Major reorganisations of the National Health Service are nothing new. The Health and Care Bill—now Act—is the latest in a long line of such reorganisations, but it’s an incredibly important one if you care about the future of our NHS’s existence as a public health provider.

As of today, 1 July, this Act will change two main things about the way the NHS is currently run in each local area. Decisions about what NHS services are available, who provides them, and who can be cared for in the NHS in each local area have previously been made by a body consisting mainly of senior doctors, nurses, and NHS administrators. First, the Health and Care Act will replace these bodies with forty-two Integrated Care Boards (ICBs) representing forty-two Integrated Care Systems (ICSs) overseeing every part of England.

Crucially, despite the government’s claims to the contrary, the Act doesn’t rule out people who work for private companies or who have a financial interest in such companies sitting on these boards. Evidence already indicates that private healthcare representatives could have a prominent decision-making role in our healthcare in some areas. The designated chair of the Bedfordshire, Luton, and Milton Keynes ICB, for example, is an executive at a private healthcare company called Queen Square Enterprises. The Integrated Care System for Bath and North East Somerset (BANES), Wiltshire, and Swindon had Virgin Care on its unofficial board of directors.

After pressure from campaigners from Protect Our NHS BANES and We Own It, the designated chair of the second ICS, Stephanie Elsy, has pledged that nobody who works for or has an interest in private companies will sit on the official board. But this conflict of interest is set to be played out across the country. Simply put, people who have a financial interest in the decisions that the board will be making should not be allowed to sit on it—but there’s no statutory protection against it, despite widespread campaigning for an amendment to do so.

The move to Integrated Care Systems in general is troubling. ICSs are said to bring healthcare, social care, mental health, and community services together into one setting, instead of continuing to provide these services separately—but they’re largely untested, so it’s unclear whether the change will actually succeed in integrating health and social care. A new study has already identified several issues, including the fact that there’s no shared understanding of what ‘integration’ means across the NHS.

Integrated Care Systems mainly affect the planning and commissioning of services. NHS campaigners have argued that increasing the role of private companies at the level where decisions about who provides services are made will bring in profit calculations and therefore worsen the quality of the service people receive from the NHS. Campaign group Keep Our NHS Public (KONP) warn that Integrated Care Systems will threaten the service we receive from the NHS not only by increasing the presence and influence of the private sector, but also by increasing the use of digitalisation and digital services (meaning fewer face-to-face appointments with GPs), and shifting the principles that underlie the NHS away from the provision of comprehensive, universal care, based on need, to a focus on the management of patient ‘demand’. KONP also say ICSs will worsen conditions for the workforce, including by expanding ‘flexible’ working, which means staff may be expected to work for different organisations across an ICS.

Second, the Act is scrapping the requirement to put contracts for services through a competitive tendering process, a process which can and often does involve private companies bidding to provide those services. Scrapping it wouldn’t necessarily be a bad thing if it was replaced with a new rule that makes the NHS the default provider of all NHS services, but that, unsurprisingly, isn’t the case with this Act. As the British Medical Association has pointed out, without making the NHS the default provider, scrapping competitive tendering only opens the door further to contracts being handed out to private companies without any transparency.