The BMA acknowledged death during childhood was rare and living standards high.

But it said that masked a number of underlying problems with the way illnesses were managed and health and well-being promoted.

And it warned cuts to social care and welfare could make the problems worse.

The BMA's report, Growing Up in the UK, highlighted issues such as obesity and foetal alcohol syndrome (babies who are born with disabilities due to the mother's drinking) as public health problems about which little was being done.

It also said there were problems with how the most common childhood diseases were dealt with.

For example, just 3% of children with asthma have their own care plans, which are deemed essential in allowing patients and their parents to keep the conditions under control.

It also said the UK had higher rates of child mortality than other developed countries - equating to 1,600 excess deaths a year.

The report, produced by the BMA's board of science, also pointed to research that suggested one in 10 children was unhappy.

Overall, the UK is ranked 16th in the United Nations league table of well-being - that is below the likes of Slovenia, Portugal and the Czech Republic.

The index takes into account factors such as health and safety, education and housing.

Prof Averil Mansfield, chair of the BMA's board of science, said: "Children should not pay the price for the economic downturn.

"While there has been some progress, I still find it shocking that for a society that considers itself to be child-friendly, that we consistently underperform in international ratings."

The BMA said it believed intervention programmes held the key, pointing to research which suggested for every £1 spent on programmes aimed at children and families, £10 was saved in the long-term.

The report mentioned parenting classes, improving maternal nutrition and targeting children born in households with unhealthy habits, such as smoking, drug use and alcohol abuse.

Prof Sir Al Aynsley-Green, the former children's tsar for England, who has given his backing to the report, added: "In 2013 we are currently experiencing the most challenging era for children, young people and their health for the last 30 years."

But a government spokeswoman said: "There's a lot of misleading stories about the effects of our tax and benefit changes.

"The truth is, our welfare reforms will improve the lives of some of the poorest families in our communities.

"Every child should have the same opportunity to lead a healthy life, no matter where they live or who they are. Working with a broad range of organisations, we have pledged to do everything possible to improve children's health."

Across the NHS more patients are being seen, but the upward trend is perhaps the greatest in A&E.

It is often said that the lack of out-of-hours GP care is the cause of rising demands on A&E.

That is certainly true. Since 2004 GPs have been able to opt out of providing night and weekend cover, leaving it to agencies to provide care.

A lack of confidence in the service has meant patients have to turn to A&E when they have not always needed emergency care.

This has been further compounded in recent months with the roll-out of the new 111 non-emergency phone line. Hospitals have reported rises in patients either because they cannot get through to 111 or have got poor advice and been told to go to their local A&E for trivial reasons.

But this does not tell the full story. The ageing population means there has been a rise in long-term conditions - about £7 in every £10 spent goes on patients with problems such as dementia and heart disease for which there is no cure.

When services are working properly in the community these patients can keep their conditions under control. But when that system fails - as it does too often - they can have crises and inevitably they end up at A&E.

For the past decade the numbers attending the units have been rising year by year. There are now more than 21 million visits annually - up 50% in a decade.

There is a combination of reasons why they have grown, including a rise in number of people with chronic conditions, such as heart disease, that end up having emergencies; the ageing population; and problems accessing out-of-hours GP care. A&E units have also had problems recruiting middle-grade doctors, which creates staffing problems.

But until recently, hospitals had just about been coping. The harsh winter seems to have tipped A&E units over the edge.

In the past few months, the waits that patients face have reached their worst levels for a long time.

The four-hour target - 95% of patients have to be seen to in this time - started to be breached in many places. Since the start of last month, the NHS overall has missed it.

There are signs that, with the weather improving so have the waiting times, but not as much as many would have liked.

The problem is that A&E is the safety net of the NHS: the place people go when there is no other option. If it breaks there is a real problem.

Over the past 18 months, the government has been considering the merits of a minimum price for alcohol and of requiring cigarettes to be sold in plain packets.

Slowly but surely its enthusiasm for the measures gathered pace.

But this year, progress has shuddered to a halt.

Neither measure was included in the legislative programme for the next 12 months, which was announced on Wednesday.

Officially, the government is saying this does not mean the plans have been abandoned.

Health Secretary Jeremy Hunt took to the airwaves on Wednesday morning to point out the government was still free to introduce legislation even if it was not in the speech.

That is true. But normally a government would have been expected to set out its plans for two such high-profile initiatives.

Only Australia has introduced plain packaging, while alcohol pricing has been tried out in just a handful of areas (although it does have its critics in that it is a fairly blunt tool in that it increases costs for responsible drinkers as well as those that consume to excess).

So it is unsurprising public health campaigners have been left disappointed.

