By Nick Triggle
BBC News health reporter
Like a niggling sore that will not go away, every time Patricia Hewitt tries to address private sector involvement in the NHS it just seems to make the situation worse.
About 250,000 health workers could be affected by the plans
In July, the government announced it was to force England's local health bodies, known as primary care trusts, to stop providing a range of services from district nursing to physiotherapy.
The thinking was that they could then concentrate on commissioning - PCTs control 75% of the NHS budget - and community services could be opened up to "alternative providers".
But for an NHS - already sensitive to private sector involvement in hospitals - that was like a red rag to a bull.
Despite slipping the announcement out after parliament had broken up for the summer, MPs and health professionals expressed outrage over a policy which could affect 250,000 health staff.
At the Labour conference a Unison motion was carried calling for a halt to expanding the private sector role in the NHS.
By the return of parliament in October, Ms Hewitt tried to soothe the sore by saying PCTs would be allowed to keep providing services if they wanted and a month later she apologised for the way it had been handled.
But the Royal College of Nursing has further inflamed the sore by launching a bid for a judicial review of the policy.
The government is reforming the way PCTs operate as part of its drive to improve access to community services.
A white paper is expected at the turn of the year outlining a range of measures to create a "patient-friendly" NHS.
WHAT IS HAPPENING?
December 2005 / January 2006 - Ministers will publish a white paper on out-of-hospital care to improve access to services including GPs, sex health clinics and social care
From April 2006 - The 300 PCTs, which control three-quarters of the NHS budget and provide some services, will be cut to about 150
By 2008 - PCTs expected to stop providing services, such as district nursing and physiotherapy, where they want to. GPs, foundation hospitals and, controversially, private firms to step in
At the heart of the reforms will be measures giving patients more choice about services from GP surgeries to mental health services.
Only on Friday Ms Hewitt was suggesting GP practices stay open longer.
Among the other measures being considered are sex health clinics in high street shops, mental health services in libraries and nurse-led GP surgeries.
To achieve these goals, ministers believe PCTs need to be able to relinquish their provider role and concentrate on commissioning.
Over the next year this is likely to see the 300 PCTs slashed in half, before services, including district nursing, occupational therapists, physios and chiropodists, are hived off by 2008 if desired.
GPs may start providing extra services or nurse co-operatives and foundation hospitals could step in.
But it is the prospect of the private sector getting involved which is causing most concern among health professionals.
Karen Jennings, head of health at public sector union Unison, said there was a "lack of confidence" in the white paper because of these proposals.
"Unison will be lobbying both nationally and locally to get these proposals thrown out."
Unison is concerned that opening up primary care to private companies will see the "profit motive" damaging the availability of services.
GPs may start providing other services in their practices
Dr Michael Dixon, chairman of the NHS Alliance, which represents primary care professionals, said it was important that clinicians and PCTs remained in control of services.
"We are not afraid of competition, but I think patients will be best served when GPs or other parts of the NHS provide the services."
The Royal College of Nursing, which is posing the most vigorous opposition to the plan, is also concerned.
The judicial review the college is seeking is contesting the policy on the grounds that the government did not consult properly.
But Howard Catton, the RCN's head of policy, said: "We are opposed to it. Patients will not be best served by having thousands of staff transferred to the private sector.
"As you can imagine our members are worried about this."
And at best the pubic remain ambivalent to the change.
During the recent white paper consultation, just 6% thought allowing more providers into the NHS was a priority.
Nonetheless, Ms Hewitt said she was not deterred from pushing forward with the policy which is threatening to overshadow some of the reforms, which many believe are badly needed.
She said: "Bringing in an outside provider to provide a particular service is a means of achieving a particular goal.
"I would not expect the public to be excited about the means of achieving something."
At the moment it remains unclear how many services will be provided by the private sector.
A poll of PCT chief executives by the Health Service Journal found nearly two thirds thought some of their services will be provided by the private sector in the future.
But Jo Webber, policy manager at the NHS Confederation, which represents health service managers, said she did not think there would be a big rush.
And she added: "It is important to remember non-NHS bodies are already providing health services.
"The Terence Higgins Trust runs some sexual health facilities and Macmillan nurses provide cancer care. It is not totally new."
However, what does seem certain is that the row is damaging the Department of Health's push to improve community services in the forthcoming white paper.
In the HSJ poll, 95% of health chiefs complained about the government's handling of the issue.
One PCT chief executive told the BBC: "We are facing months, if not years, of change and people are not happy with the way the government are going about this.
"At the same time the NHS is being asked to be innovative and energetic. It is bound to be a problem."