The switch to GP-led commissioning could create a two-tier primary health care system, with some new consortia becoming the medical equivalent of 'sink estates' - places where lower quality family doctors end up looking after poorer patients who have worse health.
This is the fear articulated in the latest issue of the prestigious The Health Service Journal (HSJ), as the government fights to defend its reforms against considerable anger and opposition from within the NHS, among academics, and in face of a highly sceptical public.
The professional journal reports that in at least 17 existing primary care trusts, high-performing GP practices have joined with others from outside their areas to form a 'shadow' consortium - or have decided to go it alone, rather than linking up with nearby surgeries that provide lower quality care.
David Stout, director of the PCT Network, told the BBC: "I am sure there will be concern about some [consortiums] being the equivalent of 'sink estates', with all the most difficult practices, [and] most deprived populations, coming together."
Frank Atherton, of the Association of Directors of Public Health (ADPH), said some consortiums could end up "cherry-picking healthier populations" and that "the more deprived and less affluent people [may] get left behind with the poor performing GPs".
The British Medical Association (BMA) and the Royal College of Nursing (RCN) have also been critical of the government's current plans - which constitute the most radical restructuring of the National Health Service since it began in 1948.
The BMA has said health secretary Andrew Lansley's proposals are "damaging" and "flawed", threatening the fabric of the NHS. Prime Minister David Cameron has been told he faces a "PR disaster", and has announced a series of public meetings around the country - which critics say are not genuine attempts at consultation, but a propaganda exercise combined with a means of politically legitimating a series of small u-turns which will be needed on practical grounds, particularly regarding speed of implementation.
Even bodies which have welcomed the "intentions" of the government's two White Papers (legislative proposals), like the NHS Confederation and the King's Fund think-tank, say that they are set to proceed too quickly and unevenly.
The Conservatives' coalition partners, the Liberal Democrats, have voted in conference against the reforms, and those close to power within the party, who are trying to reach a compromise over trying to temper the latest Conservative attempts to replace 'national' with 'variable' and 'service' with 'business' in the NHS, face power versus principle dilemmas once more.
This morning, Baroness Shirley Williams, speaking on BBC Radio 4, said the government's intended actions could both harm the NHS and imperil the coalition. She welcomed attempts to stop private providers 'cherry-picking' cheaper services and leaving expensive ones to the taxpayer. But she said that attempts to rectify this through a differential pricing policy would be "hopelessly bureaucratic".
Meanwhile, the RCN say that plans to ring-fence money for public health are well-intentioned, but it is unclear what services would be covered, how the money would be safe-guarded against funding pressures, and how a public health ‘premium’ would work in practice.
The RCN expressed concern that paying a health ‘premium’ to local authorities that showed improvements in health would be unfair to those authorities in more deprived areas where improvements were harder to come by.
Pointing to public health interventions such as screening programmes, the Royal College of Nursing said it was unclear which healthcare services would be covered by the ring-fenced budget. The challenging financial climate could also lead to local authorities potentially making cuts in their budgets threatening longer-term public health initiatives.
Other specific recommendations contained in the response include:
• More support to increase provision of occupational health nurses.
• Cross-government action on improving environments – a key determinant for public health.
• Making children’s centres ‘community hubs’ and securing their ongoing funding.
• Making prevention of health harm a fifth licensing objective.
• Ensuring every child has access to a school nurse.
• Giving more recognition to the growing problem of older people presenting with STIs.
• Ensuring universal access to physiotherapy and outpatient psychological support
• Improving investment in district nursing teams.
• Improving access to all types of counselling therapies.
The RCN also warned that services could potentially become fragmented by greater private sector involvement – something that the government is championing through its ‘responsibility deal’. Citing the example of poor action on alcohol labelling and the RCN’s call for a mandatory code, the RCN says that regulation should always be an option as in the case of seat-belts and smoking in public spaces.
Analyst Dr Peter Carter said: “Sometimes the interests of business and industry and population health are simply not aligned – regulation should always be an option where it is deemed most appropriate.”
"Let's send a message to this government loud and clear: the NHS is our future and it's not for sale," said UNISON service group executive chair Lilian Macer when she opened the trade union's health conference in Liverpool this morning (4 April).
Ms Macer said that there had been tangible victories in campaigning against the attack on the NHS, and alliances had been built which needed to be sustained and carried forward.
"We are all here to make our voices heard," she declared. "We will fight to retain and protect our public services and our NHS."