The response of Dr Janet Atherton, president of the Association of Directors of Public Health, is typical of the sentiment across the sector.

"We are disappointed," she says.

"There has been extensive public consultation on both issues and we believe that this should now be subject to early parliamentary debate.

"We strongly support both measures as effective ways to address two of the major public health issues facing this country."

Health professionals usually say the best and most effective initiatives are designed and organised locally.

But there is also a belief that they are helped if the government shows leadership on key issues.

It is why the Labour government's ban on smoking in public places was so welcomed.

Not only did it protect people from second-hand smoke, but it also encouraged more people to think about quitting.

And, what is more, it arguably kick-started a wider debate about unhealthy behaviours more generally from the quality of school dinners to drinking habits.

It is a point made by Prof Lindsey Davies, of the Faculty of Public Health.

"When it comes to policy decisions that affect everyone's health, it's actions, not words, that make a difference," she says.

"From compulsory seat belts to the smoking ban, we've seen that governments of all political persuasions need to show leadership and courage to protect people's health.

"Previously unthinkable interventions have become an everyday part of most people's lives because governments acted on the evidence for making ground-breaking policy decisions.

"We urge the UK government to think again and introduce legislation for standardised packs and minimum unit pricing."

Birmingham Council has already been busy. For the last few years it has been providing free leisure services to get its local population fit.

Two years ago Katherine Coughlan was diagnosed with diabetes. She was in her late 40s and, by her own admission, carrying too much weight.

Today she has her condition under control, has lost five stone and is exercising more days than not.

"I swim, use the gym, cycle and do dance mats. It has changed my life," the 51-year-old says.

She is just one of the many beneficiaries of Be Active, Birmingham Council's scheme to provide free leisure services to its residents.

More than 360,000 have signed up to the scheme, a third of the local population, since it was launched in 2008.

Participants register and are given a card which allows them to use a range of facilities from swimming pools and gyms to exercise classes and badminton courts for free during certain times.

There are 29 leisure facilities involved in the scheme, although Be Active sessions are also provided in other settings, such as community centres and schools, while guided bike rides are also provided.

Each leisure centre has to provide at least an hour of swimming and an hour of gym time free, although in some of the most deprived areas as much as 70% of the opening hours are for Be Active members.

Meera Rawji, 32, has been exercising regularly at the Handsworth Leisure Centre in the north of the city since October.

"I was really lazy and my daughter used to say I was too big so I decided to do something about it. When I heard about the Be Active scheme that was it. I now use the gym, go swimming, play badminton and do spin classes."

Ms Rawji and Ms Coughlan are, in fact, typical Be Active users in that the programme has been effective at targeting the so-called hard-to-reach groups.

Some 60% of people taking part are from black and minority ethnic communities, while the average age is 49 as opposed to 29 for private gyms.

Councillor Steve Bedser, the cabinet member for health and wellbeing, says: "We have been really pleased with the range of people who have taken part. When we started, some said it will just be subsidising those who were paying to use the facilities. But that has not been the case."

In fact research by Birmingham University shows that three quarters of users were not previously members of a leisure centre, gym or swimming pool.

What is more, half were overweight or obese and a fifth reported poor or very poor health.

The evaluation of the scheme has also shown other benefits, including a rise in demand for other lifestyle information, such as stopping smoking and alcohol advice.

Overall, for every £1 spent on the scheme £23 is estimated to have been recouped in health benefits.

With such impressive results it is unsurprising that other areas are showing an interest.

Officials from Birmingham have been holding workshops with other local authorities about what can be achieved.

Nonetheless, Be Active has not been immune from the squeeze on finances in local government. It has seen its budget cut in half to £2m a year in the past few years, which has forced it to reduce the hours it is able to offer free access at some centres.

But now with extra money from the NHS to accompany its new public health responsibilities, Birmingham is looking to increase what it makes available under Be Active.

A pilot is starting to see if there is interest in providing Be Active sessions in open spaces. This will include team sports, such as rounders, as well as exercise classes, such as buggy push for new mothers.

"I would like to see our investment increase," says Mr Bedser. "I have told the team to explore what else we can do. Obviously it has to be effective - money is tight - but I think we have proved so far that this really works."

As the debacle has unfolded in the past month - including reports of people waiting hours for callbacks, and ambulances being sent to attend trivial incidents - questions have been asked as to why it was felt necessary to have 46 different contracts in place.

In an interview with the BBC on Wednesday, Dame Barbara Hakin, the interim chief operating officer for NHS England, who has responsibility for the service, said she was adamant the NHS would learn from any mistakes it had made.

But this is not the first time the NHS has run into problems with an advice line.

