By Richard Hoey

British Prime Minister David Cameron is a man who likes to get his PR right.

In the summer, he used all his experience as a former head of corporate communications at Carlton TV to steer a path through the anger and acrimony generated by his reforms to the National Health Service (NHS).

He whisked up a listening exercise and an independent report, spoke some conciliatory words, and persuaded first MPs and then the House of Lords to wave through his Health and Social Care Bill to its current position on the brink of becoming law.

But just as the debate over the NHS appeared to be calming down, it has been abruptly reignited by a leaked policy document critics of the reforms describe as a ‘smoking gun’, demonstrating the Government’s intention to dismantle the state health system.

The document doesn’t sound a great deal. It is called ‘Developing commissioning support: towards service excellence’.

But its contents are explosive enough that the British Medical Association, which until now had been prevaricating over its response to the Government’s bill, has come down on the side all all-out opposition, with a series of attack ads planned soon.

The document sets out the Government’s plan to create a full-blown market in what it refers to prosaically as ‘commissioning support’, but which beyond a skeleton support staff is everything about the bread and butter job of managing the NHS.

Provision of back-office support, data analysis, tendering, procurement and contract monitoring, among many other functions, could all potentially be outsourced by the groups of family doctors who are being asked to take the reins of the NHS.

The new NHS Commissioning Board will from 2013 offer a large chunk of commissioning support via a variety of arms-length bodies, but it will gradually divest itself of them until by 2016 the NHS’s management functions are procured on an entirely open market.

The Government’s reasoning is that individual units of the NHS can no longer afford their own management support, and that it will be more efficient for them to buy it in from a menu of large national organisations – many in the private sector.

It hopes too that health organisations might be able to share outsourcing of their management functions with local authorities – which are responsible for social care – as a way of bringing the two together.

But the Government has already announced plans to allow private companies to compete for the right to run many more clinical services, and so critics are asking – if the NHS is not the doctors and nurses, and nor is it the managers who oversee it, then what is it exactly?

Is it perhaps just a brand, and a promise by the Government to patients that they won’t have to pay for their medical care?

Now, not everyone who works in the NHS in England (the reforms don’t apply in Scotland, Wales and Northern Ireland) is so worked up by the new draft document. Some indeed see it as rather constraining – given that family doctors will have to wait up to three years for an entirely free choice of where they go for commissioning support.

But I do get the feeling that this has been a key development, even if its impact has yet to be felt on the consciousness of the public at large.

The BMA is an enormously powerful organisation in British political life, often described as the country’s most successful trade union, even though it would like to see itself as rather rising above the ugly tussle of labour disputes.

Up to now, the BMA has been rather muted on the Government’s health bill, officially calling for it to be withdrawn, but doing so with notable lack of enthusiasm.

No longer – even chair Dr Hamish Meldrum, who has been the pragmatist in chief in his dealings with the Government, now seems to be ready for an all-out fight.

Perhaps more significantly, some of those senior doctors who were previously enthusiasts for the plans – which after all hand doctors at the front line significantly more powers – are now finding themselves turned off.

One such doctor, who has held senior roles at the BMA, told me despairingly of the demoralising impact the Government’s latest policy document had had.

How, he said, could he work constructively with NHS managers through a period of major change, when they had now found out they would be made redundant or their organisations spun off in yet another monumental restructure in just a few years?

Even the Government’s fans among the medical profession are beginning to turn their backs.

David Cameron will almost certainly get his bill. But the crucial PR battle – for the hearts and minds of the British public – has further to run than he appears to have foreseen.

Richard Hoey is editor of Pulse, a weekly magazine for UK primary care professionals and physicians. He writes Pulse’s editorials and muses on general practice in his weekly blog. You can follow him and read other news about the NHS at pulsetoday.co.uk.