NHS Confederation chief executive Mike Farrar said:

"The NHS is facing its biggest ever challenge, with the £20bn productivity requirement alongside the huge pressures facing the social care system and the need to continue to drive up quality of care and health outcomes. To meet this challenge we will need strong leadership and management.

"International comparisons show us that the NHS has a low spend on management relative to other systems. We need to be confident that the proposals for the NHS Commissioning Board and the Clinical Commissioning Groups will deliver a health system with the necessary management capacity.

"The Board itself recognises there are significant risks in reducing the level of management in the new system. As the trade organisation for the health service, we have consistently backed the delivery of efficiencies to ensure the maximum resource is available for commissioners to put into patient care for their populations. But, the levels of management set out here could pose a real danger to effective patient care.

"It doesn't matter whether the people filling these positions have an administrative or a clinical background, the fact remains that if insufficient money is spent on the organisation of care then patient outcomes will suffer. The best surgeons in the world will get poorer results if patients' problems aren't diagnosed early enough because insufficient management capacity was available to plan, prioritise and deploy NHS resources properly.

"I am really worried that we are reducing this capacity to dangerously low levels. I fear that this level of reduction will undermine the ability of the NHS to achieve the tasks it will be set. We urge them to reconsider the level of resource they dedicate to the organisation of patient care."