When NHS Direct - the service 111 was meant to replace - was launched, more than a decade ago, it was split into more than 30 different services. But within five years, it had morphed into a national service, after bosses realised it would be much more efficient and effective this way.

It allowed the system to become more flexible. If a local call centre was too busy, calls were channelled to other areas of the country.

By the end of its time, NHS Direct had an impressive record in dealing with enquiries promptly.

But it was not without problems.

NHS Direct was essentially a stand-alone service. It could not send an ambulance to a patient or make an appointment with an out-of-hours GP, nor could it pass details of its interaction with a patient on to another part of the health service.

When ministers unveiled the plan for 111, and it was first proposed by Labour and then advanced by the coalition government's then Health Secretary, Andrew Lansley, they talked about the need to create a more integrated service to link into local services.

But, in line with devolving power away from the centre, it was decided it should be left to local areas to set up the contracts.

This has led to a lack of consistency, and when there have been surges in demand - particularly at weekends - the services have struggled to cope and, with no flexibility to share the workload with other areas, patients have suffered.

Now NHS England looks set to order a review into the problems. Behind the scenes there is talk of what can be done to create more central control.

But this is not the only example of the NHS embarking on revolution when many have argued evolution would do.

Many have been making the same point about the wider reforms. The government wanted to give more power to GPs so scrapped primary care trusts (PCTs) and replaced them with GP-led clinical commissioning groups.

But when the plans were announced groups as diverse as the British Medical Association and the King's Fund think tank were asking why the government did not just give GPs more of a say over PCTs.

And it is not just this government that seems intent on re-inventing the NHS wheel.

In the 1960s, there was a major programme of hospital building, but by the 1970s the then Labour Health Secretary Barbara Castle was arguing care needed to be shifted away from hospital and into the community.

By the end of the 1990s Labour was embarking on another round of hospital building, but now the talk is of keeping patients out of hospital.

Dr Jonny Marshall, director of policy at the NHS Confederation, believes the health service is not good enough at tapping into the expertise it has within.

He says the nature of the "political cycle means politicians come in wanting to make a mark", which has resulted in a belief among many within the health service that there is little point trying to influence change.

"We have to change this. The NHS needs to get better at learning form what works well and what doesn't," he says.

In fact, it is a common joke within the profession that you are better off saying you are an estate agent than health manager.

It is easy to understand why.

Ministers have been quick to criticise the "pen-pushing culture" in the NHS with both current Health Secretary Jeremy Hunt and his predecessor Andrew Lansley promising to reduce bureaucracy in the NHS.

The number of managers in the health service has already been cut by nearly 7,000 in the last three years and now stands at 35,650 in England.

But in the rush to tackle the "problem" has it been properly considered whether management and leadership in the NHS actually needs sorting out?

Research to be published later this summer by the Chartered Management Institute shines an interesting light on the issue.

The work has found the NHS has a poor record in investing in its managers.

Compared to other parts of the public sector, it spends nearly 30% less on training its leaders, the research suggests.

The CMI goes on to argue that this is misguided as good management leads to an engaged workforce that is more productive and provides better care.

Ian Reynolds, the chairman of Kingston Hospital, who has been crunching the figures for the CMI, is clear.

"It may be unfashionable to say so, but overall the NHS is under-managed."

Dean Royles, director of NHS Employers, agrees managers have been unfairly targeted.

While acknowledging the failure in management over the Stafford Hospital scandal had been "deeply embarrassing", he also believes good managers are a force for good.

"We know if we have engaging managers we have an engaged workforce. These staff are more likely to be committed, work well as a team and go that extra mile for patients," he says.

The regulations were actually laid as part of the mopping up exercise following the passage of the Health and Social Care Act.

Procurement of health services used to be governed by primary care trusts, but this passed to the new GP-led clinical commissioning groups at the start of the month.

And so new rules and guidelines were required. The big question is whether they go further than the ones they are replacing.

Under Labour competition was encouraged, but critics argue these ramp that up even further by only allowing contracts to be handed out without a tendering process in the most exceptional circumstances. It is, they argue, tantamount to privatisation.

Ministers reject this - and have already rewritten the regulations once to try to diffuse the row.

What this demonstrates is that the changes to the health service are still deeply controversial - and are likely to remain so for some time yet.

But in practice the problem is not so easy to resolve. When asked about the proposal on the eve of the Royal College of Nursing's annual conference, the union's president could not hide her contempt.

Andrea Spyropoulos branded it a "stupid idea" which would waste taxpayers' money and, in all likelihood, never see the light of day.

The government though seems determined to dig its heels in. It says it will be proceeding with the pilots and launched its own attack on the RCN, claiming they had not yet satisfactorily answered the criticisms aimed at the organisation by the Stafford Hospital public inquiry.

