End of the NHS as we know it?

Amid mounting pressure from an angry medical profession, ministers seem to be staging another tactical retreat in their efforts to force key elements of Andrew Lansley's vicious Health and Social Care Bill through the House of Lords

Bizarrely, the Lords seems to have become the last bastion of democracy after MPs failed to mount much of a fight.

A Health Service Journal exclusive has revealed that the Conservatives in the Lords, led by Earl Howe, are now offering a new set of concessions on the Bill. This is because a substantial number of Lords are known to be willing to reject key clauses, including Lansley's attempt to scrap the duty of the secretary of state to provide comprehensive and universal services.

It's not clear whether this latest formula, which still fails to reinstate the previous clause one of the National Health Service Act as amended in 2006, will meet the objections of Labour, Lib Dem and cross-bench peers.

Another concession that has been offered would require the health secretary to "have regard to the NHS constitution."

But 95 hours of Lords debate in 15 sessions have so far made few significant changes to a Bill that is fundamentally flawed and focused above all on opening up a competitive market in healthcare and new opportunities for private for-profit providers to scoop up lucrative work, while leaving the costly and awkward services to the remains of the NHS.

One encouraging sign is that at the 11th hour the Labour Party seems to have finally woken up on this - at least in the Lords.

And shadow health secretary Andy Burnham is at least talking a good fight, although this resistance is a stark contrast with Ed Miliband. He and his wretched followers are running up the white flag on defence of public services.

Labour is now working with allies in the Lords to demand more changes on a range of issues that the feeble Commons scrutiny barely touched, including competition law, the powers and duties of the regulator Monitor, public health and "Health Watch," the latest ludicrous attempt to derail public accountability for NHS services.

Another late-developing conflict is NHS facilities being used for private medicine.

Just before Christmas it was revealed that the Bill would allow foundation trusts to make up to 49 per cent of their income from private medicine.

Believe it or not, the 49 per cent figure - suggested in the Lords by Lib Dem Shirley Williams - was regarded by the government as a concession from Lansley's initial proposal to scrap the limit altogether.

But it would still open the way to a massive expansion of private work at a time when foundations will find NHS funding ever harder to obtain, as the £20 billion cash squeeze tightens year by year.

Lansley, for fear that it will tilt the balance further against him and the Bill, is still adamantly refusing to allow MPs or Lords to see the Department of Health's "risk register" on the Bill, which the Information Commissioner has twice instructed him to publish.

But a leaked paper at the end of last year confirmed critics' warnings that, far from handing power to GPs, the government wants private management firms to take the reins of running the clinical commissioning groups (CCGs).

Just in case anyone thought that the new structure would offer any genuine local control, the leaked document confirms that the CCGs themselves will be far bigger - and therefore far less "local" - than early proposals suggested.

Miserly management allowances of just £25 per head of catchment population mean that the smaller CCGs would not be organisationally viable, and a process of forced merger is now taking shape.

Over 50 CCGs have already merged into larger groups, while the numbers of the bigger groups covering populations over 500,000 have doubled since March.

Size does matter, and the direction is upwards.

Even the small-catchment Wirral NHS Alliance CCG, which includes a leading pro-reform GP who was the national lead on commissioning for the Department of Health, is being refused authorisation unless it merges to form a larger unit.

The BMA is urging GPs to federate into CCGs covering between one million and five million, and the Royal College of GPs is also urging mergers, despite the obvious loss of local voice and control and the certainty that the larger organisations will be run by a bureaucracy of managers and not in any meaningful way controlled by GPs.

This process of merger is being matched by the service providers, with increasingly desperate mergers welding together struggling and financially challenged NHS trusts regardless of geography and with dire consequences for many local services and for accountability to local communities.

The message is clear and consistent - despite Lansley's rhetoric, everything happening is serving to widen and deepen health inequalities, extend the postcode lottery and ride roughshod over the needs and views of local patients.

Despite his ridiculous claim to have support from doctors, the GPs who are supposed to be "empowered" and "liberated" by the Bill are rejecting it and refusing to get involved

But while the unions stand largely passive on the Bill, opposition among the medical profession is still mounting.

The latest, biggest - and final - poll of the Royal College of GPs showed a staggering 98 per cent wanted the college to work with other royal colleges to get the Bill withdrawn. Just 5 per cent saw the Bill as beneficial.

And public health doctors, who gathered over 400 signatures for a public call for action against the Bill before Christmas, have continued to organise and agitate with a busy email list of 500 health professionals and academics actively supporting.

Hospital doctors too have been increasingly concerned and this month saw the heroic "Bevan's run" by two hospital consultants from Middlesbrough from Cardiff to the Department of Health HQ in London to focus anger and action against the Bill and publicise the issue to a wider public.

As the runners recuperate and the battle lines form up in the Lords, there is still a chance for local meetings to reach out to rally local communities against the Bill that could spell the end of our National Health Service.

The Lords is expected to return to the Bill in the second week of February.

Burnham should be pressing local Labour parties, MPs and councillors to pull out all the stops and work with pensioners, health unions and trades councils to call urgent public meetings to sound the warning, publicise what's wrong with the Bill and demand its withdrawal and the publication of the suppressed risk register.

Meanwhile the BMA, which seems prepared to call on GPs to withdraw from commissioning as part of their fight on pensions, should consider withdrawing anyway, to torpedo a Bill that most GPs want withdrawn.

Why don't the health unions encourage them to do so by offering support? Why don't they at least do something tangible to mobilise their members against the Bill?

It's high time we saw some unity in action instead of the united inaction that has been the norm for 12 months since Lansley published the Bill.

Damage has been done, but the Bill is not a done deal.

Together doctors, health workers and the public can still stop Lansley's Health Bill - and it would be the ideal antidote to Miliband's deadly defeatism and the best way to launch a fightback against hospital cuts and closures.