The Government's controversial reforms to the NHS became law today after a tortuous 14-month passage through Parliament, when the Queen granted Royal Assent to the Health and Social Care Bill.
Deputy Speaker Lindsay Hoyle's announcement in the House of Commons that assent had been given was greeted by cries of "shame" from opposition Labour MPs.
The proposals were first tabled in Parliament in January 2011, but were subjected to an unprecedented "pause" last year as Health Secretary Andrew Lansley struggled to secure the support of healthcare workers, and were amended more than 1,000 times during a lengthy passage through the House of Lords.
The new rules mean the Government can create GP commissioning groups to buy health care for patients and scrap Primary Care Trusts (PCTs).
Labour has bitterly opposed the passage of the new law, insisting it threatens the foundation of the NHS and paves the way for private services to get too involved.
A draft risk register leaked today showed that ministers were warned 18 months ago of the risk that the reforms could lead to a loss of financial control, reduced productivity and emergencies being less well managed.
The Department of Health, which refused to comment on today's leak, has resisted a ruling from the Information Commissioner that it should release the final version of the risk register in response to a freedom of information request from Labour.
Shadow health secretary Andy Burnham said today's document showed that ministers were warned before they launched the Bill that it was "likely to cause major damage to the NHS".
The document was produced on September 28 2010, and it is not known what changes were made before the completion of the transition risk register on November 10. The Bill has changed fundamentally since that date.
Identifying 43 separate areas of potential risk, the draft register rates each on a scale of one to five, where a rating of one means little likelihood and very low impact and five means almost certain to occur and very high impact.
The likelihood and impact figures are multiplied together to give an overall risk rating, with a maximum score of 25.
Among 13 areas given a risk rating of 16 - with likelihood and impact each assessed at four out of five - were:
:: Parliamentary amendments creating "unforeseen consequences for the system";
:: Costs being driven up by GP consortia using private sector organisations and staff;
:: Implementation beginning before adequate planning has been done;
:: Loss of financial control;
:: "Unhelpful conflict" between the NHS commissioning board and regulator Monitor;
:: GP consortia going bust or having to cut services for financial reasons;
:: GP leaders being drawn into managerial processes which end up driving clinical behaviour.
Other dangers, considered to have a lower rating of 12, included the risk that "NHS role in emergency preparedness/responsiveness is more difficult to manage through a more devolved organisation, and so emergencies are less well managed/mitigated".
Staff concerns and union action over the reforms could lead to "deterioration in relations, lower productivity in the Department of Health/NHS and delays in programme", the document said.
And there was a warning that strategic health authorities and primary care trusts might lose "good people" who then have to be re-employed to run the new system.
Mr Burnham told the Guardian: "Now we know why David Cameron refused to publish the risk register before the Bill was through Parliament - it's because civil servants were telling him his reorganisation was likely to cause major damage to the NHS.
"David Cameron will never be forgiven for knowingly taking these risks with the country's best-loved institution."
A Department of Health spokesman said: "We do not comment on leaks. We have always been open about risk and have published all relevant information in the impact assessments alongside the Bill.
"As the latest performance figures show, we are dealing with those risks, performance is improving - waiting times are down and mixed-sex wards are at an all-time low - and we are on course to make the efficiency savings that the NHS needs to safeguard it for the future."