But why has one proposal provoked such anger? For nurses, it is simple. They feel they are being unfairly targeted as they believe the implication is that they are motivated to become a nurse for the wrong reason.

There were 290 recommendations made by the Stafford Hospital public inquiry. Making nurses work for a year before they can even start training was not one of them.

Instead, it was the idea of government and announced as part of its package of measures in response to the public inquiry.

There has also been a lack of detail about how it will work.

Nurses already spend half of their three-year degree working on placements. Will this year as a healthcare assistant count towards that?

There is also a question mark over whether the work will need to be completed before applying, which would mean over 200,000 people working as healthcare assistants, or once someone has gained a place on a course, which would require 20,000 posts to be found.

The Department of Health has been quick to counter that all this needs to be teased out during the piloting of the initiative, which could start later this year.

But that does not seem to be convincing delegates at the nursing conference.

Gavin Wollacott, who has just finished his training and is now working in the East Midlands, says: "I worked as a healthcare assistant for 10 years and that stood me in good stead.

"But that does not mean everyone needs to. You could end up excluding lots of really talented people."

Elinor Durston, who is in her final year of training, agrees. "The only caring experience I have is that I looked after my dying mother. But I am really motivated about caring for people.

"I have done all sorts of placements during my training - in the community, in hospital and in mental health. What really matters is the quality of the mentoring you get during that."

However, away from the tribalism of the conference some do believe the idea has merit.

Southampton University expert Peter Griffiths, one of the leading nursing academics, admits there are lots of unanswered questions, but he believes if the government gets it right it could help improve the quality of nursing.

"If the work experience was properly integrated with nurse training and served to provide an extended opportunity for hands on care that would be something that was strongly welcomed by many in the profession."

It is why David Cameron worked so hard in opposition to convince voters that the NHS was safe in his hands - he knew without credibility on health the Conservative party would struggle to win votes.

And it is easy to understand why. Polling consistently shows that the NHS is near to the top if not right at the top of the public's priorities.

Last year, a survey by MORI and the Nuffield Trust asked people which areas should be protected from cuts.

At the top, by a clear margin, was the NHS. Nearly eight in 10 suggested it should be protected, compared to 51% for both schools and care of the elderly, the next areas on the list.

Defence, local authority services and benefits were all hovering around the 10% mark.

Which areas of spending should be protected from cuts?

NHS

79%

Schools

51%

Care of the elderly

51%

Police

39%

Social services

21%

Benefits

10%

Local authority services

10%

Defence

9%

Overseas aid

4%

Source: Nuffield Trust / Ipsos Mori

But does this mean the NHS is completely sacrosanct?

Perhaps not - as research by the King's Fund shows.

The think-tank has been working with Ipsos Mori to carry out some in-depth polling work with members of the public.

Rather than simply asking them a series of questions, the King's Fund held two day-long events with a total of 80 people.

The sample size was deliberately small to allow longer discussions to explore some of the challenges the health service is facing.

What it showed was that while most felt the NHS should remain free at the point of need and any reduction in quality was judged to be "unacceptable" there was still an appetite for quite radical changes.

For example, the events showed there was some support for charging people for cosmetic surgery or elective caesareans, while many agreed people who abuse services, such as drunks who end up in A&E, should be penalised.

There was also a consensus that some form of top-up, perhaps for better accommodation in hospital, should be considered as a way of raising money.

The are obviously caveats. Eighty people is not many and - as any politician will no doubt warn - there are few opportunities in modern politics to debate a single issue in such depth.

But that does not mean there should be no attempt to engage the public in a wider debate about the NHS.

This is arguably the most challenging period for the health service since it was created. Never before has there been such as sustained period of so little growth in the budget.

And it comes at a time when demand is growing from factors such as the ageing population, development of new treatments and rise in conditions such as diabetes and heart disease.

Anna Dixon, director of policy at the King's Fund, hopes it acts as a wake-up call.

"Although difficult choices lie ahead, politicians have been reluctant to discuss the future funding challenge facing the NHS.

"This research shows that people want to engage with these issues.

"With pressures to spend more on health care growing and the public finances likely to be under considerable strain for the foreseeable future, it is time for an informed public debate about how much we should spend on the NHS and how this should be funded."

The health service is damned if it doesn't act quickly enough - as was the case with Stafford Hospital - and then damned if it does - as has happened with child heart surgery in Leeds.

The problem is that compiling and interpreting the data is not an exact science.

A high death rate could be said to be a smoke alarm - a sign that something may be wrong and, therefore, needs looking into.

But just as a smoke alarm can be set off for a rather innocuous reason - the smoke from frying food, for example - so a high death rate can be accrued for perfectly justifiable reasons.

