One year since the Health and Social Care Bill was published and you could be forgiven for thinking the UK parliament and the English NHS are living in parallel universes. While MPs and Lords wrangle over the enormous 350 page bill, and lobbyists, including doctors, fight to improve on the initial offering, out in the health service radical reform is already well underway. Transition to clinician-led commissioning has progressed so fast that it’s as if the actual passing of the bill was a mere incidental detail. As one commentator told the BMJ, “we’ve taken a running jump into the abyss.” The NHS has already laid waste to huge amounts of management capacity, undermining its ability to cope as the previous years of public sector largesse begin to recede. So when the bill finally receives royal assent, what difference will it make to the health service?