The Lib Dems’ NHS limbo

Later today the health and social care bill will appear before parliament for the first time since the weekend's crushing defeat for the Liberal Democrat leadership at its party conference.

This has some odd implications. After Saturday's refusal by conference to oppose the bill, and Sunday's refusal by conference to support the bill, its official attitude must be viewed as some sort of awkward limbo. The lost souls of Lib Dem peers floating around in this purgatory (an apt metaphor for coalition government) will be under pressure from all sides when they participate in debating and voting later.

The party's collective fence-sitting is a great disappointment to Hamish Meldrum of the BMA, which has fought the coalition's health and social care bill from the outset. He thinks Lib Dems have placed themselves in an impossible position, telling themselves that the legislation is somehow a fundamental part of the coalition agreement. "Ministers have almost made it an issue of confidence in the whole coalition government as to whether this bill stands or falls," he says. "That seems to me a rather dangerous and silly corner to have backed themselves into."

Andrew Lansley's bold reforms came as something of a surprise in August 2010, for they were not even part of the coalition agreement. They were certainly not in either party's manifesto. Yet the process of supporting the bill, then pausing it and amending it, has utterly compromised the Lib Dem position. It's "a rather unfortunate corner to have backed yourself into", Meldrum adds. The process of gradual amendments has blurred the lines between rebel and government - not least when Clegg and NHS troublemaker Shirley Williams co-signed a letter, a process which either turned Clegg into a rebel ringleader or Williams into a leadership stooge.

Lib Dems want to be in power, but the party - especially its grassroots - retains many of its instincts of opposition. Critics will say they want to avoid the responsibility of being in government. They seem to think the bill is full of terrible ideas but feel they can't kill it without toppling the coalition, bringing their period in power to a premature end.

The weight of the criticisms of so many clinical groupings continues to bear down on them.

Take diabetes in Tower Hamlets. This has been transformed in the last two or three years, thanks to GPs getting together with the local hospitals to establish what's known as 'integrated care'. What would happen if competition was introduced? A host of different providers would be introduced, none of which would communicate with each other for commercial reasons. This marketplace of competing providers is what doctors fear when they contemplate the fragmentation of the NHS.

That the debate is more complex now is an unfortunate side-effect of the bill's lengthy period before parliament. Unwanted complications to all its aspects are the result of the government's many amendments, leaving neither the enthusiasts nor the opponents satisfied. Still, campaigners stripping away these bewildering layers find an easy-to-understand core: the privatisation of the NHS.

Health workers we spoke to for last week's politics.co.uk podcast on NHS reforms made clear their level of concerns about the NHS were more fundamental than ever before. "I think this is the first time I've ever worried about the structure of the NHS as a whole," Northamptonshire physio Alison Lindley admitted. Mary Locke, a ward housekeeper from Birmingham, reflects these worries: "If you can pay then great, you get to be seen. If you can't, you have to wait. That's going backwards, not going forwards."

Liberal Democrat politicians hear those pleas. They even sympathise with them. But the dynamics of coalition government have made it very hard for them to stop these changes.

The flexibility of the coalition helped prolong the bill's passage through parliament, but has eventually come to tie down both parties to a set of reforms to which the junior party is utterly fed up with. Now a kind of centrifugal force is pinning the Lib Dems to the side of the fuselage as their legislation spirals out of control. The effort of tearing themselves free seems to be beyond them.