Mortality figures are risk-adjusted, which means they take into account factors that could increase the likelihood of death, but even so their accuracy does depend on all the data being submitted properly.

There are over 300 different variables that hospitals need to provide, coving issues such as age, time of diagnosis, deprivation, lifestyle and existing illnesses.

It is not unheard of for data to be submitted incorrectly or not at all.

In the case of Leeds General Infirmary, which had its child heart surgery halted just before Easter amid concern about high death rates only for the suspension to be lifted this week, crucial details were missing which appear to have skewed the overall picture.

NHS medical director Sir Bruce Keogh explains: "In order to take case mix into account so that we compare apples with apples and oranges with oranges, one of the simple things you need is the weight of a baby.

"But weight was missing in 35% of the cases... so that data was very poor quality."

So does that mean they should not be trusted?

No, according to Prof Brian Jarman, one of the UK's leading experts on mortality data.

He believes the NHS is getting better and better at using and understanding the data.

There are now several different ways of compiling data. Dr Foster, the research group he works for, looks at four key measures - deaths in hospital, deaths within 30 days of discharge, deaths after surgery and deaths among patients in low risk conditions.

It allows them to cross reference hospitals with high rates in one area with data from another.

For example, according to latest figures, there were more than 50 cases where a trust had higher than expected death rates on one measure.

But Dr Foster was able to narrow that group down to 12 by looking for those trusts with high rates in two categories.

Prof Jarman says: "It really does depend on us getting good quality data.

"That is why we say mortality rates are not perfect, they are a sign that something may be wrong and should definitely not be ignored.

"If we have got good data I would say a high mortality rates is nearly always a sign of something not being quite right."

Over 200 new organisations are being created, including a network of GP-led groups to manage the budget and NHS England, the national board which will oversee the new system.

It has been dubbed the most radical shake-up in the history of the NHS.

But what will actually be changing?

Ever since the NHS was created GPs have acted as the gatekeepers to the service, referring patients on to the right areas.

The relationship has meant that a special bond is often created between patient and their GP - or family doctor as they are known.

It is often said GPs will be in charge of the budget, but in fact they will only get about 60% of it. The national board, NHS England, will be responsible for a number of services, including dentistry and specialist hospital care.

Polling consistently places doctors as among the highest trusted professionals.

But under the reforms GPs are getting control of the bulk of the NHS budget, so they can decide what local services to fund.

The theory is that as they are close to patients they will be better placed to know how money should be spent.

But the prospect of them holding the purse strings has caused concern that the "special relationship" could be damaged.

An Ipsos Mori poll for the British Medical Association found nearly three quarters of GPs feared this.

It argued patients could become suspicious if a doctor does not give them what they want as there could be a perception the GP is trying to save money rather than safeguarding their best interests.

This is the issue that has caused most controversy.

Critics have claimed the reforms will lead to the privatisation of the health service with health companies swooping in to "cherry pick" the most profitable services and destabilising NHS in the process.

But supporters believe the opportunities for the private sector are being overplayed. They say that if the firms can provide better services, more efficiently it will be good for patients and drive up standards across the whole sector.

Of course, the private sector is already involved in providing NHS care.

Under the Labour government they were invited to bid for contracts to carry out non-emergency operations, such as hip and knee replacements.

They have also got heavily involved in mental health care.

Meanwhile, over the past year, the coalition government has been encouraging them to get more involved in community services.

Estimates suggest £1 out of every £20 spent on health goes to a non-NHS provider. This includes both private sector firms and charities.

One of the guiding principles for the reforms has been the push to improve the coordination of care for people with chronic conditions.

There are an estimated 15m people with long-term conditions, but caring for them accounts for £7 in every £10 spent by the health and care sectors.

These are diseases such as diabetes and dementia for which there is no cure.

Instead of bouts of hospital treatment these patients need long-term support from a range of different services, it is widely argued.

But all too often such care is not available and these patients end up in hospitals when they suffer crises and emergencies.

With better planning such problems could be prevented - evidence suggests as many as a third of hospital admissions are avoidable.

If this is to succeed it is likely to see a network of integrated community clinics emerge, which run a variety of services from rehabilitation care to district nursing.

A much often overlooked part of the reforms involves public health. The term covers everything that prevents disease and prolongs life and therefore includes promoting physical activity and better diets as well as stop smoking services.

Councils historically always used to have responsibility for public health - it was only handed over to the NHS in 1974. Past successes included the building of sewers and introduction of modern immunisation programmes.

Responsibility for this will be passed to local government as part of the changes.

The belief is that councils will be better placed to influence people's lives through their powers over planning, education and leisure services.

As part of the overhaul, public health directors who have been working for primary care trusts are being transferred into local authorities.

