Speaking at a recent conference, Robert Creighton, the head of Ealing Primary Care Trust (PCT), explained that it has become difficult to concentrate on the job in hand of caring for patients, because the message they were getting from government was “everything [we have been doing] is bad, poor, unsuccessful and should be destroyed”. He went on to warn that the NHS was “at risk of blowing it seriously”—that the proposed changes could result in “a bloody awful train crash. It could collapse”.

The government changes are being pushed through by the health secretary, Andrew Lansley. The 152 primary care trusts and the 10 strategic health authorities will be replaced by around 600 consortia. A consortium will consist of groups of general practitioners (GPs). The consortia will be given £80 billion from the government to buy treatments on behalf of their patients.

Currently, PCTs are responsible for provision of health services, including GPs and other services such as dentists and pharmacists. They commission the purchase of treatments from strategic health authorities that provide hospital care.

Some 50 groups of GP practices, known as pathfinders, have been enlisted to be the first to take responsibility for commissioning. They cover around 12 million people in England, about a quarter of the population. But this is not a pilot project. Whatever happens with the pathfinder practices, the coalition government intends to press ahead with a complete reorganisation of the NHS by 2013.

It is not only the pace of change that is a problem. The shift to GP-commissioned services is intended to open the way for greater private involvement in health care. GPs will be under pressure to buy the cheapest services on offer.

The Independent’s medical editor, Jeremy Laurance, has warned of a civil war in the NHS. “The NHS is bracing itself for a price war in which hospital trusts will offer supermarket-style discounts to fight each other for business”.

For the first time, hospitals will be able to compete on price and offer two-for-one deals or cut-rate consultations. Prices are currently fixed nationally, and hospitals can only compete on quality, length of waiting lists and cleanliness of wards.

Laurance quoted an unnamed NHS executive: “There will be huge pressure on me from my board to reduce prices and increase market share. There are a lot of bullish GPs out there saying they will go to the cheapest provider already. This gives the opportunity for trusts to undercut one another on price. We will be forced to act much more commercially. Hospitals will have to think more radically about restructuring their services. It could lead to huge tension politically”.

Laurence Buckman, chairman of the General Practitioners Committee of the British Medical Association (BMA), has written an open letter to all GPs.

“[W]e remain particularly concerned about increased competition within healthcare”, he warned, “and want to prevent greater input from the commercial sector…. The pace and uncoordinated nature of change in developing commissioning is a particular issue….”

The NHS faces very real cuts in finance, despite the government claim that it has ring-fenced it from the austerity measures. In tandem with these major changes, the government is imposing a 4 percent per annum productivity gain over the course of the parliament, to make a minimum of £20 billion efficiency savings by 2014.

The social policy think tank Civitas explained that “such productivity improvement is no easy task”.

“To provide an indication of how difficult this will be, average productivity across UK private sector industry increased by 2.3% per annum over the past decade; some two percentage points less than that now required in the NHS”.

The pressure to make annual savings is already being felt. Hospital managers have warned workers that they must either accept a pay cut or face 35,000 job losses.

According to the Daily Telegraph, hospital trusts are already cutting back on services. The newspaper found that all referrals for fertility treatment have been halted in Surrey. In South West Essex, only those patients who have had cancer are being referred for fertility treatment.

In Portsmouth, for example, routine hip and knee replacements are being denied to patients who are obese or smoke. Warwickshire has cut treatment for back pain, and Manchester is refusing to treat varicose veins. All non-urgent operations have been postponed for eight weeks in Warrington. Nottinghamshire has reduced the number of X-ray and MRI scans.

Dr. Mark Porter, chairman of the BMA’s Consultants Committee, warned of a real danger to patients as a result of these cuts. “They are by and large not being axed for clinical reasons, but as an inevitable consequence of the massive cost savings that have been imposed on the NHS.

“Despite the continuing claims of real terms increases for the NHS, the reality on the ground is very different. The scale of the financial challenge facing the service is such that this is likely to be the tip of the iceberg”.