For a few heady days before Christmas last year it seemed that the government was about to achieve the impossible - a radical reform of the NHS of which almost everybody approved.

The White Paper, "The new NHS - Modern, Dependable" was issued to widespread acclaim. Doctors' leaders were happy to embrace plans that apparently would scrap the divisions created by the 1989 Thatcher reforms.

Many believed that the NHS had developed into a two-tier service, with patients of fundholding GPs receiving fast track treatment at the expense of others.

Ecstatic

Dr Sandy Macara, chairman of the BMA Council, was positively ecstatic.

BMA leader Dr Sandy Macara initially welcomed the reforms

"I warmly welcome the new pragmatic approach which replaces the disastrous internal market with a system driven by patients' clinical needs," he said.

"It closes an unhappy chapter in the recent history of the NHS and promises a better route forward."

What a difference six months makes. Earlier this month, Health Minister Alan Milburn was told by GPs at a conference in Birmingham that, far from being a brave new dawn, the government reforms were simply a cunning way to limit NHS spending - and pin the blame on GPs.

Cold on the reforms

Why had doctors - and in particular GPs - gone cold on the reforms? The answer was all about resources.

The basic tenet of the White Paper - that, as the people closest to the patients, the NHS should be led by GPs - is widely welcomed throughout the profession. Under the Tories, an internal market had been created in the NHS. Hospitals - as providers of services - had to compete against each other for business, not only from health authorities, but also from individual GP fundholders who had been given a budget to buy their own secondary care.

With control over their own funds, fundholders were able to negotiate preferential contracts, which led to their patients getting faster treatment. The so-called two-tier system divided GPs, and threatened to destroy the BMA.

Big idea

Labour's big idea was to scrap fundholding, and to replace it with a system of GP commissioning under which all patients were treated the same.

Alan Milburn faces a tough time from GPs

GPs - together with other health and social services professionals - would join forces in Primary Care Groups covering approximately 100,000 patients to decide together how to purchase hospital services.

Primary Care Groups would have to work to a three-year Health Improvement Programme drawn up the local health authority to ensure a consistent approach across a locality. A National Institute for Clinical Effectiveness would promote high quality guidelines for treatment based on scientific research, and a Commission for Health Improvement would intervene where local standards were failing.

Most GPs support the new structure, but not the underlying detail. Opposition to the reforms has so intensified that some are now calling for industrial action if the government does not back down.

Non-cooperation

Dr John Chisholm, chairman of the BMA's GP committee, has written to Alan Milburn warning him a campaign of non-cooperation is a real threat. GPs' main concern is that cash for drugs, hospital care and general practice infrastructure are now to be lumped together in a single, unified budget.

They are worried the expensive drugs and hospital treatment will use up the funds, leaving nothing for the day-to-day running of GP surgeries.

GPs also fear NHS cash will run out, and that they, and not the government, will take the blame. Concern has been heightened by the government's refusal to rule out transferring current health authority debts to Primary Care Groups.

With intense pressures on budgets, GPs are also worried their clinical freedom to prescribe and refer in the best interests of their patients will be curtailed in the quest to save money. They want a guarantee that GPs will have a majority say on Primary Care Group boards.

Finally, family doctors want an assurance that their employment status as independent contractors will be protected.

Inadequate

Mr Milburn has announced that £22m will be made available to help GPs set up Primary Care Groups, but the money was dismissed as inadequate by the profession.

The growing discontent was summed up by Dr Chisholm, who in his letter to Mr Milburn said: "There is a pressing need for the Minister to heed my call for a clear commitment to address GPs' most important concerns about his White Paper proposals.

"Obviously, the answers will colour our collective reaction to the establishment of Primary Care Groups."