They will also get a ring-fenced budget of just under £3bn a year to ensure there is money available to get the new arrangements up-and-running - the rest of local government is facing budget cuts of a quarter.

Already councils have started looking at innovative ways of tackling the issue. This includes stopping smoking near to playgrounds to introducing outdoor gyms in parks and green spaces.

Perhaps the most noticeable thing will be the fact that there will be little visible change - certainly in the short-term.

That may seem unbelievable given the amount of attention the changes have attracted.

But the upheaval that has taken place so far has largely been to the management structure.

It means as patients move around the new NHS they could be forgiven for thinking nothing has happened.

They will still go to their local GP surgery or hospital when they need help.

Indeed, many of the other factors discussed here are ones that will take some time to have an impact.

This, of course, does not mean what is happening is not important. Virtually everyone agrees - critics and supporters alike - that the NHS stands to rise or fall on the effect of the reforms.

It is just that the NHS, with its 1.4m staff and hundreds of different organisations, really is, has often been said, a bit like a supertanker - a change in direction does not happen immediately.

Over 200 new organisations are being created, including a network of GP-led groups to manage the budget and NHS England, the national board which will oversee the new system.

It has been dubbed the most radical shake-up in the history of the NHS.

But what will actually be changing?

Ever since the NHS was created GPs have acted as the gatekeepers to the service, referring patients on to the right areas.

The relationship has meant that a special bond is often created between patient and their GP - or family doctor as they are known.

It is often said GPs will be in charge of the budget, but in fact they will only get about 60% of it. The national board, NHS England, will be responsible for a number of services, including dentistry and specialist hospital care.

Polling consistently places doctors as among the highest trusted professionals.

But under the reforms GPs are getting control of the bulk of the NHS budget, so they can decide what local services to fund.

The theory is that as they are close to patients they will be better placed to know how money should be spent.

But the prospect of them holding the purse strings has caused concern that the "special relationship" could be damaged.

An Ipsos Mori poll for the British Medical Association found nearly three quarters of GPs feared this.

It argued patients could become suspicious if a doctor does not give them what they want as there could be a perception the GP is trying to save money rather than safeguarding their best interests.

This is the issue that has caused most controversy.

Critics have claimed the reforms will lead to the privatisation of the health service with health companies swooping in to "cherry pick" the most profitable services and destabilising NHS in the process.

But supporters believe the opportunities for the private sector are being overplayed. They say that if the firms can provide better services, more efficiently it will be good for patients and drive up standards across the whole sector.

Of course, the private sector is already involved in providing NHS care.

Under the Labour government they were invited to bid for contracts to carry out non-emergency operations, such as hip and knee replacements.

They have also got heavily involved in mental health care.

Meanwhile, over the past year, the coalition government has been encouraging them to get more involved in community services.

Estimates suggest £1 out of every £20 spent on health goes to a non-NHS provider, this includes both private sector firms and charities.

One of the guiding principles for the reforms has been the push to improve the coordination of care for people with chronic conditions.

There are an estimated 15m people with long-term conditions, but caring for them accounts for £7 in every £10 spent by the health and care sectors.

These are diseases such as diabetes and dementia for which there is no cure.

Instead of bouts of hospital treatment these patients need long-term support from a range of different services, it is widely argued.

But all too often such care is not available and these patients end up in hospitals when they suffer crises and emergencies.

With better planning such problems could be prevented - evidence suggests as many as a third of hospital admissions are avoidable.

If this is to succeed it is likely to see a network of integrated community clinics emerge, which run a variety of services from rehabilitation care to district nursing.

A much often overlooked part of the reforms involves public health. The term covers everything that prevents disease and prolongs life and therefore includes promoting physical activity and better diets as well as stop smoking services.

Councils historically always used to have responsibility for public health - it was only handed over to the NHS in 1974. Past successes included the building of sewers and introduction of modern immunisation programmes.

Responsibility for this will be passed to local government as part of the changes.

The belief is that councils will be better placed to influence people's lives through their powers over planning, education and leisure services.

As part of the overhaul, public health directors who have been working for primary care trusts are being transferred into local authorities.

They will also get a ring-fenced budget of just under £3bn a year to ensure there is money available to get the new arrangements up-and-running - the rest of local government is facing budget cuts of a quarter.

Already councils have started looking at innovative ways of tackling the issue. This includes stopping smoking near to playgrounds to introducing outdoor gyms in parks and green spaces.

Perhaps the most noticeable thing will be the fact that there will be little visible change - certainly in the short-term.

That may seem unbelievable given the amount of attention the changes have attracted.

But the upheaval that has taken place so far has largely been to the management structure.

