip hop track about the bill, which has now been viewed over 390,000 times on youtube. jeremy hunt was appointed health secretary in a cabinet reshuffle on 4 september 2012, succeeding lansley. he had previously co-authored a book calling for the nhs to be dismantled and replaced with a system of personal health accounts. the deputy chairman of the british medical association, kailash chand, said "jeremy hunt is new health secretary – disaster in the nhs carries on. i fear a more toxic right winger to follow the privatisation agenda." on 9 october 2011, a protest organised by uk uncut took place on westminster bridge. an estimated 2,000 health workers and activists attended the protest. on 5 march 2012, the campaign group 38 degrees erected 130 billboards in the centre of london with the aim of persuading david cameron to abandon the bill. on 25 september 2013 labour's shadow health secretary andy burnham promised that the party would repeal the health and social care act in "the first queen's speech" if elected. effect of the act in january 2015, chris ham and others from the king's fund produced a review of the government's health reforms. their conclusions as far as the act was concerned were that: the reforms resulted in greater marketisation of the nhs the reforms resulted in top-down reorganisation of the nhs which was distracting and damaging new systems of governance and accountability are complex and confusing the absence of system leadership is increasingly problematic when the nhs needs to undertake major service changes in november 2017, jeremy hunt in an interview with the health service journal said "the idea of lots of competing foundation trusts and payment by results works well when you have in your mind that most of the work the nhs does will be single episode elective care, but when you're dealing with complex patients who are going in and out of the system a lot those structures prove not to be fit for purpose." nick timmins, writing in 2018, concluded that the legislation, in its own terms, had failed. choice and competition were not, as envisaged, the driving principles of the nhs. in fact the development of integrated care systems was unpicking the "purchaser/provider" split that had been the dominant theme of nhs management since 1991. the organisations set up by the act, monitor and the nhs trust development authority had effectively been merged.