It means as patients move around the new NHS they could be forgiven for thinking nothing has happened.

They will still go to their local GP surgery or hospital when they need help.

Indeed, many of the other factors discussed here are ones that will take some time to have an impact.

This, of course, does not mean what is happening is not important. Virtually everyone agrees - critics and supporters alike - that the NHS stands to rise or fall on the effect of the reforms.

It is just that the NHS, with its 1.4m staff and hundreds of different organisations, really is, has often been said, a bit like a supertanker - a change in direction does not happen immediately.

A clearer system of rating hospitals and better regulation of managers and healthcare assistants, he argued, would ensure greater accountability, while better training for nurses could create a culture of compassionate care.

But in some ways the changes ignored the elephant in the room: the changing nature of the patient population.

It is an open secret that hospitals in the 21st Century are full of patients that should not be there.

A combination of the ageing population and advances in medicine have meant that there is a growing number of frail, elderly people who need intensive care and support.

But all too often that is not available in the community, and so they end up in hospital as an emergency case.

Two-thirds of hospital admissions are people over the age of 65. Many have multiple chronic conditions, such as heart disease and dementia.

In fact, the change in the patient population has been so acute that a King's Fund study has put the average age of a patient at over 80.

That is presenting problems for staff that no amount of training and resources can counter.

As one nurse, who has worked in the NHS for over 30 years, told me: "The patients we are seeing in hospital are completely different from the ones that were being admitted when I started out.

"These patients need a complex package of care and support.

"They need help washing, dressing and eating round-the-clock. It requires a lot more personal care than the hospital environment is designed for."

However, it need not be like this. The evidence suggests as many as a third of hospital admissions could be prevented with better systems in place in the community.

But instead of going down the numbers being admitted as emergencies is actually on the rise - it is up by nearly 40% in the past decade - and that is having a damaging impact on hospital wards.

The Royal College of Physicians has warned hospitals are "on the brink" with a mindset developing among staff that many patients are simply in the "wrong place".

Its report, Hospitals on the edge?, cautioned staff against such defeatism, but it was also clear for that to change there needed to be progress on keeping people out of hospital.

To be fair, it was a point acknowledged on Tuesday by Care Services Minister Norman Lamb.

During the government press conference to announce the response to the public inquiry, he said it had to be a "top priority", conceding "a lot of hospitals have large numbers of frail elderly that perhaps with better care would not have ended up there".

Improving the culture, accountability and transparency is clearly important, but the defining challenge for the health service over the next decade and beyond could prove to be something completely different.

Finding out information about NHS services is not so easy. They are judged against a set of 28 basic standards and either pass or fail.

So why not have an Ofsted-style system for hospitals and GP surgeries - and care homes for that matter?

That is the question posed last year by Health Secretary Jeremy Hunt.

The answer has now been provided in painstaking detail over 156 pages of a Nuffield Trust report.

The conclusion? It is possible, but be very, very careful how you proceed, minister.

First of all, we have been here before.

The health service had a quality grading system called "star ratings" as recently as 2010. But this was dropped amid criticism that it was not giving an accurate enough picture.

The Nuffield Trust makes the argument that the NHS - and hospitals in particular - are much more complicated organisations than schools.

Schools deal with a population confined to a set age range in an environment that can be measured through relatively simple testing and assessment.

There are variables, but they are often known and relatively narrow.

The NHS is a completely different matter. It sees people from the full spectrum of ages, some of whom have illnesses that cannot be cured.

Others turn to the NHS to die. For them there is no happy ending.

What is more, performance can be much more variable. Hospitals are a series of microclimates. Alongside good departments, there can exist bad ones.

Of course, schools can vary from classroom to classroom, but the range of performance tends to be much more narrow.

It is why the think tank has warned the government to be cautious.

It has suggested that if the government wants to go down this route it should consider rating hospitals by department.

But that does not mean Ofsted-style ratings will not happen.

The Department of Health has already indicated it wants to press ahead with some kind of change.

Why? The clearest conclusion of the Nuffield Trust was that despite the difficulties, the status quo was not satisfactory either.

Jennifer Dixon, the trust's chief executive, says: "There is a major gap in the information available to the public - people are left in the dark."

Change in the NHS is never far around the corner.

But while this was widely welcomed by some, it does raise a pressing question: is the government muddled in its approach to alcohol?

Up until last week, ministers seemed to be on the brink of introducing minimum pricing in England and Wales as a way of tackling rising levels of alcohol misuse.

It would have been a revolutionary move - only a handful of places in the world have taken such a tough stance.

But then the news emerged that the policy was likely to be dropped and now we learn booze will be getting cheaper.

Understandably those pressing for tough action on drinking are perplexed.

James Nicholls, research manager at Alcohol Research UK, says: "While action on the beer duty escalator will help pubs, the government needs to make its position clear on the issue of very cheap, high-strength alcohol.

"These are the products that cause the greatest levels of harm. They are also the products that David Cameron has repeatedly promised to target.

"It must explain how alternative policies will be more effective in addressing this problem."

The government, even in light of the chancellor's announcement, is maintaining it will, arguing it still wants to do something about cut-price alcohol.

But if ministers are serious, what can they do next?

In the past there has been talk of ending multi-buy offers.

And before minimum pricing was put on the table - by all accounts by the prime minister himself - the government was actually in the process of introducing a ban on below-costs sales.

That would have directly targeted the supermarkets that sell cider, wine, beer and spirits as a loss leader to entice shoppers into their stores.

Below-cost bans work by forcing retailers not to discount alcohol below the level of tax and duties placed on them.

However, one of the problems with this policy was that a quirk in tax rules means duties are levied differently from product to product.

While beer can be taxed on strength, the tax on wine and cider is predominantly linked to volume.

This has meant that while brewers have gradually been reducing the alcohol content of beer, the opposite has happened for other drinks.

A recent review by the Institute of Fiscal Studies recommended this issue be taken up with the European Union.

It argued using the tax system might be more effective in reducing problem drinking than minimum pricing.

The move would also have the effect of swelling government coffers rather than industry's.

It is easy to see why that may be more attractive to a government facing such a tricky task in balancing the budget.

But, of course, the impact in terms of hitting the pocket of consumers is the same.

And perhaps that is the crux of the problem. You only need to see the way cheaper beer is welcomed in the pubs and bars across the country to realise that targeting the price of alcohol is not an easy thing for a government to do.

Gagging is a complex subject. Severance agreements are just as common in the NHS as any other industry.

When someone leaves employment over a dispute, it is understandable that both sides may wish to keep the reasons confidential. Hence lawyers are brought in to draw up a contract.

But it is already against the law to stop whistle-blowing over a safety issue. This was made clear by the 1998 Public Interest Disclosure Act.

But something seems to have been going wrong within the health service - as the recent controversy has shown.

Gagging clauses may have been inserted in some contracts, or staff may have felt intimidated and unable to speak out because of the process they have been through.

Either way Jeremy Hunt wants to see this tackled. But the problem is that while the government does sign off some agreements, it doesn't vet them all.

Last year she did a 12,000ft tandem skydive for charity.

In fact, Andrew Lansley, who was the health secretary for the first two years of this government, was opposed to it.

However, slowly but surely, it began to gather momentum. First, a 40p threshold was put forward and then - at the end of last year - 45p was proposed and consulted on.

That would have been ground-breaking. Along with Scotland, England and Wales looked set to become one of a very select band of countries to try to tackle problem drinking in this way.

Research has suggested a 45p minimum could reduce drinking by 4.3%, potentially saving 2,000 lives within a decade. This was why the idea had such strong backing from the medical profession.

But using price is a crude tool. As well as hitting problem drinkers, it would also influence those who consume alcohol in moderation. Dropping the plan may win ministers votes, but it won't make them popular with doctors.

In fact, Andrew Lansley, who was the health secretary for the first two years of this government, was opposed to it.

However, slowly but surely it began to gather momentum. First, a 40p threshold was put forward and then - at the end of last year - 45p was proposed and consulted on.

That would have been ground-breaking. Along with Scotland, England looked set to become one of a very select band of countries to try to tackle problem drinking in this way.

Research has suggested a 45p minimum could reduce drinking by 4.3%, potentially saving 2,000 lives within a decade. This was why the idea had such strong backing from the medical experts.

Drinking levels are considerably higher than they were 40 years ago.

Consumption may have tailed off in the last few years but alcohol intake is still 40% above what it was in the early 1970s.

A quarter of adults now drink to excess, causing more than one million hospital admissions and nearly 9,000 deaths a year.

Where we are drinking has also changed. Whereas four decades ago nine in 10 drinks were consumed in pubs and restaurants, today the split is almost 50:50 between in and out-of-home boozing.

This has undoubtedly been fuelled by the availability of cheap alcohol in the shops - the very thing minimum pricing is aimed at.

James Nichols, of Alcohol Research UK, says: "Specialists across the world agree that price is a key mechanism for tackling alcohol-related harms, especially among the heaviest drinkers.

"If the government decides to abandon minimum pricing it will have to explain how it will have to address the problem of very cheap alcohol."

But using cost is a crude tool. As well as hitting problem drinkers, it would also influence those who consume alcohol in moderation. Dropping the plan may win ministers votes - but it won't make them popular with doctors and health campaigners.